"Procedure"|"Code Type"|"Revenue Code"|"Procedure Description"|"Payer"|"Plan"|"Inpatient Gross Charges"|"Inpatient Expected Reimbursement"|"Inpatient Max Reimbursement"|"Inpatient Minimal Reimbursement"|"Outpatient Gross Charges"|"Outpatient Expected Reimbursement"|"Outpatient Max Reimbursement"|"Outpatient Minimal Reimbursement" 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Managed Medicaid|MEDICAID SUPERIOR|3,271.20||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Medicare|MEDICARE ACUTE|3,271.20||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Medicare|MEDICARE PART B ONLY IP|27.26||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Aenta Medicare Advantage|AETNA MEDICARE MA|2,998.60||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|United Medicare Advantage|UHC MEDICARE GOLD MA|27.26||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|United Healthcare|UNITED HEALTHCARE|3,271.20||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Blue Cross PPO Specialty|BCBSTX OTHER|2,998.60||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Blue Cross HMO Specialty|BCBSTX HMO|3,271.20||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Access Direct Platinum|HEALTHFIRST TPA UMR|27.26||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Veterans Affairs|VETERANS ADMINISTRATION|2,998.60||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|United Healthcare|TML GROUP BENEFITS|3,271.20||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|PHCS|GROUP AND PENSION|3,271.20||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|UTMB|UTMB CORRECTIONAL MANAGED CARE|27.26||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Medicaid|SMITH COUNTY INDIGENT HEALTH|27.26||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Managed Medicaid|MEDICAID AMERIGROUP|3,271.20||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.26||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Humana Medicare Advantage|HUMANA MA|3,271.20||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Medicaid|MEDICAID|27.26||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Managed Medicare|BCBS MEDICARE PPO MA|27.26||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|United Healthcare|UNITED HEALTHCARE OTHER|3,271.20||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|27.26||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,271.20||||2,998.60||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Access Direct Platinum|HEALTHFIRST TPA|2,998.60||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,998.60||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|United Medicare Advantage|UHC AARP WELLMED HMO MA|3,271.20||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Managed Medicare|OTHER INSTITUTIONS|||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|PHCS|HUMANA INSURANCE|27.26||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Aetna|AETNA PPO|27.26||||2,998.60||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.26||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|United Healthcare|GEHA|||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Cigna|CIGNA|3,271.20||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Blue Cross PPO Specialty|BCBSTX PPO|3,271.20||||2,998.60||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,998.60||||2,998.60||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|United Medicare Advantage|UHC AARP MCR HMO MA|3,271.20||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Medicaid|MEDICAID HMO|||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Workers Compensation|WORKERS COMPENSATION OTHER|3,271.20||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Managed Medicare|HEALTHSPRING MA|27.26||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Tricare|TRICARE EAST REGION|3,271.20||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Cigna|CIGNA|27.26||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||27.26||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.26||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3,271.20||||2,998.60||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|NON CONTRACTED|COMMERCIAL OTHER 1|2,998.60||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|ChampVA|CHAMPVA CENTER|3,271.20||||||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||3,271.20||| 0042T|EAP|0350|CT-PERFUSION W/CONTRAST C|Medicaid|SMITH COUNTY JAIL|27.26||||||| 0075T|EAP|0361|IR-PLCMNT STENT VERTEBRAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||37,295.65||| 0075T|EAP|0361|IR-PLCMNT STENT VERTEBRAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||37,295.65||| 0075T|EAP|0361|IR-PLCMNT STENT VERTEBRAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|324.31||||||| 0075T|EAP|0361|IR-PLCMNT STENT VERTEBRAL|Blue Cross PPO Specialty|BCBSTX PPO|324.31||||||| 0235T|EAP|0323||Humana Medicare Advantage|HUMANA MA|||||10,018.80||| 1|DRG||HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC|Medicare|MEDICARE ACUTE|537,147.70|154518.355|154518.355|154518.355|||| 100|DRG||SEIZURES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|121,831.10|214.32|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|Managed Medicare|HEALTHSPRING MA|58,742.93|112.72|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|89,561.69|11242.06|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|74,957.72|20086.99|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|233,375.10|11480.16|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|124,594.95|9938.62|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|Humana Medicare Advantage|HUMANA MA|47,533.96|10572.42|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|Medicaid|MEDICAID|120.46|3661.19|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|57,877.83|10653.495|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|158,214.39|14265.695|20086.99|112.72|||| 100|DRG||SEIZURES W MCC|Medicare|MEDICARE ACUTE|69,264.10|11243.84|20086.99|112.72|||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|United Healthcare|UNITED HEALTHCARE|||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Medicare|MEDICARE ACUTE|26.16||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Veterans Affairs|VETERANS ADMINISTRATION|||||2,812.20||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Blue Cross HMO Specialty|BCBSTX HMO|||||26.16||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Managed Medicare|HEALTHSPRING MA|26.16||||26.16||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|United Healthcare|UNITED HEALTHCARE OTHER|||||2,812.20||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|United Medicare Advantage|UHC AARP MCR HMO MA|||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Blue Cross PPO Specialty|BCBSTX PPO|||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Humana Medicare Advantage|HUMANA MA|||||26.16||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Managed Medicaid|MEDICAID AMERIGROUP|||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.16||||26.16||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||26.16||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,008.40||| 10005|EAP|0361|US FNA 1ST LESION ULTRASO|Aetna|AETNA OTHER|||||26.16||| 10006|EAP|0361|BC EA ADD'L LESION ULTRAS|Medicare|MEDICARE ACUTE|||||2,557.60||| 10030|EAP|0361|IR-GUIDE CATHET FLUID DRA|Veterans Affairs|VETERANS ADMINISTRATION|||||1,439.80||| 10030|EAP|0361|IR-GUIDE CATHET FLUID DRA|Blue Cross PPO Specialty|BCBSTX PPO|||||12.52||| 10030|EAP|0361|CT-GUIDE CATH FLUID DRAIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|17.04||||||| 10030|EAP|0361|IR-GUIDE CATHET FLUID DRA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,345.90||| 10030|EAP|0361|CT-GUIDE CATH FLUID DRAIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.04||||||| 10030|EAP|0361|IR-GUIDE CATHET FLUID DRA|Aetna|AETNA PPO|||||12.52||| 10030|EAP|0361|CT-GUIDE CATH FLUID DRAIN|Blue Cross PPO Specialty|BCBSTX PPO|||||1,959.60||| 10030|EAP|0361|IR-GUIDE CATHET FLUID DRA|Medicare|MEDICARE ACUTE|||||1,439.80||| 10030|EAP|0361|IR-GUIDE CATHET FLUID DRA|Medicare|MEDICARE PART B ONLY IP|1,439.80||||||| 10030|EAP|0361|CT-GUIDE CATH FLUID DRAIN|NON CONTRACTED|COMMERCIAL OTHER 1|1,959.60||||||| 10030|EAP|0361|CT-GUIDE CATH FLUID DRAIN|Humana Medicare Advantage|HUMANA MA|||||1,959.60||| 10035|EAP|0361|PLACEMENT TISSUE MARKER C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||959.25||| 10060|EAP|0761|I&D ABSCESS SIMPLE|Medicare|MEDICARE ACUTE|||||1,027.70||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Healthcare|UNITED HEALTHCARE|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,035.23||| 10060|EAP|0361||Medicare|MEDICARE ACUTE|||||4.74||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Medicare|MEDICARE ACUTE|9.63||||9.63||| 10060|EAP|0510|DRAINAGE OF SKIN ABSCESS|NON CONTRACTED|COMMERCIAL OTHER 1|||||197.50||| 10060|EAP|0761|I&D ABSCESS SIMPLE|Tricare|TRICARE FOR LIFE|||||1,099.40||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,107.45||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,107.45||| 10060|EAP|0761|I&D ABSCESS SIMPLE|Humana Medicare Advantage|HUMANA MA|||||9.56||| 10060|EAP|0761|I&D ABSCESS SIMPLE|Veterans Affairs|VETERANS ADMINISTRATION|||||1,099.40||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Cigna|CIGNA|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID SUPERIOR|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Access Direct Platinum|HEALTHFIRST TPA|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Healthcare|UNITED HEALTHCARE|||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Veterans Affairs|VETERANS ADMINISTRATION|||||1,035.23||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Blue Cross HMO Specialty|BCBSTX HMO|||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,107.45||||1,035.23||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Blue Cross PPO Specialty|BCBSTX PPO|||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Humana Medicare Advantage|HUMANA MA|||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.63||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID AMERIGROUP|||||9.63||| 10060|EAP|0761|I&D ABSCESS SIMPLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,099.40||| 10060|EAP|0761|I&D ABSCESS SIMPLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,099.40||||1,027.70||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Healthcare|UNITED HEALTHCARE OTHER|||||1,107.45||| 10060|EAP|0761|I&D ABSCESS SIMPLE|Blue Cross PPO Specialty|BCBSTX PPO|||||9.56||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.63||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Tricare|TRICARE EAST REGION|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,107.45||| 10060|EAP|0761|I&D ABSCESS SIMPLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.56||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Medicaid|MEDICAID|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Medicaid|SMITH COUNTY JAIL|||||9.63||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Medicaid|MEDICAID HMO|||||1,107.45||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicare|HEALTHSPRING MA|||||9.63||| 10061|EAP|0450|I&D ABCESS COMP/MULTIPLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||17.58||| 10061|EAP|0450|I&D ABCESS COMP/MULTIPLE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||17.58||| 10061|EAP|0761|I&D ABSCESS COMPLICATED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.56||| 10061|EAP|0450|I&D ABCESS COMP/MULTIPLE|Blue Cross PPO Specialty|BCBSTX PPO|||||17.58||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Medicare|MEDICARE ACUTE|||||11.96||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Managed Medicaid|MEDICAID SUPERIOR|||||11.18||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||10.40||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11.96||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Blue Cross PPO Specialty|BCBSTX PPO|||||11.18||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||11.96||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Managed Medicaid|MEDICAID AMERIGROUP|||||11.18||| 101|DRG||SEIZURES W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|48,464.57|5295.475|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|23,648.05|35.72|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|41,870.76|5902.55|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|0.00||||||| 101|DRG||SEIZURES W/O MCC|Aetna|AETNA OTHER|22,918.50|50.39|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Aetna|AETNA PPO|98,856.02|11168.68|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|122,359.65|6127.85|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Humana Medicare Advantage|HUMANA MA|47,325.01|6123.28|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Medicaid|SMITH COUNTY JAIL|21,071.35|2999.78|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Managed Medicare|HEALTHSPRING MA|82,234.87|6128.73|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|36,966.44|6179.105|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Medicare|MEDICARE PART B ONLY IP|27,432.36|1680.08|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|50,712.91|10768.29|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Managed Medicare|MA PART B ONLY IP|114,694.70|6127.85|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Medicaid|MEDICAID|156,135.05|5310.94|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Medicare|MEDICARE ACUTE|36,169.85|6127.85|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|45,961.16|4769.66|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|31,032.25|6086.04|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|91,467.03|6228.39|11168.68|35.72|||| 101|DRG||SEIZURES W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|81,537.43|10830.55|11168.68|35.72|||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Managed Medicaid|MEDICAID AMERIGROUP|||||2,250.55||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||19.57||| 10120|EAP|0510|REMOVE FOREIGN BODY|Blue Cross PPO Specialty|BCBSTX PPO|||||3.60||| 10120|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||8.64||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,250.55||| 10140|EAP|0450|I&D HEMATOMA SEROMA FLUID|Medicare|MEDICARE ACUTE|||||5,284.25||| 10140|EAP|0360|HEMATOMA EVACUATION|Managed Medicare|HEALTHSPRING MA|10,019.95||||||| 10140|EAP|0360|HEMATOMA EVACUATION|Humana Medicare Advantage|HUMANA MA|||||87.13||| 10140|EAP|0360|HEMATOMA EVACUATION|Medicare|MEDICARE ACUTE|||||87.13||| 10140|EAP|0981|I&D HEMATOMA/SEROMA OR FL|Medicaid|SMITH COUNTY JAIL|||||9.92||| 10140|EAP|0761|I&D HEMA/SERO/FLUID|Humana Medicare Advantage|HUMANA MA|||||5,488.95||| 10140|EAP|0761|I&D HEMA/SERO/FLUID|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5,871.90||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|853.30||||||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|Humana Medicare Advantage|HUMANA MA|3,123.95||||||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|Blue Cross PPO Specialty|BCBSTX PPO|3,341.90||||29.06||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Blue Cross PPO Specialty|BCBSTX PPO|||||7.42||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Managed Medicaid|MEDICAID SUPERIOR|||||797.65||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29.06||||||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|NON CONTRACTED|COMMERCIAL OTHER 1|||||853.30||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.42||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Blue Cross HMO Specialty|BCBSTX HMO|||||7.42||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|Access Direct Platinum|HEALTHFIRST TPA|29.06||||||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,341.90||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|United Medicare Advantage|UHC AARP MCR HMO MA|3,341.90||||||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||853.30||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.42||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|Medicaid|COUNTY INDIGENT HEALTH OTHER|3,341.90||||||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.42||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||7.42||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|United Healthcare|UNITED HEALTHCARE|7.42||||||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|United Medicare Advantage|UHC MEDICARE GOLD MA|29.06||||3,341.90||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29.06||||||| 10160|EAP|0350|CT-PUNCTURE DRAINAGE OF L|Medicare|MEDICARE ACUTE|3,341.90||||3,123.95||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Medicare|MEDICARE ACUTE|||||7.42||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Managed Medicaid|MEDICAID AMERIGROUP|||||853.30||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Tricare|TRICARE EAST REGION|||||853.30||| 102|DRG||HEADACHES W MCC|Medicare|MEDICARE ACUTE|49,793.58|7963.67|7963.67|7804.4|||| 102|DRG||HEADACHES W MCC|Humana Medicare Advantage|HUMANA MA|703.90|7827.28|7963.67|7804.4|||| 102|DRG||HEADACHES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|71,799.36|7804.4|7963.67|7804.4|||| 103|DRG||HEADACHES W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59,384.75|71.44|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|270,583.20|12955.38|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Aetna|AETNA PPO|10,233.85|10233.85|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|45,813.76|5305.71|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Cigna|CIGNA|27,507.85|9763.65|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Medicaid|SMITH COUNTY JAIL|68,070.77|3796.82|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Humana Medicare Advantage|HUMANA MA|33,898.72|5662.12|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Medicare|MEDICARE ACUTE|42,674.48|5670.65|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|30,036.45|2875.46|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|79,042.14|7599.4|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|40,452.40|4571.98|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Tricare|TRICARE EAST REGION|1,177.80|7066.92|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Blue Cross PPO Specialty|BCBSTX OTHER|43,714.41|5305.71|12955.38|71.44|||| 103|DRG||HEADACHES W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|49,520.52|6036.95|12955.38|71.44|||| 11|DRG||TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|166,437.80|28354.37|28706.2|28354.37|||| 11|DRG||TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W MCC|Medicare|MEDICARE ACUTE|149,292.05|28706.2|28706.2|28354.37|||| 11010|EAP|0981|DEBRIDE SKIN AT FX SITE|Workers Compensation|GALLAGHER BASSETT|||||1,403.50||| 11010|EAP|0981|DEBRIDE SKIN AT FX SITE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,403.50||| 11011|EAP|0981|DEBRIDE SKIN MUSC AT FX S|Managed Medicaid|MEDICAID SUPERIOR|||||1,967.57||| 11011|EAP|0981|DEBRIDE SKIN MUSC AT FX S|Medicare|MEDICARE ACUTE|||||23.25||| 11011|EAP|0981|DEBRIDE SKIN MUSC AT FX S|Cigna|CIGNA|||||1,967.57||| 11012|EAP|0981|DEBRIDE W REMOVAL FM OPEN|Medicare|MEDICARE ACUTE|||||34.67||| 11012|EAP|0981|DEBRIDE W REMOVAL FM OPEN|Managed Medicare|HEALTHSPRING MA|||||34.67||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Cigna|CIGNA|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Managed Medicaid|MEDICAID SUPERIOR|13.32||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Humana Medicare Advantage|HUMANA MA|1,431.90||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|ChampVA|CHAMPVA CENTER|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Cigna|CIGNA OTHER|||||13.32||| 11042|EAP|0981|DEBRIDE SUBCUTANE TISSUE|United Healthcare|UNITED HEALTHCARE|||||7.13||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|United Healthcare|UNITED HEALTHCARE OTHER|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|PHCS|HUMANA INSURANCE|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Workers Compensation|BROOKSHIRES WORKERS COMP|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Tricare|TRICARE EAST REGION|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Medicare|MEDICARE ACUTE|13.32||||1,531.80||| 11042|EAP|0981|DEBRIDE SUBCUTANE TISSUE|Medicare|MEDICARE ACUTE|||||7.13||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Cigna|CIGNA|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Medicare|MEDICARE PART B ONLY IP|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||13.32||| 11042|EAP|0981|DEBRIDE SUBCUTANE TISSUE|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.13||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|United Healthcare|UNITED HEALTHCARE|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Medicaid|SMITH COUNTY JAIL|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Managed Medicare|HEALTHSPRING MA|1,531.80||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,431.90||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Medicaid|MEDICAID|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|NON CONTRACTED|COMMERCIAL OTHER 1|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Managed Medicare|BCBS MEDICARE PPO MA|13.32||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Tricare|TRICARE FOR LIFE|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,431.90||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Blue Cross PPO Specialty|BCBSTX PPO|13.32||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Blue Cross HMO Specialty|BCBSTX HMO|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Access Direct Platinum|HEALTHFIRST TPA|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Veterans Affairs|VETERANS ADMINISTRATION|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Workers Compensation|WORKERS COMPENSATION OTHER|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,531.80||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Access Direct Platinum|HEALTHFIRST TPA UMR|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Aenta Medicare Advantage|AETNA MEDICARE MA|1,531.80||||13.32||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Aetna|AETNA PPO|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|Aetna|AETNA OTHER|||||1,531.80||| 11042|EAP|0761|DEBRIDE SUBQ TISSUE 1ST 2|United Medicare Advantage|UHC MEDICARE GOLD MA|||||13.32||| 11043|EAP|0981|DEBRIDE MUSCLE/FASCIA 20|Medicare|MEDICARE ACUTE|||||1,543.50||| 11043|EAP|0761|DEBRIDE MUSCLE/FASCIA 1ST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,531.80||| 11043|EAP|0761|DEBRIDE MUSCLE/FASCIA 1ST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||13.32||| 11043|EAP|0761|DEBRIDE MUSCLE/FASCIA 1ST|Veterans Affairs|VETERANS ADMINISTRATION|||||13.32||| 11043|EAP|0761|DEBRIDE MUSCLE/FASCIA 1ST|Medicare|MEDICARE ACUTE|13.32||||1,531.80||| 11043|EAP|0981|DEBRIDE MUSCLE/FASCIA 20|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,543.50||| 11043|EAP|0761|DEBRIDE MUSCLE/FASCIA 1ST|Managed Medicaid|MEDICAID SUPERIOR|||||1,431.90||| 11044|EAP|0761|DEBRIDE SUBQ TIS MUSCLE B|Veterans Affairs|VETERANS ADMINISTRATION|||||73.42||| 11044|EAP|0761|DEBRIDE SUBQ TIS MUSCLE B|Medicare|MEDICARE ACUTE|||||8,443.30||| 11044|EAP|0761|DEBRIDE SUBQ TIS MUSCLE B|Blue Cross PPO Specialty|BCBSTX PPO|73.42||||73.42||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Managed Medicare|HEALTHSPRING MA|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Managed Medicare|BCBS MEDICARE PPO MA|10.85||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Cigna|CIGNA|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|United Healthcare|UNITED HEALTHCARE OTHER|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|United Healthcare|UNITED HEALTHCARE|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|United Healthcare|UNITED HEALTHCARE|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|NON CONTRACTED|COMMERCIAL OTHER 1|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.85||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.85||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Humana Medicare Advantage|HUMANA MA|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Aetna|AETNA PPO|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Cigna|CIGNA|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Medicaid|SMITH COUNTY JAIL|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Medicaid|MEDICAID|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Medicare|MEDICARE ACUTE|1,166.38||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Aetna|AETNA OTHER|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Cigna|CIGNA OTHER|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Blue Cross PPO Specialty|BCBSTX PPO|10.85||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|PHCS|HUMANA INSURANCE|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|United Medicare Advantage|UHC AARP MCR HMO MA|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Blue Cross HMO Specialty|BCBSTX HMO|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,166.38||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,247.75||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,166.38||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Access Direct Platinum|HEALTHFIRST TPA UMR|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Veterans Affairs|VETERANS ADMINISTRATION|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Workers Compensation|WORKERS COMPENSATION OTHER|||||10.85||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Managed Medicaid|MEDICAID SUPERIOR|10.85||||1,247.75||| 11045|EAP|0761|DEBRIDE SUBQ TISSUE EA AD|Access Direct Platinum|HEALTHFIRST TPA|||||1,247.75||| 11046|EAP|0761|DEBRIDE MUSCLE/FASCIA ADD|Medicare|MEDICARE ACUTE|10.85||||1,247.75||| 11046|EAP|0761|DEBRIDE MUSCLE/FASCIA ADD|Veterans Affairs|VETERANS ADMINISTRATION|||||10.85||| 11046|EAP|0761|DEBRIDE MUSCLE/FASCIA ADD|Managed Medicaid|MEDICAID SUPERIOR|||||1,166.38||| 11046|EAP|0981|DEBRIDE MUSC/FASCIA EA AD|Medicare|MEDICARE ACUTE|||||473.75||| 11102|EAP|0761|TANGENTIAL BIOPSY OF SKIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||545.10||| 11102|EAP|0761|TANGENTIAL BIOPSY OF SKIN|Medicare|MEDICARE ACUTE|||||4.74||| 11104|EAP|0761|PUNCH BX SKIN SINGLE LESI|Medicare|MEDICARE ACUTE|||||9.30||| 11104|EAP|0761|PUNCH BX SKIN SINGLE LESI|Managed Medicare|BCBS MEDICARE PPO MA|||||9.30||| 11104|EAP|0761|PUNCH BX SKIN SINGLE LESI|Medicaid|MEDICAID|||||1,069.50||| 113|DRG||ORBITAL PROCEDURES W CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|105,051.27|13227.76|13227.76|13227.76|||| 11421|EAP|0510|SKIN LESION EXCISION 1CM|Aetna|AETNA OTHER|||||6.87||| 11423|EAP|0561|EXC H-F-NK-SP B9+MARG 2.1|Aetna|AETNA PPO|||||15.46||| 115|DRG||EXTRAOCULAR PROCEDURES EXCEPT ORBIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|48,459.34|9413.69|13496.55|9413.69|||| 115|DRG||EXTRAOCULAR PROCEDURES EXCEPT ORBIT|Workers Compensation|WORKERS COMPENSATION OTHER|81,448.70|13496.55|13496.55|9413.69|||| 115|DRG||EXTRAOCULAR PROCEDURES EXCEPT ORBIT|Medicare|MEDICARE ACUTE|77,463.80|9437.26|13496.55|9413.69|||| 116|DRG||INTRAOCULAR PROCEDURES W CC/MCC|Medicare|MEDICARE ACUTE|69,155.50|11876.85|11876.85|9858.58|||| 116|DRG||INTRAOCULAR PROCEDURES W CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|98,757.68|9858.58|11876.85|9858.58|||| 117|DRG||INTRAOCULAR PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|52,607.55|7315.56|7315.56|7315.56|||| 11730|EAP|0450|RMV NAIL PLATE SINGL/SIMP|United Healthcare|UNITED HEALTHCARE OTHER|||||947.60||| 11740|EAP|0450|EVAL SUBUNGUAL HEMATOMA|Managed Medicare|HEALTHSPRING MA|||||3.74||| 11750|EAP|0450|RMV NAIL BED|Managed Medicaid|MEDICAID SUPERIOR|||||2,699.05||| 11760|EAP|0450|RPR NAIL BED|Workers Compensation|WORKERS COMPENSATION OTHER|||||993.60||| 11760|EAP|0450|RPR NAIL BED|United Healthcare|UNITED HEALTHCARE OTHER|||||993.60||| 11765|EAP|0450|EXC WEDGE SKIN NAIL FOLD|Medicaid|MEDICAID HMO|||||9.09||| 11765|EAP|0450|EXC WEDGE SKIN NAIL FOLD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,045.35||| 12|DRG||TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W CC|Medicare|MEDICARE ACUTE|172,797.85|21993.16|22427.46|21993.16|||| 12|DRG||TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES OR LARYNGECTOMY W CC|Managed Medicare|HEALTHSPRING MA|158,798.22|22427.46|22427.46|21993.16|||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Workers Compensation|WORKERS COMPENSATION OTHER|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Blue Cross PPO Specialty|BCBSTX PPO|6.56||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Workers Compensation|UT EMPLOYEE INJURY|||||705.20||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Access Direct Platinum|HEALTHFIRST TPA UMR|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Access Direct Platinum|HEALTHFIRST TPA|6.56||||||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Workers Compensation|BROOKSHIRES WORKERS COMP|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Medicare Advantage|UHC AARP MCR HMO MA|||||705.20||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Medicare Advantage|UHC MEDICARE GOLD MA|754.40||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Blue Cross HMO Specialty|BCBSTX HMO|754.40||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Blue Cross PPO Specialty|BCBSTX OTHER|||||705.20||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Aetna|AETNA PPO|6.56||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Cigna|CIGNA|||||705.20||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicaid|MEDICAID AMERIGROUP|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||705.20||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicare|HEALTHSPRING MA|6.56||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||705.20||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Cigna|CIGNA OTHER|||||705.20||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicaid|MEDICAID SUPERIOR|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Aetna|AETNA OTHER|||||705.20||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Tricare|TRICARE EAST REGION|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|NON CONTRACTED|COMMERCIAL OTHER 2|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicare|MEDICARE ACUTE|754.40||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|PHCS|HUMANA|754.40||||||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Healthcare|UNITED HEALTHCARE OTHER|754.40||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Veterans Affairs|VETERANS ADMINISTRATION|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Humana Medicare Advantage|HUMANA MA|754.40||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Healthcare|UNITED HEALTHCARE ERS|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|NON CONTRACTED|COMMERCIAL OTHER 1|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Healthcare|TML GROUP BENEFITS|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Healthcare|UNITED HEALTHCARE|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Tricare|TRICARE FOR LIFE|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicaid|SMITH COUNTY JAIL|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicare|BCBS MEDICARE PPO MA|||||705.20||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicare|MEDICARE PART B ONLY IP|6.56||||||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicaid|MEDICAID|||||6.56||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicaid|MEDICAID HMO|||||754.40||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicaid|LAW ENFORCEMENT OTHER|754.40||||||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicare|HEALTHSPRING MA|6.88||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicare|BCBS MEDICARE PPO MA|6.88||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|United Healthcare|UNITED HEALTHCARE|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicaid|MEDICAID|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|791.20||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicare|MEDICARE ACUTE|791.20||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||739.60||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||739.60||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Cigna|CIGNA|||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|United Healthcare|UNITED HEALTHCARE OTHER|||||739.60||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|NON CONTRACTED|COMMERCIAL OTHER 2|6.88||||||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Cigna|CIGNA OTHER|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.88||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Humana Medicare Advantage|HUMANA MA|6.88||||739.60||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Blue Cross HMO Specialty|BCBSTX HMO|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Blue Cross PPO Specialty|BCBSTX PPO|739.60||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID AMERIGROUP|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Cigna|CIGNA|791.20||||||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID SUPERIOR|791.20||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|PHCS|HUMANA|||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicare|MEDICARE PART B ONLY IP|791.20||||||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Aetna|AETNA PPO|791.20||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Veterans Affairs|VETERANS ADMINISTRATION|791.20||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|United Medicare Advantage|UHC AARP MCR HMO MA|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Workers Compensation|UT EMPLOYEE INJURY|||||6.88||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|United Medicare Advantage|UHC MEDICARE GOLD MA|739.60||||791.20||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Workers Compensation|WORKERS COMPENSATION OTHER|739.60||||6.88||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.62||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||876.30||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Managed Medicaid|MEDICAID SUPERIOR|7.62||||||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|United Healthcare|UNITED HEALTHCARE|||||7.62||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||876.30||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.62||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Medicare|MEDICARE ACUTE|819.15||||7.62||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Blue Cross PPO Specialty|BCBSTX PPO|819.15||||819.15||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Humana Medicare Advantage|HUMANA MA|||||7.62||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Managed Medicaid|MEDICAID AMERIGROUP|||||876.30||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|United Healthcare|UNITED HEALTHCARE OTHER|||||876.30||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Medicaid|MEDICAID HMO|||||876.30||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Medicaid|MEDICAID|876.30||||876.30||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|Humana Medicare Advantage|HUMANA MA|8.49||||976.35||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|United Healthcare|UNITED HEALTHCARE|8.49||||||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|United Healthcare|UNITED HEALTHCARE OTHER|976.35||||||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|Medicare|MEDICARE ACUTE|8.49||||8.49||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.49||||||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.49||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|Blue Cross PPO Specialty|BCBSTX PPO|8.49||||8.49||| 12006|EAP|0450|RPR LAC SIMPL 20.1-30.0CM|Humana Medicare Advantage|HUMANA MA|||||1,060.30||| 12006|EAP|0450|RPR LAC SIMPL 20.1-30.0CM|Medicare|MEDICARE ACUTE|1,060.30||||||| 12006|EAP|0450|RPR LAC SIMPL 20.1-30.0CM|Medicaid|CRIME VICTIMS COMPENSATION|1,060.30||||||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Managed Medicare|HEALTHSPRING MA|||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Tricare|TRICARE EAST REGION|||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicare|MEDICARE ACUTE|6.73||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|NON CONTRACTED|COMMERCIAL OTHER 1|6.73||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid|SMITH COUNTY JAIL|||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid|CRIME VICTIMS COMPENSATION|6.73||||||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid|MEDICAID|6.73||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Workers Compensation|WORKERS COMPENSATION OTHER|||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Workers Compensation|UT EMPLOYEE INJURY|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|United Medicare Advantage|UHC MEDICARE GOLD MA|723.48||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Blue Cross PPO Specialty|BCBSTX PPO|6.73||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||723.48||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Veterans Affairs|VETERANS ADMINISTRATION|773.95||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Blue Cross HMO Specialty|BCBSTX HMO|773.95||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Blue Cross PPO Specialty|BCBSTX OTHER|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|United Healthcare|UNITED HEALTHCARE OTHER|723.48||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Humana Medicare Advantage|HUMANA MA|||||723.48||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Access Direct Platinum|HEALTHFIRST TPA|||||6.73||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Managed Medicaid|MEDICAID SUPERIOR|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Aetna|AETNA OTHER|||||773.95||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.73||||723.48||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||723.48||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Managed Medicaid|MEDICAID AMERIGROUP|||||723.48||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicaid|MEDICAID AMERIGROUP|||||801.55||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicaid|MEDICAID SUPERIOR|||||801.55||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Blue Cross HMO Specialty|BCBSTX HMO|801.55||||749.28||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.97||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|United Medicare Advantage|UHC AARP MCR HMO MA|||||801.55||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Workers Compensation|TEXAS MUTUAL INSURANCE|||||6.97||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||801.55||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|801.55||||801.55||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Medicaid|SMITH COUNTY JAIL|||||6.97||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Medicaid|MEDICAID|||||6.97||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicare|OTHER INSTITUTIONS|||||6.97||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Medicaid|CRIME VICTIMS COMPENSATION|801.55||||||| 12013|EAP|0981|RPR WND FACE/EAR/NOSE/EYE|Aetna|AETNA PPO|||||1,180.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicare|HEALTHSPRING MA|||||801.55||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Blue Cross PPO Specialty|BCBSTX PPO|6.97||||801.55||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Medicare|MEDICARE PART B ONLY IP|801.55||||||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Medicare|MEDICARE ACUTE|749.28||||801.55||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||801.55||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|United Healthcare|UNITED HEALTHCARE|||||6.97||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Tricare|TRICARE EAST REGION|6.97||||749.28||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|United Healthcare|UNITED HEALTHCARE OTHER|||||6.97||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|United Medicare Advantage|UHC MEDICARE GOLD MA|6.97||||749.28||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Humana Medicare Advantage|HUMANA MA|||||749.28||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||749.28||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|Medicare|MEDICARE ACUTE|||||805.18||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|Blue Cross PPO Specialty|BCBSTX PPO|||||861.35||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.49||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.49||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|United Medicare Advantage|UHC MEDICARE GOLD MA|||||861.35||| 12015|EAP|0450|RPR LAC SIMPL FACE 7.6-12|Humana Medicare Advantage|HUMANA MA|||||7.88||| 12015|EAP|0450|RPR LAC SIMPL FACE 7.6-12|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.88||||||| 12015|EAP|0450|RPR LAC SIMPL FACE 7.6-12|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.88||| 12015|EAP|0450|RPR LAC SIMPL FACE 7.6-12|Medicare|MEDICARE ACUTE|847.10||||906.20||| 12015|EAP|0450|RPR LAC SIMPL FACE 7.6-12|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.88||| 12031|EAP|0450|RPR LAYER CLOSURE 2.5CM O|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,077.55||| 12031|EAP|0450|RPR LAYER CLOSURE 2.5CM O|Medicare|MEDICARE ACUTE|||||9.37||| 12031|EAP|0450|RPR LAYER CLOSURE 2.5CM O|Blue Cross PPO Specialty|BCBSTX PPO|||||1,077.55||| 12031|EAP|0450|RPR LAYER CLOSURE 2.5CM O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,077.55||| 12031|EAP|0450|RPR LAYER CLOSURE 2.5CM O|Aetna|AETNA PPO|1,077.55||||||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Cigna|CIGNA OTHER|||||949.23||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Blue Cross PPO Specialty|BCBSTX PPO|||||949.23||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,015.45||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Managed Medicaid|MEDICAID SUPERIOR|||||1,015.45||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|NON CONTRACTED|COMMERCIAL OTHER 2|||||1,015.45||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1,015.45||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Workers Compensation|UT EMPLOYEE INJURY|||||1,015.45||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,145.40||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|Blue Cross PPO Specialty|BCBSTX PPO|||||1,145.40||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|United Medicare Advantage|UHC MEDICARE GOLD MA|9.96||||||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|Medicare|MEDICARE ACUTE|||||1,145.40||| 12035|EAP|0450|RPR LAYER CLOSURE 12.6-20|Managed Medicaid|MEDICAID AMERIGROUP|||||11.36||| 12035|EAP|0450|RPR LAYER CLOSURE 12.6-20|Managed Medicare|HEALTHSPRING MA|||||1,306.40||| 12035|EAP|0450|RPR LAYER CLOSURE 12.6-20|NON CONTRACTED|COMMERCIAL OTHER 1|||||11.36||| 12035|EAP|0450|RPR LAYER CLOSURE 12.6-20|Blue Cross PPO Specialty|BCBSTX PPO|||||1,306.40||| 12036|EAP|0450|LAYER CLOSURE OF WOUND(S)|Cigna|CIGNA|||||1,343.20||| 12041|EAP|0450|RPR LAYER CLOSURE 2.5CM O|Medicare|MEDICARE ACUTE|||||928.05||| 12041|EAP|0450|RPR LAYER CLOSURE 2.5CM O|Blue Cross PPO Specialty|BCBSTX PPO|||||928.05||| 12042|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||970.60||| 12042|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Managed Medicaid|MEDICAID AMERIGROUP|||||970.60||| 12042|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Blue Cross PPO Specialty|BCBSTX PPO|||||970.60||| 12044|EAP|0450|RPR LAYER CLOSURE 7.6CM-1|Medicare|MEDICARE ACUTE|||||1,175.30||| 12051|EAP|0981|RPR WND FACE/MM 2.5CM OR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.38||| 12051|EAP|0981|RPR WND FACE/MM 2.5CM OR|Blue Cross PPO Specialty|BCBSTX PPO|||||12.38||| 12051|EAP|0981|TRAUMA PHYSICIAN CHARGE|Blue Cross PPO Specialty|BCBSTX PPO|||||788.25||| 12051|EAP|0450|RPR LAYER CLOS FACE 2.5CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,049.95||| 12051|EAP|0981|RPR WND FACE/MM 2.5CM OR|Medicaid|SMITH COUNTY JAIL|||||12.38||| 12051|EAP|0981|RPR WND FACE/MM 2.5CM OR|Managed Medicare|HEALTHSPRING MA|||||12.38||| 12051|EAP|0450|RPR LAYER CLOS FACE 2.5CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.13||| 12051|EAP|0981|RPR WND FACE/MM 2.5CM OR|Medicare|MEDICARE ACUTE|||||12.38||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|Medicare|MEDICARE ACUTE|||||8.49||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|Medicare|MEDICARE PART B ONLY IP|976.35||||||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||976.35||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|Aetna Value Network|AETNA VALUE NETWORK|||||8.49||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|Workers Compensation|UT EMPLOYEE INJURY|||||976.35||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||976.35||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||976.35||| 12054|EAP|0450|RPR LAYER CLOS FACE 7.6CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.68||| 12054|EAP|0450|RPR LAYER CLOS FACE 7.6CM|Managed Medicaid|MEDICAID SUPERIOR|1,113.20||||||| 12054|EAP|0450|RPR LAYER CLOS FACE 7.6CM|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,113.20||| 121|DRG||ACUTE MAJOR EYE INFECTIONS W CC/MCC|Humana Medicare Advantage|HUMANA MA|1,039.32|8245.14|8245.14|4581.88|||| 121|DRG||ACUTE MAJOR EYE INFECTIONS W CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|7,067.20|4581.88|8245.14|4581.88|||| 122|DRG||ACUTE MAJOR EYE INFECTIONS W/O CC/MCC|Workers Compensation|TEXAS MUTUAL INSURANCE|14,013.62|8022.84|8022.84|8022.84|||| 123|DRG||NEUROLOGICAL EYE DISORDERS|Medicare|MEDICARE PART B ONLY IP|39,805.22|1220.4|5656.33|1220.4|||| 123|DRG||NEUROLOGICAL EYE DISORDERS|Medicare|MEDICARE ACUTE|68,213.90|5656.33|5656.33|1220.4|||| 123|DRG||NEUROLOGICAL EYE DISORDERS|Blue Cross PPO Specialty|BCBSTX PPO|41,288.97|5112.19|5656.33|1220.4|||| 123|DRG||NEUROLOGICAL EYE DISORDERS|Veterans Affairs|VETERANS ADMINISTRATION|30,684.12|5567.6|5656.33|1220.4|||| 125|DRG||OTHER DISORDERS OF THE EYE W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|31,823.73|5646.405|5704.5|5646.405|||| 125|DRG||OTHER DISORDERS OF THE EYE W/O MCC|Medicare|MEDICARE ACUTE|70,533.69|5704.5|5704.5|5646.405|||| 129|DRG||MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE|Medicare|MEDICARE ACUTE|88,708.25|13845.25|18715.06|13845.25|||| 129|DRG||MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|95,659.75|18715.06|18715.06|13845.25|||| 130|DRG||MAJOR HEAD & NECK PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|89,281.66|9216.45|9216.45|9216.45|||| 131|DRG||CRANIAL/FACIAL PROCEDURES W CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|89,883.24|20558.21|58436.97|178.6|||| 131|DRG||CRANIAL/FACIAL PROCEDURES W CC/MCC|Aetna|AETNA PPO|95,517.51|39900.89|58436.97|178.6|||| 131|DRG||CRANIAL/FACIAL PROCEDURES W CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|219,387.04|178.6|58436.97|178.6|||| 131|DRG||CRANIAL/FACIAL PROCEDURES W CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|58,436.97|58436.97|58436.97|178.6|||| 131|DRG||CRANIAL/FACIAL PROCEDURES W CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|207,527.09|35456.55|58436.97|178.6|||| 131|DRG||CRANIAL/FACIAL PROCEDURES W CC/MCC|Medicare|MEDICARE ACUTE|85,103.55|16419.36|58436.97|178.6|||| 131|DRG||CRANIAL/FACIAL PROCEDURES W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|100,901.37|17846.84|58436.97|178.6|||| 13121|EAP|0981|RPR COMPLEX 2.6CM-7.5CM|Managed Medicare|HEALTHSPRING MA|||||1,898.75||| 13121|EAP|0981|RPR COMPLEX 2.6CM-7.5CM|PHCS|GROUP AND PENSION|||||1,898.75||| 13121|EAP|0981|RPR COMPLEX 2.6CM-7.5CM|Medicare|MEDICARE ACUTE|||||1,898.75||| 13121|EAP|0450|RPR COMPL SCLP ARM LEG 2.