State prevailing rates

Please note that the CHAMPUS Maximum Allowable Charges (CMAC) take precedence over the state prevailing rates listed below.

Latest update: 03-13-2019
CPT code State Provider class Modifier Current pricing Effective date
0359T IN 01 00 $500.00 2/12/2016
0359T IN 04 00 $500.00 2/12/2016
0360T IN 01 00 $62.50 2/12/2016
0360T IN 04 00 $62.50 2/12/2016
0361T IN 01 00 $62.50 2/12/2016
0361T IN 04 00 $62.50 2/12/2016
0364T IN 01 00 $62.50 1/1/2018
0364T IN 04 00 $62.50 1/1/2018
0364T IN 01 00 $62.50 7/13/2018
0364T IN 04 00 $62.50 7/13/2018
0365T IN 01 00 $62.50 2/12/2016
0365T IN 04 00 $62.50 2/12/2016
0368T IN 01 00 $62.50 2/12/2016
0368T IN 04 00 $62.50 2/12/2016
0369T IN 01 00 $62.50 2/12/2016
0369T IN 04 00 $62.50 2/12/2016
0370T IN 01 00 $125.00 2/12/2016
0370T IN 04 00 $125.00 2/12/2016
15876 IN 01 00 $286.00 1/1/2018
15876 IN 04 00 $286.00 1/1/2018
15876 IN 01 00 $286.00 7/13/2018
15876 IN 04 00 $286.00 7/13/2018
15878 IN 01 00 $915.30 1/1/2018
15878 IN 04 00 $915.30 1/1/2018
15878 IN 01 00 $915.30 7/13/2018
15878 IN 04 00 $915.30 7/13/2018
15879 IN 01 00 $915.30 1/1/2018
15879 IN 04 00 $915.30 1/1/2018
15879 IN 01 00 $915.30 7/13/2018
15879 IN 04 00 $915.30 7/13/2018
24940 IN 01 00 $1,144.10 1/1/2018
24940 IN 04 00 $1,144.10 1/1/2018
24940 IN 01 00 $1,144.10 7/13/2018
24940 IN 04 00 $1,144.10 7/13/2018
36468 IN 01 00 $200.00 2/12/2016
36468 IN 04 00 $200.00 2/12/2016
41821 IN 01 00 $91.60 1/1/2018
41821 IN 04 00 $91.60 1/1/2018
41821 IN 01 00 $91.60 7/13/2018
41821 IN 04 00 $91.60 7/13/2018
41870 IN 01 00 $354.70 1/1/2018
41870 IN 04 00 $354.70 1/1/2018
41870 IN 01 00 $354.70 7/13/2018
41870 IN 04 00 $354.70 7/13/2018
50300 IN 01 00 $1,178.40 1/1/2018
50300 IN 04 00 $1,178.40 1/1/2018
50300 IN 01 00 $1,178.40 7/13/2018
50300 IN 04 00 $1,178.40 7/13/2018
65757 IN 01 00 $3,016.88 1/1/2018
65757 IN 04 00 $3,016.88 1/1/2018
65757 IN 01 00 $3,016.88 7/13/2018
65757 IN 04 00 $3,016.88 7/13/2018
69090 IN 01 00 $68.70 2/12/2016
69090 IN 04 00 $68.70 2/12/2016
69710 IN 01 00 $1,487.30 2/12/2016
69710 IN 04 00 $1,487.30 2/12/2016
74300 IN 01 00 $1,008.50 4/18/2017
74300 IN 01 00 $1,008.50 1/1/2018
74300 IN 04 00 $468.00 1/1/2018
74300 IN 01 00 $1,008.50 7/13/2018
74300 IN 04 00 $468.00 7/13/2018
