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
0042T PA 01 00 $939.00 2/15/2016
0042T PA 04 00 $939.00 2/15/2016
0359T PA 01 00 $500.00 2/26/2016
0359T PA 04 00 $500.00 2/26/2016
0360T PA 01 00 $62.50 2/26/2016
0360T PA 04 00 $62.50 2/26/2016
0361T PA 01 00 $62.50 2/26/2016
0361T PA 04 00 $62.50 2/26/2016
0364T PA 01 00 $62.50 1/1/2018
0364T PA 04 00 $62.50 1/1/2018
0364T PA 01 00 $62.50 7/13/2018
0364T PA 04 00 $62.50 7/13/2018
0365T PA 01 00 $62.50 2/26/2016
0365T PA 04 00 $62.50 2/26/2016
0368T PA 01 00 $62.50 2/26/2016
0368T PA 04 00 $62.50 2/26/2016
0369T PA 01 00 $62.50 2/26/2016
0369T PA 04 00 $62.50 2/26/2016
0370T PA 01 00 $125.00 2/26/2016
0370T PA 04 00 $125.00 2/26/2016
15824 PA 01 00 $343.40 1/1/2018
15824 PA 04 00 $343.40 1/1/2018
15824 PA 01 00 $343.40 7/13/2018
15824 PA 04 00 $343.40 7/13/2018
15825 PA 01 00 $343.40 1/1/2018
15825 PA 04 00 $343.40 1/1/2018
15825 PA 01 00 $343.40 7/13/2018
15825 PA 04 00 $343.40 7/13/2018
15826 PA 01 00 $343.40 1/1/2018
15826 PA 04 00 $343.40 1/1/2018
15826 PA 01 00 $343.40 7/13/2018
15826 PA 04 00 $343.40 7/13/2018
15828 PA 01 00 $343.40 1/1/2018
15828 PA 04 00 $343.40 1/1/2018
15828 PA 01 00 $343.40 7/13/2018
15828 PA 04 00 $343.40 7/13/2018
15829 PA 01 00 $343.40 1/1/2018
15829 PA 04 00 $343.40 1/1/2018
15829 PA 01 00 $343.40 7/13/2018
15829 PA 04 00 $343.40 7/13/2018
15876 PA 01 00 $343.40 1/1/2018
15876 PA 04 00 $343.40 1/1/2018
15876 PA 01 00 $343.40 7/13/2018
15876 PA 04 00 $343.40 7/13/2018
15878 PA 01 00 $343.40 1/1/2018
15878 PA 04 00 $343.40 1/1/2018
15878 PA 01 00 $343.40 7/13/2018
15878 PA 04 00 $343.40 7/13/2018
15879 PA 01 00 $343.40 1/1/2018
15879 PA 04 00 $343.40 1/1/2018
15879 PA 01 00 $343.40 7/13/2018
15879 PA 04 00 $343.40 7/13/2018
17380 PA 01 00 $343.40 2/26/2016
17380 PA 04 00 $343.40 2/26/2016
21088 PA 01 00 $343.40 2/26/2016
21088 PA 04 00 $343.40 2/26/2016
21089 PA 01 00 $343.40 1/1/2018
21089 PA 04 00 $343.40 1/1/2018
21089 PA 01 00 $343.40 7/13/2018
21089 PA 04 00 $343.40 7/13/2018
22841 PA 01 00 $343.40 1/1/2018
22841 PA 04 00 $343.40 1/1/2018
22841 PA 01 00 $343.40 7/13/2018
22841 PA 04 00 $343.40 7/13/2018
24940 PA 01 00 $343.40 1/1/2018
24940 PA 04 00 $343.40 1/1/2018
24940 PA 01 00 $343.40 7/13/2018
24940 PA 04 00 $343.40 7/13/2018
32850 PA 01 00 $343.40 1/1/2018