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,523.75||||||| 13121|EAP|0981|RPR COMPLEX 2.6CM-7.5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||1,898.75||| 13121|EAP|0981|RPR COMPLEX 2.6CM-7.5CM|Managed Medicaid|MEDICAID SUPERIOR|||||1,898.75||| 13122|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Blue Cross PPO Specialty|BCBSTX PPO|||||611.50||| 13122|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Managed Medicare|HEALTHSPRING MA|||||611.50||| 13122|EAP|0981|RPR COMPLEX EA ADDL 5CM O|PHCS|GROUP AND PENSION|||||611.50||| 13122|EAP|0450|RPR COMPL SCLP ARM LEG EA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|977.50||||||| 13122|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Managed Medicaid|MEDICAID SUPERIOR|||||611.50||| 13122|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Medicare|MEDICARE ACUTE|||||611.50||| 13131|EAP|0450|RPR COMPL FHEAD HND FEET|Medicaid|LAW ENFORCEMENT OTHER|||||1,314.45||| 13131|EAP|0450|RPR COMPL FHEAD HND FEET|Medicare|MEDICARE ACUTE|||||1,314.45||| 13131|EAP|0981|RPR COMP CHIN/FHEAD 1.1CM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,568.50||| 13131|EAP|0981|RPR COMP CHIN/FHEAD 1.1CM|Medicaid|LAW ENFORCEMENT OTHER|||||1,568.50||| 13131|EAP|0981|RPR COMP CHIN/FHEAD 1.1CM|Medicare|MEDICARE ACUTE|||||1,568.50||| 13131|EAP|0981|RPR COMP CHIN/FHEAD 1.1CM|Aetna|AETNA PPO|||||1,568.50||| 13131|EAP|0981|RPR COMP CHIN/FHEAD 1.1CM|Blue Cross PPO Specialty|BCBSTX PPO|||||1,568.50||| 13131|EAP|0981|RPR COMP CHIN/FHEAD 1.1CM|Cigna|CIGNA OTHER|||||1,568.50||| 13131|EAP|0981|RPR COMP CHIN/FHEAD 1.1CM|Managed Medicaid|MEDICAID SUPERIOR|||||1,568.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,542.75||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Managed Medicaid|MEDICAID AMERIGROUP|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Managed Medicaid|MEDICAID SUPERIOR|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Cigna|CIGNA|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||2,542.75||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|United Healthcare|UNITED HEALTHCARE|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Humana Medicare Advantage|HUMANA MA|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Tricare|TRICARE EAST REGION|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Workers Compensation|WORKERS COMPENSATION OTHER|2,724.50||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Aetna|AETNA PPO|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Multiplan|WEB TPA|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Managed Medicare|HEALTHSPRING MA|||||2,724.50||| 13132|EAP|0450|RPR COMPL FHEAD HND FEET|Medicare|MEDICARE ACUTE|||||13.73||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|PHCS|GROUP AND PENSION|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Medicare|MEDICARE ACUTE|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Blue Cross HMO Specialty|BCBSTX HMO|||||2,724.50||| 13132|EAP|0981|RPR COMP CHEEK 2.6-7.5CM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2,724.50||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Managed Medicare|HEALTHSPRING MA|||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Multiplan|WEB TPA|||||9.99||| 13133|EAP|0450|RPR COMPL FHEAD HND FEET|Medicare|MEDICARE ACUTE|||||8.35||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Medicare|MEDICARE ACUTE|||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|PHCS|GROUP AND PENSION|||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Managed Medicaid|MEDICAID SUPERIOR|||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Managed Medicaid|MEDICAID AMERIGROUP|||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Workers Compensation|WORKERS COMPENSATION OTHER|9.99||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|Cigna|CIGNA|||||9.99||| 13133|EAP|0981|RPR COMPLEX EA ADDL 5CM O|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.99||| 13151|EAP|0981|RPR COMP EYE 1.1CM-2.5CM|Veterans Affairs|VETERANS ADMINISTRATION|||||18.16||| 13151|EAP|0981|RPR COMP EYE 1.1CM-2.5CM|Managed Medicaid|MEDICAID SUPERIOR|||||18.16||| 13151|EAP|0981|RPR COMP EYE 1.1CM-2.5CM|Blue Cross HMO Specialty|BCBSTX HMO|||||18.16||| 13151|EAP|0981|RPR COMP EYE 1.1CM-2.5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||18.16||| 13151|EAP|0450|RPR COMPL EYE NOSE EAR LI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,637.60||| 13151|EAP|0981|RPR COMP EYE 1.1CM-2.5CM|Medicare|MEDICARE ACUTE|||||18.16||| 13151|EAP|0450|RPR COMPL EYE NOSE EAR LI|Medicare|MEDICARE ACUTE|||||1,637.60||| 13151|EAP|0981|RPR COMP EYE 1.1CM-2.5CM|Tricare|TRICARE EAST REGION|||||18.16||| 13151|EAP|0981|RPR COMP EYE 1.1CM-2.5CM|Medicaid|MEDICAID|||||18.16||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Managed Medicare|HEALTHSPRING MA|||||33.02||| 13152|EAP|0450|RPR COMPL EYE NOSE EAR LI|Medicaid|LAW ENFORCEMENT OTHER|||||2,233.30||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Medicaid|LAW ENFORCEMENT OTHER|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Medicare|MEDICARE ACUTE|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|United Healthcare|UNITED HEALTHCARE OTHER|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|United Healthcare|UNITED HEALTHCARE|||||33.02||| 13152|EAP|0450|RPR COMPL EYE NOSE EAR LI|Cigna|CIGNA|||||19.42||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Cigna|CIGNA|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Managed Medicaid|MEDICAID SUPERIOR|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|NON CONTRACTED|COMMERCIAL OTHER 1|||||33.02||| 13152|EAP|0450|RPR COMPL EYE NOSE EAR LI|Managed Medicaid|MEDICAID SUPERIOR|||||2,233.30||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Blue Cross HMO Specialty|BCBSTX HMO|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.02||||33.02||| 13152|EAP|0450|RPR COMPL EYE NOSE EAR LI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,233.30||||||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Blue Cross PPO Specialty|BCBSTX PPO|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Blue Cross PPO Specialty|BCBSTX PPO|||||3,190.50||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|United Medicare Advantage|UHC AARP MCR HMO MA|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Access Direct Platinum|HEALTHFIRST TPA UMR|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Workers Compensation|TEXAS MUTUAL INSURANCE|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Workers Compensation|GALLAGHER BASSETT|||||33.02||| 13152|EAP|0981|RPR EYE NOSE EAR LIP 2.6C|Veterans Affairs|VETERANS ADMINISTRATION|||||33.02||| 13153|EAP|0981|RPR EYE NOSE EAR LIP EA A|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,568.50||| 13153|EAP|0981|RPR EYE NOSE EAR LIP EA A|Blue Cross PPO Specialty|BCBSTX PPO|||||1,568.50||| 13153|EAP|0981|RPR EYE NOSE EAR LIP EA A|Managed Medicaid|MEDICAID AMERIGROUP|||||1,568.50||| 13153|EAP|0981|RPR EYE NOSE EAR LIP EA A|Medicare|MEDICARE ACUTE|||||1,568.50||| 13153|EAP|0981|RPR EYE NOSE EAR LIP EA A|Managed Medicare|HEALTHSPRING MA|||||1,568.50||| 13153|EAP|0981|RPR EYE NOSE EAR LIP EA A|Cigna|CIGNA|||||1,568.50||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|72,283.75|8823.08|25618.08|34.02|||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|Tricare|TRICARE EAST REGION|124,557.97|9842.9|25618.08|34.02|||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|Medicaid|SMITH COUNTY JAIL|87,061.80|7486.9|25618.08|34.02|||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|70,155.05|11904.17|25618.08|34.02|||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|Cigna|CIGNA|70,024.81|25618.08|25618.08|34.02|||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|135,311.57|10160.41|25618.08|34.02|||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|69,732.77|34.02|25618.08|34.02|||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|101,599.42|10379.19|25618.08|34.02|||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|63,957.65|14307.46|25618.08|34.02|||| 132|DRG||CRANIAL/FACIAL PROCEDURES W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|100,268.24|9992.02|25618.08|34.02|||| 133|DRG||OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|124,828.49|25410.71|25410.71|13187.265|||| 133|DRG||OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC|Medicare|MEDICARE ACUTE|134,617.20|13187.265|25410.71|13187.265|||| 133|DRG||OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|10,354.90|16397.7|25410.71|13187.265|||| 134|DRG||OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX OTHER|19,654.55|8139.17|13765.6|8139.17|||| 134|DRG||OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC|Aetna|AETNA PPO|35,431.30|13765.6|13765.6|8139.17|||| 136|DRG||SINUS & MASTOID PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|52,387.96|10063.32|10063.32|10063.32|||| 137|DRG||MOUTH PROCEDURES W CC/MCC|Medicare|MEDICARE PART B ONLY IP|95,241.91|8605.15|15780.94|8599.35|||| 137|DRG||MOUTH PROCEDURES W CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|39,247.47|15780.94|15780.94|8599.35|||| 137|DRG||MOUTH PROCEDURES W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|47,774.51|9350.51|15780.94|8599.35|||| 137|DRG||MOUTH PROCEDURES W CC/MCC|Humana Medicare Advantage|HUMANA MA|67,438.60|8675.05|15780.94|8599.35|||| 137|DRG||MOUTH PROCEDURES W CC/MCC|Medicare|MEDICARE ACUTE|74,106.67|8599.35|15780.94|8599.35|||| 138|DRG||MOUTH PROCEDURES W/O CC/MCC|Medicaid|LAW ENFORCEMENT OTHER|42,377.83|40.03|6192.03|40.03|||| 138|DRG||MOUTH PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|54,904.96|6192.03|6192.03|40.03|||| 14041|EAP|0981|ADJACENT TISSUE TRANSFER/|Workers Compensation|WORKERS COMPENSATION OTHER|||||4,540.75||| 14301|EAP|0981|TRAUMA PHYSICIAN CHARGE|Medicare|MEDICARE ACUTE|||||5,283.75||| 14302|EAP|0981|TISSUE ADJ REPAIR/REARRAN|Medicare|MEDICARE ACUTE|||||890.25||| 146|DRG||EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC|Medicare|MEDICARE ACUTE|47,942.10|11838.67|11838.67|11838.67|||| 147|DRG||EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC|Humana Medicare Advantage|HUMANA MA|175,545.21|1772.41|8234.29|1772.41|||| 147|DRG||EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC|Medicare|MEDICARE ACUTE|30,981.71|8234.29|8234.29|1772.41|||| 149|DRG||DYSEQUILIBRIUM|Medicare|MEDICARE PART B ONLY IP|12,529.90|527.95|7516.85|527.95|||| 149|DRG||DYSEQUILIBRIUM|Cigna|CIGNA|27,819.32|7516.85|7516.85|527.95|||| 149|DRG||DYSEQUILIBRIUM|Cigna|CIGNA|44,819.20|7516.85|7516.85|527.95|||| 149|DRG||DYSEQUILIBRIUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|59,966.30|6859.87|7516.85|527.95|||| 149|DRG||DYSEQUILIBRIUM|Veterans Affairs|VETERANS ADMINISTRATION|29,652.84|5383.31|7516.85|527.95|||| 149|DRG||DYSEQUILIBRIUM|Blue Cross PPO Specialty|BCBSTX PPO|45,724.25|4828.37|7516.85|527.95|||| 149|DRG||DYSEQUILIBRIUM|Medicare|MEDICARE ACUTE|40,379.25|5374.47|7516.85|527.95|||| 149|DRG||DYSEQUILIBRIUM|United Medicare Advantage|UHC AARP MCR HMO MA|68,278.65|5374.47|7516.85|527.95|||| 15004|EAP|0981|TRAUMA PHYSICIAN CHARGE|Medicare|MEDICARE ACUTE|||||1,543.50||| 151|DRG||EPISTAXIS W/O MCC|Humana Medicare Advantage|HUMANA MA|73,727.56|5102.01|5102.01|1163.16|||| 151|DRG||EPISTAXIS W/O MCC|Medicare|MEDICARE PART B ONLY IP|11,901.75|1163.16|5102.01|1163.16|||| 151|DRG||EPISTAXIS W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|133,875.49|5092.01|5102.01|1163.16|||| 15115|EAP|0981|TRAUMA PHYSICIAN CHARGE|Medicare|MEDICARE ACUTE|||||3,151.75||| 152|DRG||OTITIS MEDIA & URI W MCC|Blue Cross PPO Specialty|BCBSTX PPO|129,058.58|8314.13|8314.13|6985.31|||| 152|DRG||OTITIS MEDIA & URI W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|52,707.80|7075.86|8314.13|6985.31|||| 152|DRG||OTITIS MEDIA & URI W MCC|Medicare|MEDICARE ACUTE|20,294.65|6985.31|8314.13|6985.31|||| 15271|EAP|0361|APPL OF SKIN SUB T/A/L <1|Medicare|MEDICARE ACUTE|||||51.15||| 15271|EAP|0361|APPL OF SKIN SUB T/A/L <1|Veterans Affairs|VETERANS ADMINISTRATION|||||51.15||| 15271|EAP|0361|APPL OF SKIN SUB T/A/L <1|Humana Medicare Advantage|HUMANA MA|||||51.15||| 15271|EAP|0361|APPL OF SKIN SUB T/A/L <1|Managed Medicare|HEALTHSPRING MA|||||51.15||| 15271|EAP|0361|APPL OF SKIN SUB T/A/L <1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||51.15||| 15271|EAP|0361|APPL OF SKIN SUB T/A/L <1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||51.15||| 15271|EAP|0361|APPL OF SKIN SUB T/A/L <1|Blue Cross PPO Specialty|BCBSTX PPO|||||51.15||| 15271|EAP|0361|APPL OF SKIN SUB T/A/L <1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||51.15||| 15271|EAP|0361|APPL OF SKIN SUB T/A/L <1|Managed Medicare|BCBS MEDICARE PPO MA|||||51.15||| 15272|EAP|0361|APPL OF SKIN SUB T/A/L <1|Humana Medicare Advantage|HUMANA MA|||||18.84||| 15272|EAP|0361|APPL OF SKIN SUB T/A/L <1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||18.84||| 15272|EAP|0361|APPL OF SKIN SUB T/A/L <1|Managed Medicare|HEALTHSPRING MA|||||18.84||| 15272|EAP|0361|APPL OF SKIN SUB T/A/L <1|Medicare|MEDICARE ACUTE|||||18.84||| 15272|EAP|0361|APPL OF SKIN SUB T/A/L <1|Veterans Affairs|VETERANS ADMINISTRATION|||||18.84||| 15273|EAP|0361|APPL OF SKIN SUB T/A/L >1|Humana Medicare Advantage|HUMANA MA|||||77.90||| 15273|EAP|0361|APPL OF SKIN SUB T/A/L >1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||77.90||| 15274|EAP|0361|APPL OF SKIN SUB T/A/L >1|Humana Medicare Advantage|HUMANA MA|||||51.15||| 15274|EAP|0361|APPL OF SKIN SUB T/A/L >1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||51.15||| 15275|EAP|0361|APPL OF SKIN SUB F/H/F <1|Medicare|MEDICARE ACUTE|||||51.15||| 15275|EAP|0361|APPL OF SKIN SUB F/H/F <1|Managed Medicare|HEALTHSPRING MA|||||51.15||| 15275|EAP|0361|APPL OF SKIN SUB F/H/F <1|Veterans Affairs|VETERANS ADMINISTRATION|||||51.15||| 15275|EAP|0361|APPL OF SKIN SUB F/H/F <1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||51.15||| 15275|EAP|0361|APPL OF SKIN SUB F/H/F <1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||51.15||| 15275|EAP|0361|APPL OF SKIN SUB F/H/F <1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||51.15||| 15275|EAP|0361|APPL OF SKIN SUB F/H/F <1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||51.15||| 15275|EAP|0361|APPL OF SKIN SUB F/H/F <1|Humana Medicare Advantage|HUMANA MA|||||51.15||| 15275|EAP|0361|APPL OF SKIN SUB F/H/F <1|Blue Cross PPO Specialty|BCBSTX PPO|||||51.15||| 15276|EAP|0361|APPL OF SKIN SUB F/H/F <1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||18.84||| 153|DRG||OTITIS MEDIA & URI W/O MCC|Medicare|MEDICARE ACUTE|67,741.21|5160.22|8360.95|119.92|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|United Healthcare|TML GROUP BENEFITS|17,074.50|8360.95|8360.95|119.92|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|7,130.25|8360.95|8360.95|119.92|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41,401.13|119.92|8360.95|119.92|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|25,193.12|4833.12|8360.95|119.92|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|51,710.03|6691.86|8360.95|119.92|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26,775.10|5828.61|8360.95|119.92|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|63,240.25|7954.93|8360.95|119.92|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26,801.10|5199.4|8360.95|119.92|||| 154|DRG||OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|58,190.05|9169.26|9169.26|9169.26|||| 155|DRG||OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC|Blue Cross PPO Specialty|BCBSTX PPO|20,848.38|5997.61|6330.38|5098.41|||| 155|DRG||OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38,572.80|5098.41|6330.38|5098.41|||| 155|DRG||OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46,138.47|6330.38|6330.38|5098.41|||| 155|DRG||OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|71,962.56|6227.72|6330.38|5098.41|||| 156|DRG||OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|29,357.25|4847.27|4847.27|4480.72|||| 156|DRG||OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|23,709.35|4480.72|4847.27|4480.72|||| 158|DRG||DENTAL & ORAL DISEASES W CC|Cigna|CIGNA OTHER|59,849.41|16642.81|16642.81|107.16|||| 158|DRG||DENTAL & ORAL DISEASES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38,977.79|107.16|16642.81|107.16|||| 158|DRG||DENTAL & ORAL DISEASES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|56,466.35|7963.38|16642.81|107.16|||| 158|DRG||DENTAL & ORAL DISEASES W CC|Medicare|MEDICARE ACUTE|34,559.57|6137.07|16642.81|107.16|||| 159|DRG||DENTAL & ORAL DISEASES W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|27,414.76|3616.85|4606.34|3616.85|||| 159|DRG||DENTAL & ORAL DISEASES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|50,664.53|4606.34|4606.34|3616.85|||| 16000|EAP|0450|TX BURN 1ST DEGREE|Blue Cross PPO Specialty|BCBSTX PPO|||||453.65||| 16000|EAP|0450|TX BURN 1ST DEGREE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||485.30||| 16000|EAP|0450|TX BURN 1ST DEGREE|Managed Medicaid|MEDICAID AMERIGROUP|||||4.22||| 16000|EAP|0450|TX BURN 1ST DEGREE|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.22||| 16000|EAP|0450|TX BURN 1ST DEGREE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||485.30||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Humana Medicare Advantage|HUMANA MA|||||5.54||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Tricare|TRICARE EAST REGION|||||5.54||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Blue Cross PPO Specialty|BCBSTX PPO|||||595.55||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|United Healthcare|UNITED HEALTHCARE OTHER|||||637.10||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|United Healthcare|UNITED HEALTHCARE|||||5.54||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||637.10||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Medicaid|MEDICAID|||||5.54||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.54||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.54||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Veterans Affairs|VETERANS ADMINISTRATION|||||5.54||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Managed Medicaid|MEDICAID AMERIGROUP|||||637.10||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||637.10||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Managed Medicaid|MEDICAID SUPERIOR|||||5.54||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|250,113.11|28589.16|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|244,273.50|40356.36|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|228,862.30|28027.57|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|231,532.74|61652.31|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|Managed Medicare|HEALTHSPRING MA|248,057.14|28648.08|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|United Healthcare|UNITED HEALTHCARE|62,610.58|57685.11|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|Medicare|MEDICARE ACUTE|194,203.50|28307.925|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|196,591.12|112079.525|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|128,634.54|28023.56|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|183,395.25|28002.25|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|158,728.75|28026.69|112079.525|28002.25|||| 163|DRG||MAJOR CHEST PROCEDURES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|299,384.72|28027.57|112079.525|28002.25|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|56,403.04|15169.8|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|132,331.94|20188.85|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|276,213.87|19416.4|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|103,238.44|14678.225|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|139,325.39|16272.465|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|78,902.20|14998.51|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|50,415.63|15466.19|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Blue Cross HMO Specialty|BCBSTX HMO|83,387.91|142.88|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|51,848.58|107.16|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|61,035.40|6205.38|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|Medicare|MEDICARE ACUTE|110,981.30|15466.19|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE OTHER|92,417.33|29964.02|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|154,195.74|15175.69|29964.02|107.16|||| 164|DRG||MAJOR CHEST PROCEDURES W CC|NON CONTRACTED|COMMERCIAL OTHER 1|117,500.60|26050.16|29964.02|107.16|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|56,348.98|21887.13|21887.13|125.02|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|115,045.80|21887.13|21887.13|125.02|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|101,040.99|12563.16|21887.13|125.02|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|155,259.86|11642.64|21887.13|125.02|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|114,172.80|11536.89|21887.13|125.02|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|124,863.71|11642.64|21887.13|125.02|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|163,888.82|12577.8|21887.13|125.02|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98,578.36|125.02|21887.13|125.02|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|110,901.79|11431.88|21887.13|125.02|||| 165|DRG||MAJOR CHEST PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|68,364.52|11642.64|21887.13|125.02|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|Managed Medicare|HEALTHSPRING MA|225,747.82|22184.84|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|604,000.11|35914.09|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|238,925.19|22184.84|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|Medicaid|MEDICAID|184,891.22|9142.93|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|Medicare|MEDICARE ACUTE|186,099.24|21755.12|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|United Healthcare|UNITED HEALTHCARE OTHER|89,039.05|44156.57|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|201,843.21|500.08|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|96,841.87|23751.42|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|228,774.47|14537.26|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|84,536.85|14537.26|44156.57|500.08|||| 166|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|74,253.53|10913.72|44156.57|500.08|||| 167|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|79,222.92|11788.91|12884.7|42.51|||| 167|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W CC|Veterans Affairs|VETERANS ADMINISTRATION|92,387.49|12007.97|12884.7|42.51|||| 167|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|169,779.13|11898.44|12884.7|42.51|||| 167|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|75,798.67|8592.17|12884.7|42.51|||| 167|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|82,030.88|11773.03|12884.7|42.51|||| 167|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W CC|Medicaid|MEDICAID|116,895.25|6296.78|12884.7|42.51|||| 167|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W CC|Medicare|MEDICARE ACUTE|70,212.40|11788.47|12884.7|42.51|||| 167|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|228.25|42.51|12884.7|42.51|||| 167|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|148,358.01|12884.7|12884.7|42.51|||| 168|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|157,666.30|11016.33|11016.33|8559.26|||| 168|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|54,358.31|8715.05|11016.33|8559.26|||| 168|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|89,852.59|11016.33|11016.33|8559.26|||| 168|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|97,863.27|8559.26|11016.33|8559.26|||| 168|DRG||OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|60,283.75|11016.33|11016.33|8559.26|||| 17250|EAP|0510|CHEM CAUT OF GRANLTJ TISS|Medicare|MEDICARE ACUTE|||||196.67||| 17250|EAP|0361||Medicare|MEDICARE ACUTE|||||4.72||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|75,096.44|7573.42|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Blue Cross HMO Specialty|BCBSTX HMO|193,351.39|7610.57|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,657.28|107.16|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Blue Cross PPO Specialty|BCBSTX PPO|94,196.14|9803.865|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Veterans Affairs|VETERANS ADMINISTRATION|46,988.87|9016.48|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Humana Medicare Advantage|HUMANA MA|170,151.20|9213.67|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Workers Compensation|WORKERS COMPENSATION OTHER|47,082.50|13168.86|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|United Healthcare|UNITED HEALTHCARE OTHER|95,908.39|17095.92|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Tricare|TRICARE EAST REGION|100,868.82|7655.76|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Managed Medicare|HEALTHSPRING MA|174,226.16|9292.195|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|United Medicare Advantage|UHC MEDICARE GOLD MA|128,798.20|9208.99|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|316.46|11979.81|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Medicaid|MEDICAID|124,874.82|6296.78|17095.92|107.16|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Medicare|MEDICARE ACUTE|79,650.70|9208.99|17095.92|107.16|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Tricare|TRICARE EAST REGION|48,579.37|3971.73|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|74,209.32|6035.08|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|56,894.22|6035.08|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Medicaid|SMITH COUNTY INDIGENT HEALTH|120,537.98|4652.89|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|70,049.50|5911.24|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|45,755.92|8077.735|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|40,486.48|7681.82|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Medicare|MEDICARE ACUTE|38,005.75|6035.08|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|115,526.21|6045.35|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Aetna|AETNA PPO|42,899.12|9659.03|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Humana Medicare Advantage|HUMANA MA|60,846.98|5911.24|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|94,793.16|178.6|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Brinson Benefits|THE HEALTH PLAN SMITH CO|30,554.25|30554.25|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|44,732.56|6104.21|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|78,724.97|14389.5|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|71,019.80|10011.89|30554.25|178.6|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|69,955.36|5939.4|30554.25|178.6|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|60,784.36||||||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|130,707.41||||||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|35,135.46|14951.8|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46,306.46|13301.26|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicare|BCBS MEDICARE PPO MA|31,471.35|10413.69|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|482.75|57.53|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicaid|MEDICAID SUPERIOR|58,055.04|13301.26|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|124,231.15|22876.5|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Cigna|CIGNA OTHER|35,056.26|19460.45|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Blue Cross PPO Specialty|BCBSTX OTHER|95,731.60|12499.03|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicaid|MEDICAID AMERIGROUP|75,681.75|13301.26|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Humana Medicare Advantage|HUMANA MA|56,512.89|11877.97|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Aetna|AETNA PPO|84,432.48|22966.73|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|47,595.06|12499.03|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Workers Compensation|UT EMPLOYEE INJURY|44,686.22|19788.13|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35,612.02|14951.8|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|58,226.72|12696.46|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Medicaid|MEDICAID|45,217.33|8365.57|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Medicare|MEDICARE ACUTE|69,183.16|11877.97|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|64,905.62|11661.6|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Access Direct Platinum|HEALTHFIRST TPA|27,202.31|14951.8|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicare|HEALTHSPRING MA|95,685.18|11877.97|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Medicare|MEDICARE PART B ONLY IP|26,395.23|5917.575|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Cigna|CIGNA|72,894.70|19460.45|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Healthcare|UNITED HEALTHCARE|41,448.93|12720.84|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Healthcare|UNITED HEALTHCARE|101,906.92|22384.24|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Healthcare|UNITED HEALTHCARE OTHER|34,889.36|22384.24|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Healthcare|TML GROUP BENEFITS|126,773.21|22384.24|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|81,385.94|13805.57|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|66,754.11||||||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|74,759.91|11643.85|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|77,767.23|52426.4|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|54,224.03|13837.85|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|59,003.08|13267.155|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|PHCS|HUMANA|32,959.01|10413.69|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|79,204.75|13837.85|52426.4|57.53|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Rusk State Hospital|RUSK STATE HOSP|87,672.84|42959.69|52426.4|57.53|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|131,803.30|8092.3|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|United Medicare Advantage|UHC AARP MCR HMO MA|31,395.39|7916.15|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|99,642.76|8247.75|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Medicare|MEDICARE PART B ONLY IP|14,848.25|751.1|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Medicare|MEDICARE ACUTE|66,441.06|8105.5|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|44,594.26|8078.22|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Managed Medicaid|MEDICAID AMERIGROUP|59,797.01|11526.88|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|187,681.31|8226.52|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Blue Cross PPO Specialty|BCBSTX PPO|35,855.82|8653.18|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Workers Compensation|WORKERS COMPENSATION OTHER|40,112.33|13404.26|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|100,579.05|204.12|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Humana Medicare Advantage|HUMANA MA|74,132.18|8247.75|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|67,276.65|10608.635|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|234,488.61|8105.5|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43,716.28|10434.9|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Managed Medicare|HEALTHSPRING MA|48,668.50|11660.72|13404.26|204.12|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Managed Medicare|BCBS MEDICARE PPO MA|44,308.83|8813.605|13404.26|204.12|||| 179|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|26,245.50|6036.54|9894.61|6022.02|||| 179|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|299.53|7660.33|9894.61|6022.02|||| 179|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC|Workers Compensation|UT EMPLOYEE INJURY|95,396.22|9894.61|9894.61|6022.02|||| 179|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC|Medicare|MEDICARE ACUTE|47,154.93|6022.02|9894.61|6022.02|||| 179|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|62,567.27|6134.26|9894.61|6022.02|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63,913.93|10733.92|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|United Healthcare|UNITED HEALTHCARE OTHER|37,437.44|20415.92|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|54,894.75|10749.08|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|111,873.26|10723.955|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Medicare|MEDICARE ACUTE|101,947.18|10748.2|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Medicaid|MEDICAID|106,050.55|7668.575|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|74,100.65|238.14|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|116,648.93|10946.18|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|73,954.20|11515.84|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Humana Medicare Advantage|HUMANA MA|95,276.68|10754.5|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95,123.02|15596.555|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Managed Medicare|HEALTHSPRING MA|109,087.02|10720.92|20415.92|238.14|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|152,862.18|10720.92|20415.92|238.14|||| 181|DRG||RESPIRATORY NEOPLASMS W CC|Managed Medicare|HEALTHSPRING MA|58,866.88|7605.37|7736.19|89.3|||| 181|DRG||RESPIRATORY NEOPLASMS W CC|Humana Medicare Advantage|HUMANA MA|25,999.10|7586.77|7736.19|89.3|||| 181|DRG||RESPIRATORY NEOPLASMS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|50,958.43|89.3|7736.19|89.3|||| 181|DRG||RESPIRATORY NEOPLASMS W CC|Medicare|MEDICARE ACUTE|60,471.38|7670.78|7736.19|89.3|||| 181|DRG||RESPIRATORY NEOPLASMS W CC|Medicaid|MEDICAID|71,328.43|6367.02|7736.19|89.3|||| 181|DRG||RESPIRATORY NEOPLASMS W CC|United Medicare Advantage|UHC AARP MCR HMO MA|14,613.36|7736.19|7736.19|89.3|||| 181|DRG||RESPIRATORY NEOPLASMS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|115,013.12|7603.21|7736.19|89.3|||| 182|DRG||RESPIRATORY NEOPLASMS W/O CC/MCC|Medicare|MEDICARE ACUTE|45,711.57|6014.62|6014.62|6013.9|||| 182|DRG||RESPIRATORY NEOPLASMS W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|82,058.64|6013.9|6014.62|6013.9|||| 183|DRG||MAJOR CHEST TRAUMA W MCC|Blue Cross PPO Specialty|BCBSTX PPO|31,197.77|10123.21|18120.82|9565.01|||| 183|DRG||MAJOR CHEST TRAUMA W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|105,830.98|11082.15|18120.82|9565.01|||| 183|DRG||MAJOR CHEST TRAUMA W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|75,463.17|18120.82|18120.82|9565.01|||| 183|DRG||MAJOR CHEST TRAUMA W MCC|Medicare|MEDICARE ACUTE|102,443.27|9565.01|18120.82|9565.01|||| 184|DRG||MAJOR CHEST TRAUMA W CC|Humana Medicare Advantage|HUMANA MA|92,435.87|6992.24|7137.84|35.72|||| 184|DRG||MAJOR CHEST TRAUMA W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|108,786.55|6986.5|7137.84|35.72|||| 184|DRG||MAJOR CHEST TRAUMA W CC|Medicare|MEDICARE PART B ONLY IP|43,675.05|1002.74|7137.84|35.72|||| 184|DRG||MAJOR CHEST TRAUMA W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|284.00|35.72|7137.84|35.72|||| 184|DRG||MAJOR CHEST TRAUMA W CC|Blue Cross PPO Specialty|BCBSTX PPO|65,356.55|6819.88|7137.84|35.72|||| 184|DRG||MAJOR CHEST TRAUMA W CC|Medicare|MEDICARE ACUTE|67,973.43|6928.835|7137.84|35.72|||| 184|DRG||MAJOR CHEST TRAUMA W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|114,348.37|7137.84|7137.84|35.72|||| 185|DRG||MAJOR CHEST TRAUMA W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|267.13|7595.69|7595.69|5394.1|||| 185|DRG||MAJOR CHEST TRAUMA W/O CC/MCC|Medicare|MEDICARE ACUTE|48,920.48|5394.1|7595.69|5394.1|||| 185|DRG||MAJOR CHEST TRAUMA W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|63,714.11|5394.1|7595.69|5394.1|||| 186|DRG||PLEURAL EFFUSION W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|36,290.25|9749.5|19517.68|107.16|||| 186|DRG||PLEURAL EFFUSION W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34,512.26|107.16|19517.68|107.16|||| 186|DRG||PLEURAL EFFUSION W MCC|Humana Medicare Advantage|HUMANA MA|67,818.76|7931.315|19517.68|107.16|||| 186|DRG||PLEURAL EFFUSION W MCC|Medicare|MEDICARE ACUTE|56,968.87|9750.38|19517.68|107.16|||| 186|DRG||PLEURAL EFFUSION W MCC|Aetna|AETNA PPO|118,055.99|19517.68|19517.68|107.16|||| 186|DRG||PLEURAL EFFUSION W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28,977.87|6671.26|19517.68|107.16|||| 187|DRG||PLEURAL EFFUSION W CC|Managed Medicare|HEALTHSPRING MA|26,947.97|7040.84|70795.84|6912.21|||| 187|DRG||PLEURAL EFFUSION W CC|PHCS|HUMANA|102,602.66|70795.84|70795.84|6912.21|||| 187|DRG||PLEURAL EFFUSION W CC|Medicare|MEDICARE ACUTE|68,218.55|6912.21|70795.84|6912.21|||| 187|DRG||PLEURAL EFFUSION W CC|Blue Cross PPO Specialty|BCBSTX PPO|44,524.69|7156.66|70795.84|6912.21|||| 188|DRG||PLEURAL EFFUSION W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|20,666.75|20666.75|20666.75|284.06|||| 188|DRG||PLEURAL EFFUSION W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|9,877.01|284.06|20666.75|284.06|||| 188|DRG||PLEURAL EFFUSION W/O CC/MCC|Medicare|MEDICARE ACUTE|45,493.85|5321.61|20666.75|284.06|||| 188|DRG||PLEURAL EFFUSION W/O CC/MCC|Aetna|AETNA OTHER|42,787.61|9430.8|20666.75|284.06|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|United Healthcare|UNITED HEALTHCARE|214,418.05|20113.03|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|United Healthcare|UNITED HEALTHCARE OTHER|125,103.50|14389.03|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|117,461.28|7940.41|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|United Medicare Advantage|UHC AARP MCR HMO MA|73,511.07|8093.11|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Medicaid|MEDICAID|284,155.05|11788.98|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Medicaid|COUNTY INDIGENT HEALTH OTHER|83,777.75|5581.79|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Medicare|MEDICARE ACUTE|79,191.67|7954.05|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|United Medicare Advantage|UHC MEDICARE GOLD MA|62,966.97|8010.19|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|100,934.59|11507.49|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Aenta Medicare Advantage|AETNA MEDICARE MA|22,658.87|7926.77|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Humana Medicare Advantage|HUMANA MA|71,567.30|7947.9|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|NON CONTRACTED|COMMERCIAL OTHER 1|114,526.83|114526.83|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Managed Medicaid|MEDICAID AMERIGROUP|47,508.62|8875.04|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Managed Medicaid|MEDICAID SUPERIOR|62,183.31|12193.7|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|61,711.41|12193.7|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|61,099.49|8875.04|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Managed Medicare|HEALTHSPRING MA|84,880.46|8093.11|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Managed Medicare|OTHER INSTITUTIONS|341.99|8124.56|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Veterans Affairs|VETERANS ADMINISTRATION|81,396.85|8093.11|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38,088.45|7130.15|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Blue Cross HMO Specialty|BCBSTX HMO|57,463.20|5704.12|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|107,632.75|214.32|114526.83|214.32|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Blue Cross PPO Specialty|BCBSTX