74300 IN 01 00 $743.00 1/1/2019
74300 IN 04 00 $743.00 1/1/2019
74300 IN 01 TC $450.00 1/1/2018
74300 IN 04 TC $450.00 1/1/2018
74300 IN 01 TC $450.00 7/13/2018
74300 IN 04 TC $450.00 7/13/2018
74328 IN 01 00 $1,121.00 1/1/2018
74328 IN 04 00 $805.50 1/1/2018
74328 IN 01 00 $1,121.00 7/13/2018
74328 IN 04 00 $805.50 7/13/2018
74328 IN 01 00 $340.00 1/1/2019
74328 IN 04 00 $340.00 1/1/2019
74328 IN 01 TC $770.66 1/1/2018
74328 IN 04 TC $770.66 1/1/2018
74328 IN 01 TC $770.66 7/13/2018
74328 IN 04 TC $770.66 7/13/2018
74330 IN 01 00 $2,222.25 4/18/2017
74330 IN 01 00 $2,778.00 1/1/2018
74330 IN 04 00 $761.25 1/1/2018
74330 IN 01 00 $2,778.00 7/13/2018
74330 IN 04 00 $761.25 7/13/2018
74330 IN 01 00 $2,934.00 1/1/2019
74330 IN 04 00 $2,934.00 1/1/2019
74330 IN 01 TC $719.92 1/1/2018
74330 IN 04 TC $719.92 1/1/2018
74330 IN 01 TC $719.92 7/13/2018
74330 IN 04 TC $719.92 7/13/2018
75894 IN 01 00 $9,140.25 1/1/2018
75894 IN 04 00 $1,887.00 1/1/2018
75894 IN 01 00 $9,140.25 7/13/2018
75894 IN 04 00 $1,887.00 7/13/2018
75894 IN 01 TC $1,826.53 1/1/2018
75894 IN 04 TC $1,826.53 1/1/2018
75894 IN 01 TC $1,826.53 7/13/2018
75894 IN 04 TC $1,826.53 7/13/2018
76001 IN 01 00 $1,261.00 4/18/2017
76001 IN 01 00 $1,939.00 1/1/2018
76001 IN 04 00 $613.00 1/1/2018
76001 IN 01 00 $1,939.00 7/13/2018
76001 IN 04 00 $613.00 7/13/2018
76001 IN 01 00 $1,410.00 1/1/2019
76001 IN 04 00 $1,410.00 1/1/2019
76001 IN 01 TC $581.88 1/1/2018
76001 IN 04 TC $581.88 1/1/2018
76001 IN 01 TC $581.88 7/13/2018
76001 IN 04 TC $581.88 7/13/2018
77385 IN 01 00 $1,868.00 2/12/2016
77385 IN 04 00 $1,868.00 2/12/2016
77386 IN 01 00 $4,392.00 2/12/2016
77386 IN 04 00 $4,392.00 2/12/2016
79300 IN 01 00 $437.80 1/1/2018
79300 IN 04 00 $437.80 1/1/2018
79300 IN 01 00 $437.80 7/13/2018
79300 IN 04 00 $437.80 7/13/2018
80300 IN 01 00 $179.93 2/12/2016
80300 IN 04 00 $179.93 2/12/2016
80301 IN 01 00 $360.00 2/12/2016
80301 IN 04 00 $360.00 2/12/2016
80302 IN 01 00 $150.00 2/12/2016
80302 IN 04 00 $150.00 2/12/2016
80320 IN 01 00 $123.00 2/12/2016
80320 IN 04 00 $123.00 2/12/2016
80321 IN 01 00 $70.00 2/12/2016
80321 IN 04 00 $70.00 2/12/2016
80324 IN 01 00 $50.00 2/12/2016
80324 IN 04 00 $50.00 2/12/2016
80329 IN 01 00 $198.00 2/12/2016