32850 PA 04 00 $343.40 1/1/2018
32850 PA 01 00 $343.40 7/13/2018
32850 PA 04 00 $343.40 7/13/2018
33930 PA 01 00 $343.40 1/1/2018
33930 PA 04 00 $343.40 1/1/2018
33930 PA 01 00 $343.40 7/13/2018
33930 PA 04 00 $343.40 7/13/2018
33940 PA 01 00 $343.40 1/1/2018
33940 PA 04 00 $343.40 1/1/2018
33940 PA 01 00 $343.40 7/13/2018
33940 PA 04 00 $343.40 7/13/2018
36468 PA 01 00 $279.00 2/26/2016
36468 PA 04 00 $279.00 2/26/2016
41821 PA 01 00 $343.40 1/1/2018
41821 PA 04 00 $343.40 1/1/2018
41821 PA 01 00 $343.40 7/13/2018
41821 PA 04 00 $343.40 7/13/2018
41870 PA 01 00 $343.40 1/1/2018
41870 PA 04 00 $343.40 1/1/2018
41870 PA 01 00 $343.40 7/13/2018
41870 PA 04 00 $343.40 7/13/2018
43496 PA 01 00 $343.40 1/1/2018
43496 PA 04 00 $343.40 1/1/2018
43496 PA 01 00 $343.40 7/13/2018
43496 PA 04 00 $343.40 7/13/2018
45390 PA 01 00 $13,037.00 2/26/2016
45390 PA 04 00 $13,037.00 2/26/2016
47133 PA 01 00 $343.40 1/1/2018
47133 PA 04 00 $343.40 1/1/2018
47133 PA 01 00 $343.40 7/13/2018
47133 PA 04 00 $343.40 7/13/2018
48160 PA 01 00 $343.40 1/1/2018
48160 PA 04 00 $343.40 1/1/2018
48160 PA 01 00 $343.40 7/13/2018
48160 PA 04 00 $343.40 7/13/2018
48550 PA 01 00 $343.40 1/1/2018
48550 PA 04 00 $343.40 1/1/2018
48550 PA 01 00 $343.40 7/13/2018
48550 PA 04 00 $343.40 7/13/2018
49906 PA 01 00 $343.40 1/1/2018
49906 PA 04 00 $343.40 1/1/2018
49906 PA 01 00 $343.40 7/13/2018
49906 PA 04 00 $343.40 7/13/2018
50300 PA 01 00 $343.40 1/1/2018
50300 PA 04 00 $343.40 1/1/2018
50300 PA 01 00 $343.40 7/13/2018
50300 PA 04 00 $343.40 7/13/2018
50323 PA 01 00 $4,441.00 10/15/2018
50323 PA 04 00 $4,441.00 10/15/2018
55970 PA 01 00 $343.40 1/1/2018
55970 PA 04 00 $343.40 1/1/2018
55970 PA 01 00 $343.40 7/13/2018
55970 PA 04 00 $343.40 7/13/2018
55980 PA 01 00 $343.40 1/1/2018
55980 PA 04 00 $343.40 1/1/2018
55980 PA 01 00 $343.40 7/13/2018
55980 PA 04 00 $343.40 7/13/2018
58974 PA 01 00 $343.40 2/26/2016
58974 PA 04 00 $343.40 2/26/2016
65767 PA 01 00 $343.40 1/1/2018
65767 PA 04 00 $343.40 1/1/2018
65767 PA 01 00 $343.40 7/13/2018
65767 PA 04 00 $343.40 7/13/2018
65771 PA 01 00 $343.40 2/26/2016
65771 PA 04 00 $343.40 2/26/2016
69090 PA 01 00 $343.40 2/26/2016
69090 PA 04 00 $343.40 2/26/2016
69710 PA 01 00 $343.40 2/26/2016
69710 PA 04 00 $343.40 2/26/2016