PPO|121,679.98|10149.1|114526.83|214.32|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|74,798.92|7691.35|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|58,218.83|7556.88|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|United Healthcare|UNITED HEALTHCARE OTHER|90,736.62|13540.38|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|63,249.54|8084.85|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Managed Medicare|BCBS MEDICARE PPO MA|149,379.50|7541.08|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Managed Medicare|HEALTHSPRING MA|56,729.94|7561.48|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Managed Medicaid|MEDICAID SUPERIOR|77,126.87|14778.87|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41,035.96|9020.8|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|57,918.44|7568.785|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Managed Medicaid|MEDICAID AMERIGROUP|59,010.65|6660.61|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|62,314.45|7840.705|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Humana Medicare Advantage|HUMANA MA|74,068.49|7542.89|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Cigna|CIGNA|43,425.50|11771.76|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Veterans Affairs|VETERANS ADMINISTRATION|59,542.17|7626.415|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|27,838.70|7691.35|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|394.61|9742.63|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Medicare|MEDICARE ACUTE|64,675.18|7560.6|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Medicare|MEDICARE PART B ONLY IP|9,247.40|607.76|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|49,008.55|194.48|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|39,651.32|7561.48|14778.87|194.48|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|717.32|7691.35|14778.87|194.48|||| 19000|EAP|0361|BC PUNCTURE ASPIRATION CY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||12.01||| 19000|EAP|0361|BC PUNCTURE ASPIRATION CY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,381.15||| 19000|EAP|0361|BC PUNCTURE ASPIRATION CY|Humana Medicare Advantage|HUMANA MA|||||12.01||| 19000|EAP|0361|BC PUNCTURE ASPIRATION CY|Aetna|AETNA PPO|||||1,381.15||| 19000|EAP|0361|BC PUNCTURE ASPIRATION CY|Blue Cross PPO Specialty|BCBSTX PPO|||||1,381.15||| 19030|EAP|0361|BC INJ PROC DUCTO/GLACTOG|Medicare|MEDICARE ACUTE|||||8.41||| 19030|EAP|0361|BC INJ PROC DUCTO/GLACTOG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.41||| 19030|EAP|0361|BC INJ PROC DUCTO/GLACTOG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||967.15||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|United Medicare Advantage|UHC AARP MCR HMO MA|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|United Medicare Advantage|UHC MEDICARE GOLD MA|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Access Direct Platinum|HEALTHFIRST TPA UMR|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Cigna|CIGNA|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Humana Medicare Advantage|HUMANA MA|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Blue Cross HMO Specialty|BCBSTX HMO|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Blue Cross PPO Specialty|BCBSTX PPO|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Aenta Medicare Advantage|AETNA MEDICARE MA|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Aetna|AETNA PPO|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Managed Medicare|HEALTHSPRING MA|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|United Healthcare|UNITED HEALTHCARE OTHER|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|United Healthcare|UNITED HEALTHCARE|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|NON CONTRACTED|COMMERCIAL OTHER 1|||||21.24||| 19081|EAP|0361|BC BX BREAST 1ST LESION S|Medicare|MEDICARE ACUTE|||||21.24||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Medicare|MEDICARE ACUTE|30.31||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|PHCS|GROUP AND PENSION|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|NON CONTRACTED|COMMERCIAL OTHER 2|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|NON CONTRACTED|COMMERCIAL OTHER 1|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|United Healthcare|UNITED HEALTHCARE OTHER|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Managed Medicare|HEALTHSPRING MA|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Aetna Value Network|AETNA VALUE NETWORK|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Aetna|AETNA PPO|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Aenta Medicare Advantage|AETNA MEDICARE MA|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Tricare|TRICARE EAST REGION|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Blue Cross PPO Specialty|BCBSTX PPO|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|United Healthcare|UNITED HEALTHCARE|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Managed Medicare|BCBS MEDICARE PPO MA|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Blue Cross HMO Specialty|BCBSTX HMO|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Humana Medicare Advantage|HUMANA MA|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Cigna|CIGNA|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Managed Medicaid|MEDICAID AMERIGROUP|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Managed Medicaid|MEDICAID SUPERIOR|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Veterans Affairs|VETERANS ADMINISTRATION|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Multiplan|WEB TPA|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Access Direct Platinum|HEALTHFIRST TPA UMR|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Access Direct Platinum|HEALTHFIRST TPA|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|United Medicare Advantage|UHC AARP MCR HMO MA|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||30.31||| 19083|EAP|0361|US BX BREAST 1ST LESION U|United Medicare Advantage|UHC MEDICARE GOLD MA|||||30.31||| 19084|EAP|0361|US BX BREAST ADD LESION I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Humana Medicare Advantage|HUMANA MA|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Blue Cross PPO Specialty|BCBSTX PPO|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Managed Medicare|HEALTHSPRING MA|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|United Healthcare|UNITED HEALTHCARE|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|United Healthcare|UNITED HEALTHCARE OTHER|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Tricare|TRICARE EAST REGION|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Medicare|MEDICARE ACUTE|||||7.95||| 19084|EAP|0361|US BX BREAST ADD LESION I|Multiplan|WEB TPA|||||7.95||| 19085|EAP|0361|MRI BX BREAST 1ST LESION|NON CONTRACTED|COMMERCIAL OTHER 1|||||28.33||| 19085|EAP|0361|MRI BX BREAST 1ST LESION|Medicare|MEDICARE ACUTE|||||28.33||| 19085|EAP|0361|MRI BX BREAST 1ST LESION|Tricare|TRICARE FOR LIFE|||||28.33||| 19085|EAP|0361|MRI BX BREAST 1ST LESION|Blue Cross PPO Specialty|BCBSTX PPO|||||28.33||| 19085|EAP|0361|MRI BX BREAST 1ST LESION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||28.33||| 19085|EAP|0361|MRI BX BREAST 1ST LESION|Managed Medicaid|MEDICAID SUPERIOR|||||28.33||| 19085|EAP|0361|MRI BX BREAST 1ST LESION|Aenta Medicare Advantage|AETNA MEDICARE MA|||||28.33||| 19085|EAP|0361|MRI BX BREAST 1ST LESION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||28.33||| 19085|EAP|0361|MRI BX BREAST 1ST LESION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||28.33||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Veterans Affairs|VETERANS ADMINISTRATION|84,737.37|6283.85|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|355.09|8138.46|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|103,656.34|6283.85|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Managed Medicaid|MEDICAID SUPERIOR|39,127.61|6660.61|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|30,798.84|5083.1|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|49,934.71|6660.61|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|52,254.50|6182.61|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Humana Medicare Advantage|HUMANA MA|36,672.74|6283.85|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Managed Medicare|HEALTHSPRING MA|33,665.62|6872.265|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Blue Cross PPO Specialty|BCBSTX PPO|37,206.90|6205.38|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|383.24|68.04|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Medicare|MEDICARE ACUTE|50,230.07|6183.05|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|United Medicare Advantage|UHC AARP MCR HMO MA|40,754.50|6183.05|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|401.63|6182.17|8138.46|68.04|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58,147.24|6283.85|8138.46|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|91,620.65|7954.05|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|481.36|5147.41|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Medicare|MEDICARE ACUTE|39,839.61|5175.13|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|14,650.05|5175.57|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|59,374.85|5255.14|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|36,895.42|4179.51|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,870.13|68.04|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX OTHER|14,223.75|4916.64|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|45,207.12|5174.69|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|73,385.67|8601.34|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|362.84|8875.04|8875.04|68.04|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|49,739.64|5147.41|8875.04|68.04|||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.62||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.62||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|Humana Medicare Advantage|HUMANA MA|||||9.62||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|Blue Cross PPO Specialty|BCBSTX PPO|||||9.62||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|Blue Cross HMO Specialty|BCBSTX HMO|||||9.62||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.62||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||691.90||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|Medicaid|MEDICAID|||||9.62||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|Medicare|MEDICARE ACUTE|9.62||||9.62||| 19281|EAP|0361|US PERQ DEVICE BREAST 1ST|United Healthcare|UNITED HEALTHCARE OTHER|||||9.62||| 19282|EAP|0320|US PERQ DEVICE BREAST EA|United Healthcare|UNITED HEALTHCARE OTHER|||||571.75||| 19282|EAP|0320|US PERQ DEVICE BREAST EA|Medicare|MEDICARE ACUTE|||||571.75||| 19282|EAP|0320|US PERQ DEVICE BREAST EA|Managed Medicare|HEALTHSPRING MA|||||571.75||| 19282|EAP|0320|US PERQ DEVICE BREAST EA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||571.75||| 19282|EAP|0320|US PERQ DEVICE BREAST EA|Blue Cross PPO Specialty|BCBSTX PPO|||||571.75||| 19282|EAP|0320|US PERQ DEVICE BREAST EA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||571.75||| 19282|EAP|0320|US PERQ DEVICE BREAST EA|Humana Medicare Advantage|HUMANA MA|||||571.75||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Cigna|CIGNA|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Humana Medicare Advantage|HUMANA MA|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Managed Medicaid|MEDICAID SUPERIOR|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Managed Medicaid|MEDICAID AMERIGROUP|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Access Direct Platinum|HEALTHFIRST TPA|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Blue Cross PPO Specialty|BCBSTX PPO|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Aetna|AETNA PPO|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Medicare|MEDICARE ACUTE|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Managed Medicare|BCBS MEDICARE PPO MA|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|Managed Medicare|HEALTHSPRING MA|||||9.62||| 19285|EAP|0361|US PERQ DEV BREAST 1ST US|United Healthcare|UNITED HEALTHCARE|||||9.62||| 19286|EAP|0361|BC US BREAST HOOKWIRE ADD|Medicare|MEDICARE ACUTE|||||5.68||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Managed Medicare|BCBS MEDICARE PPO MA|87,743.25|8573.18|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Blue Cross HMO Specialty|BCBSTX HMO|66,954.53|7599.99|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|82,742.24|136.08|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Blue Cross PPO Specialty|BCBSTX PPO|91,158.68|8940.39|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Brinson Benefits|THE HEALTH PLAN SMITH CO|127,159.05|127159.05|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|56,096.44|10138.62|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Managed Medicare|HEALTHSPRING MA|49,979.58|8600.46|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|104,308.40|9623.84|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|56,713.48|9623.84|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Humana Medicare Advantage|HUMANA MA|65,427.33|8584.87|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Cigna|CIGNA OTHER|23,303.81|13721.71|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Cigna|CIGNA|67,380.64|13721.71|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|57,697.67|11005.18|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|39,447.94|11258.2|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|75,945.90|11734.915|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|88,401.12|8663.16|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Veterans Affairs|VETERANS ADMINISTRATION|58,057.22|8601.34|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Medicare|MEDICARE ACUTE|63,823.92|8600.46|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Medicaid|MEDICAID|62,971.11|11283.3|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Medicaid|SMITH COUNTY JAIL|815.92|3665.79|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|60,090.76|8601.34|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|90,099.88|8677.24|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|66,156.32|8677.24|127159.05|136.08|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|73,896.73|13721.71|127159.05|136.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|56,820.84|8106.38|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|51,078.85|6160.02|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Medicaid|MEDICAID|43,326.75|3388.26|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Medicare|MEDICARE PART B ONLY IP|18,231.17|842.75|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Medicare|MEDICARE ACUTE|48,823.42|6160.02|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Veterans Affairs|VETERANS ADMINISTRATION|58,267.06|6163.28|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|71,945.86|7266.31|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|433.00|10878.93|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32,074.32|7962.08|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|United Healthcare|UNITED HEALTHCARE OTHER|8,792.60|10517.47|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|United Medicare Advantage|UHC AARP MCR HMO MA|44,490.29|6260.33|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Medicaid|MEDICAID HMO|15,750.41|3388.26|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|102,384.50|7378.78|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicare|HEALTHSPRING MA|45,799.42|6260.33|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Blue Cross HMO Specialty|BCBSTX HMO|120,024.25|10651.71|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46,766.20|107.16|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Aetna|AETNA OTHER|38,061.80|11240.79|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicare|BCBS MEDICARE PPO MA|47,612.90|6131.86|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,490.56|5387.33|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Humana Medicare Advantage|HUMANA MA|64,450.28|6151.03|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Cigna|CIGNA|38,701.16|9143.69|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|71,179.64|6131.86|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Cigna|CIGNA OTHER|30,554.25|9143.69|11240.79|107.16|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Blue Cross PPO Specialty|BCBSTX PPO|44,253.96|6112.36|11240.79|107.16|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|201.32|35.72|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|16,192.75|4663.37|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|57,365.58|4382.615|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|28,048.80|3377.9|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|17,471.48|3377.9|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|21,430.50|5026.89|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|45,775.31|5008.73|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|42,675.50|6555.22|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38,949.52|3377.9|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|61,957.31|6522.45|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|7.11|100.04|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|41,725.13|5103.3|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Medicare|MEDICARE ACUTE|39,150.90|5026.89|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Medicaid|SUPERIOR HEALTHPLAN CHIP|13,814.05|2124.46|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Tricare|TRICARE EAST REGION|12,339.25|2922.01|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|14,561.90|14561.9|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|49,421.75|5026.89|14561.9|35.72|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|28,709.45|8073.34|14561.9|35.72|||| 196|DRG||INTERSTITIAL LUNG DISEASE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46,521.97|10668.83|10668.83|178.6|||| 196|DRG||INTERSTITIAL LUNG DISEASE W MCC|Medicare|MEDICARE ACUTE|52,436.50|10668.83|10668.83|178.6|||| 196|DRG||INTERSTITIAL LUNG DISEASE W MCC|Humana Medicare Advantage|HUMANA MA|72,576.30|8916.21|10668.83|178.6|||| 196|DRG||INTERSTITIAL LUNG DISEASE W MCC|Blue Cross HMO Specialty|BCBSTX HMO|49,610.87|9455.11|10668.83|178.6|||| 196|DRG||INTERSTITIAL LUNG DISEASE W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|53,390.13|178.6|10668.83|178.6|||| 197|DRG||INTERSTITIAL LUNG DISEASE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59,999.09|178.6|178.6|178.6|||| 199|DRG||PNEUMOTHORAX W MCC|Medicare|MEDICARE ACUTE|845.79|11128.79|73378.605|11128.79|||| 199|DRG||PNEUMOTHORAX W MCC|PHCS|HUMANA|96,622.45|66669.49|73378.605|11128.79|||| 199|DRG||PNEUMOTHORAX W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|110,757.75|11146.24|73378.605|11128.79|||| 199|DRG||PNEUMOTHORAX W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47,763.94|21859.47|73378.605|11128.79|||| 199|DRG||PNEUMOTHORAX W MCC|Humana Medicare Advantage|HUMANA MA|173,731.06|12263.54|73378.605|11128.79|||| 199|DRG||PNEUMOTHORAX W MCC|Blue Cross PPO Specialty|BCBSTX PPO|150,918.15|73378.605|73378.605|11128.79|||| 20|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W MCC|Humana Medicare Advantage|HUMANA MA|76,966.55|60640.72|128077.36|46327.5|||| 20|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|408,672.05|128077.36|128077.36|46327.5|||| 20|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W MCC|Medicaid|MEDICAID|787,410.59|46327.5|128077.36|46327.5|||| 20|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W MCC|Medicare|MEDICARE ACUTE|577,544.19|69797.885|128077.36|46327.5|||| 200|DRG||PNEUMOTHORAX W CC|Medicare|MEDICARE ACUTE|55,880.12|7344.53|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Medicare|MEDICARE PART B ONLY IP|14,504.60|186.8|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Tricare|TRICARE EAST REGION|9,195.50|2813.77|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|United Healthcare|UNITED HEALTHCARE OTHER|47,371.75|16433.74|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|228.25|42.51|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|118,423.35|7223.53|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Veterans Affairs|VETERANS ADMINISTRATION|154,057.42|7221.81|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|249.32|7193.65|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|40,245.82|9311.08|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Blue Cross HMO Specialty|BCBSTX HMO|64,328.10|6203.75|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Blue Cross PPO Specialty|BCBSTX PPO|56,310.11|7297.89|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Managed Medicare|HEALTHSPRING MA|54,885.59|7283.17|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Managed Medicare|BCBS MEDICARE PPO MA|122,505.42|7207.98|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|97,319.79|7344.53|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Managed Medicaid|MEDICAID SUPERIOR|82,274.83|11082.15|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|63,603.50|7137.84|16433.74|42.51|||| 200|DRG||PNEUMOTHORAX W CC|Humana Medicare Advantage|HUMANA MA|55,772.32|7272.135|16433.74|42.51|||| 201|DRG||PNEUMOTHORAX W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|36,382.89|6772.73|83783.67|4745.53|||| 201|DRG||PNEUMOTHORAX W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|83,783.67|83783.67|83783.67|4745.53|||| 201|DRG||PNEUMOTHORAX W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|289.47|4745.53|83783.67|4745.53|||| 201|DRG||PNEUMOTHORAX W/O CC/MCC|Medicare|MEDICARE ACUTE|24,874.84|5222.99|83783.67|4745.53|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Medicaid|MEDICAID|15,259.25|4500.09|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|United Healthcare|UNITED HEALTHCARE|13,141.50|11220.53|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Medicare|MEDICARE ACUTE|38,096.15|6485.96|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Tricare|TRICARE EAST REGION|15,109.18|2029.9|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|36,395.87|8321.12|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21,774.75|8321.12|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Cigna|CIGNA OTHER|66,154.66|9754.92|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Humana Medicare Advantage|HUMANA MA|58,025.68|6457.8|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|19,402.31|3035.11|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|129.78|4524.04|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|482.75|57.53|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Aetna|AETNA PPO|28,777.25|11992.2|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18,590.25|34.02|11992.2|34.02|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|36,365.62|6383.28|11992.2|34.02|||| 20206|EAP|0350|CT-NEEDLE BIOPSY MUSCLE|Blue Cross PPO Specialty|BCBSTX PPO|||||2,704.80||| 20206|EAP|0350|CT-NEEDLE BIOPSY MUSCLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,704.80||| 20206|EAP|0350|CT-NEEDLE BIOPSY MUSCLE|Humana Medicare Advantage|HUMANA MA|23.52||||23.52||| 20206|EAP|0350|CT-NEEDLE BIOPSY MUSCLE|Cigna|CIGNA|2,704.80||||||| 20206|EAP|0361|US NEEDLE BIOPSY MUSCLE|Medicare|MEDICARE ACUTE|||||25.66||| 20206|EAP|0350|CT-NEEDLE BIOPSY MUSCLE|Medicaid|MEDICAID|||||2,704.80||| 20206|EAP|0350|CT-NEEDLE BIOPSY MUSCLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||23.52||| 20206|EAP|0350|CT-NEEDLE BIOPSY MUSCLE|Managed Medicare|HEALTHSPRING MA|2,704.80||||||| 20220|EAP|0350|CT-BONE BIOPSY TROCAR/NEE|Medicaid|SMITH COUNTY JAIL|26.18||||||| 20220|EAP|0350|CT-BONE BIOPSY TROCAR/NEE|Medicaid|MEDICAID|26.18||||||| 20220|EAP|0350|CT-BONE BIOPSY TROCAR/NEE|Medicare|MEDICARE ACUTE|3,010.70||||26.18||| 20220|EAP|0350|CT-BONE BIOPSY TROCAR/NEE|United Medicare Advantage|UHC AARP MCR HMO MA|3,010.70||||3,010.70||| 20220|EAP|0350|CT-BONE BIOPSY TROCAR/NEE|Cigna|CIGNA|||||3,010.70||| 20220|EAP|0350|CT-BONE BIOPSY TROCAR/NEE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,010.70||| 20220|EAP|0350|CT-BONE BIOPSY TROCAR/NEE|Humana Medicare Advantage|HUMANA MA|3,010.70||||3,010.70||| 20220|EAP|0350|CT-BONE BIOPSY TROCAR/NEE|Blue Cross PPO Specialty|BCBSTX PPO|3,010.70||||3,010.70||| 20225|EAP|0350|CT-BONE BIOPSY TROCAR/NEE|Medicare|MEDICARE ACUTE|||||38.89||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|28,218.50|4732.63|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Brinson Benefits|THE HEALTH PLAN SMITH CO|103.29|103.29|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12,989.75|118.24|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|27,712.63|4023.08|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|203.47|5062.92|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|10,048.50|2690.34|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|18,276.13|3793.625|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Cigna|CIGNA OTHER|3,234.50|3234.5|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Cigna|CIGNA|16,677.25|6878.36|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|19,604.37|6604.02|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|13,144.25|6626.33|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Medicaid|SMITH COUNTY JAIL|28,114.50|1908.87|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Medicaid|SUPERIOR HEALTHPLAN CHIP|11,677.25|1692.04|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Medicare|MEDICARE ACUTE|33,876.94|5078.275|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|15,294.50|8211.82|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|37,929.87|8211.82|8211.82|103.29|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Tricare|TRICARE EAST REGION|23,668.28|2187.355|8211.82|103.29|||| 204|DRG||RESPIRATORY SIGNS & SYMPTOMS|Medicare|MEDICARE ACUTE|32,371.41|5743.925|6768.27|5743.925|||| 204|DRG||RESPIRATORY SIGNS & SYMPTOMS|Blue Cross PPO Specialty|BCBSTX PPO|40,269.15|6768.27|6768.27|5743.925|||| 205|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|62,528.02|10257.4|14635.29|104.38|||| 205|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC|Humana Medicare Advantage|HUMANA MA|72,129.50|10003.79|14635.29|104.38|||| 205|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|231,538.58|14635.29|14635.29|104.38|||| 205|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC|Medicare|MEDICARE PART B ONLY IP|25,818.71|104.38|14635.29|104.38|||| 205|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|56,732.54|9033.87|14635.29|104.38|||| 20501|EAP|0361|XR-INJECT-SINUS TRACT|Managed Medicare|HEALTHSPRING MA|||||8.32||| 20501|EAP|0361|XR-INJECT-SINUS TRACT|Medicaid|COUNTY INDIGENT HEALTH OTHER|956.80||||||| 20501|EAP|0361|XR-INJECT-SINUS TRACT|Medicaid|MEDICAID|8.32||||||| 20501|EAP|0361|XR-INJECT-SINUS TRACT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||956.80||| 20501|EAP|0361|XR-INJECT-SINUS TRACT|Blue Cross PPO Specialty|BCBSTX PPO|||||956.80||| 20501|EAP|0361|XR-INJECT-SINUS TRACT|Humana Medicare Advantage|HUMANA MA|8.32||||8.32||| 20501|EAP|0361|XR-INJECT-SINUS TRACT|Blue Cross HMO Specialty|BCBSTX HMO|956.80||||||| 20526|EAP|0510|THER INJECTION, CARP TUNN|Humana Medicare Advantage|HUMANA MA|||||309.17||| 20526|EAP|0361|THER INJECTION, CARP TUNN|Blue Cross PPO Specialty|BCBSTX PPO|||||7.42||| 20526|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.42||| 20526|EAP|0361|THER INJECTION, CARP TUNN|Medicare|MEDICARE ACUTE|||||7.42||| 20526|EAP|0361|THER INJECTION, CARP TUNN|Tricare|TRICARE EAST REGION|||||7.42||| 20550|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Managed Medicare|HEALTHSPRING MA|||||276.67||| 20550|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.64||| 20550|EAP|0361||United Healthcare|GOLDEN RULE|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|United Healthcare|UNITED HEALTHCARE|||||276.67||| 20550|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.64||| 20550|EAP|0361||Tricare|TRICARE EAST REGION|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|NON CONTRACTED|COMMERCIAL OTHER 1|||||276.67||| 20550|EAP|0361||Medicare|MEDICARE ACUTE|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Medicare|MEDICARE ACUTE|||||276.67||| 20550|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||276.67||| 20550|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|United Medicare Advantage|UHC AARP MCR HMO MA|||||276.67||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||276.67||| 20550|EAP|0361||Medicare|MEDICARE PART B ONLY IP|||||6.64||| 20550|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Aenta Medicare Advantage|AETNA MEDICARE MA|||||276.67||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||276.67||| 20550|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.64||| 20550|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Blue Cross HMO Specialty|BCBSTX HMO|||||276.67||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||276.67||| 20550|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Managed Medicare|BCBS MEDICARE PPO MA|||||276.67||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||276.67||| 20550|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Blue Cross PPO Specialty|BCBSTX PPO|||||276.67||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||276.67||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||276.67||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Managed Medicaid|MEDICAID SUPERIOR|||||276.67||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Cigna|CIGNA OTHER|||||276.67||| 20550|EAP|0361||Cigna|CIGNA|||||6.64||| 20550|EAP|0510|INJ TENDON SHEALTH/LIGAME|Humana Medicare Advantage|HUMANA MA|||||276.67||| 20550|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.64||| 20551|EAP|0510|INJ TENDON ORIGIN/INSERTI|Humana Medicare Advantage|HUMANA MA|||||276.67||| 20551|EAP|0510|INJ TENDON ORIGIN/INSERTI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||276.67||| 20551|EAP|0510|INJ TENDON ORIGIN/INSERTI|Blue Cross HMO Specialty|BCBSTX HMO|||||276.67||| 20551|EAP|0510|INJ TENDON ORIGIN/INSERTI|Aetna|AETNA PPO|||||276.67||| 20551|EAP|0510|INJ TENDON ORIGIN/INSERTI|Medicare|MEDICARE ACUTE|||||276.67||| 20551|EAP|0510|INJ TENDON ORIGIN/INSERTI|Medicare|MEDICARE ACUTE|||||2.95||| 20552|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||7.42||| 20552|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.42||| 20552|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||7.42||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|United Healthcare|UNITED HEALTHCARE|||||309.17||| 20552|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||7.42||| 20552|EAP|0361||Medicare|MEDICARE ACUTE|||||7.42||| 20552|EAP|0361|PM/TRIGGER POINT INJECTIO|Medicare|MEDICARE ACUTE|||||527.75||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|Medicare|MEDICARE ACUTE|||||309.17||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|United Medicare Advantage|UHC AARP MCR HMO MA|||||309.17||| 20552|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.42||| 20552|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.42||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||309.17||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||309.17||| 20552|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.42||| 20552|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||7.42||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||309.17||| 20552|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.42||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||309.17||| 20552|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.42||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|Managed Medicare|HEALTHSPRING MA|||||309.17||| 20552|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||7.42||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|Blue Cross PPO Specialty|BCBSTX PPO|||||309.17||| 20552|EAP|0361|INJ TRIGGER POINT 1/2 MUS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.42||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||309.17||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|Cigna|CIGNA|||||309.17||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|Humana Medicare Advantage|HUMANA MA|||||309.17||| 20552|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.42||| 20552|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||7.42||| 20552|EAP|0510|INJ TRIGGER POINT, 1/2 MU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||309.17||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Humana Medicare Advantage|HUMANA MA|||||309.17||| 20553|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||7.42||| 20553|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.42||| 20553|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||7.42||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Managed Medicaid|MEDICAID AMERIGROUP|||||309.17||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Blue Cross HMO Specialty|BCBSTX HMO|||||309.17||| 20553|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||7.42||| 20553|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||7.42||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Blue Cross PPO Specialty|BCBSTX PPO|||||309.17||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||309.17||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Aenta Medicare Advantage|AETNA MEDICARE MA|||||309.17||| 20553|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.42||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||309.17||| 20553|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.42||| 20553|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.42||| 20553|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.42||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|United Medicare Advantage|UHC AARP MCR HMO MA|||||309.17||| 20553|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||7.42||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||309.17||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||309.17||| 20553|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.42||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||309.17||| 20553|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.42||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||309.17||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Medicare|MEDICARE ACUTE|||||309.17||| 20553|EAP|0361||PHCS|HUMANA|||||7.42||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|United Healthcare|UNITED HEALTHCARE|||||309.17||| 20553|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||7.42||| 20553|EAP|0361||United Healthcare|TML GROUP BENEFITS|||||7.42||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Managed Medicare|HEALTHSPRING MA|||||309.17||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Managed Medicare|BCBS MEDICARE PPO MA|||||309.17||| 20553|EAP|0510|INJECT TRIGGER POINTS, =/|Tricare|TRICARE EAST REGION|||||309.17||| 20553|EAP|0361||Medicare|MEDICARE ACUTE|||||7.42||| 20553|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||7.42||| 206|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC|Medicare|MEDICARE ACUTE|34,595.85|6071.66|8682.48|713.24|||| 206|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|136,999.81|713.24|8682.48|713.24|||| 206|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC|Workers Compensation|WORKERS COMPENSATION OTHER|49,297.57|8682.48|8682.48|713.24|||| 206|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|57,587.40|5863.16|8682.48|713.24|||| 206|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|142,686.45|6166.83|8682.48|713.24|||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Managed Medicaid|MEDICAID AMERIGROUP|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Cigna|CIGNA|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Cigna|CIGNA OTHER|||||7.42||| 20600|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||7.42||| 20600|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Aetna|AETNA OTHER|||||7.42||| 20600|EAP|0510|DRAIN/INJECT JOINT/BURSA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||309.17||| 20600|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Blue Cross PPO Specialty|BCBSTX PPO|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Blue Cross HMO Specialty|BCBSTX HMO|||||7.42||| 20600|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.42||| 20600|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.42||| 20600|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||7.42||| 20600|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.42||| 20600|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA|||||7.42||| 20600|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Humana Medicare Advantage|HUMANA MA|||||7.42||| 20600|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Workers Compensation|UT EMPLOYEE INJURY|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.42||| 20600|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.42||| 20600|EAP|0361||PHCS|HUMANA|||||7.42||| 20600|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||7.42||| 20600|EAP|0361||Medicare|MEDICARE ACUTE|||||7.42||| 20600|EAP|0361||Tricare|TRICARE EAST REGION|||||7.42||| 20600|EAP|0361||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Tricare|TRICARE EAST REGION|||||7.42||| 20600|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|United Healthcare|UNITED HEALTHCARE|||||7.42||| 20600|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Managed Medicare|BCBS MEDICARE PPO MA|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Medicare|MEDICARE ACUTE|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Managed Medicare|HEALTHSPRING MA|||||7.42||| 20600|EAP|0510|DRAIN/INJ SM JOINT/BURSA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.42||| 20600|EAP|0361||Medicare|MEDICARE PART B ONLY IP|||||7.42||| 20600|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.42||| 20600|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||7.42||| 20604|EAP|0361|DRAIN/INJ JOINT/BURSA W/U|United Healthcare|UNITED HEALTHCARE|||||6.64||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Workers Compensation|UT EMPLOYEE INJURY|||||309.17||| 20605|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||309.17||| 20605|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.42||| 20605|EAP|0450|ASP JOINT INTERMEDIATE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.95||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||309.17||| 20605|EAP|0510|DRAIN/INJECT JOINT/BURSA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||309.17||| 20605|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||309.17||| 20605|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||7.42||| 20605|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Blue Cross PPO Specialty|BCBSTX PPO|||||309.17||| 20605|EAP|0510|DRAIN/INJECT JOINT/BURSA|Blue Cross PPO Specialty|BCBSTX PPO|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||309.17||| 20605|EAP|0361||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||309.17||| 20605|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||7.42||| 20605|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.42||| 20605|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||7.42||| 20605|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Aetna|AETNA OTHER|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Aetna|AETNA PPO|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Humana Medicare Advantage|HUMANA MA|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Managed Medicaid|MEDICAID SUPERIOR|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Cigna|CIGNA|||||309.17||| 20605|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||309.17||| 20605|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.42||| 20605|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Managed Medicaid|MEDICAID AMERIGROUP|||||309.17||| 20605|EAP|0361||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||309.17||| 20605|EAP|0361||Aetna|AETNA PPO|||||7.42||| 20605|EAP|0361||Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||7.42||| 20605|EAP|0361||Cigna|CIGNA|||||7.42||| 20605|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Blue Cross PPO Specialty|BCBSTX OTHER|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Medicaid|MEDICAID|||||309.17||| 20605|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||7.42||| 20605|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||7.42||| 20605|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.42||| 20605|EAP|0361||Aetna Value Network|AETNA VALUE NETWORK|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||309.17||| 20605|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.42||| 20605|EAP|0361||Managed Medicare|TEXAS COMMUNITY CARE MA|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Managed Medicare|HEALTHSPRING MA|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Managed Medicare|BCBS MEDICARE PPO MA|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Blue Cross HMO Specialty|BCBSTX HMO|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Medicare|MEDICARE ACUTE|||||309.17||| 20605|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Humana Medicare Advantage|HUMANA MA|||||985.55||| 20605|EAP|0510|DRAIN/INJECT JOINT/BURSA|Medicare|MEDICARE ACUTE|||||309.17||| 20605|EAP|0450|ASP JOINT INTERMEDIATE|Medicare|MEDICARE ACUTE|7.95||||7.95||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|United Medicare Advantage|UHC AARP MCR HMO MA|||||309.17||| 20605|EAP|0361||Medicare|MEDICARE ACUTE|||||7.42||| 20605|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||7.42||| 20605|EAP|0510|DRAIN/INJECT JOINT/BURSA|Tricare|TRICARE EAST REGION|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Workers Compensation|WORKERS COMPENSATION OTHER|||||309.17||| 20605|EAP|0361||Tricare|TRICARE FOR LIFE|||||7.42||| 20605|EAP|0361||Tricare|TRICARE EAST REGION|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|Tricare|TRICARE EAST REGION|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|United Healthcare|GEHA|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|PHCS|HUMANA INSURANCE|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|United Healthcare|UNITED HEALTHCARE OTHER|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|NON CONTRACTED|COMMERCIAL OTHER 1|||||309.17||| 20605|EAP|0361||United Healthcare|GOLDEN RULE|||||7.42||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|United Healthcare|UNITED HEALTHCARE|||||309.17||| 20605|EAP|0510|DRAIN/INJ MED JOINT/BURSA|United Healthcare|GOLDEN RULE|||||309.17||| 20605|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||7.42||| 20606|EAP|0510|DRAIN/INJ JOINT/BURSA W/U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.04||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|United Healthcare|AARP|||||309.17||| 20610|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||7.42||| 20610|EAP|0361||United Healthcare|TML GROUP BENEFITS|||||7.42||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|United Healthcare|UNITED HEALTHCARE OTHER|||||1,084.45||| 20610|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|United Healthcare|UNITED HEALTHCARE|||||309.17||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|United Healthcare|UNITED HEALTHCARE|||||309.17||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|United Healthcare|UNITED HEALTHCARE OTHER|||||21.86||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Tricare|TRICARE