80329 IN 04 00 $198.00 2/12/2016
80333 IN 01 00 $60.00 2/12/2016
80333 IN 04 00 $60.00 2/12/2016
80335 IN 01 00 $30.00 2/12/2016
80335 IN 04 00 $30.00 2/12/2016
80337 IN 01 00 $60.00 2/12/2016
80337 IN 04 00 $60.00 2/12/2016
80346 IN 01 00 $60.00 2/12/2016
80346 IN 04 00 $60.00 2/12/2016
80348 IN 01 00 $50.00 2/12/2016
80348 IN 04 00 $50.00 2/12/2016
80349 IN 01 00 $40.00 2/12/2016
80349 IN 04 00 $40.00 2/12/2016
80350 IN 01 00 $67.49 2/12/2016
80350 IN 04 00 $67.49 2/12/2016
80354 IN 01 00 $50.00 2/12/2016
80354 IN 04 00 $50.00 2/12/2016
80355 IN 01 00 $30.00 2/12/2016
80355 IN 04 00 $30.00 2/12/2016
80356 IN 01 00 $40.00 2/12/2016
80356 IN 04 00 $40.00 2/12/2016
80357 IN 01 00 $59.28 2/12/2016
80357 IN 04 00 $59.28 2/12/2016
80359 IN 01 00 $56.28 2/12/2016
80359 IN 04 00 $56.28 2/12/2016
80360 IN 01 00 $40.00 2/12/2016
80360 IN 04 00 $40.00 2/12/2016
80362 IN 01 00 $30.00 2/12/2016
80362 IN 04 00 $30.00 2/12/2016
80363 IN 01 00 $70.00 2/12/2016
80363 IN 04 00 $70.00 2/12/2016
80365 IN 01 00 $60.00 2/12/2016
80365 IN 04 00 $60.00 2/12/2016
80366 IN 01 00 $40.00 2/12/2016
80366 IN 04 00 $40.00 2/12/2016
80367 IN 01 00 $50.00 2/12/2016
80367 IN 04 00 $50.00 2/12/2016
80368 IN 01 00 $60.00 2/12/2016
80368 IN 04 00 $60.00 2/12/2016
80369 IN 01 00 $50.00 2/12/2016
80369 IN 04 00 $50.00 2/12/2016
80371 IN 01 00 $59.28 2/12/2016
80371 IN 04 00 $59.28 2/12/2016
80372 IN 01 00 $40.00 2/12/2016
80372 IN 04 00 $40.00 2/12/2016
80373 IN 01 00 $50.00 2/12/2016
80373 IN 04 00 $50.00 2/12/2016
81266 IN 01 00 $1,768.00 2/12/2016
81266 IN 04 00 $1,768.00 2/12/2016
86860 IN 01 00 $54.00 1/1/2018
86860 IN 04 00 $54.00 1/1/2018
86860 IN 01 00 $54.00 7/13/2018
86860 IN 04 00 $54.00 7/13/2018
86891 IN 01 00 $90.00 1/1/2018
86891 IN 04 00 $90.00 1/1/2018
86891 IN 01 00 $90.00 7/13/2018
86891 IN 04 00 $90.00 7/13/2018
86921 IN 01 00 $122.00 1/1/2018
86921 IN 04 00 $122.00 1/1/2018
86921 IN 01 00 $122.00 7/13/2018
86921 IN 04 00 $122.00 7/13/2018
86930 IN 01 00 $9.00 1/1/2018
86930 IN 04 00 $9.00 1/1/2018
86930 IN 01 00 $9.00 7/13/2018
86930 IN 04 00 $9.00 7/13/2018
86931 IN 01 00 $9.00 1/1/2018
86931 IN 04 00 $9.00 1/1/2018
86931 IN 01 00 $9.00 7/13/2018
86931 IN 04 00 $9.00 7/13/2018
86932 IN 01 00 $9.00 1/1/2018
86932 IN 04 00 $9.00 1/1/2018