69949 PA 01 00 $343.40 1/1/2018
69949 PA 04 00 $343.40 1/1/2018
69949 PA 01 00 $343.40 7/13/2018
69949 PA 04 00 $343.40 7/13/2018
69979 PA 01 00 $343.40 1/1/2018
69979 PA 04 00 $343.40 1/1/2018
69979 PA 01 00 $343.40 7/13/2018
69979 PA 04 00 $343.40 7/13/2018
74300 PA 01 00 $938.00 4/19/2017
74300 PA 01 00 $938.00 1/1/2018
74300 PA 04 00 $556.00 1/1/2018
74300 PA 01 00 $938.00 7/13/2018
74300 PA 04 00 $556.00 7/13/2018
74300 PA 01 00 $754.00 1/1/2019
74300 PA 04 00 $754.00 1/1/2019
74300 PA 01 TC $517.30 1/1/2018
74300 PA 04 TC $517.30 1/1/2018
74300 PA 01 TC $517.30 7/13/2018
74300 PA 04 TC $517.30 7/13/2018
74328 PA 01 00 $3,075.00 1/1/2018
74328 PA 04 00 $584.00 1/1/2018
74328 PA 01 00 $3,075.00 7/13/2018
74328 PA 04 00 $584.00 7/13/2018
74328 PA 01 00 $345.00 1/1/2019
74328 PA 04 00 $345.00 1/1/2019
74328 PA 01 TC $749.05 1/1/2018
74328 PA 04 TC $749.05 1/1/2018
74328 PA 01 TC $749.05 7/13/2018
74328 PA 04 TC $749.05 7/13/2018
74330 PA 01 00 $1,473.90 1/1/2018
74330 PA 04 00 $701.00 1/1/2018
74330 PA 01 00 $1,473.90 7/13/2018
74330 PA 04 00 $701.00 7/13/2018
74330 PA 01 00 $893.50 1/1/2019
74330 PA 04 00 $893.50 1/1/2019
74330 PA 01 TC $655.59 1/1/2018
74330 PA 04 TC $655.59 1/1/2018
74330 PA 01 TC $655.59 7/13/2018
74330 PA 04 TC $655.59 7/13/2018
74340 PA 01 00 $459.89 1/1/2019
74340 PA 04 00 $459.89 1/1/2019
74360 PA 01 00 $444.00 1/1/2019
74360 PA 04 00 $444.00 1/1/2019
75894 PA 01 00 $5,265.00 1/1/2018
75894 PA 04 00 $2,677.00 1/1/2018
75894 PA 01 00 $5,265.00 7/13/2018
75894 PA 04 00 $2,677.00 7/13/2018
75894 PA 01 TC $2,609.45 1/1/2018
75894 PA 04 TC $2,609.45 1/1/2018
75894 PA 01 TC $2,609.45 7/13/2018
75894 PA 04 TC $2,609.45 7/13/2018
75970 PA 01 00 $1,461.00 1/1/2019
75970 PA 04 00 $1,461.00 1/1/2019
76001 PA 01 00 $798.00 4/19/2017
76001 PA 01 00 $1,049.58 1/1/2018
76001 PA 04 00 $542.80 1/1/2018
76001 PA 01 00 $1,049.58 7/13/2018
76001 PA 04 00 $542.80 7/13/2018
76001 PA 01 00 $873.00 1/1/2019
76001 PA 04 00 $873.00 1/1/2019
76001 PA 01 TC $507.89 1/1/2018
76001 PA 04 TC $507.89 1/1/2018
76001 PA 01 TC $507.89 7/13/2018
76001 PA 04 TC $507.89 7/13/2018
76998 PA 01 00 $3,750.00 2/26/2016
76998 PA 04 00 $1,122.00 2/26/2016
77336 PA 01 26 $85.00 1/1/2018
77336 PA 04 26 $85.00 1/1/2018
77336 PA 01 26 $85.00 7/13/2018