EAST REGION|||||1,084.45||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Tricare|TRICARE FOR LIFE|||||309.17||| 20610|EAP|0361||Tricare|TRICARE EAST REGION|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|NON CONTRACTED|COMMERCIAL OTHER 1|||||309.17||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Tricare|TRICARE EAST REGION|||||309.17||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|NON CONTRACTED|COMMERCIAL OTHER 1|||||309.17||| 20610|EAP|0361||PHCS|HUMANA|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|PHCS|HUMANA|||||309.17||| 20610|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Medicare|MEDICARE ACUTE|||||309.17||| 20610|EAP|0361||Medicare|MEDICARE ACUTE|7.42||||7.42||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|Medicare|MEDICARE ACUTE|1,084.45||||21.86||| 20610|EAP|0361||Medicare|MEDICARE PART B ONLY IP|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Managed Medicare|BCBS MEDICARE PPO MA|||||309.17||| 20610|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||7.42||| 20610|EAP|0361||Managed Medicare|HEALTHSPRING MA|9.43||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||309.17||| 20610|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.42||| 20610|EAP|0361||Managed Medicare|UNIVERSAL HEALTHCARE MA|||||7.42||| 20610|EAP|0361||Managed Medicare|ETMC AFFILIATE HOSPITALS|||||7.42||| 20610|EAP|0361||Medicaid|MEDICAID|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Medicaid|MEDICAID HMO|||||309.17||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Managed Medicare|HEALTHSPRING MA|||||309.17||| 20610|EAP|0361||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||7.42||| 20610|EAP|0361||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|United Medicare Advantage|UHC AARP MCR HMO MA|||||309.17||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||309.17||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|United Medicare Advantage|UHC AARP MCR HMO MA|||||309.17||| 20610|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.42||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|||||21.86||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||309.17||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,513.90||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||309.17||| 20610|EAP|0361||United Medicare Advantage|UHC AARP WELLMED HMO MA|||||7.42||| 20610|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Access Direct Platinum|HEALTHFIRST TPA|||||309.17||| 20610|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA|||||7.42||| 20610|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||309.17||| 20610|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||309.17||| 20610|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.42||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,084.45||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,084.45||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Workers Compensation|TEXAS MUTUAL INSURANCE|||||309.17||| 20610|EAP|0361||Workers Compensation|TEXAS MUTUAL INSURANCE|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Managed Medicaid|MEDICAID AMERIGROUP|||||309.17||| 20610|EAP|0361||Workers Compensation|UT EMPLOYEE INJURY|||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||309.17||| 20610|EAP|0361||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.43||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||309.17||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.43||||9.43||| 20610|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.43||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||309.17||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.43||||21.86||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Managed Medicaid|MEDICAID SUPERIOR|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||309.17||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,084.45||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21.86||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Managed Medicaid|MEDICAID SUPERIOR|||||309.17||| 20610|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Workers Compensation|UT EMPLOYEE INJURY|||||309.17||| 20610|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||309.17||| 20610|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Managed Medicaid|MEDICAID AMERIGROUP|||||309.17||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Managed Medicaid|MEDICAID SUPERIOR|||||9.43||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Workers Compensation|WORKERS COMPENSATION OTHER|||||309.17||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||309.17||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Medicaid|MEDICAID|||||309.17||| 20610|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.42||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|Managed Medicaid|MEDICAID AMERIGROUP|||||21.86||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.43||||21.86||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Cigna|CIGNA|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Cigna|CIGNA OTHER|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|ChampVA|CHAMPVA CENTER|||||309.17||| 20610|EAP|0361||Cigna|CIGNA|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Managed Medicare|HEALTHSPRING MA|||||309.17||| 20610|EAP|0361||Cigna|CIGNA OTHER|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Humana Medicare Advantage|HUMANA MA|||||309.17||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|Humana Medicare Advantage|HUMANA MA|9.43||||21.86||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Humana Medicare Advantage|HUMANA MA|9.43||||1,013.73||| 20610|EAP|0361||Humana Medicare Advantage|HUMANA MA|9.43||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Humana Medicare Advantage|HUMANA MA|||||309.17||| 20610|EAP|0450|ASP JOINT MAJOR|Blue Cross PPO Specialty|BCBSTX PPO|||||1,351.25||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||309.17||| 20610|EAP|0450|ASP JOINT MAJOR|Medicare|MEDICARE ACUTE|||||1,351.25||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Medicare|MEDICARE ACUTE|||||309.17||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Medicare|MEDICARE ACUTE|1,084.45||||1,084.45||| 20610|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Blue Cross PPO Specialty|BCBSTX OTHER|||||309.17||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|Blue Cross PPO Specialty|BCBSTX PPO|1,013.73||||21.86||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|PHCS|GROUP AND PENSION|||||309.17||| 20610|EAP|0361||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Blue Cross PPO Specialty|BCBSTX PPO|||||309.17||| 20610|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|1,013.73||||7.42||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Blue Cross PPO Specialty|BCBSTX PPO|1,013.73||||1,084.45||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|PHCS|HUMANA|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Blue Cross PPO Specialty|BCBSTX OTHER|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||309.17||| 20610|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|1,084.45||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Blue Cross HMO Specialty|BCBSTX HMO|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Tricare|TRICARE EAST REGION|||||309.17||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Aetna|AETNA PPO|||||9.43||| 20610|EAP|0361||Aetna|AETNA OTHER|||||7.42||| 20610|EAP|0361||Aetna|AETNA PPO|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Aetna|AETNA OTHER|||||309.17||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,084.45||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Aetna|AETNA PPO|||||309.17||| 20610|EAP|0361||United Healthcare|AARP|||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|United Healthcare|UNITED HEALTHCARE OTHER|||||309.17||| 20610|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,084.45||||7.42||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Blue Cross HMO Specialty|BCBSTX HMO|||||309.17||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||309.17||| 20610|EAP|0361|XR-DRAIN/INJ JOINT/BURSA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,084.45||||1,084.45||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Blue Cross PPO Specialty|BCBSTX PPO|||||309.17||| 20610|EAP|0361||Aetna Value Network|AETNA VALUE NETWORK|||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||309.17||| 20610|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||7.42||| 20610|EAP|0510|DRAIN/INJECT JOINT/BURSA|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||309.17||| 20610|EAP|0361|DRAIN/INJ JOINT/BURSA W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,084.45||||2,513.90||| 20610|EAP|0510|DRAIN/INJ MAJOR JOINT/BUR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||309.17||| 20610|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.42||| 20611|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.42||| 20611|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.42||| 20611|EAP|0510|DRAIN/INJ JOINT/BURSA W/U|Medicare|MEDICARE ACUTE|||||309.17||| 20611|EAP|0361||Medicare|MEDICARE ACUTE|||||7.42||| 20611|EAP|0361||Tricare|TRICARE EAST REGION|||||7.42||| 20680|EAP|0981|REMOVAL OF IMPLANT; DEEP|United Healthcare|UNITED HEALTHCARE OTHER|||||21.32||| 20680|EAP|0981|REMOVAL OF IMPLANT; DEEP|ChampVA|CHAMPVA CENTER|||||21.32||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Blue Cross HMO Specialty|BCBSTX HMO|437,870.31||||||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Veterans Affairs|VETERANS ADMINISTRATION|495,367.03|39362.29|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Workers Compensation|TEXAS MUTUAL INSURANCE|362,112.02|56288.08|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Workers Compensation|WORKERS COMPENSATION OTHER|315,725.39|56288.08|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|941,556.11|55877.65|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Blue Cross PPO Specialty|BCBSTX PPO|337,748.17|1570.94|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Managed Medicare|HEALTHSPRING MA|417,129.62|33487.81|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Managed Medicare|BCBS MEDICARE PPO MA|491,950.63|32728.96|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Managed Medicaid|MEDICAID SUPERIOR|451,905.53|39566.625|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|245,192.53|40356.36|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Access Direct Platinum|HEALTHFIRST TPA UMR|527,865.50|54773.99|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|628,590.67|48531.215|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|252,757.84|285.76|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Humana Medicare Advantage|HUMANA MA|283,063.43|32750.56|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Medicare|MEDICARE ACUTE|321,797.99|33418.46|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Medicaid|COUNTY INDIGENT HEALTH OTHER|842,281.41|30102.89|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Medicaid|MEDICAID|252,592.32|27742.125|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Tricare|TRICARE EAST REGION|219,891.70|43644.2|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|United Healthcare|UNITED HEALTHCARE|300,424.99|87920.56|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|UTMB|UTMB CORRECTIONAL MANAGED CARE|216,862.68|39264.39|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|United Healthcare|UNITED HEALTHCARE OTHER|657,504.70|113678.56|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|United Medicare Advantage|UHC MEDICARE GOLD MA|372,209.80|33418.46|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|385,985.87|32728.96|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Rusk State Hospital|RUSK STATE HOSP|616,094.09|301886.1|301886.1|285.76|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|United Medicare Advantage|UHC AARP MCR HMO MA|465,519.19|39362.29|301886.1|285.76|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|100,540.22|15057.545|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|United Medicare Advantage|UHC AARP MCR HMO MA|112,242.04|15200.04|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|United Medicare Advantage|UHC MEDICARE GOLD MA|130,062.28|14914.17|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|United Healthcare|UNITED HEALTHCARE|227,619.35|32263.81|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|United Healthcare|UNITED HEALTHCARE|2,973.31|29401.81|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Tricare|TRICARE EAST REGION|67,037.50|11155.06|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|PHCS|HUMANA|136,286.96|940.38|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|United Healthcare|UNITED HEALTHCARE OTHER|324,061.27|52297.81|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Medicaid|MOLINA HEALTHCARE OF TEXAS|72,565.44|11788.98|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Medicaid|MEDICAID|162,071.14|11788.98|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Medicaid|COUNTY INDIGENT HEALTH OTHER|117,081.25|11788.98|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|130,956.25|130956.25|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Medicare|MEDICARE ACUTE|123,603.32|14915.05|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|NON CONTRACTED|COMMERCIAL OTHER 1|125,239.21|125239.21|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Humana Medicare Advantage|HUMANA MA|109,061.75|14919.39|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Managed Medicaid|MEDICAID AMERIGROUP|16,841.75|7041.99|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Managed Medicaid|MEDICAID SUPERIOR|206,189.86|19310.24|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118,886.13|18342.465|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|UTMB|UTMB CORRECTIONAL MANAGED CARE|83,261.69|16288.98|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|104,243.50|18744.48|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Managed Medicare|HEALTHSPRING MA|163,513.04|14914.61|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Managed Medicare|WELLCARE CHOICE MA|133,310.93|17774.34|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|157,394.38|14914.61|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Aetna|AETNA PPO|134,220.01|31423.87|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Blue Cross HMO Specialty|BCBSTX HMO|101,561.55|13247.84|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|79,754.63|107.16|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Aenta Medicare Advantage|AETNA MEDICARE MA|69,074.60|14900.53|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Access Direct Platinum|HEALTHFIRST TPA UMR|983.73|18759.68|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Blue Cross PPO Specialty|BCBSTX PPO|109,152.81|16549.95|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|214,852.95|26690.08|130956.25|107.16|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Veterans Affairs|VETERANS ADMINISTRATION|137,435.10|14915.05|130956.25|107.16|||| 21|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W CC|Humana Medicare Advantage|HUMANA MA|475,577.65|46688.85|50685.97|46688.85|||| 21|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W CC|Veterans Affairs|VETERANS ADMINISTRATION|718,985.07|50685.97|50685.97|46688.85|||| 21|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W CC|Medicare|MEDICARE ACUTE|187,147.12|47639.63|50685.97|46688.85|||| 21|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W CC|United Medicare Advantage|UHC AARP MCR HMO MA|441,836.37|47639.63|50685.97|46688.85|||| 21085|EAP|0981|TRAUMA PHYSICIAN CHARGE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||33.02||| 21310|EAP|0981|TRAUMA PHYSICIAN CHARGE|Medicare|MEDICARE ACUTE|||||435.25||| 21320|EAP|0981|CLSD TX NASAL BONE FX|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,684.25||| 21320|EAP|0981|CLOSED TX NASAL FX W/S|Blue Cross PPO Specialty|BCBSTX PPO|||||1,725.25||| 21320|EAP|0981|CLSD TX NASAL BONE FX|Blue Cross PPO Specialty|BCBSTX PPO|||||1,684.25||| 21320|EAP|0450|TREAT NOSE FRACTURE|Workers Compensation|WORKERS COMPENSATION OTHER|||||27.32||| 21320|EAP|0981|CLSD TX NASAL BONE FX|Medicare|MEDICARE ACUTE|||||1,684.25||| 21336|EAP|0981|OPEN TX SEPTAL FX W/WO ST|Blue Cross PPO Specialty|BCBSTX PPO|||||2,641.75||| 21337|EAP|0981|CLSD TX NASAL SEPTAL FX|Access Direct Platinum|HEALTHFIRST TPA UMR|||||18.16||| 21337|EAP|0981|CLSD TX NASAL SEPTAL FX|Cigna|CIGNA|||||18.16||| 21337|EAP|0981|CLSD TX NASAL SEPTAL FX|Blue Cross PPO Specialty|BCBSTX PPO|||||18.16||| 21356|EAP|0981|OPEN TX ZYGOMATIC ARCH FX|Cigna|CIGNA OTHER|||||3,752.25||| 21365|EAP|0981|OPEN TX COMP FX MALAR W F|NON CONTRACTED|COMMERCIAL OTHER 1|||||7,482.50||| 21365|EAP|0981|OPEN TX COMP FX MALAR W F|Medicare|MEDICARE ACUTE|||||7,482.50||| 21365|EAP|0981|OPEN TX COMP FX MALAR W F|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,482.50||| 21365|EAP|0981|OPEN TX COMP FX MALAR W F|Blue Cross PPO Specialty|BCBSTX PPO|||||7,482.50||| 21365|EAP|0981|OPEN TX COMP FX MALAR W F|Managed Medicaid|MEDICAID SUPERIOR|||||7,482.50||| 21390|EAP|0981|OPEN TX ORBITAL FLR FX BL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||64.02||| 21390|EAP|0981|OPEN TX ORBITAL FLR FX BL|Cigna|CIGNA OTHER|||||64.02||| 21390|EAP|0981|OPEN TX ORBITAL FLR FX BL|Managed Medicaid|MEDICAID SUPERIOR|||||64.02||| 21390|EAP|0981|OPEN TX ORBIT PERIORBIT I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6,356.50||| 21390|EAP|0981|OPEN TX ORBITAL FLR FX BL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||64.02||| 21390|EAP|0981|OPEN TX ORBITAL FLR FX BL|Blue Cross PPO Specialty|BCBSTX PPO|||||64.02||| 21390|EAP|0981|OPEN TX ORBITAL FLR FX BL|Workers Compensation|TEXAS MUTUAL INSURANCE|||||64.02||| 21390|EAP|0981|OPEN TX ORBITAL FLR FX BL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||64.02||| 21406|EAP|0981|OPEN TX ORBITAL FX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5,266.75||| 21407|EAP|0981|OPEN TX ORBIT FX W IMPLAN|Blue Cross PPO Specialty|BCBSTX PPO|||||5,778.75||| 21407|EAP|0981|OPEN TX ORBIT FX W IMPLAN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5,778.75||| 21407|EAP|0981|OPEN TX ORBIT FX W IMPLAN|Workers Compensation|TEXAS MUTUAL INSURANCE|||||5,778.75||| 21422|EAP|0981|OPEN TX PALATAL/MAXILLARY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,266.75||| 21422|EAP|0981|OPEN TX PALATAL/MAXILLARY|Humana Medicare Advantage|HUMANA MA|||||5,266.75||| 21423|EAP|0981|OPEN REDUCT MAXILLA W RF|Medicare|MEDICARE ACUTE|||||5,993.75||| 21423|EAP|0981|OPEN REDUCT MAXILLA W RF|Cigna|CIGNA|||||5,993.75||| 21423|EAP|0981|OPEN REDUCT MAXILLA W RF|Blue Cross PPO Specialty|BCBSTX PPO|||||5,993.75||| 21440|EAP|0981|CLSD TX MANDIBULAR RIDGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,898.75||| 21440|EAP|0981|CLSD TX MANDIBULAR RIDGE|Managed Medicare|HEALTHSPRING MA|||||1,898.75||| 21440|EAP|0981|CLSD TX MANDIBULAR RIDGE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,898.75||| 21440|EAP|0981|CLSD TX MANDIBULAR RIDGE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,898.75||| 21450|EAP|0981|CLSD TX MANDIBULAR FX W/O|Blue Cross PPO Specialty|BCBSTX PPO|||||23.61||| 21451|EAP|0981|CLSD TX MANDIBULAR FX W M|Medicaid|SMITH COUNTY JAIL|||||3,450.75||| 21453|EAP|0981|CLSD TX MANDIBLE FX W FIX|Cigna|CIGNA OTHER|||||44.50||| 21453|EAP|0981|CLSD TX MANDIBLE FX W FIX|Blue Cross PPO Specialty|BCBSTX PPO|||||44.50||| 21461|EAP|0981|OPEN TX MANDIBULAR FX W/O|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5,902.50||| 21461|EAP|0981|OPEN TX MANDIBULAR FX W/O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||61.54||| 21461|EAP|0981|OPEN TX MANDIBULAR FX W/O|Blue Cross PPO Specialty|BCBSTX PPO|||||61.54||| 21461|EAP|0981|OPEN TX MANDIBULAR FX W/O|Aenta Medicare Advantage|AETNA MEDICARE MA|||||61.54||| 21462|EAP|0981|ORIF MANDIBULAR FX W/IM|Humana Medicare Advantage|HUMANA MA|||||72.65||| 21462|EAP|0981|ORIF MANDIBULAR FX W/IM|Blue Cross HMO Specialty|BCBSTX HMO|||||72.65||| 21462|EAP|0981|ORIF MANDIBULAR FX W/IM|Blue Cross PPO Specialty|BCBSTX PPO|||||72.65||| 21462|EAP|0981|ORIF MANDIBULAR FX W/IM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||72.65||| 21462|EAP|0981|ORIF MANDIBULAR FX W/IM|Aetna|AETNA PPO|||||72.65||| 21462|EAP|0981|ORIF MANDIBULAR FX W/IM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||72.65||| 21462|EAP|0981|ORIF MANDIBULAR FX W/IM|Medicaid|SMITH COUNTY JAIL|||||72.65||| 21462|EAP|0981|OPEN TX MANDIBULAR FX W F|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||6,381.75||| 21470|EAP|0981|OPEN TX COMP MANDIBULAR F|Workers Compensation|WORKERS COMPENSATION OTHER|||||9,625.50||| 21470|EAP|0981|OPEN TX COMP MANDIBULAR F|Veterans Affairs|VETERANS ADMINISTRATION|||||9,625.50||| 21470|EAP|0981|OPEN TX COMP MANDIBULAR F|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9,625.50||| 21470|EAP|0981|OPEN TX COMP MANDIBULAR F|Managed Medicaid|MEDICAID SUPERIOR|||||9,625.50||| 215|DRG||OTHER HEART ASSIST SYSTEM IMPLANT|Medicare|MEDICARE ACUTE|184,314.69|72738.775|126397.58|272.16|||| 215|DRG||OTHER HEART ASSIST SYSTEM IMPLANT|Humana Medicare Advantage|HUMANA MA|672,419.02|81822.165|126397.58|272.16|||| 215|DRG||OTHER HEART ASSIST SYSTEM IMPLANT|Managed Medicare|HEALTHSPRING MA|413,479.12|71966.12|126397.58|272.16|||| 215|DRG||OTHER HEART ASSIST SYSTEM IMPLANT|Blue Cross HMO Specialty|BCBSTX HMO|219,362.87|272.16|126397.58|272.16|||| 215|DRG||OTHER HEART ASSIST SYSTEM IMPLANT|Veterans Affairs|VETERANS ADMINISTRATION|488,134.63|72738.335|126397.58|272.16|||| 215|DRG||OTHER HEART ASSIST SYSTEM IMPLANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|274,445.51|126397.58|126397.58|272.16|||| 21550|EAP|0360|CT-BIOPSY OF NECK/CHEST|United Medicare Advantage|UHC MEDICARE GOLD MA|2,950.90||||||| 21550|EAP|0360|CT-BIOPSY OF NECK/CHEST|Aetna|AETNA PPO|||||2,950.90||| 21550|EAP|0360|CT-BIOPSY OF NECK/CHEST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,758.45||| 21550|EAP|0360|CT-BIOPSY OF NECK/CHEST|Humana Medicare Advantage|HUMANA MA|||||2,950.90||| 21550|EAP|0360|CT-BIOPSY OF NECK/CHEST|Medicare|MEDICARE ACUTE|2,950.90||||||| 21550|EAP|0360|CT-BIOPSY OF NECK/CHEST|Medicaid|MEDICAID|25.66||||||| 21550|EAP|0360|CT-BIOPSY OF NECK/CHEST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||25.66||| 216|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC|Medicaid|SMITH COUNTY INDIGENT HEALTH|257,934.60|26736.83|255714.86|500.08|||| 216|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC|Medicare|MEDICARE ACUTE|234,138.07|52007.35|255714.86|500.08|||| 216|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC|Blue Cross PPO Specialty|BCBSTX PPO|294,374.27|785.47|255714.86|500.08|||| 216|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|347,981.10|500.08|255714.86|500.08|||| 216|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC|Aetna|AETNA QHP HMO|659,833.60|255714.86|255714.86|500.08|||| 216|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|402,875.77|52656.225|255714.86|500.08|||| 218|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W/O CC/MCC|Medicare|MEDICARE ACUTE|206,171.59|30923.24|30923.24|30923.24|||| 219|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|269,181.69|42511.56|45210.13|39624.47|||| 219|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC|Managed Medicare|BCBS MEDICARE PPO MA|249,762.82|40329.66|45210.13|39624.47|||| 219|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC|Managed Medicare|HEALTHSPRING MA|358,618.63|45210.13|45210.13|39624.47|||| 219|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|217,516.05|39624.47|45210.13|39624.47|||| 219|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC|Medicare|MEDICARE ACUTE|267,440.98|43522.37|45210.13|39624.47|||| 22|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|174,146.35|28346.39|28346.39|340.2|||| 22|DRG||INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|275,331.77|340.2|28346.39|340.2|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|United Medicare Advantage|UHC AARP MCR HMO MA|161,462.48|26054.92|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Medicare|MEDICARE ACUTE|206,832.31|30398.31|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|216,082.29|30397.03|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|184,239.35|30398.31|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Humana Medicare Advantage|HUMANA MA|193,802.48|28534.35|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Cigna|CIGNA|186,146.27|70702.71|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|169,710.05|42974.935|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Blue Cross PPO Specialty|BCBSTX PPO|252,973.63|561.05|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Aetna|AETNA OTHER|188,513.10|75107.72|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Blue Cross HMO Specialty|BCBSTX HMO|179,862.88|30044.99|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|169,970.05|142.88|75107.72|142.88|||| 220|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|197,798.05|51639.93|75107.72|142.88|||| 221|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|191,792.67|49305.125|50585.02|26474.94|||| 221|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC|Cigna|CIGNA|145,717.19|50585.02|50585.02|26474.94|||| 221|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|207,730.10|26474.94|50585.02|26474.94|||| 221|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC|Tricare|TRICARE EAST REGION|159,656.58|28334.36|50585.02|26474.94|||| 221|DRG||CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC|Medicare|MEDICARE ACUTE|194,022.65|26503.96|50585.02|26474.94|||| 222|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|361,406.73|361406.73|361406.73|785.47|||| 222|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W MCC|Blue Cross PPO Specialty|BCBSTX PPO|584,996.60|1795.36|361406.73|785.47|||| 222|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W MCC|Blue Cross PPO Specialty|BCBSTX OTHER|282,854.93|785.47|361406.73|785.47|||| 222|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|243,873.76|64723.79|361406.73|785.47|||| 223|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W/O MCC|Humana Medicare Advantage|HUMANA MA|482.75|57.53|27517.12|57.53|||| 223|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W/O MCC|Medicaid|MEDICAID|303,296.99|27517.12|27517.12|57.53|||| 224|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|222,043.30|42722.94|42722.94|242.39|||| 224|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC|Medicare|MEDICARE ACUTE|263,095.85|41868.94|42722.94|242.39|||| 224|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC|Veterans Affairs|VETERANS ADMINISTRATION|191,686.15|42295.72|42722.94|242.39|||| 224|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|247,136.44|242.39|42722.94|242.39|||| 224|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC|Humana Medicare Advantage|HUMANA MA|320,957.67|42722.94|42722.94|242.39|||| 225|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W/O MCC|Medicare|MEDICARE ACUTE|241,944.96|32932.1|64723.79|32281.17|||| 225|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W/O MCC|Humana Medicare Advantage|HUMANA MA|320,734.33|32281.17|64723.79|32281.17|||| 225|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|174,408.03|32932.1|64723.79|32281.17|||| 225|DRG||CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|332,422.82|64723.79|64723.79|32281.17|||| 226|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|239,342.08|38753.13|90575.87|125.02|||| 226|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|174,342.05|38753.13|90575.87|125.02|||| 226|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC|Medicare|MEDICARE ACUTE|232,302.26|38353.285|90575.87|125.02|||| 226|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|173,263.02|90575.87|90575.87|125.02|||| 226|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC|Veterans Affairs|VETERANS ADMINISTRATION|466,503.18|37980.72|90575.87|125.02|||| 226|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC|Humana Medicare Advantage|HUMANA MA|318,404.57|38371.285|90575.87|125.02|||| 226|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|358,968.55|37980.72|90575.87|125.02|||| 226|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|211,885.01|125.02|90575.87|125.02|||| 226|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC|Blue Cross PPO Specialty|BCBSTX PPO|3,834.08|1078.9|90575.87|125.02|||| 227|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|192,049.90|43752.23|43752.23|107.16|||| 227|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC|Humana Medicare Advantage|HUMANA MA|156,176.13|15024.61|43752.23|107.16|||| 227|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|342,816.12|30581.06|43752.23|107.16|||| 227|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|190,244.75|107.16|43752.23|107.16|||| 227|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC|Medicare|MEDICARE ACUTE|228,709.93|29963.8|43752.23|107.16|||| 227|DRG||CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|242,085.75|30581.06|43752.23|107.16|||| 228|DRG||OTHER CARDIOTHORACIC PROCEDURES W MCC|Medicare|MEDICARE ACUTE|306,358.37|35778.11|46867.21|35778.11|||| 228|DRG||OTHER CARDIOTHORACIC PROCEDURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|703,587.75|46867.21|46867.21|35778.11|||| 228|DRG||OTHER CARDIOTHORACIC PROCEDURES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|195,734.52|35778.11|46867.21|35778.11|||| 228|DRG||OTHER CARDIOTHORACIC PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|158,248.69|36504.06|46867.21|35778.11|||| 229|DRG||OTHER CARDIOTHORACIC PROCEDURES W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|135,610.70|21518.02|23808.92|21518.02|||| 229|DRG||OTHER CARDIOTHORACIC PROCEDURES W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|1,370.20|23808.92|23808.92|21518.02|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Medicaid|MEDICAID|291,026.50|46327.5|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Medicare|MEDICARE ACUTE|150,749.92|32105.99|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|United Healthcare|UNITED HEALTHCARE OTHER|140,858.76|470.02|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|United Medicare Advantage|UHC AARP MCR HMO MA|226,945.53|32754.5|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|345,268.04|32432.405|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|United Healthcare|TML GROUP BENEFITS|163,645.69|664.84|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Veterans Affairs|VETERANS ADMINISTRATION|225,021.05|32105.99|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Aenta Medicare Advantage|AETNA MEDICARE MA|236,930.12|32078.71|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Blue Cross PPO Specialty|BCBSTX PPO|167,280.80|37074.08|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|222,471.45|194.76|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Blue Cross HMO Specialty|BCBSTX HMO|183,643.68|26473.85|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Managed Medicare|HEALTHSPRING MA|182,743.90|32106.87|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Managed Medicare|BCBS MEDICARE PPO MA|135,620.66|32754.5|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|150,020.65|32754.5|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Humana Medicare Advantage|HUMANA MA|181,002.04|32100.395|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Cigna|CIGNA|127,092.56|57799.96|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|498,558.22|45773.275|57799.96|194.76|||| 23|DRG||CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|508,381.75|43181.81|57799.96|194.76|||| 23066|EAP|0361|CT-BIOPSY SHOULDER TISSUE|United Healthcare|UNITED HEALTHCARE|||||64.01||| 231|DRG||CORONARY BYPASS W PTCA W MCC|Humana Medicare Advantage|HUMANA MA|297,929.57|46344.44|48478.45|897.68|||| 231|DRG||CORONARY BYPASS W PTCA W MCC|Blue Cross HMO Specialty|BCBSTX HMO|510,073.85|48478.45|48478.45|897.68|||| 231|DRG||CORONARY BYPASS W PTCA W MCC|Blue Cross PPO Specialty|BCBSTX PPO|279,288.96|897.68|48478.45|897.68|||| 232|DRG||CORONARY BYPASS W PTCA W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|217,644.36|34824.27|41829.12|34824.27|||| 232|DRG||CORONARY BYPASS W PTCA W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|235,556.59|41829.12|41829.12|34824.27|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|Veterans Affairs|VETERANS ADMINISTRATION|279,480.91|44811.2|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|Managed Medicare|HEALTHSPRING MA|317,309.65|43913.62|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|Managed Medicaid|MEDICAID AMERIGROUP|195,592.47|34770.01|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|Humana Medicare Advantage|HUMANA MA|324,041.06|43883.4|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|Aetna|AETNA PPO|201,875.86|98276.59|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|264,783.94|410.78|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|Blue Cross PPO Specialty|BCBSTX PPO|251,151.35|102714.79|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|Medicare|MEDICARE ACUTE|284,416.19|43913.62|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|Medicaid|MEDICAID|265,473.27|20154.97|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|United Healthcare|UNITED HEALTHCARE OTHER|182,981.03|182981.03|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|278,637.77|44811.2|182981.03|410.78|||| 233|DRG||CORONARY BYPASS W CARDIAC CATH W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|285,476.97|42057.91|182981.03|410.78|||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Medicare|MEDICARE ACUTE|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|United Healthcare|UNITED HEALTHCARE OTHER|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|United Healthcare|UNITED HEALTHCARE|||||1,143.74||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|United Healthcare|UNITED HEALTHCARE|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Tricare|TRICARE EAST REGION|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||11.11||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Blue Cross PPO Specialty|BCBSTX PPO|||||11.11||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Managed Medicare|HEALTHSPRING MA|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Blue Cross HMO Specialty|BCBSTX HMO|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Aetna|AETNA PPO|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,143.74||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Cigna|CIGNA|||||11.11||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Humana Medicare Advantage|HUMANA MA|||||11.11||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Managed Medicaid|MEDICAID SUPERIOR|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Veterans Affairs|VETERANS ADMINISTRATION|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||11.11||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Workers Compensation|WORKERS COMPENSATION OTHER|||||11.11||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||11.11||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,176.47||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|Workers Compensation|UT EMPLOYEE INJURY|||||1,143.74||| 23350|EAP|0361|XR-INJECTION FOR SHOULDER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11.11||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Managed Medicare|HEALTHSPRING MA|201,199.90|29852.66|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|226,915.73|28212.445|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Cigna|CIGNA OTHER|249,583.87|122387.56|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Cigna|CIGNA|187,577.25|44658.69|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Humana Medicare Advantage|HUMANA MA|204,066.82|30153.885|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|206,228.84|214.32|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Blue Cross PPO Specialty|BCBSTX OTHER|338,716.60|1122.1|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|191,241.33|34949.49|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|271,898.70|29824.5|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|162,709.18|41080.83|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Medicare|MEDICARE ACUTE|181,848.83|25973.03|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Medicaid|MEDICAID|174,807.70|21867.93|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|United Healthcare|UNITED HEALTHCARE|199,229.37|61621.77|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|218,764.18|27898.325|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|181,175.80|181175.8|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|United Healthcare|UNITED HEALTHCARE|279,683.50|30515.7|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|235,646.87|29738.86|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|242,891.82|29824.5|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|163,706.95|22444.81|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|227,611.40|29861.46|207141.3|214.32|||| 234|DRG||CORONARY BYPASS W CARDIAC CATH W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|207,141.30|207141.3|207141.3|214.32|||| 235|DRG||CORONARY BYPASS W/O CARDIAC CATH W MCC|Medicare|MEDICARE ACUTE|179,889.28|24285.92|24285.92|428.64|||| 235|DRG||CORONARY BYPASS W/O CARDIAC CATH W MCC|Blue Cross PPO Specialty|BCBSTX PPO|287,747.49|1234.31|24285.92|428.64|||| 235|DRG||CORONARY BYPASS W/O CARDIAC CATH W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|384,160.54|428.64|24285.92|428.64|||| 23500|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.04||| 23500|EAP|0361||Cigna|CIGNA|||||6.04||| 23500|EAP|0510|TREAT CLAVICLE FRACTURE|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 23500|EAP|0510|TREAT CLAVICLE FRACTURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||251.67||| 23500|EAP|0510|TREAT CLAVICLE FRACTURE|Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 23500|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 23500|EAP|0510|TREAT CLAVICLE FRACTURE|Blue Cross HMO Specialty|BCBSTX HMO|||||251.67||| 23500|EAP|0510|TREAT CLAVICLE FRACTURE|Medicare|MEDICARE ACUTE|||||251.67||| 23500|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 23500|EAP|0510|TREAT CLAVICLE FRACTURE|United Healthcare|UNITED HEALTHCARE OTHER|||||251.67||| 23500|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.04||| 23500|EAP|0510|TREAT CLAVICLE FRACTURE|Managed Medicare|HEALTHSPRING MA|||||251.67||| 23500|EAP|0361||Medicaid|MEDICAID|||||6.04||| 23570|EAP|0510|TREAT SHOULDER BLADE FX W|Managed Medicare|HEALTHSPRING MA|||||251.67||| 23570|EAP|0510|TREAT SHOULDER BLADE FX W|Medicare|MEDICARE ACUTE|||||251.67||| 23570|EAP|0510|TREAT SHOULDER BLADE FX W|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||251.67||| 23575|EAP|0450|TREAT SHOULDER BLADE FX|Managed Medicaid|MEDICAID AMERIGROUP|||||29.89||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|136,975.02|22662.6|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|139,793.96|170.1|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|151,320.94|26659.58|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|151,156.60|32046.4|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Cigna|CIGNA|150,023.31|44362.69|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Humana Medicare Advantage|HUMANA MA|129,873.43|23363.29|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Cigna|CIGNA OTHER|133,259.57|44306.69|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Managed Medicare|HEALTHSPRING MA|136,180.49|23392.1|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|158,386.98|35546.125|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|United Healthcare|UNITED HEALTHCARE|156,356.86|47688.43|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|183,072.13|23613.31|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|123,367.95|19707.41|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|PHCS|GROUP AND PENSION|125,982.55|86927.96|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Medicare|MEDICARE ACUTE|145,140.55|23392.1|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|154,703.89|154703.89|154703.89|170.1|||| 236|DRG||CORONARY BYPASS W/O CARDIAC CATH W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|174,689.65|32487.64|154703.89|170.1|||| 23600|EAP|0510|TREAT HUMERUS FRACTURE W/|Humana Medicare Advantage|HUMANA MA|||||251.67||| 23600|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||6.04||| 23600|EAP|0510|TREAT HUMERUS FRACTURE W/|Aenta Medicare Advantage|AETNA MEDICARE MA|||||251.67||| 23600|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.04||| 23600|EAP|0510|TREAT HUMERUS FRACTURE W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||251.67||| 23600|EAP|0510|TREAT HUMERUS FRACTURE W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||251.67||| 23600|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.04||| 23600|EAP|0510|TREAT HUMERUS FRACTURE W/|Medicaid|MEDICAID HMO|||||251.67||| 23600|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 23600|EAP|0510|TREAT HUMERUS FRACTURE W/|Medicare|MEDICARE ACUTE|||||251.67||| 23605|EAP|0450|TX FX PROX HUMERUS W MANI|Medicare|MEDICARE ACUTE|||||39.67||| 23620|EAP|0361|TREAT HUMERUS FX W/O MANI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.04||| 23620|EAP|0361|TREAT HUMERUS FX W/O MANI|Medicare|MEDICARE ACUTE|||||6.04||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Access Direct Platinum|HEALTHFIRST TPA UMR|||||10.73||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,233.95||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||10.73||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,233.95||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,233.95||||||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Aenta Medicare Advantage|AETNA MEDICARE MA|||||10.73||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Blue Cross HMO Specialty|BCBSTX HMO|1,233.95||||||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Blue Cross PPO Specialty|BCBSTX PPO|||||1,233.95||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Managed Medicaid|MEDICAID AMERIGROUP|10.73||||1,233.95||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,233.95||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Humana Medicare Advantage|HUMANA MA|||||10.73||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|United Healthcare|UNITED HEALTHCARE OTHER|1,233.95||||||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||10.73||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|NON CONTRACTED|COMMERCIAL OTHER 1|||||10.73||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Medicare|MEDICARE ACUTE|1,153.48||||1,233.95||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||10.73||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Medicare|MEDICARE ACUTE|150,848.27|26907.74|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Medicaid|MEDICAID|265,712.02|24863.11|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|278,597.83|27366.44|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|65,226.48|24230.99|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|420,587.71|33843.59|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Humana Medicare Advantage|HUMANA