86932 IN 01 00 $9.00 7/13/2018
86932 IN 04 00 $9.00 7/13/2018
86950 IN 01 00 $45.00 1/1/2018
86950 IN 04 00 $45.00 1/1/2018
86950 IN 01 00 $45.00 7/13/2018
86950 IN 04 00 $45.00 7/13/2018
86970 IN 01 00 $144.00 1/1/2018
86970 IN 04 00 $144.00 1/1/2018
86970 IN 01 00 $144.00 7/13/2018
86970 IN 04 00 $144.00 7/13/2018
86971 IN 01 00 $144.00 1/1/2018
86971 IN 04 00 $144.00 1/1/2018
86971 IN 01 00 $144.00 7/13/2018
86971 IN 04 00 $144.00 7/13/2018
86972 IN 01 00 $144.00 1/1/2018
86972 IN 04 00 $144.00 1/1/2018
86972 IN 01 00 $144.00 7/13/2018
86972 IN 04 00 $144.00 7/13/2018
86975 IN 01 00 $144.00 1/1/2018
86975 IN 04 00 $144.00 1/1/2018
86975 IN 01 00 $144.00 7/13/2018
86975 IN 04 00 $144.00 7/13/2018
86976 IN 01 00 $144.00 1/1/2018
86976 IN 04 00 $144.00 1/1/2018
86976 IN 01 00 $144.00 7/13/2018
86976 IN 04 00 $144.00 7/13/2018
86977 IN 01 00 $144.00 1/1/2018
86977 IN 04 00 $144.00 1/1/2018
86977 IN 01 00 $144.00 7/13/2018
86977 IN 04 00 $144.00 7/13/2018
86978 IN 01 00 $144.00 1/1/2018
86978 IN 04 00 $144.00 1/1/2018
86978 IN 01 00 $144.00 7/13/2018
86978 IN 04 00 $144.00 7/13/2018
90650 IN 01 00 $175.00 1/1/2019
90650 IN 04 00 $175.00 1/1/2019
90681 IN 01 00 $185.00 1/1/2019
90681 IN 04 00 $185.00 1/1/2019
90696 IN 01 00 $120.00 1/1/2019
90696 IN 04 00 $120.00 1/1/2019
90736 IN 01 00 $235.51 7/19/2017
90736 IN 04 00 $235.51 7/19/2017
90736 IN 01 00 $254.35 7/20/2017
90736 IN 04 00 $254.35 7/20/2017
90736 IN 01 00 $254.35 1/1/2018
90736 IN 04 00 $254.35 1/1/2018
90736 IN 01 NU $235.51 10/19/2016
90736 IN 04 NU $235.51 10/19/2016
90993 IN 01 00 $4,391.00 1/1/2018
90993 IN 04 00 $4,391.00 1/1/2018
90993 IN 01 00 $4,391.00 7/13/2018
90993 IN 04 00 $4,391.00 7/13/2018
92594 IN 01 00 $50.75 1/1/2018
92594 IN 04 00 $50.75 1/1/2018
92594 IN 01 00 $50.75 7/13/2018
92594 IN 04 00 $50.75 7/13/2018
92921 IN 01 00 $9,308.00 1/1/2018
92921 IN 04 00 $9,308.00 1/1/2018
92921 IN 01 00 $9,308.00 7/13/2018
92921 IN 04 00 $9,308.00 7/13/2018
92929 IN 01 00 $10,098.25 1/1/2018
92929 IN 04 00 $10,098.25 1/1/2018
92929 IN 01 00 $10,098.25 7/13/2018
92929 IN 04 00 $10,098.25 7/13/2018
92978 IN 01 00 $2,114.50 1/1/2018
92978 IN 04 00 $2,114.50 1/1/2018
92978 IN 01 00 $2,114.50 7/13/2018
92978 IN 04 00 $2,114.50 7/13/2018