77336 PA 04 26 $85.00 7/13/2018
77371 PA 01 00 $92,739.00 1/1/2018
77371 PA 04 00 $70,967.00 1/1/2018
77371 PA 01 00 $92,739.00 7/13/2018
77371 PA 04 00 $70,967.00 7/13/2018
77371 PA 01 00 $86,778.00 1/1/2019
77371 PA 04 00 $86,778.00 1/1/2019
77385 PA 01 00 $12,311.00 2/26/2016
77385 PA 04 00 $12,311.00 2/26/2016
77386 PA 01 00 $10,270.89 2/26/2016
77386 PA 04 00 $10,270.89 2/26/2016
77425 PA 01 00 $292.00 1/1/2018
77425 PA 04 00 $292.00 1/1/2018
77425 PA 01 00 $292.00 7/13/2018
77425 PA 04 00 $292.00 7/13/2018
77425 PA 01 26 $292.00 1/1/2018
77425 PA 04 26 $292.00 1/1/2018
77425 PA 01 26 $292.00 7/13/2018
77425 PA 04 26 $292.00 7/13/2018
77525 PA 01 00 $20,504.00 1/1/2018
77525 PA 04 00 $20,504.00 1/1/2018
77525 PA 01 00 $20,504.00 7/13/2018
77525 PA 04 00 $20,504.00 7/13/2018
78609 PA 01 00 $343.40 1/1/2018
78609 PA 04 00 $343.40 1/1/2018
78609 PA 01 00 $343.40 7/13/2018
78609 PA 04 00 $343.40 7/13/2018
78609 PA 01 TC $267.78 1/1/2018
78609 PA 04 TC $267.78 1/1/2018
78609 PA 01 TC $267.78 7/13/2018
78609 PA 04 TC $267.78 7/13/2018
79300 PA 01 00 $343.40 1/1/2018
79300 PA 04 00 $343.40 1/1/2018
79300 PA 01 00 $343.40 7/13/2018
79300 PA 04 00 $343.40 7/13/2018
80300 PA 01 00 $165.00 2/26/2016
80300 PA 04 00 $165.00 2/26/2016
80301 PA 01 00 $810.00 2/26/2016
80301 PA 04 00 $810.00 2/26/2016
80320 PA 01 00 $215.00 2/26/2016
80320 PA 04 00 $215.00 2/26/2016
80324 PA 01 00 $110.00 2/26/2016
80324 PA 04 00 $110.00 2/26/2016
80329 PA 01 00 $205.00 2/26/2016
80329 PA 04 00 $205.00 2/26/2016
80335 PA 01 00 $150.00 2/26/2016
80335 PA 04 00 $150.00 2/26/2016
80346 PA 01 00 $150.00 2/26/2016
80346 PA 04 00 $150.00 2/26/2016
80348 PA 01 00 $150.00 2/26/2016
80348 PA 04 00 $150.00 2/26/2016
80349 PA 01 00 $129.00 2/26/2016
80349 PA 04 00 $129.00 2/26/2016
80354 PA 01 00 $133.00 2/26/2016
80354 PA 04 00 $133.00 2/26/2016
80355 PA 01 00 $100.00 2/26/2016
80355 PA 04 00 $100.00 2/26/2016
80356 PA 01 00 $75.00 2/26/2016
80356 PA 04 00 $75.00 2/26/2016
80357 PA 01 00 $150.00 2/26/2016
80357 PA 04 00 $150.00 2/26/2016
80359 PA 01 00 $100.00 2/26/2016
80359 PA 04 00 $100.00 2/26/2016
80360 PA 01 00 $383.00 2/26/2016
80360 PA 04 00 $383.00 2/26/2016
80362 PA 01 00 $150.00 2/26/2016
80362 PA 04 00 $150.00 2/26/2016
80363 PA 01 00 $75.00 2/26/2016
80363 PA 04 00 $75.00 2/26/2016