MA|163,127.14|24448.255|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|207,724.26|26284.34|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|367,540.20|38992.55|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Managed Medicare|HEALTHSPRING MA|358,347.89|26897.23|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|124,549.29|31276.745|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|131,573.15|306.18|38992.55|306.18|||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|148,482.30|34598.43|38992.55|306.18|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|67,475.95|23786.21|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Aetna|AETNA PPO|88,087.17|135.63|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|163,327.77|22622.78|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Blue Cross PPO Specialty|BCBSTX OTHER|396,715.28|1907.57|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|470,348.12|25274.79|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Managed Medicare|HEALTHSPRING MA|112,538.18|23555.025|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|92,876.03|25694.63|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Humana Medicare Advantage|HUMANA MA|114,031.58|23786.21|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|130,031.45|130031.45|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|117,397.30|23060.9|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|88,778.57|20570.28|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|158,500.60|23256.89|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Medicaid|MEDICAID|471,192.58|27158.37|130031.45|135.63|||| 24|DRG||CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC|Medicare|MEDICARE ACUTE|125,904.47|23250.59|130031.45|135.63|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|Medicare|MEDICARE ACUTE|79,185.99|16428.13|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|Medicaid|MEDICAID|84,497.39|8499.95|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|United Medicare Advantage|UHC AARP MCR HMO MA|261,869.41|16745.94|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|124,456.80|16439.85|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|Humana Medicare Advantage|HUMANA MA|158,872.85|16399.8|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97,131.36|13348.515|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|Managed Medicaid|MEDICAID AMERIGROUP|194,417.64|21376.91|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|323,059.45|13182.12|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|Blue Cross PPO Specialty|BCBSTX PPO|93,198.27|18637.87|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|190,303.15|446.5|29233.54|446.5|||| 240|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|129,395.92|29233.54|29233.54|446.5|||| 241|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|107,807.92|9777.38|9777.38|9777.38|||| 241|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W/O CC/MCC|Medicare|MEDICARE ACUTE|235,226.21|9777.38|9777.38|9777.38|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|114,136.25|43091.21|52152.69|21644.44|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|Blue Cross PPO Specialty|BCBSTX PPO|103,784.76|25373.55|52152.69|21644.44|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|Managed Medicare|HEALTHSPRING MA|193,031.42|22075.01|52152.69|21644.44|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|201,706.41|22075.01|52152.69|21644.44|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180,642.82|52152.69|52152.69|21644.44|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|Humana Medicare Advantage|HUMANA MA|170,786.20|21644.44|52152.69|21644.44|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|Medicare|MEDICARE ACUTE|121,788.48|22075.01|52152.69|21644.44|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|147,179.26|22075.01|52152.69|21644.44|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|206,707.65|22075.01|52152.69|21644.44|||| 242|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|186,640.45|21861.505|52152.69|21644.44|||| 24220|EAP|0361|XR-INJECTION FOR ELBOW AR|Aetna|AETNA PPO|||||13.52||| 243|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|98,891.08|15307.67|15519.31|68.04|||| 243|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W CC|United Medicare Advantage|UHC AARP MCR HMO MA|249,552.93|15453.87|15519.31|68.04|||| 243|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|161,751.89|15453.87|15519.31|68.04|||| 243|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W CC|Medicare|MEDICARE PART B ONLY IP|54,881.07|15519.31|15519.31|68.04|||| 243|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W CC|Medicare|MEDICARE ACUTE|107,099.48|15163.19|15519.31|68.04|||| 243|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|78,445.86|15172.95|15519.31|68.04|||| 243|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W CC|Humana Medicare Advantage|HUMANA MA|107,908.91|15453.87|15519.31|68.04|||| 243|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|79,210.25|68.04|15519.31|68.04|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|110,743.09|12183.54|37602.62|12183.54|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|89,704.95|12671.49|37602.62|12183.54|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|58,940.30|12644.21|37602.62|12183.54|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|Cigna|CIGNA|128,374.65|37602.62|37602.62|12183.54|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|74,560.65|12910.07|37602.62|12183.54|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|97,350.46|31178.9|37602.62|12183.54|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|91,923.81|12910.07|37602.62|12183.54|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|Medicare|MEDICARE ACUTE|74,759.98|12672.37|37602.62|12183.54|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|73,681.22|24564.43|37602.62|12183.54|||| 244|DRG||PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|70,697.25|12652.01|37602.62|12183.54|||| 245|DRG||AICD GENERATOR PROCEDURES|UTMB|UTMB CORRECTIONAL MANAGED CARE|127,230.50|29775.23|29775.23|178.6|||| 245|DRG||AICD GENERATOR PROCEDURES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|168,119.14|178.6|29775.23|178.6|||| 24500|EAP|0510|TREAT HUMERUS SHAFT FX W/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||251.67||| 24500|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.04||| 24500|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 24505|EAP|0450|TX FX HUMERUS W MANIP|Medicare|MEDICARE ACUTE|||||3,437.35||| 24505|EAP|0450|TX FX HUMERUS W MANIP|Workers Compensation|TEXAS MUTUAL INSURANCE|29.89||||||| 24530|EAP|0361|CL TREAT HUMERUS FRACTURE|Humana Medicare Advantage|HUMANA MA|||||251.67||| 24530|EAP|0361|CL TREAT HUMERUS FRACTURE|Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 24530|EAP|0361|CL TREAT HUMERUS FRACTURE|Managed Medicaid|MEDICAID AMERIGROUP|||||427.84||| 24530|EAP|0361|CL TREAT HUMERUS FRACTURE|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 24530|EAP|0361|CL TREAT HUMERUS FRACTURE|Blue Cross HMO Specialty|BCBSTX HMO|||||251.67||| 24530|EAP|0361|CL TREAT HUMERUS FRACTURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||251.67||| 24530|EAP|0361|CL TREAT HUMERUS FRACTURE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.04||| 24530|EAP|0361|CL TREAT HUMERUS FRACTURE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||251.67||| 24530|EAP|0361|CL TREAT HUMERUS FRACTURE|Medicaid|MEDICAID|||||251.67||| 24535|EAP|0450|TX FX SUPRATRANSCON HUMER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|29.89||||||| 24535|EAP|0450|TX FX SUPRATRANSCON HUMER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||29.89||| 24576|EAP|0510|TREAT HUMERUS CONDYLAR FX|Medicare|MEDICARE ACUTE|||||251.67||| 24576|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 24576|EAP|0510|TREAT HUMERUS CONDYLAR FX|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Veterans Affairs|VETERANS ADMINISTRATION|102,117.40|18693.3|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Access Direct Platinum|HEALTHFIRST TPA UMR|170,876.41|33768.1|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|137,081.55|29890.6|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Aenta Medicare Advantage|AETNA MEDICARE MA|162,939.99|19058.88|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Blue Cross PPO Specialty|BCBSTX PPO|125,462.15|21991.45|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Blue Cross PPO Specialty|BCBSTX OTHER|88,662.93|21991.45|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Aetna|AETNA OTHER|152,464.83|43929.39|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Aetna|AETNA PPO|104,600.12|18694.18|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Blue Cross HMO Specialty|BCBSTX HMO|122,042.50|18694.35|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|125,596.80|107.16|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Humana Medicare Advantage|HUMANA MA|121,713.85|18694.82|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|115,915.99|21334.975|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|114,683.48|19864.02|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Managed Medicare|HEALTHSPRING MA|207,829.57|19058.88|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|205,747.25|18666.02|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Medicaid|MEDICAID|227,264.86|19958.225|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Medicare|MEDICARE ACUTE|117,283.67|18694.18|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|United Medicare Advantage|UHC AARP MCR HMO MA|185,011.25|19058.88|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|United Medicare Advantage|UHC MEDICARE GOLD MA|147,886.98|18703.72|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|173,826.91|18700.02|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|United Healthcare|UNITED HEALTHCARE OTHER|273,487.31|60449.26|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|United Healthcare|UNITED HEALTHCARE|134,049.04|37553.26|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|PHCS|HUMANA|156,846.27|18692.98|60449.26|107.16|||| 246|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|NON CONTRACTED|COMMERCIAL OTHER 1|183,305.75|45041.51|60449.26|107.16|||| 24600|EAP|0510|TX DISLOC ELBOW WO ANESTH|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||242.80||| 24600|EAP|0450|TX DISLOC ELBOW WO ANESTH|Medicaid|SMITH COUNTY JAIL|||||11.21||| 24600|EAP|0450|TX DISLOC ELBOW WO ANESTH|Managed Medicare|BCBS MEDICARE PPO MA|||||11.21||| 24600|EAP|0450|TX DISLOC ELBOW WO ANESTH|Managed Medicaid|MEDICAID AMERIGROUP|||||1,289.15||| 24600|EAP|0510|TX DISLOC ELBOW WO ANESTH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||242.80||| 24600|EAP|0450|TX DISLOC ELBOW WO ANESTH|Aetna|AETNA PPO|||||11.21||| 24600|EAP|0450|TX DISLOC ELBOW WO ANESTH|Blue Cross PPO Specialty|BCBSTX PPO|||||1,289.15||| 24600|EAP|0450|TX DISLOC ELBOW WO ANESTH|Blue Cross HMO Specialty|BCBSTX HMO|11.21||||||| 24640|EAP|0450|TX RAD HD SUBLUX W MANIP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.91||| 24640|EAP|0450|TX RAD HD SUBLUX W MANIP|Managed Medicaid|MEDICAID AMERIGROUP|||||742.83||| 24650|EAP|0510|TREAT RADIUS FX H/N W/O M|Medicare|MEDICARE ACUTE|||||251.67||| 24650|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 24650|EAP|0510|TREAT RADIUS FX H/N W/O M|Tricare|TRICARE EAST REGION|||||251.67||| 24650|EAP|0510|TREAT RADIUS FX H/N W/O M|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 24650|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 24650|EAP|0510|TREAT RADIUS FX H/N W/O M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||251.67||| 24650|EAP|0510|TREAT RADIUS FX H/N W/O M|Humana Medicare Advantage|HUMANA MA|||||251.67||| 24650|EAP|0510|TREAT RADIUS FX H/N W/O M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||251.67||| 24650|EAP|0510|TREAT RADIUS FX H/N W/O M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||251.67||| 24655|EAP|0450|TREAT RADIUS FRACTURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,437.35||| 24655|EAP|0450|TREAT RADIUS FRACTURE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||29.89||| 24670|EAP|0361|CLD TX ULNAR FX PROXIMAL|Managed Medicaid|MEDICAID AMERIGROUP|||||427.84||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|105,959.66|12682.02|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95,981.81|12682.02|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|82,156.19|12647.29|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|United Healthcare|UNITED HEALTHCARE|97,016.99|24082.71|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|United Healthcare|TML GROUP BENEFITS|76,265.95|24082.71|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|88,034.80|24082.71|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Tricare|TRICARE FOR LIFE|73,313.22|13599.43|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|80,326.79|67294.21|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|49,422.75|10533.56|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Medicaid|MEDICAID|91,776.48|11955.59|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Medicaid|LAW ENFORCEMENT OTHER|61,752.50|12493.1|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Medicare|MEDICARE ACUTE|90,788.25|12449.05|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|95,583.67|12682.02|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|106,716.78|20590.14|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|892.24|19155.97|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|103,984.44|19274.255|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Tricare|TRICARE EAST REGION|85,658.55|14279.4|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Access Direct Platinum|HEALTHFIRST TPA|96,104.15|18160.51|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|136,400.15|22208.86|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|United Healthcare|UNITED HEALTHCARE|98,244.03|24082.71|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|97,178.20|18583.99|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|110,816.30|12420.89|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|79,432.78|11989.02|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|92,174.17|71.44|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|105,731.65|12452.29|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Aetna|AETNA PPO|80,134.33|27765.27|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Aetna|AETNA OTHER|163,808.93|30047.2|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Blue Cross PPO Specialty|BCBSTX OTHER|92,553.30|11989.02|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|92,294.25|14103.51|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|87,902.21|14103.51|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Cigna|CIGNA|124,883.56|24524.56|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Humana Medicare Advantage|HUMANA MA|82,945.25|12433.89|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|66,883.25|19864.02|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|84,876.20|18899.575|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Managed Medicare|HEALTHSPRING MA|96,704.66|12449.05|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|88,539.97|12434.97|67294.21|71.44|||| 247|DRG||PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|80,615.30|12433.57|67294.21|71.44|||| 248|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W NON-DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|100,875.09|18631.37|26030.63|18224.55|||| 248|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W NON-DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Humana Medicare Advantage|HUMANA MA|113,912.37|18265.66|26030.63|18224.55|||| 248|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W NON-DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Medicare|MEDICARE ACUTE|181,379.25|18274.61|26030.63|18224.55|||| 248|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W NON-DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|Medicaid|MEDICAID|924,613.62|26030.63|26030.63|18224.55|||| 248|DRG||PERCUTANEOUS CARDIOVASCULAR PROCEDURES W NON-DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS|UTMB|UTMB CORRECTIONAL MANAGED CARE|308,950.15|18224.55|26030.63|18224.55|||| 249|DRG||PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|84,432.17|12020.29|22684.88|118.01|||| 249|DRG||PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|88,018.55|11800.12|22684.88|118.01|||| 249|DRG||PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC|United Healthcare|GOLDEN RULE|81,719.23|22684.88|22684.88|118.01|||| 249|DRG||PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC|Medicare|MEDICARE PART B ONLY IP|155,622.23|11808.04|22684.88|118.01|||| 249|DRG||PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC|Medicare|MEDICARE ACUTE|91,640.91|118.01|22684.88|118.01|||| 249|DRG||PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99,027.19|19864.02|22684.88|118.01|||| 249|DRG||PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC|Managed Medicare|HEALTHSPRING MA|106,690.25|118.01|22684.88|118.01|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|113,737.82|29044.22|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|132,786.55|29044.22|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Blue Cross HMO Specialty|BCBSTX HMO|131,904.40|178.6|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|215,298.89|312.13|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Managed Medicare|HEALTHSPRING MA|364,419.60|25904.16|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Managed Medicare|BCBS MEDICARE PPO MA|215,490.95|25029.81|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|262,462.68|25400.72|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|249,149.09|36702.51|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|607,667.33|48162.79|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|283,865.76|87620.56|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Medicaid|MEDICAID|212,740.52|46327.5|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|Medicare|MEDICARE ACUTE|151,115.15|25369.89|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|81,263.49|48519.2|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|United Healthcare|UNITED HEALTHCARE OTHER|141,166.89|52013.3|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|324,541.27|25325.75|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|United Healthcare|UNITED HEALTHCARE|157,216.47|52013.3|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|229,542.60|23203.93|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|252,654.37|25904.16|87620.56|178.6|||| 25|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|190,779.09|23177.93|87620.56|178.6|||| 250|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|166,250.28|15569.85|17564.37|14020.51|||| 250|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC|Medicare|MEDICARE ACUTE|99,211.13|15414.15|17564.37|14020.51|||| 250|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC|Humana Medicare Advantage|HUMANA MA|94,441.53|15263.45|17564.37|14020.51|||| 250|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC|Managed Medicare|HEALTHSPRING MA|164,993.70|15428.23|17564.37|14020.51|||| 250|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC|Blue Cross HMO Specialty|BCBSTX HMO|76,170.78|14020.51|17564.37|14020.51|||| 250|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC|Blue Cross PPO Specialty|BCBSTX PPO|157,756.29|17564.37|17564.37|14020.51|||| 251|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|72,848.23|104.91|11392.26|104.91|||| 251|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|73,469.16|10731.77|11392.26|104.91|||| 251|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|79,633.82|11392.26|11392.26|104.91|||| 251|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC|Managed Medicare|HEALTHSPRING MA|856.02|10519.16|11392.26|104.91|||| 251|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC|Humana Medicare Advantage|HUMANA MA|101,854.12|10504.75|11392.26|104.91|||| 251|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC|Medicaid|MEDICAID|96,053.30|10533.56|11392.26|104.91|||| 251|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC|Medicare|MEDICARE ACUTE|87,542.41|10614.85|11392.26|104.91|||| 251|DRG||PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|75,410.88|10505.08|11392.26|104.91|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|191,833.25|19472.115|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|156,991.17|19459.115|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Medicare|MEDICARE PART B ONLY IP|35,410.60|4074.37|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Medicare|MEDICARE ACUTE|110,863.97|19284.61|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|146,568.35|19288.05|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|111,653.78|19899.29|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|107,998.40|14921.975|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|177,093.64|19661.78|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|123,671.50|19284.61|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Managed Medicare|HEALTHSPRING MA|165,528.40|19283.73|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,144.47|206.67|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|440,139.18|2697.25|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Access Direct Platinum|HEALTHFIRST TPA|63,441.60|24493.11|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|249,316.81|27356.38|27356.38|206.67|||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|120,482.36|19661.78|27356.38|206.67|||| 25246|EAP|0361|XR-INJECTION FOR WRIST AR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||14.47||| 25246|EAP|0361|XR-INJECTION FOR WRIST AR|Workers Compensation|UT EMPLOYEE INJURY|||||1,532.28||| 25246|EAP|0361|XR-INJECTION FOR WRIST AR|Workers Compensation|WORKERS COMPENSATION OTHER|||||14.47||| 25246|EAP|0361|XR-INJECTION FOR WRIST AR|Blue Cross PPO Specialty|BCBSTX PPO|||||1,532.28||| 25246|EAP|0361|XR-INJECTION FOR WRIST AR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14.47||| 25246|EAP|0361|XR-INJECTION FOR WRIST AR|Managed Medicaid|MEDICAID AMERIGROUP|||||14.47||| 25246|EAP|0361|XR-INJECTION FOR WRIST AR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||14.47||| 25246|EAP|0361|XR-INJECTION FOR WRIST AR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,532.28||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Medicare|MEDICARE ACUTE|95,938.76|15587.26|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Medicare|MEDICARE PART B ONLY IP|62,603.60|6458.3|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|62,113.55|15543.49|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|75,061.12|15585.1|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|95,465.42|15590.7|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|113,737.69|15886.42|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Cigna|CIGNA|215,859.88|29897.04|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|118,339.32|15590.61|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|109,762.22|13182.12|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Managed Medicaid|MEDICAID SUPERIOR|149,766.98|13182.12|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|113,476.29|14661.72|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|155,811.08|15886.42|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|93,571.26|107.16|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|120,546.94|17615.3|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|86,438.89|17571.435|29897.04|107.16|||| 253|DRG||OTHER VASCULAR PROCEDURES W CC|Veterans Affairs|VETERANS ADMINISTRATION|79,891.77|15591.615|29897.04|107.16|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|75,317.74|11373.3|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|79,838.86|12289.9|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Aetna|AETNA PPO|67,933.55|28226.22|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|72,128.85|71.44|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|67,078.37|10447.32|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|72,181.23|11375.53|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|67,773.98|11270.58|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|147,326.58|11097.465|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|78,262.98|97.31|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|79,516.35|11479.6|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Cigna|CIGNA|66,474.55|18728.83|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Tricare|TRICARE EAST REGION|80,523.09|12295.78|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|65,755.15|30941.7|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|97,730.94|13525.63|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|63,250.03|11479.6|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|89,102.94|11375.53|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|91,952.37|8775.98|30941.7|71.44|||| 254|DRG||OTHER VASCULAR PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|71,824.54|11271.46|30941.7|71.44|||| 255|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|97,379.44|16127.35|16127.35|10899.12|||| 255|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|89,806.37|10899.12|16127.35|10899.12|||| 25500|EAP|0510|TREAT FX OF RADIUS SHAFT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.04||| 25500|EAP|0510|TREAT FX OF RADIUS SHAFT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||251.67||| 25500|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 25500|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||6.04||| 25500|EAP|0510|TREAT FX OF RADIUS SHAFT|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 25500|EAP|0510|TREAT FX OF RADIUS SHAFT|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 25500|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 25500|EAP|0361||Cigna|CIGNA|||||6.04||| 25500|EAP|0510|TREAT FX OF RADIUS SHAFT|NON CONTRACTED|COMMERCIAL OTHER 1|||||251.67||| 25505|EAP|0510|TREAT FX OF RADIUS SHAFT|Managed Medicare|HEALTHSPRING MA|||||1,468.75||| 25505|EAP|0510|TREAT FX OF RADIUS SHAFT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,468.75||| 25505|EAP|0361||Medicare|MEDICARE ACUTE|||||35.25||| 25505|EAP|0510|TREAT FX OF RADIUS SHAFT|Managed Medicaid|MEDICAID AMERIGROUP|||||1,468.75||| 25505|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||35.25||| 25505|EAP|0510|TREAT FX OF RADIUS SHAFT|Managed Medicaid|MEDICAID SUPERIOR|||||1,468.75||| 25505|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||35.25||| 25505|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||35.25||| 25505|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||35.25||| 25505|EAP|0510|TREAT FX OF RADIUS SHAFT|Blue Cross PPO Specialty|BCBSTX PPO|||||1,468.75||| 25505|EAP|0510|TREAT FX OF RADIUS SHAFT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,468.75||| 25530|EAP|0510|TREAT FX OF ULNAR SHAFT W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||251.67||| 25530|EAP|0510|TREAT FX OF ULNAR SHAFT W|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 25530|EAP|0510|TREAT FX OF ULNAR SHAFT W|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 25530|EAP|0510|TREAT FX OF ULNAR SHAFT W|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 25530|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 25530|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 25530|EAP|0510|TREAT FX OF ULNAR SHAFT W|Medicare|MEDICARE ACUTE|||||251.67||| 25530|EAP|0510|TREAT FX OF ULNAR SHAFT W|Medicaid|MEDICAID|||||251.67||| 25535|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 25535|EAP|0510|TREAT FX OF ULNAR SHAFT W|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 25535|EAP|0510|TREAT FX OF ULNAR SHAFT W|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 25560|EAP|0510|TREAT FX RADIUS & ULNA W/|Tricare|TRICARE EAST REGION|||||251.67||| 25560|EAP|0510|TREAT FX RADIUS & ULNA W/|Medicare|MEDICARE ACUTE|||||251.67||| 25560|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.04||| 25560|EAP|0510|TREAT FX RADIUS & ULNA W/|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 25560|EAP|0510|TREAT FX RADIUS & ULNA W/|Blue Cross PPO Specialty|BCBSTX OTHER|||||251.67||| 25560|EAP|0510|TREAT FX RADIUS & ULNA W/|Humana Medicare Advantage|HUMANA MA|||||251.67||| 25565|EAP|0450|TX FX RADIUS ULNA W MANIP|Managed Medicaid|MEDICAID AMERIGROUP|||||29.89||| 25565|EAP|0510|TREAT FX RADIUS & ULNA W/|Managed Medicaid|MEDICAID SUPERIOR|||||1,468.75||| 25565|EAP|0510|TREAT FX RADIUS & ULNA W/|Cigna|CIGNA OTHER|||||1,468.75||| 25565|EAP|0450|TX FX RADIUS ULNA W MANIP|Humana Medicare Advantage|HUMANA MA|||||29.89||| 25565|EAP|0450|TX FX RADIUS ULNA W MANIP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,437.35||| 25565|EAP|0450|TX FX RADIUS ULNA W MANIP|Aetna|AETNA OTHER|||||3,437.35||| 25565|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||35.25||| 25565|EAP|0510|TREAT FX RADIUS & ULNA W/|Medicaid|MEDICAID|||||1,468.75||| 25565|EAP|0510|TREAT FX RADIUS & ULNA W/|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,468.75||| 25565|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||35.25||| 25565|EAP|0450|TX FX RADIUS ULNA W MANIP|Medicare|MEDICARE ACUTE|3,437.35||||29.89||| 256|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC|Medicare|MEDICARE ACUTE|67,928.51|10745.21|13958.34|2466.11|||| 256|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC|Medicare|MEDICARE PART B ONLY IP|53,727.94|2466.11|13958.34|2466.11|||| 256|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|144,171.02|13958.34|13958.34|2466.11|||| 256|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC|Humana Medicare Advantage|HUMANA MA|111,687.72|10899.12|13958.34|2466.11|||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Blue Cross HMO Specialty|BCBSTX HMO|||||251.67||| 25600|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 25600|EAP|0450|TX FX RADIAL WO MANIP|Blue Cross PPO Specialty|BCBSTX PPO|||||941.70||| 25600|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Aetna|AETNA PPO|||||251.67||| 25600|EAP|0361||Aetna|AETNA OTHER|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||251.67||| 25600|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 25600|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||251.67||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 25600|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 25600|EAP|0450|TX FX RADIAL WO MANIP|Managed Medicaid|MEDICAID AMERIGROUP|||||1,007.40||| 25600|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Humana Medicare Advantage|HUMANA MA|||||251.67||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Cigna|CIGNA|||||251.67||| 25600|EAP|0361||Cigna|CIGNA|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||251.67||| 25600|EAP|0361||Cigna|CIGNA OTHER|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||251.67||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|United Medicare Advantage|UHC AARP MCR HMO MA|||||251.67||| 25600|EAP|0450|TX FX RADIAL WO MANIP|Workers Compensation|WORKERS COMPENSATION OTHER|||||8.76||| 25600|EAP|0450|TX FX RADIAL WO MANIP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,007.40||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||251.67||| 25600|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.04||| 25600|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|United Healthcare|UNITED HEALTHCARE OTHER|||||251.67||| 25600|EAP|0450|TX FX RADIAL WO MANIP|Managed Medicaid|MEDICAID SUPERIOR|||||1,007.40||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Aetna|AETNA OTHER|||||251.67||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|United Healthcare|UNITED HEALTHCARE|||||251.67||| 25600|EAP|0361||United Healthcare|UNITED HEALTHCARE ERS|||||6.04||| 25600|EAP|0450|TX FX RADIAL WO MANIP|United Healthcare|UNITED HEALTHCARE OTHER|||||1,007.40||| 25600|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.04||| 25600|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|United Healthcare|GOLDEN RULE|||||251.67||| 25600|EAP|0450|TX FX RADIAL WO MANIP|Medicare|MEDICARE PART B ONLY IP|1,007.40||||||| 25600|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Medicare|MEDICARE ACUTE|||||251.67||| 25600|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||6.04||| 25600|EAP|0450|TX FX RADIAL WO MANIP|Medicare|MEDICARE ACUTE|||||8.76||| 25600|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|NON CONTRACTED|COMMERCIAL OTHER 1|||||251.67||| 25600|EAP|0450|TX FX RADIAL WO MANIP|NON CONTRACTED|COMMERCIAL OTHER 1|1,007.40||||1,007.40||| 25600|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.04||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.04||| 25600|EAP|0450|TX FX RADIAL WO MANIP|Medicaid|MEDICAID|||||1,007.40||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||251.67||| 25600|EAP|0510|TREAT FX RADIUS/ULNA SEP|Medicaid|MEDICAID|||||251.67||| 25600|EAP|0361||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||6.04||| 25600|EAP|0361||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.04||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Medicaid|MEDICAID|||||3,213.18||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3,437.35||| 25605|EAP|0361|TREAT FRACTURE RADIUS/ULN|Managed Medicare|HEALTHSPRING MA|||||1,526.25||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Managed Medicare|HEALTHSPRING MA|||||29.89||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,213.18||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Medicare|MEDICARE ACUTE|3,437.35||||29.89||| 25605|EAP|0361|TREAT FRACTURE RADIUS/ULN|Medicare|MEDICARE ACUTE|||||2,594.63||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Tricare|TRICARE EAST REGION|||||3,437.35||| 25605|EAP|0361|TREAT FRACTURE RADIUS/ULN|United Healthcare|UNITED HEALTHCARE|||||36.63||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,437.35||| 25605|EAP|0361|TREAT FRACTURE RADIUS/ULN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,526.25||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|United Medicare Advantage|UHC AARP MCR HMO MA|3,437.35||||3,437.35||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.89||||29.89||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Humana Medicare Advantage|HUMANA MA|29.89||||29.89||| 25605|EAP|0361|TREAT FRACTURE RADIUS/ULN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,526.25||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Managed Medicaid|MEDICAID AMERIGROUP|||||29.89||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Managed Medicaid|MEDICAID SUPERIOR|||||3,437.35||| 25605|EAP|0361|TREAT FRACTURE RADIUS/ULN|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||1,526.25||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,213.18||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Aetna|AETNA PPO|||||29.89||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,437.35||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Blue Cross PPO Specialty|BCBSTX PPO|||||3,437.35||| 25630|EAP|0361|CL TREAT WRIST BONE FRACT|Aetna|BOON CHAPMAN|||||6.04||| 25630|EAP|0361|CL TREAT WRIST BONE FRACT|Medicare|MEDICARE ACUTE|||||427.84||| 25630|EAP|0361|CL TREAT WRIST BONE FRACT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||251.67||| 25650|EAP|0510|CLSD TX ULNAR STYLOID FX|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.43||| 257|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|54,357.47|65.78|7508.79|65.78|||| 257|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|69,086.30|7508.79|7508.79|65.78|||| 259|DRG||CARDIAC PACEMAKER DEVICE REPLACEMENT W/O MCC|Medicare|MEDICARE PART B ONLY IP|56,183.72|9940.71|12683.73|9940.71|||| 259|DRG||CARDIAC PACEMAKER DEVICE REPLACEMENT W/O MCC|Medicare|MEDICARE ACUTE|97,486.05|12683.73|12683.73|9940.71|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Veterans Affairs|VETERANS ADMINISTRATION|208,365.54|18008.5|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST TPA|135,684.59|26377.08|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|201,646.60|28522.88|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|236,497.18|17969.13|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|180,053.03|17996.41|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|309,567.14|17996.41|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|136,053.10|38252.57|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|80,271.25|9005.245|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|136,079.32|25507.03|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|146,695.12|20476.6|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|169,602.97|20476.6|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|237,765.71|35.72|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Blue Cross HMO Specialty|BCBSTX HMO|58,125.85|17406.62|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Aetna|BOON CHAPMAN|82,012.80|38529.37|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|177,112.49|18120.815|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE|254,545.02|39676.09|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|335,551.47|18347.29|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|221,265.24|18347.29|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Medicaid|MEDICAID|121,519.71|17295.42|39676.09|35.72|||| 26|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC|Medicare|MEDICARE ACUTE|147,527.32|17997.29|39676.09|35.72|||| 260|DRG||CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W MCC|Medicare|MEDICARE ACUTE|242,348.08|21584.91|21584.91|21584.91|||| 261|DRG||CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC|Humana Medicare Advantage|HUMANA MA|98,666.95|12079.955|12199.03|11979.48|||| 261|DRG||CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|111,865.97|11979.48|12199.03|11979.48|||| 261|DRG||CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC|Medicare|MEDICARE ACUTE|93,638.64|12199.03|12199.03|11979.48|||| 26115|EAP|0361|EXC HAND LES SC < 1.5 CM|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,538.33||| 264|DRG||OTHER CIRCULATORY SYSTEM O.R. PROCEDURES|Medicaid|MEDICAID|1,553.01|11421.02|26284.34|250.04|||| 264|DRG||OTHER CIRCULATORY SYSTEM O.R. PROCEDURES|Medicare|MEDICARE ACUTE|129,780.81|19238.08|26284.34|250.04|||| 264|DRG||OTHER CIRCULATORY SYSTEM O.R. PROCEDURES|United Medicare Advantage|UHC AARP MCR HMO MA|218,985.12|19424.21|26284.34|250.04|||| 264|DRG||OTHER CIRCULATORY SYSTEM O.R. PROCEDURES|United Medicare Advantage|UHC MEDICARE GOLD MA|136,440.74|19424.21|26284.34|250.04|||| 264|DRG||OTHER CIRCULATORY SYSTEM O.R. PROCEDURES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|108,363.20|250.04|26284.34|250.04|||| 264|DRG||OTHER CIRCULATORY SYSTEM O.R. PROCEDURES|Managed Medicare|BCBS MEDICARE PPO MA|57,640.25|19023.79|26284.34|250.04|||| 264|DRG||OTHER CIRCULATORY SYSTEM O.R. PROCEDURES|Managed Medicare|HEALTHSPRING MA|174,707.35|19097.43|26284.34|250.04|||| 264|DRG||OTHER CIRCULATORY SYSTEM O.R. PROCEDURES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|63,955.07|26284.34|26284.34|250.04|||| 264|DRG||OTHER CIRCULATORY SYSTEM O.R. PROCEDURES|Humana Medicare Advantage|HUMANA MA|280,639.73|19055.06|26284.34|250.04|||| 266|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|245,022.91|40354.22|41183.21|40339.93|||| 266|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W MCC|Managed Medicare|BCBS MEDICARE PPO MA|201,395.23|40339.93|41183.21|40339.93|||| 266|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W MCC|Medicare|MEDICARE ACUTE|251,113.96|41183.21|41183.21|40339.93|||| 26600|EAP|0510|TREAT METACARPAL FX W/O M|Medicare|MEDICARE ACUTE|||||251.67||| 26600|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 26600|EAP|0510|TREAT METACARPAL FX W/O M|United Healthcare|UNITED HEALTHCARE|||||251.67||| 26600|EAP|0510|TREAT METACARPAL FX W/O M|Medicaid|MEDICAID|||||251.67||| 26600|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 26600|EAP|0510|TREAT METACARPAL FX W/O M|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 26600|EAP|0510|TREAT METACARPAL FX W/O M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||251.67||| 26600|EAP|0510|TREAT METACARPAL FX W/O M|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 26600|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 26600|EAP|0510|TREAT METACARPAL FX W/O M|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 26605|EAP|0510|TREAT METACARPAL FX W/MAN|United Medicare Advantage|UHC AARP MCR HMO MA|||||251.67||| 26605|EAP|0510|TREAT METACARPAL FX W/MAN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||251.67||| 26605|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 26605|EAP|0510|TREAT METACARPAL FX W/MAN|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 26605|EAP|0450|TX FX METACARPAL W MANIP|Managed Medicaid|MEDICAID SUPERIOR|||||11.32||| 26605|EAP|0510|TREAT METACARPAL FX W/MAN|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 26605|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.04||| 26605|EAP|0450|TX FX METACARPAL W MANIP|Medicaid|SMITH COUNTY JAIL|||||11.32||| 26605|EAP|0510|TREAT METACARPAL FX W/MAN|Tricare|TRICARE EAST REGION|||||251.67||| 26605|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.04||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|United Healthcare|UNITED HEALTHCARE|184,341.89|67176.4|109905.27|35.72|||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|Medicare|MEDICARE ACUTE|197,823.45|33082.27|109905.27|35.72|||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|Aetna|AETNA OTHER|194,401.39|109905.27|109905.27|35.72|||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|197,215.55|35.72|109905.27|35.72|||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|190,381.25|39708.6|109905.27|35.72|||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|246,499.80|38530.63|109905.27|35.72|||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|Humana Medicare Advantage|HUMANA MA|198,437.09|32412.71|109905.27|35.72|||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|1,892.51|32421.53|109905.27|35.72|||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|Managed Medicare|HEALTHSPRING MA|186,504.30|32426.99|109905.27|35.72|||| 267|DRG||ENDOVASCULAR CARDIAC VALVE REPLACEMENT & SUPPLEMENT PROCEDURES W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|185,223.55|32399.71|109905.27|35.72|||| 26700|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.04||| 26700|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 26700|EAP|0510|TREAT KNUCKLE DISLOCATION|Managed Medicaid|MEDICAID AMERIGROUP|||||427.84||| 26700|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 26700|EAP|0510|TREAT KNUCKLE DISLOCATION|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 26700|EAP|0510|TREAT KNUCKLE DISLOCATION|Cigna|CIGNA OTHER|||||251.67||| 26700|EAP|0510|TREAT KNUCKLE DISLOCATION|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 26700|EAP|0510|TREAT KNUCKLE DISLOCATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||251.67||| 26700|EAP|0450|TX DISLOC KNUCKLE W MANIP|Medicaid|MEDICAID HMO|||||923.45||| 26720|EAP|0361||Medicaid|MEDICAID HMO|||||6.04||| 26720|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 26720|EAP|0510|TREAT FINGER FRACTURE EA|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 26720|EAP|0510|TREAT FINGER FRACTURE EA|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 