92978 IN 01 TC $2,025.29 1/1/2018
92978 IN 04 TC $2,025.29 1/1/2018
92978 IN 01 TC $2,025.29 7/13/2018
92978 IN 04 TC $2,025.29 7/13/2018
93299 IN 01 00 $100.00 4/18/2017
93299 IN 01 00 $455.00 1/1/2018
93299 IN 04 00 $100.00 1/1/2018
93299 IN 01 00 $455.00 7/13/2018
93299 IN 04 00 $100.00 7/13/2018
93299 IN 01 00 $455.00 1/1/2019
93299 IN 04 00 $455.00 1/1/2019
93620 IN 01 00 $19,986.75 1/1/2018
93620 IN 04 00 $6,240.00 1/1/2018
93620 IN 01 00 $19,986.75 7/13/2018
93620 IN 04 00 $6,240.00 7/13/2018
93620 IN 01 TC $5,627.60 1/1/2018
93620 IN 04 TC $5,627.60 1/1/2018
93620 IN 01 TC $5,627.60 7/13/2018
93620 IN 04 TC $5,627.60 7/13/2018
93621 IN 01 00 $8,541.00 1/1/2019
93621 IN 04 00 $8,541.00 1/1/2019
93623 IN 01 00 $5,512.00 1/1/2019
93623 IN 04 00 $5,512.00 1/1/2019
93662 IN 01 00 $4,980.00 1/1/2019
93662 IN 04 00 $4,980.00 1/1/2019
97005 IN 01 00 $155.81 4/20/2017
97005 IN 04 00 $155.81 4/20/2017
99000 IN 01 00 $31.00 4/18/2017
99000 IN 04 00 $31.00 4/18/2017
99000 IN 01 00 $31.00 1/1/2018
99000 IN 04 00 $31.00 1/1/2018
99000 IN 01 00 $31.00 7/13/2018
99000 IN 04 00 $31.00 7/13/2018
99001 IN 01 00 $50.30 4/18/2017
99001 IN 04 00 $50.00 4/18/2017
99001 IN 01 00 $50.30 1/1/2018
99001 IN 04 00 $50.00 1/1/2018
99001 IN 01 00 $50.30 7/13/2018
99001 IN 04 00 $50.00 7/13/2018
99001 IN 01 00 $47.65 1/1/2019
99001 IN 04 00 $47.65 1/1/2019
99002 IN 01 00 $15.00 1/1/2018
99002 IN 04 00 $12.00 1/1/2018
99002 IN 01 00 $15.00 7/13/2018
99002 IN 04 00 $12.00 7/13/2018
99071 IN 01 00 $10.00 2/12/2016
99071 IN 04 00 $10.00 2/12/2016
99075 IN 01 00 $1.70 2/12/2016
99075 IN 04 00 $1.70 2/12/2016
99455 IN 01 00 $450.00 2/12/2016
99455 IN 04 00 $135.00 2/12/2016
99606 IN 01 00 $154.06 2/12/2016
99606 IN 04 00 $154.06 2/12/2016
A0225 IN 01 00 $225.00 1/1/2018
A0225 IN 04 00 $225.00 1/1/2018
A0225 IN 01 00 $225.00 7/13/2018
A0225 IN 04 00 $225.00 7/13/2018
A0431 IN 01 00 $2,560.54 12/10/2015
A0431 IN 04 00 $2,560.54 12/10/2015
A0431 IN 01 00 $1,849.99 1/1/2018
A0431 IN 04 00 $1,849.99 1/1/2018
A0431 IN 01 00 $1,849.99 4/9/2018
A0431 IN 04 00 $1,849.99 4/9/2018
A0431 IN 01 00 $1,572.49 1/1/2019
A0431 IN 04 00 $1,572.49 1/1/2019
A0436 IN 01 00 $47.51 12/10/2015
A0436 IN 04 00 $47.51 12/10/2015
A0436 IN 01 00 $34.32 1/1/2018