80364 PA 01 00 $205.00 2/26/2016
80364 PA 04 00 $205.00 2/26/2016
80365 PA 01 00 $137.00 2/26/2016
80365 PA 04 00 $137.00 2/26/2016
80368 PA 01 00 $105.18 2/26/2016
80368 PA 04 00 $105.18 2/26/2016
80369 PA 01 00 $113.26 2/26/2016
80369 PA 04 00 $113.26 2/26/2016
80371 PA 01 00 $50.00 2/26/2016
80371 PA 04 00 $50.00 2/26/2016
80372 PA 01 00 $150.00 2/26/2016
80372 PA 04 00 $150.00 2/26/2016
80373 PA 01 00 $75.00 2/26/2016
80373 PA 04 00 $75.00 2/26/2016
81244 PA 01 00 $1,958.00 1/1/2018
81244 PA 04 00 $1,958.00 1/1/2018
81244 PA 01 00 $1,958.00 7/13/2018
81244 PA 04 00 $1,958.00 7/13/2018
81257 PA 01 00 $987.00 2/26/2016
81257 PA 04 00 $987.00 2/26/2016
81402 PA 01 00 $667.76 3/24/2017
81402 PA 04 00 $667.76 3/24/2017
81508 PA 01 00 $299.00 2/26/2016
81508 PA 04 00 $256.00 2/26/2016
86860 PA 01 00 $54.00 1/1/2018
86860 PA 04 00 $54.00 1/1/2018
86860 PA 01 00 $54.00 7/13/2018
86860 PA 04 00 $54.00 7/13/2018
86891 PA 01 00 $90.00 1/1/2018
86891 PA 04 00 $90.00 1/1/2018
86891 PA 01 00 $90.00 7/13/2018
86891 PA 04 00 $90.00 7/13/2018
86921 PA 01 00 $86.00 1/1/2018
86921 PA 04 00 $18.60 1/1/2018
86921 PA 01 00 $86.00 7/13/2018
86921 PA 04 00 $18.60 7/13/2018
86921 PA 01 00 $86.00 1/1/2019
86921 PA 04 00 $86.00 1/1/2019
86930 PA 01 00 $9.00 1/1/2018
86930 PA 04 00 $9.00 1/1/2018
86930 PA 01 00 $9.00 7/13/2018
86930 PA 04 00 $9.00 7/13/2018
86931 PA 01 00 $9.00 1/1/2018
86931 PA 04 00 $9.00 1/1/2018
86931 PA 01 00 $9.00 7/13/2018
86931 PA 04 00 $9.00 7/13/2018
86932 PA 01 00 $9.00 1/1/2018
86932 PA 04 00 $9.00 1/1/2018
86932 PA 01 00 $9.00 7/13/2018
86932 PA 04 00 $9.00 7/13/2018
86950 PA 01 00 $45.00 1/1/2018
86950 PA 04 00 $45.00 1/1/2018
86950 PA 01 00 $45.00 7/13/2018
86950 PA 04 00 $45.00 7/13/2018
86970 PA 01 00 $74.00 1/1/2018
86970 PA 04 00 $74.00 1/1/2018
86970 PA 01 00 $74.00 7/13/2018
86970 PA 04 00 $74.00 7/13/2018
86972 PA 01 00 $144.00 1/1/2018
86972 PA 04 00 $144.00 1/1/2018
86972 PA 01 00 $144.00 7/13/2018
86972 PA 04 00 $144.00 7/13/2018
86975 PA 01 00 $144.00 1/1/2018
86975 PA 04 00 $144.00 1/1/2018
86975 PA 01 00 $144.00 7/13/2018
86975 PA 04 00 $144.00 7/13/2018
86976 PA 01 00 $144.00 1/1/2018
86976 PA 04 00 $144.00 1/1/2018
86976 PA 01 00 $144.00 7/13/2018
86976 PA 04 00 $144.00 7/13/2018
86977 PA 01 00 $599.00 1/1/2018