26725|EAP|0450|TX FX FINGER EACH W MANIP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,159.20||||||| 26725|EAP|0450|TX FX FINGER EACH W MANIP|Humana Medicare Advantage|HUMANA MA|||||10.08||| 26725|EAP|0450|TX FX FINGER EACH W MANIP|Blue Cross PPO Specialty|BCBSTX PPO|||||10.08||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Medicare|MEDICARE ACUTE|||||251.67||| 26740|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|United Healthcare|GOLDEN RULE|||||251.67||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|United Healthcare|UNITED HEALTHCARE|||||251.67||| 26740|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.04||| 26740|EAP|0361||Tricare|TRICARE EAST REGION|||||6.04||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||251.67||| 26740|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.04||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Blue Cross HMO Specialty|BCBSTX HMO|||||251.67||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 26740|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|NON CONTRACTED|COMMERCIAL OTHER 1|||||251.67||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||251.67||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||251.67||| 26740|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Cigna|CIGNA|||||251.67||| 26740|EAP|0361||Cigna|CIGNA|||||6.04||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Humana Medicare Advantage|HUMANA MA|||||251.67||| 26740|EAP|0510|TREAT FINGER FX INVG JT W|Workers Compensation|UT EMPLOYEE INJURY|||||251.67||| 26740|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA|||||6.04||| 26740|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.04||| 26750|EAP|0510|TREAT FINGER FX DSTL W/O|Humana Medicare Advantage|HUMANA MA|||||251.67||| 26750|EAP|0361||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.04||| 26750|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 26750|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 26750|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||6.04||| 26750|EAP|0510|TREAT FINGER FX DSTL W/O|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 26750|EAP|0510|TREAT FINGER FX DSTL W/O|Blue Cross HMO Specialty|BCBSTX HMO|||||251.67||| 26750|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 26770|EAP|0450|TX DISLOC FINGER JT W MAN|Medicaid|MEDICAID|||||910.80||| 26770|EAP|0450|TX DISLOC FINGER JT W MAN|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||7.92||| 26770|EAP|0450|TX DISLOC FINGER JT W MAN|Medicare|MEDICARE ACUTE|||||7.92||| 26770|EAP|0450|TX DISLOC FINGER JT W MAN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.92||||||| 26770|EAP|0510|TREAT FINGER DISLOCATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.43||| 26770|EAP|0450|TX DISLOC FINGER JT W MAN|Blue Cross PPO Specialty|BCBSTX PPO|||||7.92||| 26770|EAP|0450|TX DISLOC FINGER JT W MAN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.92||||||| 26770|EAP|0450|TX DISLOC FINGER JT W MAN|Managed Medicaid|MEDICAID SUPERIOR|||||910.80||| 26770|EAP|0450|TX DISLOC FINGER JT W MAN|Managed Medicaid|MEDICAID AMERIGROUP|||||910.80||| 26770|EAP|0450|TX DISLOC FINGER JT W MAN|Cigna|CIGNA|||||7.92||| 268|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W MCC|Humana Medicare Advantage|HUMANA MA|136,974.85|39361.39|45518.12|38501.91|||| 268|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|193,422.08|45518.12|45518.12|38501.91|||| 268|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W MCC|Medicare|MEDICARE ACUTE|164,302.25|38501.91|45518.12|38501.91|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|180,515.05|180515.05|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|146,623.11|25186.41|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|United Healthcare|UNITED HEALTHCARE|138,941.50|50497.11|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|Medicare|MEDICARE ACUTE|164,839.42|24695.11|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|1,766.02|25186.41|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|165,602.83|24695.11|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|157,973.50|35.72|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|132,062.48|28184.61|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|117,014.43|24695.11|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|149,407.50|24694.23|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|213,809.66|12196.36|180515.05|35.72|||| 269|DRG||AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC|Humana Medicare Advantage|HUMANA MA|146,082.43|25186.41|180515.05|35.72|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|161,171.28|14710.34|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|ChampVA|CHAMPVA CENTER|84,475.05|15757.79|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|102,859.75|16334.7|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Aetna|AETNA PPO|136,122.55|42273.71|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|111,081.14|15507.7|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Aetna|AETNA OTHER|320,825.74|122251.02|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|130,742.91|13885.7|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|121,797.10|51.88|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|100,709.67|14434.58|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|136,178.30|20212.46|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|94,661.50|14577.315|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|149,266.32|28367.34|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|85,032.99|28367.34|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|104,273.64|28367.34|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|136,241.48|14566.72|122251.02|51.88|||| 27|DRG||CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|78,200.45|47066.94|122251.02|51.88|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|873,588.43|59770.52|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|214,123.39|29334.13|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|Medicaid|MEDICAID|172,821.80|22375.72|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|Medicare|MEDICARE ACUTE|188,496.28|29619.815|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|138,381.03|29914.3|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|293,996.89|49459.22|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|139,195.22|34368.94|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|158,061.63|29325.33|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|Managed Medicare|HEALTHSPRING MA|89,054.70|29325.33|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|189,340.72|25998.14|59770.52|22375.72|||| 270|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|191,030.44|29328.705|59770.52|22375.72|||| 27040|EAP|0361|CT-BIOPSY OF SOFT TISSUES|Humana Medicare Advantage|HUMANA MA|||||44.50||| 27040|EAP|0361|CT-BIOPSY OF SOFT TISSUES|Blue Cross PPO Specialty|BCBSTX PPO|||||5,117.50||| 27040|EAP|0361|CT-BIOPSY OF SOFT TISSUES|Medicare|MEDICARE ACUTE|||||44.50||| 27041|EAP|0361|CT-BIOPSY OF SOFT TISSUES|UTMB|UTMB CORRECTIONAL MANAGED CARE|11,574.75||||||| 27041|EAP|0361|CT-BIOPSY OF SOFT TISSUES|Medicare|MEDICARE ACUTE|10,819.88||||10,819.88||| 27041|EAP|0361|CT-BIOPSY OF SOFT TISSUES|United Medicare Advantage|UHC AARP MCR HMO MA|11,574.75||||11,574.75||| 27041|EAP|0361|CT-BIOPSY OF SOFT TISSUES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11,574.75||| 27041|EAP|0361|CT-BIOPSY OF SOFT TISSUES|Blue Cross PPO Specialty|BCBSTX PPO|100.65||||11,574.75||| 27041|EAP|0361|CT-BIOPSY OF SOFT TISSUES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|100.65||||||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Humana Medicare Advantage|HUMANA MA|||||15.70||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Managed Medicaid|MEDICAID AMERIGROUP|||||15.70||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||15.70||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Blue Cross HMO Specialty|BCBSTX HMO|||||15.70||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Blue Cross PPO Specialty|BCBSTX PPO|||||15.70||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,662.52||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Aetna|AETNA PPO|||||15.70||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,616.26||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,662.52||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||15.70||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Access Direct Platinum|HEALTHFIRST TPA UMR|||||15.70||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,662.52||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||15.70||| 27093|EAP|0361|XR-INJECTION FOR HIP ARTH|Medicare|MEDICARE ACUTE|||||1,662.52||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|United Healthcare|UNITED HEALTHCARE OTHER|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Aetna|AETNA PPO|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Blue Cross PPO Specialty|BCBSTX PPO|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Blue Cross HMO Specialty|BCBSTX HMO|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|United Healthcare|UNITED HEALTHCARE|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Managed Medicaid|MEDICAID AMERIGROUP|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Managed Medicaid|MEDICAID SUPERIOR|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,569.86||| 27096|EAP|0361|INJ PAIN SI JOINT UNILAT|Cigna|CIGNA|||||1,569.86||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|193,297.67|47888.12|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|118,341.53|20748.695|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|121,887.06|20753.03|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|201,847.64|21161.16|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|198,811.47|21840.83|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|107,047.81|23722.9|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Aetna|AETNA PPO|167,916.10|49469.79|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Blue Cross HMO Specialty|BCBSTX HMO|128,393.85|20166.21|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|67,226.57|122.47|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|184,252.03|20737.94|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|Medicare|MEDICARE ACUTE|111,613.04|21161.16|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE|121,541.51|41994.13|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|220,161.83|21100.6|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE OTHER|133,721.07|41994.13|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE|73,725.69|41994.13|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|212,759.38|20774.34|49469.79|122.47|||| 271|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|94,081.39|20753.03|49469.79|122.47|||| 27197|EAP|0510|CLSD TX PELVIC RING FX|Medicare|MEDICARE ACUTE|||||2.43||| 27197|EAP|0510|CLSD TX PELVIC RING FX|Managed Medicare|HEALTHSPRING MA|||||2.43||| 272|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|132,695.14|107.16|30788.99|107.16|||| 272|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|84,370.60|17776.9|30788.99|107.16|||| 272|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|68,967.13|15557.29|30788.99|107.16|||| 272|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|119,247.23|12463.93|30788.99|107.16|||| 272|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|56,199.82|2496.59|30788.99|107.16|||| 272|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|112,502.61|15558.17|30788.99|107.16|||| 272|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|91,226.55|15856.73|30788.99|107.16|||| 272|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC|United Healthcare|TML GROUP BENEFITS|173,657.99|30788.99|30788.99|107.16|||| 272|DRG||OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC|Tricare|TRICARE EAST REGION|83,625.69|10940.16|30788.99|107.16|||| 27246|EAP|0361|TREAT THIGH FX W/O MANJ|Medicare|MEDICARE ACUTE|||||6.04||| 27250|EAP|0450|TX DISLOC HIP WO ANESTH|Medicaid|MEDICAID|||||13.34||| 27250|EAP|0450|TX DISLOC HIP WO ANESTH|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.60||||||| 27250|EAP|0450|TX DISLOC HIP WO ANESTH|Medicare|MEDICARE ACUTE|||||11.60||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.34||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.34||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Humana Medicare Advantage|HUMANA MA|||||9.34||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.34||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Blue Cross PPO Specialty|BCBSTX PPO|||||9.34||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.34||||||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Medicare|MEDICARE ACUTE|9.34||||9.34||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Medicare|MEDICARE PART B ONLY IP|9.34||||||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|United Healthcare|UNITED HEALTHCARE OTHER|9.34||||||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|United Healthcare|TML GROUP BENEFITS|9.34||||||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.34||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Managed Medicare|BCBS MEDICARE PPO MA|||||9.34||| 273|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC|Medicare|MEDICARE ACUTE|155,375.23|22070.54|24800.47|102.06|||| 273|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|172,201.05|22070.54|24800.47|102.06|||| 273|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|212,467.75|102.06|24800.47|102.06|||| 273|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|154,992.02|24800.47|24800.47|102.06|||| 273|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|55,441.81|21635.65|24800.47|102.06|||| 273|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|2,074.78|21642.74|24800.47|102.06|||| 27369|EAP|0322|NJX CONTRST KNEE ARTHG/CT|Humana Medicare Advantage|HUMANA MA|||||862.50||| 27369|EAP|0322|NJX CONTRST KNEE ARTHG/CT|Blue Cross PPO Specialty|BCBSTX PPO|||||7.50||| 27369|EAP|0322|NJX CONTRST KNEE ARTHG/CT|Medicare|MEDICARE ACUTE|||||806.25||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|Medicare|MEDICARE ACUTE|124,070.27|18986.04|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|Medicare|MEDICARE PART B ONLY IP|2,076.63|18538.12|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|United Healthcare|UNITED HEALTHCARE|166,254.47|37399.39|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|135,568.56|37399.39|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|180,838.88|18986.04|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|124,617.25|23280.73|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|271,268.02|18986.04|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|Aetna|AETNA PPO|189,877.85|49711.59|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|222,317.41|20222.66|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|Managed Medicare|HEALTHSPRING MA|54,728.62|18986.04|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|Humana Medicare Advantage|HUMANA MA|205,766.05|18986.04|49711.59|18538.12|||| 274|DRG||PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|199,678.37|19922.43|49711.59|18538.12|||| 27500|EAP|0510|CLSD TX FEMORAL SHAFT FX|Managed Medicaid|MEDICAID SUPERIOR|||||2.43||| 27502|EAP|0450|TREAT FEMORAL SHAFT FX|United Healthcare|UNITED HEALTHCARE|21.97||||||| 27502|EAP|0450|TREAT FEMORAL SHAFT FX|United Healthcare|UNITED HEALTHCARE OTHER|21.97||||||| 27502|EAP|0450|TREAT FEMORAL SHAFT FX|Blue Cross PPO Specialty|BCBSTX PPO|21.97||||||| 27516|EAP|0510|TREAT THIGH FX SEPARATION|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 27520|EAP|0510|TREAT KNEECAP FX W/O MANI|Managed Medicare|HEALTHSPRING MA|||||251.67||| 27520|EAP|0510|TREAT KNEECAP FX W/O MANI|Medicare|MEDICARE ACUTE|||||251.67||| 27520|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.04||| 27520|EAP|0510|TREAT KNEECAP FX W/O MANI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||251.67||| 27520|EAP|0361||Workers Compensation|WORKERS COMPENSATION OTHER|||||6.04||| 27520|EAP|0510|TREAT KNEECAP FX W/O MANI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||251.67||| 27520|EAP|0510|TREAT KNEECAP FX W/O MANI|Humana Medicare Advantage|HUMANA MA|||||251.67||| 27520|EAP|0510|TREAT KNEECAP FX W/O MANI|Cigna|CIGNA OTHER|||||251.67||| 27530|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 27530|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.04||| 27530|EAP|0510|TREAT KNEE FX PROXIMAL W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||251.67||| 27530|EAP|0510|TREAT KNEE FX PROXIMAL W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||251.67||| 27530|EAP|0510|TREAT KNEE FX PROXIMAL W/|Medicare|MEDICARE ACUTE|||||251.67||| 27530|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 27530|EAP|0450|TREAT KNEE FRACTURE|Medicaid|MEDICAID|6.34||||||| 27530|EAP|0510|TREAT KNEE FX PROXIMAL W/|Medicaid|MEDICAID|||||251.67||| 27532|EAP|0361|TREAT KNEE FX PROX W/WO M|Blue Cross HMO Specialty|BCBSTX HMO|||||70.41||| 27550|EAP|0450|TX DISLOC KNEE WO ANESTH|Blue Cross PPO Specialty|BCBSTX PPO|||||13.34||| 27560|EAP|0450|TX DISLOC KNEECAP WO ANES|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.78||| 27750|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.04||| 27750|EAP|0510|TREATMENT OF TIBIA FX W/O|Managed Medicaid|MEDICAID SUPERIOR|||||251.67||| 27750|EAP|0510|TREATMENT OF TIBIA FX W/O|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 27750|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 27750|EAP|0361||Cigna|CIGNA|||||6.04||| 27752|EAP|0450|TX FX TIBIA W MANIP|Medicare|MEDICARE ACUTE|18.42||||||| 27752|EAP|0450|TX FX TIBIA W MANIP|Cigna|CIGNA|18.42||||||| 27752|EAP|0450|TX FX TIBIA W MANIP|Managed Medicaid|MEDICAID AMERIGROUP|18.42||||||| 27752|EAP|0450|TX FX TIBIA W MANIP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.42||||||| 27760|EAP|0361||Workers Compensation|WORKERS COMPENSATION OTHER|||||6.04||| 27760|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 27760|EAP|0510|CLOSED MEDIAL ANKLE FX W/|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 27760|EAP|0361||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.04||| 27760|EAP|0510|CLOSED MEDIAL ANKLE FX W/|Humana Medicare Advantage|HUMANA MA|||||251.67||| 27760|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.04||| 27760|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 27762|EAP|0450|TX FX MEDIAL MALLEOLUS W|Medicaid|MEDICAID|||||21.97||| 27780|EAP|0510|TREATMENT OF FIBULA FX W/|Cigna|CIGNA|||||251.67||| 27780|EAP|0510|TREATMENT OF FIBULA FX W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||251.67||| 27780|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 27780|EAP|0510|TREATMENT OF FIBULA FX W/|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 27780|EAP|0510|TREATMENT OF FIBULA FX W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||251.67||| 27786|EAP|0510|TREATMENT OF ANKLE FX LAT|United Healthcare|UNITED HEALTHCARE|||||251.67||| 27786|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 27786|EAP|0510|TREATMENT OF ANKLE FX LAT|Medicare|MEDICARE ACUTE|||||251.67||| 27786|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.04||| 27786|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.04||| 27786|EAP|0510|TREATMENT OF ANKLE FX LAT|Medicaid|MEDICAID|||||251.67||| 27786|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.04||| 27786|EAP|0510|TREATMENT OF ANKLE FX LAT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||251.67||| 27786|EAP|0510|TREATMENT OF ANKLE FX LAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||251.67||| 27786|EAP|0510|TREATMENT OF ANKLE FX LAT|Blue Cross HMO Specialty|BCBSTX HMO|||||251.67||| 27786|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||6.04||| 27786|EAP|0361||Tricare|TRICARE EAST REGION|||||6.04||| 27786|EAP|0510|TREATMENT OF ANKLE FX LAT|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 27786|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||6.04||| 27786|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 27786|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.04||| 27786|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 27786|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.04||| 27786|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 27786|EAP|0510|TREATMENT OF ANKLE FX LAT|Managed Medicaid|MEDICAID AMERIGROUP|||||251.67||| 27786|EAP|0510|TREATMENT OF ANKLE FX LAT|Humana Medicare Advantage|HUMANA MA|||||251.67||| 27808|EAP|0361||Cigna|CIGNA|||||6.04||| 27808|EAP|0510|CL TREATMENT OF ANKLE FRA|Cigna|CIGNA|||||6.04||| 27808|EAP|0510|CL TREATMENT OF ANKLE FRA|Humana Medicare Advantage|HUMANA MA|||||6.04||| 27808|EAP|0510|CL TREATMENT OF ANKLE FRA|Medicare|MEDICARE ACUTE|||||6.04||| 27808|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.04||| 27810|EAP|0450|TX FX BIMALLEOLAR W MANIP|Medicare|MEDICARE ACUTE|21.97||||21.97||| 27810|EAP|0450|TX FX BIMALLEOLAR W MANIP|Blue Cross HMO Specialty|BCBSTX HMO|21.97||||||| 27810|EAP|0450|TX FX BIMALLEOLAR W MANIP|Managed Medicaid|MEDICAID SUPERIOR|||||21.97||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.97||||||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||21.97||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|Humana Medicare Advantage|HUMANA MA|||||21.97||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|Cigna|CIGNA|||||21.97||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||21.97||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|Blue Cross PPO Specialty|BCBSTX PPO|21.97||||21.97||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|Blue Cross HMO Specialty|BCBSTX HMO|21.97||||||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|Medicaid|MEDICAID|21.97||||||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|United Healthcare|UNITED HEALTHCARE|21.97||||||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|NON CONTRACTED|COMMERCIAL OTHER 1|||||21.97||| 27818|EAP|0450|TX FX TRIMALLEOLAR W MANI|Medicare|MEDICARE ACUTE|21.97||||21.97||| 27824|EAP|0510|CLSD TREAT LOWER LEG FRAC|Blue Cross PPO Specialty|BCBSTX PPO|||||242.84||| 27840|EAP|0510|TREATMENT OF ANKLE DISLOC|Medicare|MEDICARE ACUTE|||||251.67||| 27840|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 27840|EAP|0450|TX DISLOC ANKLE WO ANESTH|Medicare|MEDICARE ACUTE|1,100.80||||10.24||| 27840|EAP|0450|TX DISLOC ANKLE WO ANESTH|Tricare|TRICARE FOR LIFE|||||10.24||| 27840|EAP|0450|TX DISLOC ANKLE WO ANESTH|Tricare|TRICARE EAST REGION|||||1,177.60||| 27840|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.04||| 27840|EAP|0510|TREATMENT OF ANKLE DISLOC|Managed Medicare|HEALTHSPRING MA|||||251.67||| 27840|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.04||| 27840|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.04||| 27840|EAP|0510|TREATMENT OF ANKLE DISLOC|Aetna|AETNA OTHER|||||251.67||| 27840|EAP|0510|TREATMENT OF ANKLE DISLOC|Blue Cross PPO Specialty|BCBSTX PPO|||||251.67||| 27840|EAP|0450|TX DISLOC ANKLE WO ANESTH|Blue Cross PPO Specialty|BCBSTX PPO|1,177.60||||1,177.60||| 28|DRG||SPINAL PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|355,712.25|31964.7|74868.12|21927.7|||| 28|DRG||SPINAL PROCEDURES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|474,810.44|74868.12|74868.12|21927.7|||| 28|DRG||SPINAL PROCEDURES W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|236,739.27|46625.01|74868.12|21927.7|||| 28|DRG||SPINAL PROCEDURES W MCC|Medicare|MEDICARE ACUTE|306,218.51|32282.19|74868.12|21927.7|||| 28|DRG||SPINAL PROCEDURES W MCC|Medicaid|MEDICAID|528,291.15|21927.7|74868.12|21927.7|||| 28|DRG||SPINAL PROCEDURES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|206,127.05|32509.47|74868.12|21927.7|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|PHCS|HUMANA|75,529.50|7808.76|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|62,767.43|62767.43|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|51,576.05|10232.37|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|62,052.58|10233.25|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|119,211.97|10419.49|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|United Healthcare|UNITED HEALTHCARE|25,308.68|19303.33|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|207,518.72|10206.43|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Medicaid|MEDICAID|158,864.55|6183.33|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Medicaid|LAW ENFORCEMENT OTHER|32,896.24|8098.625|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Medicare|MEDICARE ACUTE|65,554.05|10232.37|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63,850.03|10329.375|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Veterans Affairs|VETERANS ADMINISTRATION|67,328.58|10236.255|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|482.75|57.53|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|72,933.80|11251.71|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|72,693.93|107.16|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Tricare|TRICARE EAST REGION|60,828.66|10356.93|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Blue Cross HMO Specialty|BCBSTX HMO|64,357.21|9419.805|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Aetna|AETNA OTHER|120,910.69|21043.5|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Managed Medicare|HEALTHSPRING MA|67,333.25|10233.25|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|55,632.58|10325.93|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Managed Medicare|BCBS MEDICARE PPO MA|63,475.14|10233.25|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|67,044.30|12617.02|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Managed Medicaid|MEDICAID AMERIGROUP|125,631.17|21300.72|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|68,842.99|12974.44|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Cigna|CIGNA OTHER|89,318.41|20404.46|62767.43|57.53|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Humana Medicare Advantage|HUMANA MA|71,657.25|10231.09|62767.43|57.53|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Humana Medicare Advantage|HUMANA MA|57,510.10|6581.01|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43,074.33|10472.735|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Managed Medicaid|MEDICAID SUPERIOR|87,039.58|10055.15|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Managed Medicare|HEALTHSPRING MA|41,754.62|6599.53|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|55,136.05|6585.45|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Blue Cross HMO Specialty|BCBSTX HMO|72,092.64|5654.25|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44,500.74|53.58|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Blue Cross PPO Specialty|BCBSTX PPO|51,178.38|6651.48|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35,778.37|5913.81|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Blue Cross PPO Specialty|BCBSTX OTHER|33,746.31|6651.48|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|56,987.57|8520.51|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|40,124.28|6640.25|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Veterans Affairs|VETERANS ADMINISTRATION|45,357.01|6709.13|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Medicare|MEDICARE ACUTE|42,522.87|6598.65|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Medicare|MEDICARE PART B ONLY IP|22,427.75|1257.22|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Medicaid|MEDICAID|130,306.92|5094.94|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|15,649.25|6582.72|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|40,116.40|6709.13|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|United Medicare Advantage|UHC AARP MCR HMO MA|56,668.74|6709.13|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|76,754.29|6597.77|10472.735|53.58|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Tricare|TRICARE EAST REGION|43,414.75|422.95|10472.735|53.58|||| 28190|EAP|0450|RMV FB FOOT SUBQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,930.20||| 28190|EAP|0450|RMV FB FOOT SUBQ|Cigna|CIGNA|||||2,930.20||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|55,207.21|5415.94|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37,852.08|5415.94|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|51,107.78|5318.02|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|28,235.60|5403.35|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Medicare|MEDICARE ACUTE|43,002.43|5333.07|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|27,095.20|2599.3|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|28,438.10|5364.89|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|183.96|6911.46|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|30,759.12|5085.71|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16,184.78|35.72|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|40,453.53|35.72|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47,129.93|7913.26|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|57,253.06|10890.32|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|39,407.03|5415.94|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|65,111.75|5332.19|10890.32|35.72|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|76,226.65|5375.68|10890.32|35.72|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|Managed Medicare|HEALTHSPRING MA|157,625.59|11365.3|21301.25|11157.36|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|Humana Medicare Advantage|HUMANA MA|81,836.06|11157.49|21301.25|11157.36|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40,544.86|16705.1|21301.25|11157.36|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|Medicare|MEDICARE ACUTE|84,872.36|11159.52|21301.25|11157.36|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|United Healthcare|UNITED HEALTHCARE OTHER|85,682.39|21301.25|21301.25|11157.36|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|70,886.40|11157.36|21301.25|11157.36|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|59,456.25|11365.3|21301.25|11157.36|||| 284|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W CC|Medicare|MEDICARE ACUTE|68,931.77|5304.205|5304.205|5304.205|||| 28400|EAP|0510|CLSD TX CALCANEAL FX W/O|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||251.67||| 28400|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 28400|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.04||| 28400|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 28400|EAP|0510|CLSD TX CALCANEAL FX W/O|Medicare|MEDICARE ACUTE|||||251.67||| 28400|EAP|0361||Medicaid|MEDICAID|||||6.04||| 28430|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.04||| 28430|EAP|0510|TREATMENT OF ANKLE FX TAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||251.67||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Managed Medicare|BCBS MEDICARE PPO MA|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Managed Medicare|HEALTHSPRING MA|||||6.04||| 28470|EAP|0361||Medicaid|MEDICAID|||||6.04||| 28470|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.04||| 28470|EAP|0450|TREAT METATARSAL FX|United Healthcare|UNITED HEALTHCARE OTHER|6.34||||||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Tricare|TRICARE FOR LIFE|||||6.04||| 28470|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Medicare|MEDICARE ACUTE|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|United Medicare Advantage|UHC AARP MCR HMO MA|||||6.04||| 28470|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.04||| 28470|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.04||| 28470|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.04||| 28470|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Humana Medicare Advantage|HUMANA MA|||||6.04||| 28470|EAP|0361||Cigna|CIGNA|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Cigna|CIGNA|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Managed Medicaid|MEDICAID SUPERIOR|||||6.04||| 28470|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 28470|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 28470|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Blue Cross PPO Specialty|BCBSTX PPO|||||6.04||| 28470|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.04||| 28470|EAP|0510|TREATMENT METATARSAL FX W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.04||| 28475|EAP|0450|TX FX METATARSAL W MANIP|Humana Medicare Advantage|HUMANA MA|||||14.28||| 28490|EAP|0361||Medicare|MEDICARE ACUTE|||||6.04||| 28490|EAP|0510|TREAT BIG TOE FRACTURE W/|Medicare|MEDICARE ACUTE|||||251.67||| 28490|EAP|0510|TREAT BIG TOE FRACTURE W/|Managed Medicare|HEALTHSPRING MA|||||251.67||| 28490|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.04||| 28510|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.04||| 28510|EAP|0361||Medicaid|MEDICAID HMO|||||6.04||| 28515|EAP|0450|TX FX OTH THAN GRT TOE W|Blue Cross PPO Specialty|BCBSTX PPO|||||7.86||| 28515|EAP|0450|TX FX OTH THAN GRT TOE W|Managed Medicaid|MEDICAID SUPERIOR|||||7.86||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|United Healthcare|UNITED HEALTHCARE OTHER|80,290.09|80290.09|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|United Healthcare|UNITED HEALTHCARE|35,818.75|26008.43|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|191,133.50|13466.86|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|132,401.14|13593.65|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|156,916.56|14114.36|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Medicaid|MEDICAID|182,116.92|7655.6|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Medicare|MEDICARE ACUTE|80,635.99|13349.94|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|117,495.67|13313.67|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Cigna|CIGNA|58,293.51|22611.25|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Humana Medicare Advantage|HUMANA MA|110,795.70|13346.17|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|87,218.31|10055.15|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|149,525.61|16997.77|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Managed Medicare|HEALTHSPRING MA|79,714.25|13341.39|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|392,286.39|750.12|80290.09|750.12|||| 286|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC|Blue Cross PPO Specialty|BCBSTX PPO|91,105.50|14807.63|80290.09|750.12|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|51,962.75|7618.7|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|48,626.59|7733.13|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Aetna|AETNA PPO|56,962.05|14575.33|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|38,944.58|6573.73|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54,732.25|102.06|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|51,984.50|7606.47|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|31,279.55|7737.31|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|67,603.16|9432.485|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|56,652.65|10795.28|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Cigna|CIGNA OTHER|48,930.47|11856.14|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Humana Medicare Advantage|HUMANA MA|55,646.35|7604.31|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|41,785.32|10795.28|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Managed Medicare|HEALTHSPRING MA|78,227.27|7606.47|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|51,681.27|7737.31|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|63,729.49|63729.49|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|76,077.88|9799.79|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|76,673.92|11665.09|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|63,798.22|7578.31|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|78,357.02|7606.47|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Medicare|MEDICARE ACUTE|58,363.25|7606.47|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Medicare|MEDICARE PART B ONLY IP|45,947.61|2641.56|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Medicaid|MEDICAID|60,183.37|6789.49|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|Tricare|TRICARE EAST REGION|61,527.75|6880.09|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|PHCS|GROUP AND PENSION|106,872.69|73742.16|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|70,164.64|70164.64|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|55,386.01|7671.45|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|771.21|7751.22|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|65,944.81|7606.03|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|United Healthcare|UNITED HEALTHCARE|67,534.94|13637.44|73742.16|102.06|||| 287|DRG||CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|43,623.68|7652.57|73742.16|102.06|||| 288|DRG||ACUTE & SUBACUTE ENDOCARDITIS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|162,293.62|15839.65|21913.14|13688.96|||| 288|DRG||ACUTE & SUBACUTE ENDOCARDITIS W MCC|Medicaid|MEDICAID|322,480.63|21913.14|21913.14|13688.96|||| 288|DRG||ACUTE & SUBACUTE ENDOCARDITIS W MCC|Medicare|MEDICARE ACUTE|106,419.39|15870.47|21913.14|13688.96|||| 288|DRG||ACUTE & SUBACUTE ENDOCARDITIS W MCC|Humana Medicare Advantage|HUMANA MA|106,156.30|13688.96|21913.14|13688.96|||| 289|DRG||ACUTE & SUBACUTE ENDOCARDITIS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|107,859.34|10391.76|10412.9|10391.76|||| 289|DRG||ACUTE & SUBACUTE ENDOCARDITIS W CC|Medicare|MEDICARE ACUTE|92,728.37|10412.9|10412.9|10391.76|||| 29|DRG||SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS|NON CONTRACTED|COMMERCIAL OTHER 1|197,777.10|197777.1|197777.1|18214.7|||| 29|DRG||SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|142,258.13|18881.85|197777.1|18214.7|||| 29|DRG||SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS|Medicare|MEDICARE ACUTE|93,889.38|18881.85|197777.1|18214.7|||| 29|DRG||SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|113,978.14|18214.7|197777.1|18214.7|||| 29|DRG||SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS|Blue Cross PPO Specialty|BCBSTX PPO|207,179.72|21427.2|197777.1|18214.7|||| 29|DRG||SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS|Cigna|CIGNA|146,751.65|33000.03|197777.1|18214.7|||| 29|DRG||SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS|Access Direct Platinum|HEALTHFIRST TPA UMR|71,454.20|25484.84|197777.1|18214.7|||| 29|DRG||SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS|Aenta Medicare Advantage|AETNA MEDICARE MA|152,603.10|18853.69|197777.1|18214.7|||| 29065|EAP|0510|APPLICATION OF LONG ARM C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||263.33||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||263.33||| 29065|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.32||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Managed Medicaid|MEDICAID SUPERIOR|||||263.33||| 29065|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.32||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Cigna|CIGNA OTHER|||||263.33||| 29065|EAP|0361||Cigna|CIGNA OTHER|||||6.32||| 29065|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||6.32||| 29065|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.32||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Blue Cross PPO Specialty|BCBSTX PPO|||||263.33||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Blue Cross PPO Specialty|BCBSTX OTHER|||||263.33||| 29065|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.32||| 29065|EAP|0450|APPLY LONG ARM CAST|Blue Cross PPO Specialty|BCBSTX PPO|||||4.76||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Blue Cross HMO Specialty|BCBSTX HMO|||||263.33||| 29065|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||6.32||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Managed Medicaid|MEDICAID AMERIGROUP|||||263.33||| 29065|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.32||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||263.33||| 29065|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.32||| 29065|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.32||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||263.33||| 29065|EAP|0361||Medicaid|MEDICAID|||||6.32||| 29065|EAP|0361||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.32||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Medicaid|MEDICAID|||||263.33||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||263.33||| 29065|EAP|0510|APPLICATION OF LONG ARM C|United Healthcare|UNITED HEALTHCARE ERS|||||263.33||| 29065|EAP|0510|APPLICATION OF LONG ARM C|United Healthcare|UNITED HEALTHCARE|||||263.33||| 29065|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.32||| 29065|EAP|0361||Medicare|MEDICARE ACUTE|||||6.32||| 29065|EAP|0510|APPLICATION OF LONG ARM C|Medicare|MEDICARE ACUTE|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|NON CONTRACTED|COMMERCIAL OTHER 1|||||263.33||| 29075|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||6.32||| 29075|EAP|0361||PHCS|HUMANA|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Medicare|MEDICARE ACUTE|||||263.33||| 29075|EAP|0361||Medicare|MEDICARE ACUTE|||||6.32||| 29075|EAP|0361||Tricare|TRICARE EAST REGION|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Tricare|TRICARE EAST REGION|||||447.67||| 29075|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|United Healthcare|GOLDEN RULE|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|United Healthcare|UNITED HEALTHCARE|||||263.33||| 29075|EAP|0361||Medicaid|MEDICAID|||||6.32||| 29075|EAP|0361||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Medicaid|MEDICAID|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Managed Medicare|HEALTHSPRING MA|||||263.33||| 29075|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.32||| 29075|EAP|0361||Managed Medicare|OTHER INSTITUTIONS|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Aetna|AETNA PPO|||||263.33||| 29075|EAP|0361||Aetna|AETNA OTHER|||||6.32||| 29075|EAP|0361||Aetna|BOON CHAPMAN|||||6.32||| 29075|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Blue Cross HMO Specialty|BCBSTX HMO|||||263.33||| 29075|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||6.32||| 29075|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.32||| 29075|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Blue Cross PPO Specialty|BCBSTX PPO|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Medicaid|MEDICAID HMO|||||263.33||| 29075|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Humana Medicare Advantage|HUMANA MA|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|United Healthcare|UNITED HEALTHCARE OTHER|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Cigna|CIGNA OTHER|||||263.33||| 29075|EAP|0361||Cigna|CIGNA OTHER|||||6.32||| 29075|EAP|0361||Cigna|CIGNA|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Managed Medicaid|MEDICAID AMERIGROUP|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Managed Medicaid|MEDICAID SUPERIOR|||||263.33||| 29075|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||263.33||| 29075|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.32||| 29075|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.32||| 29075|EAP|0361||Workers Compensation|TEXAS MUTUAL INSURANCE|||||6.32||| 29075|EAP|0361||Workers Compensation|WORKERS COMPENSATION OTHER|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Workers Compensation|UT