A0436 IN 04 00 $34.32 1/1/2018
A0436 IN 01 00 $34.32 4/9/2018
A0436 IN 04 00 $34.32 4/9/2018
A0436 IN 01 00 $29.17 1/1/2019
A0436 IN 04 00 $29.17 1/1/2019
A4206 IN 01 00 $0.26 1/1/2018
A4206 IN 04 00 $0.26 1/1/2018
A4206 IN 01 00 $0.26 7/13/2018
A4206 IN 04 00 $0.26 7/13/2018
A4208 IN 01 00 $5.50 1/1/2018
A4208 IN 04 00 $5.50 1/1/2018
A4208 IN 01 00 $5.50 7/13/2018
A4208 IN 04 00 $5.50 7/13/2018
A4209 IN 01 00 $50.00 4/18/2017
A4209 IN 04 00 $50.00 4/18/2017
A4209 IN 01 00 $50.00 1/1/2018
A4209 IN 04 00 $50.00 1/1/2018
A4209 IN 01 00 $50.00 7/13/2018
A4209 IN 04 00 $50.00 7/13/2018
A4209 IN 01 00 $30.00 1/1/2019
A4209 IN 04 00 $30.00 1/1/2019
A4210 IN 01 00 $100.00 4/18/2017
A4210 IN 04 00 $100.00 4/18/2017
A4210 IN 01 00 $100.00 1/1/2018
A4210 IN 04 00 $100.00 1/1/2018
A4210 IN 01 00 $100.00 7/13/2018
A4210 IN 04 00 $100.00 7/13/2018
A4211 IN 01 00 $15.00 1/1/2018
A4211 IN 04 00 $15.00 1/1/2018
A4211 IN 01 00 $15.00 7/13/2018
A4211 IN 04 00 $15.00 7/13/2018
A4212 IN 01 00 $50.00 4/18/2017
A4212 IN 04 00 $50.00 4/18/2017
A4212 IN 01 00 $50.00 1/1/2018
A4212 IN 04 00 $50.00 1/1/2018
A4212 IN 01 00 $50.00 7/13/2018
A4212 IN 04 00 $50.00 7/13/2018
A4212 IN 01 00 $15.00 1/1/2019
A4212 IN 04 00 $15.00 1/1/2019
A4213 IN 01 00 $7.00 1/1/2018
A4213 IN 04 00 $7.00 1/1/2018
A4213 IN 01 00 $7.00 7/13/2018
A4213 IN 04 00 $7.00 7/13/2018
A4215 IN 01 00 $15.00 4/18/2017
A4215 IN 04 00 $15.00 4/18/2017
A4215 IN 01 00 $30.00 1/1/2018
A4215 IN 04 00 $30.00 1/1/2018
A4215 IN 01 00 $30.00 7/13/2018
A4215 IN 04 00 $30.00 7/13/2018
A4215 IN 01 00 $30.00 1/1/2019
A4215 IN 04 00 $30.00 1/1/2019
A4218 IN 01 00 $0.58 1/1/2018
A4218 IN 04 00 $0.58 1/1/2018
A4218 IN 01 00 $0.58 7/13/2018
A4218 IN 04 00 $0.58 7/13/2018
A4220 IN 01 00 $100.00 1/1/2018
A4220 IN 04 00 $100.00 1/1/2018
A4220 IN 01 00 $100.00 7/13/2018
A4220 IN 04 00 $100.00 7/13/2018
A4223 IN 01 00 $555.00 4/18/2017
A4223 IN 04 00 $555.00 4/18/2017
A4223 IN 01 00 $555.00 1/1/2018
A4223 IN 04 00 $555.00 1/1/2018
A4223 IN 01 00 $555.00 7/13/2018
A4223 IN 04 00 $555.00 7/13/2018
A4223 IN 01 00 $61.80 1/1/2019
A4223 IN 04 00 $61.80 1/1/2019
A4223 IN 01 NU $555.00 1/1/2018
A4223 IN 04 NU $555.00 1/1/2018
A4223 IN 01 NU $555.00 7/13/2018
A4223 IN 04 NU $555.00 7/13/2018