86977 PA 04 00 $144.00 1/1/2018
86977 PA 01 00 $599.00 7/13/2018
86977 PA 04 00 $144.00 7/13/2018
86978 PA 01 00 $144.00 1/1/2018
86978 PA 04 00 $144.00 1/1/2018
86978 PA 01 00 $144.00 7/13/2018
86978 PA 04 00 $144.00 7/13/2018
90661 PA 01 00 $35.00 1/1/2019
90661 PA 04 00 $35.00 1/1/2019
90681 PA 01 00 $314.00 1/1/2019
90681 PA 04 00 $314.00 1/1/2019
90696 PA 01 00 $127.00 1/1/2019
90696 PA 04 00 $127.00 1/1/2019
90736 PA 01 00 $235.51 7/19/2017
90736 PA 04 00 $235.51 7/19/2017
90736 PA 01 00 $254.35 7/20/2017
90736 PA 04 00 $254.35 7/20/2017
90736 PA 01 00 $254.35 1/1/2018
90736 PA 04 00 $254.35 1/1/2018
90736 PA 01 NU $235.51 10/19/2016
90736 PA 04 NU $235.51 10/19/2016
90993 PA 01 00 $3,629.00 1/1/2018
90993 PA 04 00 $1,828.28 1/1/2018
90993 PA 01 00 $3,629.00 7/13/2018
90993 PA 04 00 $1,828.28 7/13/2018
92594 PA 01 00 $114.00 1/1/2018
92594 PA 04 00 $114.00 1/1/2018
92594 PA 01 00 $114.00 7/13/2018
92594 PA 04 00 $114.00 7/13/2018
92921 PA 01 00 $1,000.00 1/1/2018
92921 PA 04 00 $1,000.00 1/1/2018
92921 PA 01 00 $1,000.00 7/13/2018
92921 PA 04 00 $1,000.00 7/13/2018
92929 PA 01 00 $1,000.00 1/1/2018
92929 PA 04 00 $1,000.00 1/1/2018
92929 PA 01 00 $1,000.00 7/13/2018
92929 PA 04 00 $1,000.00 7/13/2018
92978 PA 01 00 $4,309.40 1/1/2018
92978 PA 04 00 $2,903.94 1/1/2018
92978 PA 01 00 $4,309.40 7/13/2018
92978 PA 04 00 $2,903.94 7/13/2018
92978 PA 01 00 $1,146.00 1/1/2019
92978 PA 04 00 $1,146.00 1/1/2019
92993 PA 01 00 $343.40 1/1/2018
92993 PA 04 00 $343.40 1/1/2018
92993 PA 01 00 $343.40 7/13/2018
92993 PA 04 00 $343.40 7/13/2018
93010 PA 01 26 $40.00 1/1/2018
93010 PA 04 26 $35.00 1/1/2018
93010 PA 01 26 $40.00 7/13/2018
93010 PA 04 26 $35.00 7/13/2018
93010 PA 01 26 $66.00 1/1/2019
93010 PA 04 26 $66.00 1/1/2019
93299 PA 01 00 $167.00 4/19/2017
93299 PA 04 00 $159.00 4/19/2017
93299 PA 01 00 $167.00 1/1/2018
93299 PA 04 00 $159.00 1/1/2018
93299 PA 01 00 $167.00 7/13/2018
93299 PA 04 00 $159.00 7/13/2018
93299 PA 01 00 $128.00 1/1/2019
93299 PA 04 00 $128.00 1/1/2019
93531 PA 01 00 $17,564.22 1/1/2018
93531 PA 04 00 $8,023.00 1/1/2018
93531 PA 01 00 $17,564.22 7/13/2018
93531 PA 04 00 $8,023.00 7/13/2018
93531 PA 01 00 $21,965.22 1/1/2019
93531 PA 04 00 $21,965.22 1/1/2019
93531 PA 01 TC $7,552.09 1/1/2018
93531 PA 04 TC $7,552.09 1/1/2018