EMPLOYEE INJURY|||||263.33||| 29075|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.32||| 29075|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||6.32||| 29075|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||263.33||| 29075|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.32||| 29075|EAP|0510|APPLICATION OF FOREARM CA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||263.33||| 29075|EAP|0510|APPLICATION OF FOREARM CA|United Medicare Advantage|UHC AARP MCR HMO MA|||||263.33||| 29075|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.32||| 291|DRG||HEART FAILURE & SHOCK W MCC|Veterans Affairs|VETERANS ADMINISTRATION|39,413.50|8668.82|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35,732.88|12414.49|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|191,004.31|13365.775|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Access Direct Platinum|HEALTHFIRST TPA|89,322.67|11353.94|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|83,452.75|8640.66|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicare|BCBS MEDICARE PPO MA|55,016.75|8649.52|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|78,581.30|8667.94|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicare|HOSPICE OF EAST TEXAS|597.91|8667.94|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Humana Medicare Advantage|HUMANA MA|66,874.97|8672.64|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Cigna|CIGNA|86,025.63|13848.28|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|84,628.60|11694.73|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicaid|MEDICAID SUPERIOR|30,895.37|4999.07|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|75,391.19|9831.5|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicare|HEALTHSPRING MA|75,956.81|8668.82|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|145,522.51|83331.87|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Blue Cross PPO Specialty|BCBSTX OTHER|23,384.73|8450.46|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Blue Cross PPO Specialty|BCBSTX PPO|68,174.92|9135.27|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Blue Cross HMO Specialty|BCBSTX HMO|100,550.05|7765.65|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|56,817.95|142.88|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|44,035.40|4195.76|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Medicaid|MEDICAID|86,554.43|6183.33|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Medicaid|SMITH COUNTY JAIL|27,178.29|3463.19|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Medicaid|SMITH COUNTY INDIGENT HEALTH|115,739.87|6183.33|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Medicare|MEDICARE PART B ONLY IP|10,922.99|4752.055|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Medicare|MEDICARE ACUTE|54,778.70|8667.94|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|90,346.32|8668.82|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|387.69|8653.66|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|50,661.96|8667.3|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|United Healthcare|UNITED HEALTHCARE OTHER|34,527.53|15928.89|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|United Healthcare|UNITED HEALTHCARE|70,811.25|15928.89|83331.87|142.88|||| 291|DRG||HEART FAILURE & SHOCK W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|264.18|8618.52|83331.87|142.88|||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Medicare|MEDICARE ACUTE|||||5.50||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Medicare|MEDICARE PART B ONLY IP|632.50||||||| 29105|EAP|0510|APPLY LONG ARM SPLINT|Medicare|MEDICARE ACUTE|||||150.42||| 29105|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||3.61||| 29105|EAP|0450|APPLY LONG ARM SPLINT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.50||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Medicaid|MEDICAID|||||5.50||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Medicaid|CRIME VICTIMS COMPENSATION|5.50||||||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||632.50||| 29105|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||3.61||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Humana Medicare Advantage|HUMANA MA|632.50||||591.25||| 29105|EAP|0361||Medicare|MEDICARE ACUTE|||||3.61||| 29105|EAP|0510|APPLY LONG ARM SPLINT|Cigna|CIGNA OTHER|||||150.42||| 29105|EAP|0510|APPLY LONG ARM SPLINT|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||150.42||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Managed Medicaid|MEDICAID AMERIGROUP|||||591.25||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||632.50||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Managed Medicaid|MEDICAID SUPERIOR|||||5.50||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Veterans Affairs|VETERANS ADMINISTRATION|632.50||||||| 29105|EAP|0361||Workers Compensation|ZURICH COMPANY|||||3.61||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||591.25||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Access Direct Platinum|HEALTHFIRST TPA|||||5.50||| 29105|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.61||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||587.65||| 29125|EAP|0510|APPLY FOREARM SPLINT|United Medicare Advantage|UHC AARP MCR HMO MA|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Access Direct Platinum|HEALTHFIRST TPA|||||5.11||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.11||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||587.65||| 29125|EAP|0510|APPLY FOREARM SPLINT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||119.17||| 29125|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||2.86||| 29125|EAP|0510|APPLY FOREARM SPLINT|Workers Compensation|BROOKSHIRES WORKERS COMP|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Workers Compensation|UT EMPLOYEE INJURY|||||587.65||| 29125|EAP|0510|APPLY FOREARM SPLINT|Workers Compensation|WORKERS COMPENSATION OTHER|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Veterans Affairs|VETERANS ADMINISTRATION|5.11||||549.33||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Workers Compensation|WORKERS COMPENSATION OTHER|5.11||||549.33||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.11||||549.33||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID SUPERIOR|||||5.11||| 29125|EAP|0510|APPLY FOREARM SPLINT|Managed Medicaid|MEDICAID AMERIGROUP|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID AMERIGROUP|||||5.11||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Cigna|CIGNA|||||549.33||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Humana Medicare Advantage|HUMANA MA|||||587.65||| 29125|EAP|0510|APPLY FOREARM SPLINT|Humana Medicare Advantage|HUMANA MA|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross HMO Specialty|BCBSTX HMO|||||587.65||| 29125|EAP|0510|APPLY FOREARM SPLINT|Cigna|CIGNA|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.11||| 29125|EAP|0510|APPLY FOREARM SPLINT|Blue Cross PPO Specialty|BCBSTX PPO|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross PPO Specialty|BCBSTX PPO|||||5.11||| 29125|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||2.86||| 29125|EAP|0510|APPLY FOREARM SPLINT|Blue Cross PPO Specialty|BCBSTX OTHER|||||119.17||| 29125|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.86||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||587.65||| 29125|EAP|0510|APPLY FOREARM SPLINT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.11||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Aetna|AETNA OTHER|||||587.65||| 29125|EAP|0510|APPLY FOREARM SPLINT|Aetna|AETNA OTHER|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicare|HEALTHSPRING MA|||||587.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.11||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.11||| 29125|EAP|0510|APPLY FOREARM SPLINT|Managed Medicare|HEALTHSPRING MA|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicaid|MEDICAID|||||549.33||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicaid|CRIME VICTIMS COMPENSATION|5.11||||||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicaid|MEDICAID HMO|||||587.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||587.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Medicare Advantage|UHC AARP MCR HMO MA|||||587.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.11||| 29125|EAP|0361||Medicaid|SMITH COUNTY JAIL|||||2.86||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Healthcare|UNITED HEALTHCARE|||||587.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Healthcare|UNITED HEALTHCARE|||||549.33||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Healthcare|UNITED HEALTHCARE OTHER|||||587.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Tricare|TRICARE EAST REGION|||||549.33||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||587.65||| 29125|EAP|0510|APPLY FOREARM SPLINT|Tricare|TRICARE EAST REGION|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.11||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|NON CONTRACTED|COMMERCIAL OTHER 2|||||587.65||| 29125|EAP|0510|APPLY FOREARM SPLINT|Medicare|MEDICARE ACUTE|||||119.17||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicare|MEDICARE ACUTE|587.65||||587.65||| 29125|EAP|0361||Medicare|MEDICARE ACUTE|||||2.86||| 29130|EAP|0450|APPLY FINGER SPLINT STATI|Medicare|MEDICARE ACUTE|||||4.56||| 29130|EAP|0450|APPLY FINGER SPLINT STATI|Medicaid|MEDICAID HMO|||||4.56||| 292|DRG||HEART FAILURE & SHOCK W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26,803.94|71.44|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|420.47|6245.44|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|Blue Cross PPO Specialty|BCBSTX PPO|23,895.98|6245.44|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40,972.49|9831.5|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|Humana Medicare Advantage|HUMANA MA|66,385.45|6307.635|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|Managed Medicare|HEALTHSPRING MA|42,020.79|6477.28|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|Veterans Affairs|VETERANS ADMINISTRATION|43,052.15|6303.89|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|Medicaid|MEDICAID|30,735.57|3559.8|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|Medicare|MEDICARE ACUTE|408.44|6251.87|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|Medicare|MEDICARE PART B ONLY IP|28,879.43|3430.99|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|United Healthcare|UNITED HEALTHCARE OTHER|24,035.25|10717.5|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|21,248.25|9588.985|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|United Medicare Advantage|UHC AARP MCR HMO MA|23,747.25|6252.75|10717.5|71.44|||| 292|DRG||HEART FAILURE & SHOCK W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38,014.62|6355.03|10717.5|71.44|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|52,371.25|4852.65|6335.61|3841.84|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|322.48|4879.81|6335.61|3841.84|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Medicare|MEDICARE ACUTE|28,836.10|4879.81|6335.61|3841.84|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|12,547.85|4851.65|6335.61|3841.84|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16,834.84|6335.61|6335.61|3841.84|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|40,050.25|4878.93|6335.61|3841.84|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|37,567.95|4916.03|6335.61|3841.84|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|31,079.30|4862.03|6335.61|3841.84|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|27,687.32|4519.42|6335.61|3841.84|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|72,901.40|3841.84|6335.61|3841.84|||| 29345|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||6.32||| 29345|EAP|0361||Cigna|CIGNA|||||6.32||| 29345|EAP|0510|APPLICATION OF LONG LEG C|Managed Medicaid|MEDICAID SUPERIOR|||||263.33||| 29345|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.32||| 29345|EAP|0510|APPLICATION OF LONG LEG C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||263.33||| 29345|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.32||| 29345|EAP|0361||Medicaid|MEDICAID|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|NON CONTRACTED|COMMERCIAL OTHER 1|||||263.33||| 29405|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|PHCS|GROUP AND PENSION|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|Medicare|MEDICARE ACUTE|||||263.33||| 29405|EAP|0361||Medicare|MEDICARE ACUTE|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Tricare|TRICARE FOR LIFE|||||263.33||| 29405|EAP|0361||Tricare|TRICARE EAST REGION|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|United Healthcare|UNITED HEALTHCARE|||||263.33||| 29405|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||6.32||| 29405|EAP|0361||Managed Medicare|OTHER INSTITUTIONS|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Managed Medicare|OTHER INSTITUTIONS|||||263.33||| 29405|EAP|0361||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Medicaid|MEDICAID HMO|||||263.33||| 29405|EAP|0361||Medicaid|LAW ENFORCEMENT OTHER|||||6.32||| 29405|EAP|0361||Medicaid|MEDICAID|||||6.32||| 29405|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.32||| 29405|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||263.33||| 29405|EAP|0361||Workers Compensation|WORKERS COMPENSATION OTHER|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Workers Compensation|UT EMPLOYEE INJURY|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|Workers Compensation|WORKERS COMPENSATION OTHER|||||263.33||| 29405|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.32||| 29405|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Access Direct Platinum|HEALTHFIRST TPA UMR|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||263.33||| 29405|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Medicaid|MEDICAID|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|Managed Medicare|HEALTHSPRING MA|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|Managed Medicaid|MEDICAID AMERIGROUP|||||263.33||| 29405|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||263.33||| 29405|EAP|0361||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.32||| 29405|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.32||| 29405|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|Managed Medicaid|MEDICAID SUPERIOR|||||263.33||| 29405|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Humana Medicare Advantage|HUMANA MA|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|Cigna|CIGNA|||||447.67||| 29405|EAP|0361||Cigna|CIGNA|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Cigna|CIGNA OTHER|||||263.33||| 29405|EAP|0510|APPLY SHORT LEG CAST|Cigna|CIGNA|||||263.33||| 29405|EAP|0361||Aetna|AETNA PPO|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Aenta Medicare Advantage|AETNA MEDICARE MA|||||263.33||| 29405|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||263.33||| 29405|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Blue Cross PPO Specialty|BCBSTX PPO|||||263.33||| 29405|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.32||| 29405|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||6.32||| 29405|EAP|0510|APPLY SHORT LEG CAST|Blue Cross HMO Specialty|BCBSTX HMO|||||263.33||| 29445|EAP|0761|APPLY RIDIG LEG CAST|Blue Cross HMO Specialty|BCBSTX HMO|||||13.90||| 29445|EAP|0761|APPLY RIDIG LEG CAST|Blue Cross PPO Specialty|BCBSTX PPO|||||13.90||| 29445|EAP|0761|APPLY RIDIG LEG CAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||13.90||| 29445|EAP|0761|APPLY RIDIG LEG CAST|Humana Medicare Advantage|HUMANA MA|||||1,494.25||| 29445|EAP|0761|APPLY RIDIG LEG CAST|Access Direct Platinum|HEALTHFIRST TPA UMR|||||13.90||| 29445|EAP|0761|APPLY RIDIG LEG CAST|Veterans Affairs|VETERANS ADMINISTRATION|||||1,598.50||| 29445|EAP|0761|APPLY RIDIG LEG CAST|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,598.50||| 29445|EAP|0761|APPLY RIDIG LEG CAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,598.50||| 29445|EAP|0761|APPLY RIDIG LEG CAST|Managed Medicare|HEALTHSPRING MA|||||1,598.50||| 29445|EAP|0761|APPLY RIDIG LEG CAST|Medicare|MEDICARE ACUTE|||||13.90||| 29505|EAP|0450|APPLY LONG LEG SPLINT|PHCS|HUMANA|645.15||||||| 29505|EAP|0450|APPLY LONG LEG SPLINT|Medicare|MEDICARE ACUTE|5.61||||||| 29505|EAP|0510|APPLICATION LONG LEG SPLI|Medicare|MEDICARE ACUTE|||||151.05||| 29505|EAP|0450|APPLY LONG LEG SPLINT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||645.15||| 29505|EAP|0450|APPLY LONG LEG SPLINT|Managed Medicaid|MEDICAID SUPERIOR|||||645.15||| 29505|EAP|0450|APPLY LONG LEG SPLINT|Managed Medicaid|MEDICAID AMERIGROUP|||||645.15||| 29505|EAP|0510|APPLICATION LONG LEG SPLI|Blue Cross HMO Specialty|BCBSTX HMO|||||151.05||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Aetna|AETNA PPO|||||5.21||| 29515|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||3.61||| 29515|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||3.61||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Blue Cross PPO Specialty|BCBSTX PPO|599.15||||5.21||| 29515|EAP|0510|APPLICATION OF LOWER LEG|Blue Cross PPO Specialty|BCBSTX PPO|||||150.42||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.21||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|ChampVA|CHAMPVA CENTER|||||5.21||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Humana Medicare Advantage|HUMANA MA|||||599.15||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Managed Medicaid|MEDICAID SUPERIOR|599.15||||5.21||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|599.15||||||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Managed Medicaid|MEDICAID AMERIGROUP|||||5.21||| 29515|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||3.61||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.21||||560.08||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||560.08||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|United Medicare Advantage|UHC AARP MCR HMO MA|||||599.15||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Workers Compensation|WORKERS COMPENSATION OTHER|||||560.08||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Veterans Affairs|VETERANS ADMINISTRATION|||||599.15||| 29515|EAP|0510|APPLICATION OF LOWER LEG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||150.42||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.21||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.21||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.21||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||599.15||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|599.15||||599.15||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||599.15||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Medicaid|MEDICAID HMO|||||599.15||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Medicaid|MEDICAID|5.21||||5.21||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Managed Medicare|HEALTHSPRING MA|||||599.15||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|United Healthcare|UNITED HEALTHCARE|||||5.21||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Tricare|TRICARE EAST REGION|||||599.15||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|Medicare|MEDICARE ACUTE|560.08||||599.15||| 29515|EAP|0361||Medicare|MEDICARE ACUTE|3.61||||3.61||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.21||| 29515|EAP|0450|APPLY SPLINT LOWER LEG|PHCS|HUMANA|599.15||||||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Managed Medicare|HEALTHSPRING MA|||||5.06||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.06||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Managed Medicare|HEALTHSPRING MA|||||581.90||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Managed Medicare|BCBS MEDICARE PPO MA|||||5.06||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||581.90||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.06||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.06||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Medicare|MEDICARE ACUTE|5.06||||581.90||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.06||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|United Medicare Advantage|UHC MEDICARE GOLD MA|||||581.90||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.06||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||581.90||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||543.95||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Humana Medicare Advantage|HUMANA MA|||||5.06||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Humana Medicare Advantage|HUMANA MA|||||581.90||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Cigna|CIGNA|||||581.90||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Blue Cross HMO Specialty|BCBSTX HMO|||||5.06||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Blue Cross PPO Specialty|BCBSTX PPO|||||581.90||| 29581|EAP|0761|APPL MULTLAY COMPRS LWR L|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||581.90||| 296|DRG||CARDIAC ARREST, UNEXPLAINED W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|42,947.11|21657.13|21657.13|9907.07|||| 296|DRG||CARDIAC ARREST, UNEXPLAINED W MCC|Medicare|MEDICARE ACUTE|68,923.93|9907.07|21657.13|9907.07|||| 296|DRG||CARDIAC ARREST, UNEXPLAINED W MCC|United Healthcare|UNITED HEALTHCARE|214,093.32|18587.25|21657.13|9907.07|||| 296|DRG||CARDIAC ARREST, UNEXPLAINED W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|85,925.25|14902.69|21657.13|9907.07|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Tricare|TRICARE EAST REGION|62,691.54|5271.38|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|71,955.13|9310.005|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|United Healthcare|UNITED HEALTHCARE|32,358.65|17158.65|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Medicare|MEDICARE ACUTE|45,944.99|9238.51|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|101,865.95|9404.22|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Aetna|AETNA PPO|29,712.16|16835.37|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|34,671.28|9848.22|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Managed Medicare|HEALTHSPRING MA|46,254.72|8556.22|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|58,059.38|9226.77|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|96,194.10|189.65|17158.65|189.65|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|66,089.05|9944.66|17158.65|189.65|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Humana Medicare Advantage|HUMANA MA|663,683.10|105298.16|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Managed Medicare|BCBS MEDICARE PPO MA|550,241.23|105262.16|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Managed Medicare|HEALTHSPRING MA|568,647.88|84042.085|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Blue Cross PPO Specialty|BCBSTX PPO|967,324.45|196367.5|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|632,510.96|696.54|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|882,840.65|109557.6|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Blue Cross HMO Specialty|BCBSTX HMO|489,643.21|83168.295|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Aetna|AETNA PPO|617,794.09|239921.3|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Veterans Affairs|VETERANS ADMINISTRATION|770,198.26|107481.64|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Workers Compensation|TEXAS MUTUAL INSURANCE|763,733.45|125235.32|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Medicaid|SMITH COUNTY INDIGENT HEALTH|411,328.39|50533.73|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Medicaid|MEDICAID|777,962.66|47688.625|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|Medicare|MEDICARE ACUTE|776,927.20|105289.44|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|United Healthcare|UNITED HEALTHCARE OTHER|525,785.39|227964.36|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|United Medicare Advantage|UHC MEDICARE GOLD MA|1,049,333.40|107596.22|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,399,328.83|118872.18|762916.61|696.54|||| 3|DRG||ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.|NON CONTRACTED|COMMERCIAL OTHER 1|1,105,676.24|762916.61|762916.61|696.54|||| 30|DRG||SPINAL PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|156,453.45|30518.58|30518.58|147.73|||| 30|DRG||SPINAL PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|61,515.50|13750.86|30518.58|147.73|||| 30|DRG||SPINAL PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|32,625.95|147.73|30518.58|147.73|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Veterans Affairs|VETERANS ADMINISTRATION|20,898.25|7039.17|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Managed Medicare|HEALTHSPRING MA|75,603.75|6922.75|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Humana Medicare Advantage|HUMANA MA|480.09|6894.59|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Managed Medicaid|MEDICAID AMERIGROUP|17,995.99|6790.41|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55,296.78|6790.41|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,407.58|85.9|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Medicaid|MEDICAID|552.11|4270.7|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Medicare|MEDICARE ACUTE|48,814.37|6921.87|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Medicare|MEDICARE PART B ONLY IP|15,516.25|6922.75|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|24,637.38|6978.73|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|66,704.49|6952.385|47889.35|85.9|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|United Healthcare|UNITED HEALTHCARE OTHER|47,889.35|47889.35|47889.35|85.9|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|27,454.55|27454.55|27454.55|272.16|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|32,133.98|5293.335|27454.55|272.16|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|265.89|4930.9|27454.55|272.16|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|Aetna|AETNA PPO|20,061.73|7090.36|27454.55|272.16|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|96,090.37|272.16|27454.55|272.16|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|58,056.72|5257.98|27454.55|272.16|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|277.61|6827.11|27454.55|272.16|||| 302|DRG||ATHEROSCLEROSIS W MCC|Medicare|MEDICARE ACUTE|25,878.77|7331.78|7331.78|7331.78|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|37,398.50|4990.88|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|34,352.37|6895.99|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15,265.57|6477.83|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|40,763.80|5067.43|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,150.21|4770.98|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18,782.79|35.72|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|54,139.02|5055.9|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|35,109.75|4991.76|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Medicaid|MEDICAID|24,246.84|3084.33|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Medicare|MEDICARE PART B ONLY IP|25,981.51|4994.24|6895.99|35.72|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Medicare|MEDICARE ACUTE|36,928.87|5067.43|6895.99|35.72|||| 30300|EAP|0450|REM FB INTRANASAL|Managed Medicaid|MEDICAID AMERIGROUP|||||560.05||| 30300|EAP|0450|REM FB INTRANASAL|Managed Medicaid|MEDICAID SUPERIOR|||||560.05||| 304|DRG||HYPERTENSION W MCC|Medicare|MEDICARE ACUTE|52,566.44|7335.285|36370.29|7335.285|||| 304|DRG||HYPERTENSION W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|36,370.29|36370.29|36370.29|7335.285|||| 304|DRG||HYPERTENSION W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42,155.43|7397.19|36370.29|7335.285|||| 304|DRG||HYPERTENSION W MCC|Aetna|AETNA OTHER|35,070.57|14083.62|36370.29|7335.285|||| 305|DRG||HYPERTENSION W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|44,049.43|7575.67|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|20,002.12|6866.85|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Humana Medicare Advantage|HUMANA MA|102,116.77|1388.29|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|95,068.93|6751.92|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|62,719.16|5676.19|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Managed Medicare|HEALTHSPRING MA|482.75|57.53|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|32,920.80|4720.115|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19,930.69|35.72|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|49,288.42|4155.26|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Aetna|AETNA OTHER|28,558.25|9253.48|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|54,437.21|964.31|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|24,366.64|24366.635|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Medicaid|SMITH COUNTY INDIGENT HEALTH|37,308.18|3569.93|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Medicaid|MEDICAID|11,422.27|3023.65|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Medicare|MEDICARE PART B ONLY IP|23,596.45|2143.67|24366.635|35.72|||| 305|DRG||HYPERTENSION W/O MCC|Medicare|MEDICARE ACUTE|54,774.88|5380.09|24366.635|35.72|||| 307|DRG||CARDIAC CONGENITAL & VALVULAR DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|18,556.75|6224.47|6224.47|6101.73|||| 307|DRG||CARDIAC CONGENITAL & VALVULAR DISORDERS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|45,498.50|6101.73|6224.47|6101.73|||| 307|DRG||CARDIAC CONGENITAL & VALVULAR DISORDERS W/O MCC|Humana Medicare Advantage|HUMANA MA|50,390.61|6224.47|6224.47|6101.73|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|99,187.12|7800.39|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|28,746.50|7773.11|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25,827.55|71.44|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|57,973.62|8172.44|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Managed Medicare|HEALTHSPRING MA|105,216.99|7868.745|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32,769.17|8601.48|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,066.67|8601.48|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Cigna|CIGNA|61,500.72|12221.43|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|45,775.11|7792.61|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|United Healthcare|UNITED HEALTHCARE|40,499.07|10931.23|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|United Healthcare|UNITED HEALTHCARE OTHER|33,665.62|14057.62|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54,371.64|7801.27|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|44,112.91|9186.455|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Medicare|MEDICARE ACUTE|61,202.05|7800.39|14057.62|71.44|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Medicare|MEDICARE PART B ONLY IP|7,954.65|136.87|14057.62|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Medicare|MEDICARE PART B ONLY IP|9,429.25|462.43|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Medicare|MEDICARE ACUTE|33,470.75|5434.04|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53,160.23|5433.6|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|United Medicare Advantage|UHC AARP WELLMED HMO MA|24,000.79|7540.91|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|United Medicare Advantage|UHC AARP MCR HMO MA|52,276.81|5519.04|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|United Healthcare|UNITED HEALTHCARE|146.60|8951.57|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|24,388.63|6709.13|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Cigna|CIGNA|42,756.60|7597.035|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Humana Medicare Advantage|HUMANA MA|32,055.25|5519.04|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|357.25|5913.81|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Managed Medicaid|MEDICAID SUPERIOR|34,921.55|5913.81|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Medicaid|COUNTY INDIGENT HEALTH OTHER|37,244.35|3719.38|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39,377.29|4790.95|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Managed Medicare|HEALTHSPRING MA|26,256.88|5433.6|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|40,908.13|5433.16|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Managed Medicare|BCBS MEDICARE PPO MA|17,806.25|5433.16|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Blue Cross PPO Specialty|BCBSTX PPO|11,841.63|5184.16|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Aetna|AETNA PPO|21,991.62|9567.19|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30,409.25|71.44|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Blue Cross HMO Specialty|BCBSTX HMO|23,181.12|4406.92|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|61,914.19|5405.88|9567.19|71.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Veterans Affairs|VETERANS ADMINISTRATION|21,738.97|5476.54|9567.19|71.44|||| 30901|EAP|0450|CONTROL NOSE BLEED ANT/SI|United Medicare Advantage|UHC AARP MCR HMO MA|||||754.40||| 30901|EAP|0450|CONTROL NOSE BLEED ANT/SI|Blue Cross PPO Specialty|BCBSTX PPO|||||6.56||| 30901|EAP|0450|CONTROL NOSE BLEED ANT/SI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.56||| 30901|EAP|0450|CONTROL NOSE BLEED ANT/SI|Humana Medicare Advantage|HUMANA MA|||||6.56||| 30901|EAP|0450|CONTROL NOSE BLEED ANT/SI|Medicare|MEDICARE ACUTE|||||6.56||| 30901|EAP|0450|CONTROL NOSE BLEED ANT/SI|Medicare|MEDICARE PART B ONLY IP|6.56||||||| 30903|EAP|0450|CONTROL NOSEBLEED ANT COM|Medicare|MEDICARE ACUTE|7.79||||7.79||| 30903|EAP|0450|CONTROL NOSEBLEED ANT COM|Humana Medicare Advantage|HUMANA MA|||||837.43||| 30905|EAP|0450|CONTROL OF NOSEBLEED|Medicare|MEDICARE ACUTE|||||392.38||| 31|DRG||VENTRICULAR SHUNT PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|185,031.66|26272.795|26272.795|26272.795|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|21,995.75|4385.17|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Medicaid|CRIME VICTIMS COMPENSATION|13,734.50|3719.38|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|63,689.91|4405.7|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|27,704.48|4415.24|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30,002.72|4415.24|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|17,158.55|17158.55|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|25,218.75|5687.25|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|136.01|5687.25|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|10,796.50|4415.24|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|23,484.07|4353.03|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|23,316.10|4353.03|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|23,204.25|4352.15|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Cigna|CIGNA|50,352.94|5755.2|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|20,384.91|4415.24|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Cigna|CIGNA|25,097.25|5481.14|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20,786.01|35.72|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|251.07|3245.6|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|27,946.76|3818.02|17158.55|35.72|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|24,561.63|3818.02|17158.55|35.72|||| 311|DRG||ANGINA PECTORIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|57,147.41|5107.85|5107.85|5082.425|||| 311|DRG||ANGINA PECTORIS|Medicare|MEDICARE ACUTE|43,100.37|5082.425|5107.85|5082.425|||| 312|DRG||SYNCOPE & COLLAPSE|Blue Cross PPO Specialty|BCBSTX PPO|12,466.12|5242.56|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|72,526.62|102.06|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Blue Cross HMO Specialty|BCBSTX HMO|30,640.92|4626.26|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Humana Medicare Advantage|HUMANA MA|66,147.94|5754.75|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|62,309.46|62309.46|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Managed Medicare|HEALTHSPRING MA|61,988.47|5810.475|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Veterans Affairs|VETERANS ADMINISTRATION|38,866.75|5764.04|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35,153.67|7460.13|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Access Direct Platinum|HEALTHFIRST TPA|36,216.30|7460.13|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Medicare|MEDICARE PART B ONLY IP|44,739.15|1255.67|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|Medicare|MEDICARE ACUTE|42,978.46|5764.92|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|United Medicare Advantage|UHC MEDICARE GOLD MA|63,029.16|5755.875|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|48,946.11|5856.91|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|United Healthcare|UNITED HEALTHCARE OTHER|64,740.72|9665.28|62309.46|102.06|||| 312|DRG||SYNCOPE & COLLAPSE|UTMB|UTMB CORRECTIONAL MANAGED CARE|121,624.53|5842.97|62309.46|102.06|||| 313|DRG||CHEST PAIN|NON CONTRACTED|COMMERCIAL OTHER 1|78,445.50|4802.57|8171.55|47.65|||| 313|DRG||CHEST PAIN|United Medicare Advantage|UHC MEDICARE GOLD MA|40,728.05|5289.31|8171.55|47.65|||| 313|DRG||CHEST PAIN|United Medicare Advantage|UHC AARP MCR HMO MA|61,667.85|1669.44|8171.55|47.65|||| 313|DRG||CHEST PAIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|60,404.37|4289.53|8171.55|47.65|||| 313|DRG||CHEST PAIN|Medicaid|MEDICAID|27,368.52|3275.02|8171.55|47.65|||| 313|DRG||CHEST PAIN|Medicare|MEDICARE ACUTE|33,517.31|5210.37|8171.55|47.65|||| 313|DRG||CHEST PAIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47,752.85|5289.31|8171.55|47.65|||| 313|DRG||CHEST PAIN|Medicare|MEDICARE PART B ONLY IP|29,677.73|1627.45|8171.55|47.65|||| 313|DRG||CHEST PAIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25,498.47|8018.91|8171.55|47.65|||| 313|DRG||CHEST PAIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|37,483.45|8018.91|8171.55|47.65|||| 313|DRG||CHEST PAIN|Access Direct Platinum|HEALTHFIRST TPA|461.10|8171.55|8171.55|47.65|||| 313|DRG||CHEST PAIN|Tricare|TRICARE FOR LIFE|25,982.75|3783.11|8171.55|47.65|||| 313|DRG||CHEST PAIN|Veterans Affairs|VETERANS ADMINISTRATION|64,766.02|5289.31|8171.55|47.65|||| 313|DRG||CHEST PAIN|Managed Medicare|BCBS MEDICARE PPO MA|11,685.50|5208.18|8171.55|47.65|||| 313|DRG||CHEST PAIN|Managed Medicare|HEALTHSPRING MA|69,254.97|6206.88|8171.55|47.65|||| 313|DRG||CHEST PAIN|Managed Medicaid|MEDICAID AMERIGROUP|51,708.12|5632.26|8171.55|47.65|||| 313|DRG||CHEST PAIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39,110.19|47.65|8171.55|47.65|||| 313|DRG||CHEST PAIN|Humana Medicare Advantage|HUMANA MA|47,633.20|5180.62|8171.55|47.65|||| 313|DRG||CHEST PAIN|Cigna|CIGNA|5,588.75|5588.75|8171.55|47.65|||| 313|DRG||CHEST PAIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|56,188.80|68.04|8171.55|47.65|||| 313|DRG||CHEST PAIN|Blue Cross HMO Specialty|BCBSTX HMO|27,667.07|4082.54|8171.55|47.65|||| 313|DRG||CHEST PAIN|Blue Cross PPO Specialty|BCBSTX PPO|39,520.32|4802.57|8171.55|47.65|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|70,865.35|13736.85|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|202,467.40|571.52|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Humana Medicare Advantage|HUMANA MA|84,221.79|12392.34|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|116,335.37|16448.515|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95,479.12|12105.17|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Managed Medicare|HEALTHSPRING MA|103,135.90|12419.62|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|142,615.32|12392.34|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Managed Medicare|BCBS MEDICARE PPO MA|115,092.90|12392.34|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|723.77|12420.5|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|65,590.23|12419.62|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|Medicaid|MEDICAID|484,747.41|12664.72|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|149,779.55|12419.62|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|195,325.75|12430.04|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|76,815.89|12652.87|69643.25|571.52|||| 314|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|100,932.25|69643.25|69643.25|571.52|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|29,457.24|6669.64|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|52,437.64|6665.555|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Medicaid|MEDICAID HMO|117,364.26|7825.7|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|PHCS|HUMANA INSURANCE|138.36|138.36|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Medicare|MEDICARE ACUTE|33,421.43|6607.99|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12,279.75|8532.36|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|37,856.55|6607.99|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|64,732.35|7726.23|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|240.58|5776.7|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Humana Medicare Advantage|HUMANA MA|62,414.75|6600.21|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Aetna|AETNA OTHER|82,301.22|12521.07|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127,861.44|321.48|12521.07|138.36|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Blue Cross PPO Specialty|BCBSTX PPO|28,973.65|6490.56|12521.07|138.36|||| 31500|EAP|0450|INTUBATION EMERGENCY|Blue Cross PPO Specialty|BCBSTX PPO|9.40||||9.40||| 31500|EAP|0450|INTUBATION EMERGENCY|Blue Cross PPO Specialty|BCBSTX OTHER|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Blue Cross PPO Specialty|BCBSTX OTHER|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Blue Cross HMO Specialty|BCBSTX HMO|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.40||||9.40||| 31500|EAP|0361|INTUBATION EMERGENCY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.04||||3.04||| 31500|EAP|0361|INTUBATION EMERGENCY|Aenta Medicare Advantage|AETNA MEDICARE MA|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Aetna|AETNA QHP HMO|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Aenta Medicare Advantage|AETNA MEDICARE MA|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Aetna|AETNA PPO|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Cigna|CIGNA|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|ChampVA|CHAMPVA CENTER|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Cigna|CIGNA|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Humana Medicare Advantage|HUMANA MA|9.40||||9.40||| 31500|EAP|0361|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID AMERIGROUP|9.40||||9.40||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID SUPERIOR|9.40||||9.40||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.40||||9.40||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.40||||9.40||| 31500|EAP|0361|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID AMERIGROUP|3.04||||3.04||| 31500|EAP|0361|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID SUPERIOR|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.04||||3.04||| 31500|EAP|0450|INTUBATION EMERGENCY|United Medicare Advantage|UHC AARP MCR HMO MA|9.40||||9.40||| 31500|EAP|0361|INTUBATION EMERGENCY|United Medicare Advantage|UHC AARP MCR HMO MA|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.40||||9.40||| 31500|EAP|0450|INTUBATION EMERGENCY|United Medicare