A4230 IN 01 00 $11.50 1/1/2018
A4230 IN 04 00 $11.50 1/1/2018
A4230 IN 01 00 $11.50 7/13/2018
A4230 IN 04 00 $11.50 7/13/2018
A4230 IN 01 NU $11.50 1/1/2018
A4230 IN 04 NU $11.50 1/1/2018
A4230 IN 01 NU $11.50 7/13/2018
A4230 IN 04 NU $11.50 7/13/2018
A4231 IN 01 00 $28.99 1/1/2018
A4231 IN 04 00 $28.99 1/1/2018
A4231 IN 01 00 $28.99 7/13/2018
A4231 IN 04 00 $28.99 7/13/2018
A4232 IN 01 00 $3.60 1/1/2018
A4232 IN 04 00 $3.60 1/1/2018
A4232 IN 01 00 $3.60 7/13/2018
A4232 IN 04 00 $3.60 7/13/2018
A4244 IN 01 00 $2.40 1/1/2018
A4244 IN 04 00 $2.40 1/1/2018
A4244 IN 01 00 $2.40 7/13/2018
A4244 IN 04 00 $2.40 7/13/2018
A4245 IN 01 00 $3.00 1/1/2018
A4245 IN 04 00 $3.00 1/1/2018
A4245 IN 01 00 $3.00 7/13/2018
A4245 IN 04 00 $3.00 7/13/2018
A4246 IN 01 00 $8.00 1/1/2018
A4246 IN 04 00 $8.00 1/1/2018
A4246 IN 01 00 $8.00 7/13/2018
A4246 IN 04 00 $8.00 7/13/2018
A4247 IN 01 00 $13.00 1/1/2018
A4247 IN 04 00 $13.00 1/1/2018
A4247 IN 01 00 $13.00 7/13/2018
A4247 IN 04 00 $13.00 7/13/2018
A4248 IN 01 00 $15.00 1/1/2018
A4248 IN 04 00 $15.00 1/1/2018
A4248 IN 01 00 $15.00 7/13/2018
A4248 IN 04 00 $15.00 7/13/2018
A4250 IN 01 00 $0.68 1/1/2018
A4250 IN 04 00 $0.68 1/1/2018
A4250 IN 01 00 $0.68 7/13/2018
A4250 IN 04 00 $0.68 7/13/2018
A4262 IN 01 00 $12.00 1/1/2018
A4262 IN 04 00 $12.00 1/1/2018
A4262 IN 01 00 $12.00 7/13/2018
A4262 IN 04 00 $12.00 7/13/2018
A4263 IN 01 00 $40.00 1/1/2018
A4263 IN 04 00 $40.00 1/1/2018
A4263 IN 01 00 $40.00 7/13/2018
A4263 IN 04 00 $40.00 7/13/2018
A4263 IN 01 00 $1,040.00 1/1/2019
A4263 IN 04 00 $1,040.00 1/1/2019
A4270 IN 01 00 $50.00 1/1/2018
A4270 IN 04 00 $50.00 1/1/2018
A4270 IN 01 00 $50.00 7/13/2018
A4270 IN 04 00 $50.00 7/13/2018
A4281 IN 01 00 $78.60 1/1/2018
A4281 IN 04 00 $78.60 1/1/2018
A4281 IN 01 00 $78.60 7/13/2018
A4281 IN 04 00 $78.60 7/13/2018
A4284 IN 01 00 $17.64 1/1/2018
A4284 IN 04 00 $17.64 1/1/2018
A4284 IN 01 00 $17.64 7/13/2018
A4284 IN 04 00 $17.64 7/13/2018
A4285 IN 01 00 $78.60 1/1/2018
A4285 IN 04 00 $78.60 1/1/2018
A4285 IN 01 00 $78.60 7/13/2018
A4285 IN 04 00 $78.60 7/13/2018
A4300 IN 01 00 $21.00 1/1/2018
A4300 IN 04 00 $21.00 1/1/2018
A4300 IN 01 00 $21.00 7/13/2018
A4300 IN 04 00 $21.00 7/13/2018
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