93531 PA 01 TC $7,552.09 7/13/2018
93531 PA 04 TC $7,552.09 7/13/2018
93618 PA 01 00 $1,126.25 1/1/2018
93618 PA 04 00 $1,126.25 1/1/2018
93618 PA 01 00 $1,126.25 7/13/2018
93618 PA 04 00 $1,126.25 7/13/2018
93620 PA 01 00 $15,260.00 1/1/2018
93620 PA 04 00 $6,437.00 1/1/2018
93620 PA 01 00 $15,260.00 7/13/2018
93620 PA 04 00 $6,437.00 7/13/2018
93620 PA 01 00 $18,046.25 1/1/2019
93620 PA 04 00 $18,046.25 1/1/2019
93620 PA 01 TC $5,768.40 1/1/2018
93620 PA 04 TC $5,768.40 1/1/2018
93620 PA 01 TC $5,768.40 7/13/2018
93620 PA 04 TC $5,768.40 7/13/2018
93621 PA 01 00 $15,566.00 4/19/2017
93621 PA 01 00 $18,243.00 1/1/2018
93621 PA 04 00 $4,633.00 1/1/2018
93621 PA 01 00 $18,243.00 7/13/2018
93621 PA 04 00 $4,633.00 7/13/2018
93621 PA 01 00 $8,350.00 1/1/2019
93621 PA 04 00 $8,350.00 1/1/2019
93621 PA 01 TC $4,514.03 1/1/2018
93621 PA 04 TC $4,514.03 1/1/2018
93621 PA 01 TC $4,514.03 7/13/2018
93621 PA 04 TC $4,514.03 7/13/2018
93623 PA 01 00 $29,192.00 4/19/2017
93623 PA 01 00 $29,192.00 1/1/2018
93623 PA 04 00 $1,964.00 1/1/2018
93623 PA 01 00 $29,192.00 7/13/2018
93623 PA 04 00 $1,964.00 7/13/2018
93623 PA 01 00 $600.00 1/1/2019
93623 PA 04 00 $600.00 1/1/2019
93623 PA 01 TC $1,802.92 1/1/2018
93623 PA 04 TC $1,802.92 1/1/2018
93623 PA 01 TC $1,802.92 7/13/2018
93623 PA 04 TC $1,802.92 7/13/2018
93641 PA 01 00 $2,066.00 1/1/2019
93641 PA 04 00 $2,066.00 1/1/2019
93662 PA 01 00 $6,740.00 1/1/2019
93662 PA 04 00 $6,740.00 1/1/2019
94772 PA 01 TC $247.30 1/1/2018
94772 PA 04 TC $247.30 1/1/2018
94772 PA 01 TC $247.30 7/13/2018
94772 PA 04 TC $247.30 7/13/2018
97610 PA 01 00 $513.00 2/28/2017
97610 PA 04 00 $513.00 2/28/2017
99000 PA 01 00 $26.00 4/19/2017
99000 PA 04 00 $25.00 4/19/2017
99000 PA 01 00 $26.00 1/1/2018
99000 PA 04 00 $26.00 1/1/2018
99000 PA 01 00 $26.00 7/13/2018
99000 PA 04 00 $26.00 7/13/2018
99001 PA 01 00 $68.41 4/19/2017
99001 PA 04 00 $68.41 4/19/2017
99001 PA 01 00 $68.41 1/1/2018
99001 PA 04 00 $68.41 1/1/2018
99001 PA 01 00 $68.41 7/13/2018
99001 PA 04 00 $68.41 7/13/2018
99001 PA 01 00 $71.15 1/1/2019
99001 PA 04 00 $71.15 1/1/2019
99002 PA 01 00 $110.00 1/1/2018
99002 PA 04 00 $110.00 1/1/2018
99002 PA 01 00 $110.00 7/13/2018
99002 PA 04 00 $110.00 7/13/2018
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