Advantage|UHC MEDICARE GOLD MA|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Workers Compensation|TEXAS MUTUAL INSURANCE|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Workers Compensation|WORKERS COMPENSATION OTHER|9.40||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Veterans Affairs|VETERANS ADMINISTRATION|9.40||||9.40||| 31500|EAP|0361|INTUBATION EMERGENCY|Veterans Affairs|VETERANS ADMINISTRATION|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.04||||3.04||| 31500|EAP|0361|INTUBATION EMERGENCY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.40||||9.40||| 31500|EAP|0450|INTUBATION EMERGENCY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.40||||9.40||| 31500|EAP|0361|INTUBATION EMERGENCY|Access Direct Platinum|HEALTHFIRST TPA UMR|3.04||||3.04||| 31500|EAP|0450|INTUBATION EMERGENCY|Access Direct Platinum|HEALTHFIRST TPA UMR|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Workers Compensation|WORKERS COMPENSATION OTHER|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicaid|MOLINA HEALTHCARE OF TEXAS|9.40||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicaid|CRIME VICTIMS COMPENSATION|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|United Medicare Advantage|UHC MEDICARE GOLD MA|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicaid|MEDICAID|9.40||||9.40||| 31500|EAP|0361|INTUBATION EMERGENCY|Medicaid|MEDICAID|3.04||||3.04||| 31500|EAP|0361|INTUBATION EMERGENCY|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Medicaid|CRIME VICTIMS COMPENSATION|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicaid|SMITH COUNTY INDIGENT HEALTH|9.40||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicaid|COUNTY INDIGENT HEALTH OTHER|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Humana Medicare Advantage|HUMANA MA|3.04||||3.04||| 31500|EAP|0361|INTUBATION EMERGENCY|Managed Medicare|HEALTHSPRING MA|3.04||||3.04||| 31500|EAP|0361|INTUBATION EMERGENCY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.04||||3.04||| 31500|EAP|0361|INTUBATION EMERGENCY|Managed Medicare|BCBS MEDICARE PPO MA|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.40||||9.40||| 31500|EAP|0450|INTUBATION EMERGENCY|Aetna|AETNA PPO|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Managed Medicare|WELLCARE CHOICE MA|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicare|HEALTHSPRING MA|9.40||||9.40||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicare|BCBS MEDICARE PPO MA|9.40||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicare|WELLCARE CHOICE MA|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Tricare|TRICARE EAST REGION|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Tricare|TRICARE EAST REGION|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.40||||||| 31500|EAP|0450|INTUBATION EMERGENCY|Blue Cross HMO Specialty|BCBSTX HMO|9.40||||9.40||| 31500|EAP|0361|INTUBATION EMERGENCY|Blue Cross PPO Specialty|BCBSTX PPO|3.04||||3.04||| 31500|EAP|0450|INTUBATION EMERGENCY|United Healthcare|UNITED HEALTHCARE|9.40||||9.40||| 31500|EAP|0450|INTUBATION EMERGENCY|United Healthcare|UNITED HEALTHCARE OTHER|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|United Healthcare|UNITED HEALTHCARE|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|United Healthcare|TML GROUP BENEFITS|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|United Healthcare|UNITED HEALTHCARE|9.40||||||| 31500|EAP|0361|INTUBATION EMERGENCY|United Healthcare|UNITED HEALTHCARE OTHER|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Medicare|MEDICARE ACUTE|3.04||||3.04||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicare|MEDICARE ACUTE|9.40||||9.40||| 31500|EAP|0361|INTUBATION EMERGENCY|NON CONTRACTED|COMMERCIAL OTHER 1|3.04||||||| 31500|EAP|0361|INTUBATION EMERGENCY|Rusk State Hospital|RUSK STATE HOSP|3.04||||||| 31500|EAP|0450|INTUBATION EMERGENCY|PHCS|HUMANA|9.40||||||| 31500|EAP|0450|INTUBATION EMERGENCY|NON CONTRACTED|COMMERCIAL OTHER 1|9.40||||||| 31530|EAP|0450|LARYNGOSCOPY W/FB REMOVAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||60.02||| 316|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|87,436.93|5440.03|5440.03|190.95|||| 316|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|19,047.67|190.95|5440.03|190.95|||| 316|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC|Medicare|MEDICARE ACUTE|37,307.50|5355.78|5440.03|190.95|||| 316|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|96,887.39|5101.33|5440.03|190.95|||| 31634|EAP|0361|BRONCHOSCOPY BALLOON OCCL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||147.03||| 31634|EAP|0361|BRONCHOSCOPY BALLOON OCCL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||147.03||| 31634|EAP|0361|BRONCHOSCOPY BALLOON OCCL|Medicare|MEDICARE ACUTE|||||147.03||| 31641|EAP|0361|BRONCHOSCOPY AEX GEN TUMO|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||7,188.84||| 31641|EAP|0361|BRONCHOSCOPY AEX GEN TUMO|United Healthcare|UNITED HEALTHCARE|7,188.84||||||| 31641|EAP|0361|BRONCHOSCOPY AEX GEN TUMO|Medicare|MEDICARE ACUTE|7,188.84||||6,846.51||| 31641|EAP|0361|BRONCHOSCOPY AEX GEN TUMO|Blue Cross PPO Specialty|BCBSTX PPO|||||6,846.51||| 31641|EAP|0361|BRONCHOSCOPY AEX GEN TUMO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7,188.84||| 31647|EAP|0361|BRONCH RIGID/FLEX BALLOON|Humana Medicare Advantage|HUMANA MA|147.03||||||| 31647|EAP|0361|BRONCH RIGID/FLEX BALLOON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|147.03||||||| 31647|EAP|0361|BRONCH RIGID/FLEX BALLOON|Aenta Medicare Advantage|AETNA MEDICARE MA|147.03||||||| 31647|EAP|0361|BRONCH RIGID/FLEX BALLOON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|147.03||||||| 31647|EAP|0361|BRONCH RIGID/FLEX BALLOON|Blue Cross PPO Specialty|BCBSTX PPO|147.03||||||| 31647|EAP|0361|BRONCH RIGID/FLEX BALLOON|Medicare|MEDICARE ACUTE|147.03||||||| 31647|EAP|0361|BRONCH RIGID/FLEX BALLOON|United Healthcare|UNITED HEALTHCARE|147.03||||||| 31647|EAP|0361|BRONCH RIGID/FLEX BALLOON|Managed Medicare|HEALTHSPRING MA|147.03||||||| 31648|EAP|0361|BRONCH RIGID/FLEX W/REML|Medicare|MEDICARE ACUTE|7,722.75||||||| 31648|EAP|0361|BRONCH RIGID/FLEX W/REML|Humana Medicare Advantage|HUMANA MA|7,722.75||||||| 31651|EAP|0361|BRONCH RIGID/FLEX BALLOON|United Medicare Advantage|UHC MEDICARE GOLD MA|34.54||||||| 31651|EAP|0361|BRONCH RIGID/FLEX BALLOON|Aenta Medicare Advantage|AETNA MEDICARE MA|3,626.70||||||| 31651|EAP|0361|BRONCH RIGID/FLEX BALLOON|Managed Medicare|HEALTHSPRING MA|3,626.70||||||| 31651|EAP|0361|BRONCH RIGID/FLEX BALLOON|Medicare|MEDICARE ACUTE|3,626.70||||||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|United Healthcare|UNITED HEALTHCARE|||||33.98||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|United Healthcare|UNITED HEALTHCARE OTHER|3,482.95||||3,567.90||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|NON CONTRACTED|COMMERCIAL OTHER 1|||||33.98||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Medicare|MEDICARE ACUTE|33.98||||3,567.90||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Medicaid|MEDICAID|33.98||||||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Medicaid|SMITH COUNTY JAIL|||||33.98||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Managed Medicare|HEALTHSPRING MA|3,567.90||||3,567.90||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|33.98||||33.98||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.98||||3,567.90||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Managed Medicaid|MEDICAID AMERIGROUP|||||3,567.90||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Cigna|CIGNA|||||3,567.90||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Humana Medicare Advantage|HUMANA MA|3,567.90||||33.98||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|United Healthcare|UNITED HEALTHCARE|33.98||||||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Blue Cross HMO Specialty|BCBSTX HMO|||||3,567.90||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Blue Cross PPO Specialty|BCBSTX PPO|33.98||||33.98||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,567.90||||3,482.95||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Aenta Medicare Advantage|AETNA MEDICARE MA|3,567.90||||3,482.95||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Access Direct Platinum|HEALTHFIRST TPA UMR|||||33.98||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|Veterans Affairs|VETERANS ADMINISTRATION|3,567.90||||3,567.90||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33.98||||3,482.95||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|United Medicare Advantage|UHC AARP MCR HMO MA|3,567.90||||3,567.90||| 31652|EAP|0361|BRONCH EBUS SAMPLNG 1/2 N|United Medicare Advantage|UHC MEDICARE GOLD MA|3,482.95||||33.98||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|United Medicare Advantage|UHC AARP MCR HMO MA|||||3,567.90||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|United Medicare Advantage|UHC MEDICARE GOLD MA|3,482.95||||||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|Veterans Affairs|VETERANS ADMINISTRATION|||||33.98||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,567.90||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|Blue Cross PPO Specialty|BCBSTX PPO|3,567.90||||3,567.90||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|Humana Medicare Advantage|HUMANA MA|33.98||||3,482.95||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||33.98||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,482.95||||||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|Managed Medicare|HEALTHSPRING MA|3,567.90||||||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|Medicare|MEDICARE ACUTE|3,567.90||||33.98||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,567.90||||||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|United Healthcare|UNITED HEALTHCARE OTHER|||||3,567.90||| 31653|EAP|0361|BRONCH EBUS SAMPLNG 3/> N|United Healthcare|UNITED HEALTHCARE|3,567.90||||||| 31654|EAP|0361|BRNSCHSC TNDSC EBUS DX/TX|Medicare|MEDICARE ACUTE|||||73.52||| 31654|EAP|0361|BRNSCHSC TNDSC EBUS DX/TX|Humana Medicare Advantage|HUMANA MA|||||73.52||| 31654|EAP|0361|BRNSCHSC TNDSC EBUS DX/TX|Blue Cross PPO Specialty|BCBSTX PPO|||||73.52||| 31654|EAP|0361|BRNSCHSC TNDSC EBUS DX/TX|United Medicare Advantage|UHC AARP MCR HMO MA|73.52||||||| 31720|EAP|0410|SUCTION NT|Veterans Affairs|VETERANS ADMINISTRATION|589.95||||||| 31720|EAP|0410|SUCTION NT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|589.95||||||| 31720|EAP|0410|SUCTION NT|United Medicare Advantage|UHC AARP MCR HMO MA|5.13||||||| 31720|EAP|0410|SUCTION NT|United Medicare Advantage|UHC MEDICARE GOLD MA|589.95||||||| 31720|EAP|0410|SUCTION NT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|589.95||||||| 31720|EAP|0410|SUCTION NT|United Medicare Advantage|UHC AARP WELLMED HMO MA|589.95||||||| 31720|EAP|0410|SUCTION NT|Aenta Medicare Advantage|AETNA MEDICARE MA|589.95||||||| 31720|EAP|0410|SUCTION NT|Blue Cross HMO Specialty|BCBSTX HMO|589.95||||||| 31720|EAP|0410|SUCTION NT|Blue Cross PPO Specialty|BCBSTX PPO|5.13||||||| 31720|EAP|0410|SUCTION NT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|589.95||||||| 31720|EAP|0410|SUCTION NT|Managed Medicaid|MEDICAID SUPERIOR|5.13||||||| 31720|EAP|0410|SUCTION NT|Managed Medicaid|MEDICAID AMERIGROUP|||||589.95||| 31720|EAP|0410|SUCTION NT|Humana Medicare Advantage|HUMANA MA|551.48||||||| 31720|EAP|0410|SUCTION NT|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.13||||||| 31720|EAP|0410|SUCTION NT|Medicaid|MEDICAID|5.13||||||| 31720|EAP|0410|SUCTION NT|Managed Medicare|HEALTHSPRING MA|5.13||||||| 31720|EAP|0410|SUCTION NT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.13||||||| 31720|EAP|0410|SUCTION NT|Managed Medicare|HOSPICE OF EAST TEXAS|5.13||||||| 31720|EAP|0410|SUCTION NT|Tricare|TRICARE EAST REGION|5.13||||||| 31720|EAP|0410|SUCTION NT|Medicare|MEDICARE ACUTE|5.13||||||| 32|DRG||VENTRICULAR SHUNT PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE OTHER|199,876.78|77461.7|77461.7|13287.72|||| 32|DRG||VENTRICULAR SHUNT PROCEDURES W CC|Medicare|MEDICARE ACUTE|95,390.12|13311.87|77461.7|13287.72|||| 32|DRG||VENTRICULAR SHUNT PROCEDURES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|70,269.59|17836.61|77461.7|13287.72|||| 32|DRG||VENTRICULAR SHUNT PROCEDURES W CC|Brinson Benefits|THE HEALTH PLAN SMITH CO|64,252.35|64252.35|77461.7|13287.72|||| 32|DRG||VENTRICULAR SHUNT PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|185,392.36|26816.38|77461.7|13287.72|||| 32|DRG||VENTRICULAR SHUNT PROCEDURES W CC|Blue Cross HMO Specialty|BCBSTX HMO|134,701.32|13287.72|77461.7|13287.72|||| 320|DRG||OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES W/O MCC|Medicare|MEDICARE ACUTE|107,806.60|14138.42|14138.42|14138.42|||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|United Medicare Advantage|UHC AARP MCR HMO MA|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Veterans Affairs|VETERANS ADMINISTRATION|27.57||||||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|27.57||||||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Aenta Medicare Advantage|AETNA MEDICARE MA|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.57||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Blue Cross HMO Specialty|BCBSTX HMO|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Blue Cross PPO Specialty|BCBSTX PPO|27.57||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Managed Medicaid|MEDICAID AMERIGROUP|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.57||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Cigna|CIGNA OTHER|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Humana Medicare Advantage|HUMANA MA|27.57||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|NON CONTRACTED|COMMERCIAL OTHER 1|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Medicare|MEDICARE ACUTE|27.57||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|United Healthcare|UNITED HEALTHCARE|||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Managed Medicare|HEALTHSPRING MA|27.57||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.57||||27.57||| 32405|EAP|0360|CT-PERCUT BX LUNG/MEDIAST|Medicaid|MEDICAID|27.57||||||| 32550|EAP|0361|INSERT PLEURAL CATH|Medicare|MEDICARE ACUTE|12,852.85||||13,749.70||| 32550|EAP|0361|INSERT PLEURAL CATH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13,749.40||||||| 32550|EAP|0361|INSERT PLEURAL CATH|Veterans Affairs|VETERANS ADMINISTRATION|119.56||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,315.55||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|United Medicare Advantage|UHC MEDICARE GOLD MA|2,477.10||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,477.10||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Veterans Affairs|VETERANS ADMINISTRATION|2,477.10||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Humana Medicare Advantage|HUMANA MA|2,477.10||||||| 32551|EAP|0761|INSERTION OF CHEST TUBE|Humana Medicare Advantage|HUMANA MA|36.74||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.54||||||| 32551|EAP|0761|INSERTION OF CHEST TUBE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,225.10||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Managed Medicaid|MEDICAID AMERIGROUP|2,477.10||||||| 32551|EAP|0761|INSERTION OF CHEST TUBE|Managed Medicaid|MEDICAID AMERIGROUP|4,225.10||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Blue Cross PPO Specialty|BCBSTX PPO|2,477.10||||||| 32551|EAP|0361|CT-THORACOSTOMY TUBE W/WA|Blue Cross PPO Specialty|BCBSTX PPO|28.47||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Aetna|AETNA PPO|21.54||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Managed Medicaid|MEDICAID SUPERIOR|2,477.10||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Access Direct Platinum|HEALTHFIRST TPA UMR|21.54||||||| 32551|EAP|0761|INSERTION OF CHEST TUBE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,949.55||||||| 32551|EAP|0761|INSERTION OF CHEST TUBE|Medicaid|MEDICAID|36.74||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Medicaid|CRIME VICTIMS COMPENSATION|21.54||||||| 32551|EAP|0361|CT-THORACOSTOMY TUBE W/WA|Managed Medicare|HEALTHSPRING MA|3,274.05||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|United Medicare Advantage|UHC AARP MCR HMO MA|2,477.10||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Managed Medicare|BCBS MEDICARE PPO MA|2,477.10||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,315.55||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Managed Medicare|HEALTHSPRING MA|21.54||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|United Healthcare|UNITED HEALTHCARE OTHER|21.54||||||| 32551|EAP|0761|INSERTION OF CHEST TUBE|NON CONTRACTED|COMMERCIAL OTHER 1|36.74||||||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|NON CONTRACTED|COMMERCIAL OTHER 1|21.54||||||| 32551|EAP|0361|CT-THORACOSTOMY TUBE W/WA|Medicare|MEDICARE ACUTE|28.47||||||| 32551|EAP|0510|INSERTION OF CHEST TUBE|Medicare|MEDICARE ACUTE|||||44.08||| 32551|EAP|0450|THORACENTESIS TUBE HEMOTH|Medicare|MEDICARE ACUTE|21.54||||||| 32551|EAP|0761|INSERTION OF CHEST TUBE|Medicare|MEDICARE ACUTE|3,949.55||||||| 32554|EAP|0761|ASPIRATE PLEURA W/O IMAGI|Medicare|MEDICARE ACUTE|3,760.35||||||| 32554|EAP|0761|ASPIRATE PLEURA W/O IMAGI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|34.98||||||| 32554|EAP|0450|THORACENTESIS W/O GUIDING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,850.20||| 32554|EAP|0761|ASPIRATE PLEURA W/O IMAGI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.98||||||| 32554|EAP|0510|THORACENTESIS PLEURA W/O|Blue Cross PPO Specialty|BCBSTX PPO|||||693.33||| 32554|EAP|0761|ASPIRATE PLEURA W/O IMAGI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,760.35||||||| 32554|EAP|0761|ASPIRATE PLEURA W/O IMAGI|Humana Medicare Advantage|HUMANA MA|34.98||||||| 32554|EAP|0450|THORACENTESIS W/O GUIDING|Humana Medicare Advantage|HUMANA MA|33.48||||||| 32554|EAP|0761|ASPIRATE PLEURA W/O IMAGI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,022.70||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Veterans Affairs|VETERANS ADMINISTRATION|14.74||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,695.10||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,695.10||| 32555|EAP|0450|THORACENTESIS NEEDLE W/GU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.84||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,695.10||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,695.10||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,584.55||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Humana Medicare Advantage|HUMANA MA|1,695.10||||14.74||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,695.10||||1,695.10||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,695.10||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Blue Cross HMO Specialty|BCBSTX HMO|||||14.74||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Blue Cross PPO Specialty|BCBSTX PPO|14.74||||1,695.10||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||14.74||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|14.74||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Blue Cross PPO Specialty|BCBSTX PPO|1,695.10||||1,695.10||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,695.10||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,584.55||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Medicaid|MEDICAID|1,695.10||||||| 32555|EAP|0360|CT-ASPIRATE PLEURA W/ IMA|Medicaid|CRIME VICTIMS COMPENSATION|28.47||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Managed Medicare|HEALTHSPRING MA|14.74||||1,695.10||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||14.74||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|United Healthcare|UNITED HEALTHCARE|14.74||||||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,695.10||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Medicare|MEDICARE PART B ONLY IP|1,695.10||||||| 32555|EAP|0360|CT-ASPIRATE PLEURA W/ IMA|Medicare|MEDICARE ACUTE|3,060.53||||3,060.53||| 32555|EAP|0450|THORACENTESIS NEEDLE W/GU|Medicare|MEDICARE ACUTE|4,466.60||||4,175.30||| 32555|EAP|0510|ASPIRATE PLEURA W/ IMAGIN|Medicare|MEDICARE ACUTE|||||668.33||| 32555|EAP|0361|US ASPIRATE PLEURA W/ IMA|Medicare|MEDICARE ACUTE|14.74||||1,695.10||| 32556|EAP|0510|INSERT CATH PLEURA W/O IM|Medicare|MEDICARE ACUTE|||||1,658.75||| 32556|EAP|0361||Medicare|MEDICARE ACUTE|||||39.81||| 32556|EAP|0510|INSERT CATH PLEURA W/O IM|Managed Medicare|HEALTHSPRING MA|||||1,658.75||| 32556|EAP|0510|INSERT CATH PLEURA W/O IM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,658.75||| 32556|EAP|0510|INSERT CATH PLEURA W/O IM|Blue Cross PPO Specialty|BCBSTX PPO|||||1,658.75||| 32556|EAP|0510|INSERT CATH PLEURA W/O IM|Blue Cross HMO Specialty|BCBSTX HMO|||||1,658.75||| 32556|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||39.81||| 32556|EAP|0510|INSERT CATH PLEURA W/O IM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39.81||||39.81||| 32556|EAP|0510|INSERT CATH PLEURA W/O IM|Humana Medicare Advantage|HUMANA MA|||||1,658.75||| 32556|EAP|0510|INSERT CATH PLEURA W/O IM|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,658.75||| 32557|EAP|0361|IR-FLUORO GUIDE CHEST TUB|Access Direct Platinum|HEALTHFIRST TPA UMR|2,051.60||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.95||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Veterans Affairs|VETERANS ADMINISTRATION|2,179.25||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|United Medicare Advantage|UHC MEDICARE GOLD MA|18.95||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|United Medicare Advantage|UHC AARP MCR HMO MA|2,179.25||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Humana Medicare Advantage|HUMANA MA|18.95||||18.95||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,179.25||| 32557|EAP|0361|IR-FLUORO GUIDE CHEST TUB|Humana Medicare Advantage|HUMANA MA|17.84||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,179.25||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.95||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Blue Cross PPO Specialty|BCBSTX PPO|2,179.25||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,179.25||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Aenta Medicare Advantage|AETNA MEDICARE MA|18.95||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Aetna|AETNA PPO|18.95||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Medicaid|MEDICAID|18.95||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Managed Medicare|HEALTHSPRING MA|2,179.25||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Managed Medicare|BCBS MEDICARE PPO MA|2,179.25||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,037.13||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|NON CONTRACTED|COMMERCIAL OTHER 1|2,037.13||||||| 32557|EAP|0360|CT-CHEST TUBE FOR PNEUMO|Medicare|MEDICARE ACUTE|2,179.25||||2,179.25||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|379,974.89|30812.46|62381.64|393.78|||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|341,609.50|30090.1|62381.64|393.78|||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|United Healthcare|TML GROUP BENEFITS|105,047.81|62381.64|62381.64|393.78|||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|Medicaid|MEDICAID|274,858.05|20060.37|62381.64|393.78|||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|Medicare|MEDICARE ACUTE|146,114.92|30204.51|62381.64|393.78|||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|238,409.95|393.78|62381.64|393.78|||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|Blue Cross PPO Specialty|BCBSTX PPO|155,504.60|35687.56|62381.64|393.78|||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|Humana Medicare Advantage|HUMANA MA|485,218.55|30512.625|62381.64|393.78|||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47,577.58|31895.98|62381.64|393.78|||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|100,888.40|50969.27|62381.64|393.78|||| 32601|EAP|0361|PLERUOSCOPY WITHOUT BIOPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||164.46||| 32601|EAP|0361|PLERUOSCOPY WITHOUT BIOPS|Medicare|MEDICARE ACUTE|||||164.46||| 32609|EAP|0361|PLEUROSCOPY WITH BIOPSY O|Managed Medicare|HEALTHSPRING MA|19,268.30||||||| 32609|EAP|0361|PLEUROSCOPY WITH BIOPSY O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|164.46||||||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|257,813.90|20969.34|32261.64|303.62|||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Veterans Affairs|VETERANS ADMINISTRATION|184,108.16|15374.16|32261.64|303.62|||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Blue Cross PPO Specialty|BCBSTX PPO|111,104.18|16868.4|32261.64|303.62|||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|154,639.95|303.62|32261.64|303.62|||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Managed Medicaid|MEDICAID SUPERIOR|235,835.91|31895.98|32261.64|303.62|||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Cigna|CIGNA OTHER|151,629.91|32261.64|32261.64|303.62|||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Humana Medicare Advantage|HUMANA MA|104,285.55|15551.645|32261.64|303.62|||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|359,061.22|15401.44|32261.64|303.62|||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Medicare|MEDICARE ACUTE|108,640.95|15402.32|32261.64|303.62|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|57,344.40|9925.63|19923.75|107.16|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|Multiplan|WEB TPA|57,608.90|19923.75|19923.75|107.16|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|77,121.77|10106.29|19923.75|107.16|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|39,724.33|883.28|19923.75|107.16|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|106,323.06|10125.32|19923.75|107.16|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|124,490.60|9915.45|19923.75|107.16|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|68,875.04|13634.06|19923.75|107.16|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|44,481.85|8417.12|19923.75|107.16|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|76,112.84|107.16|19923.75|107.16|||| 328|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|65,842.60|10470.86|19923.75|107.16|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Access Direct Platinum|HEALTHFIRST TPA|764,452.39|46051.27|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|280,349.01|35978.11|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|ChampVA|CHAMPVA CENTER|99,050.65|19310.97|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|293,271.97|1234.31|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Aetna|BOON CHAPMAN|784,003.06|391019.53|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|223,742.71|476.28|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|377,643.58|57881.47|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|433,735.26|58017.285|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|297,104.96|28776.87|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Cigna|CIGNA|278,034.70|137638.85|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|370,051.55|28211.4|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|286,065.06|36403.44|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Medicare|MEDICARE ACUTE|173,590.71|28183.24|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|202,449.70|202449.7|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|187,435.26|28693.11|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|United Healthcare|UNITED HEALTHCARE OTHER|333,534.45|60943.62|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|258,428.50|22108.085|391019.53|476.28|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|103,689.43|15439.3|391019.53|476.28|||| 33|DRG||VENTRICULAR SHUNT PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|53,075.03|10811.71|11641.25|10595.06|||| 33|DRG||VENTRICULAR SHUNT PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|44,337.96|10714.54|11641.25|10595.06|||| 33|DRG||VENTRICULAR SHUNT PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|43,016.05|10595.06|11641.25|10595.06|||| 33|DRG||VENTRICULAR SHUNT PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|80,980.29|11641.25|11641.25|10595.06|||| 33|DRG||VENTRICULAR SHUNT PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|45,222.60|11459.48|11641.25|10595.06|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Veterans Affairs|VETERANS ADMINISTRATION|153,202.29|15309.6|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|119,020.61|15439.3|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|140,544.91|19382.94|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|195,572.35|21826.51|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|122,598.80|142.88|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Blue Cross HMO Specialty|BCBSTX HMO|130,928.86|12640.245|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Aetna|BOON CHAPMAN|1,076.82|31964.02|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|ChampVA|CHAMPVA CENTER|241,281.77|36007.85|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX OTHER|133,611.32|16250.3|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|104,323.02|17133.21|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Managed Medicare|BCBS MEDICARE PPO MA|86,054.55|15136.62|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST TPA|123,865.84|19382.94|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|83,874.80|15148.47|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Managed Medicaid|MEDICAID AMERIGROUP|92,725.96|14074.68|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|79,731.37|19583.375|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|124,729.43|15152.73|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Medicaid|COUNTY INDIGENT HEALTH OTHER|101,950.80|11790.66|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Medicaid|SUPERIOR HEALTHPLAN CHIP|91,690.90|91690.9|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Medicare|MEDICARE ACUTE|128,172.27|15149.35|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Texas Workforce Commission|DIS DETER SERV (DDS)|61,597.55|18479.26|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Rusk State Hospital|RUSK STATE HOSP|104,655.54|51281.21|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|NON CONTRACTED|COMMERCIAL OTHER 1|86,898.56|86898.56|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE OTHER|137,286.73|22526.045|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|118,071.11|21825.35|91690.9|142.88|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|87,610.28|15157.25|91690.9|142.88|||| 33010|EAP|0481|PERICARDIOCENTESIS|Medicare|MEDICARE ACUTE|19.37||||||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|109,141.03|10746.15|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|69,764.55|18747.15|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43,951.55|12698.22|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|78,449.40|15149.35|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|80,779.83|11507.01|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|118,509.18|11493.62|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|109,689.91|107.16|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|87,968.03|13543.54|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|113,140.74|15121.19|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|1,154.05|10649.22|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|101,359.22|10746.15|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|106,345.98|10564.01|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|88,959.59|10497.22|20025.92|107.16|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|127,673.83|20025.92|20025.92|107.16|||| 33206|EAP|0481|ATRIAL SINGLE CHAMBER PM|Medicare|MEDICARE ACUTE|156.78||||156.78||| 33207|EAP|0481|VENTRICULAR SINGLE CHAMBR|United Medicare Advantage|UHC MEDICARE GOLD MA|16,461.90||||||| 33207|EAP|0481|VENTRICULAR SINGLE CHAMBR|Humana Medicare Advantage|HUMANA MA|||||156.78||| 33207|EAP|0481|VENTRICULAR SINGLE CHAMBR|Managed Medicare|HEALTHSPRING MA|16,461.90||||||| 33207|EAP|0481|VENTRICULAR SINGLE CHAMBR|Medicare|MEDICARE ACUTE|16,069.95||||16,461.90||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|United Healthcare|UNITED HEALTHCARE|||||16,461.90||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|United Healthcare|UNITED HEALTHCARE OTHER|16,461.90||||||| 33208|EAP|0481|BI-V PPM PROC CHRG|Medicare|MEDICARE ACUTE|17,398.50||||165.70||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Medicare|MEDICARE PART B ONLY IP|16,461.90||||||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Medicare|MEDICARE ACUTE|156.78||||16,461.90||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Medicaid|MEDICAID|16,461.90||||||| 33208|EAP|0481|BI-V PPM PROC CHRG|Managed Medicare|HEALTHSPRING MA|16,461.90||||17,398.50||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Managed Medicare|HEALTHSPRING MA|16,461.90||||16,461.90||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Managed Medicare|BCBS MEDICARE PPO MA|156.78||||156.78||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Aenta Medicare Advantage|AETNA MEDICARE MA|16,461.90||||156.78||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Aetna|AETNA PPO|||||156.78||| 33208|EAP|0481|BI-V PPM PROC CHRG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|156.78||||165.70||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|156.78||||156.78||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Blue Cross PPO Specialty|BCBSTX PPO|16,461.90||||16,461.90||| 33208|EAP|0481|BI-V PPM PROC CHRG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16,069.95||||165.70||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Blue Cross PPO Specialty|BCBSTX OTHER|16,461.90||||||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Blue Cross HMO Specialty|BCBSTX HMO|16,461.90||||16,069.95||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16,461.90||||156.78||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16,461.90||||16,069.95||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Cigna|CIGNA|156.78||||||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Humana Medicare Advantage|HUMANA MA|16,461.90||||156.78||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Veterans Affairs|VETERANS ADMINISTRATION|||||156.78||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|156.78||||||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|156.78||||156.78||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|United Medicare Advantage|UHC AARP MCR HMO MA|16,461.90||||16,461.90||| 33208|EAP|0481|BI-V PPM PROC CHRG|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||17,398.50||| 33208|EAP|0481|BI-V PPM PROC CHRG|United Medicare Advantage|UHC MEDICARE GOLD MA|16,461.90||||17,398.50||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|United Medicare Advantage|UHC MEDICARE GOLD MA|16,461.90||||156.78||| 33208|EAP|0481|BI-V PPM PROC CHRG|United Medicare Advantage|UHC AARP MCR HMO MA|16,461.90||||17,398.50||| 33208|EAP|0481|BI-V PPM PROC CHRG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17,398.50||||17,398.50||| 33208|EAP|0481|DUAL CHAMBER PACEMAKER IM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16,461.90||||17,398.50||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|Blue Cross PPO Specialty|BCBSTX OTHER|9,353.40||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|89.08||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|Managed Medicare|HEALTHSPRING MA|9,130.70||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|Managed Medicare|BCBS MEDICARE PPO MA|89.08||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|Medicaid|MEDICAID|9,353.40||||||| 33210|EAP|0481|PACER (TEMPORARY) PROCEDU|NON CONTRACTED|COMMERCIAL OTHER 1|89.08||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|Medicare|MEDICARE ACUTE|89.08||||||| 33210|EAP|0481|PACER (TEMPORARY) PROCEDU|Medicare|MEDICARE ACUTE|9,130.70||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|United Healthcare|UNITED HEALTHCARE|9,353.40||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|Blue Cross HMO Specialty|BCBSTX HMO|9,353.40||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|89.08||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|Humana Medicare Advantage|HUMANA MA|9,353.40||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9,353.40||||||| 33210|EAP|0481|PACER (TEMPORARY) PROCEDU|United Medicare Advantage|UHC MEDICARE GOLD MA|9,353.40||||||| 33210|EAP|0481|PACER (TEMPORARY) PROCEDU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|89.08||||||| 33210|EAP|0481|TEMP PACEMAKER W/LEAD|United Medicare Advantage|UHC AARP MCR HMO MA|9,353.40||||||| 33212|EAP|0481|INSERT/REPLACE GENERATOR|Humana Medicare Advantage|HUMANA MA|103.11||||||| 33213|EAP|0481|INSERT/REPLACE GENERATOR|Medicare|MEDICARE ACUTE|12,887.70||||12,887.70||| 33213|EAP|0481|INSERT/REPLACE GENERATOR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||12,887.70||| 33213|EAP|0481|INSERT/REPLACE GENERATOR|Humana Medicare Advantage|HUMANA MA|||||12,887.70||| 33214|EAP|0481|UPGRADE - SINGLE TO DUAL|Medicare|MEDICARE ACUTE|||||208.66||| 33215|EAP|0481|REPOSITION PM/ICD RT ATR/|Medicare|MEDICARE ACUTE|5,795.35||||5,936.70||| 33215|EAP|0481|REPOSITION PM/ICD RT ATR/|United Healthcare|UNITED HEALTHCARE|||||5,936.70||| 33215|EAP|0481|REPOSITION PM/ICD RT ATR/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,936.70||||56.54||| 33215|EAP|0481|REPOSITION PM/ICD RT ATR/|Blue Cross PPO Specialty|BCBSTX PPO|||||5,936.70||| 33215|EAP|0481|REPOSITION PM/ICD RT ATR/|Managed Medicare|HEALTHSPRING MA|5,936.70||||||| 33215|EAP|0481|REPOSITION PM/ICD RT ATR/|United Medicare Advantage|UHC MEDICARE GOLD MA|5,936.70||||||| 33215|EAP|0481|REPOSITION PM/ICD RT ATR/|Humana Medicare Advantage|HUMANA MA|5,936.70||||5,795.35||| 33216|EAP|0481|INSERT SINGLE LEAD (PM OR|Medicare|MEDICARE ACUTE|103.11||||10,065.50||| 33216|EAP|0481|INSERT SINGLE LEAD (PM OR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||98.20||| 33216|EAP|0481|INSERT SINGLE LEAD (PM OR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.11||||||| 33216|EAP|0481|INSERT SINGLE LEAD (PM OR|Humana Medicare Advantage|HUMANA MA|103.11||||||| 33217|EAP|0481|INSERT DUAL LEADS (PM OR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||135.01||| 33222|EAP|0481|SKIN POCKET REVISION PACE|Medicare|MEDICARE ACUTE|8,034.98||||78.39||| 33222|EAP|0481|SKIN POCKET REVISION PACE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8,230.95||| 33222|EAP|0481|SKIN POCKET REVISION PACE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||78.39||| 33222|EAP|0481|SKIN POCKET REVISION PACE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8,230.95||| 33223|EAP|0481|SKIN POCKET REVISION DEFI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||10,833.90||| 33223|EAP|0481|SKIN POCKET REVISION DEFI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10,833.90||| 33223|EAP|0481|SKIN POCKET REVISION DEFI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||10,575.95||| 33223|EAP|0481|SKIN POCKET REVISION DEFI|Medicare|MEDICARE ACUTE|10,833.90||||10,833.90||| 33223|EAP|0481|SKIN POCKET REVISION DEFI|Humana Medicare Advantage|HUMANA MA|||||10,833.90||| 33224|EAP|0481|INSRT ELCTRD LT VENT PAC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||15,338.40||| 33224|EAP|0481|INSRT ELCTRD LT VENT PAC|Medicare|MEDICARE ACUTE|||||146.08||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|Humana Medicare Advantage|HUMANA MA|61.37||||61.37||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|Medicaid|MEDICAID|6,443.85||||||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|United Medicare Advantage|UHC MEDICARE GOLD MA|6,443.85||||5,800.20||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,443.85||||6,443.85||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,290.43||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|Medicare|MEDICARE ACUTE|5,800.20||||55.24||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|Blue Cross PPO Specialty|BCBSTX PPO|61.37||||||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,800.20||||5,800.20||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|United Medicare Advantage|UHC AARP MCR HMO MA|||||5,800.20||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,443.85||||55.24||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|Veterans Affairs|VETERANS ADMINISTRATION|61.37||||6,443.85||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|Managed Medicare|BCBS MEDICARE PPO MA|6,443.85||||61.37||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|Humana Medicare Advantage|HUMANA MA|61.37||||5,800.20||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||55.24||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||5,800.20||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|Medicare|MEDICARE ACUTE|6,290.43||||6,443.85||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|United Healthcare|UNITED HEALTHCARE|||||6,443.85||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|Managed Medicare|HEALTHSPRING MA|||||6,290.43||| 33225|EAP|0481|BI-V ICD PROC CHRG ADD-ON|United Medicare Advantage|UHC MEDICARE GOLD MA|6,443.85||||6,443.85||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|Managed Medicare|HEALTHSPRING MA|||||5,800.20||| 33225|EAP|0481|BI-V PPM PROC CHRG ADD-ON|United Healthcare|UNITED HEALTHCARE OTHER|||||55.24||| 33226|EAP|0481|REPOS PREV IMPL CVS INCL|Medicare|MEDICARE ACUTE|65.73||||||| 33226|EAP|0481|REPOS PREV IMPL CVS INCL|Blue Cross PPO Specialty|BCBSTX PPO|||||6,901.65||| 33227|EAP|0481|R/R PULSE GEN ONLY SINGLE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||176.59||| 33227|EAP|0481|R/R PULSE GEN ONLY SINGLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||176.59||| 33227|EAP|0481|R/R PULSE GEN ONLY SINGLE|Medicare|MEDICARE ACUTE|||||18,541.95||| 33227|EAP|0481|R/R PULSE GEN ONLY SINGLE|Humana Medicare Advantage|HUMANA MA|||||176.59||| 33228|EAP|0481|R/R PULSE GEN ONLY DUAL L|Blue Cross PPO Specialty|BCBSTX PPO|||||201.09||| 33228|EAP|0481|R/R PULSE GEN ONLY DUAL L|Aetna|AETNA PPO|||||201.09||| 33228|EAP|0481|R/R PULSE GEN ONLY DUAL L|Humana Medicare Advantage|HUMANA MA|||||21,114.45||| 33228|EAP|0481|R/R PULSE GEN ONLY DUAL L|Medicare|MEDICARE ACUTE|21,114.45||||20,611.73||| 33228|EAP|0481|R/R PULSE GEN ONLY DUAL L|Medicare|MEDICARE PART B ONLY IP|21,114.45||||||| 33228|EAP|0481|R/R PULSE GEN ONLY DUAL L|Managed Medicare|HEALTHSPRING MA|||||21,114.45||| 33229|EAP|0481|R/R PULSE GEN ONLY MULTI|United Healthcare|UNITED HEALTHCARE OTHER|||||221.62||| 33229|EAP|0481|R/R PULSE GEN ONLY MULTI|Humana Medicare Advantage|HUMANA MA|||||23,270.10||| 33229|EAP|0481|R/R PULSE GEN ONLY MULTI|United Medicare Advantage|UHC AARP MCR HMO MA|||||23,270.10||| 33229|EAP|0481|R/R PULSE GEN ONLY MULTI|Medicare|MEDICARE ACUTE|||||221.62||| 33229|EAP|0481|R/R PULSE GEN ONLY MULTI|Managed Medicare|HEALTHSPRING MA|||||23,270.10||| 33233|EAP|0481|REMOVAL OF PACEMAKER GENE|Humana Medicare Advantage|HUMANA MA|||||78.39||| 33233|EAP|0481|REMOVAL OF PACEMAKER GENE|United Medicare Advantage|UHC AARP MCR HMO MA|||||8,230.95||| 33233|EAP|0481|REMOVAL OF PACEMAKER GENE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8,230.95||| 33233|EAP|0481|REMOVAL OF PACEMAKER GENE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,230.95||||||| 33233|EAP|0481|REMOVAL OF PACEMAKER GENE|Managed Medicare|HEALTHSPRING MA|||||8,230.95||| 33233|EAP|0481|REMOVAL OF PACEMAKER GENE|Medicare|MEDICARE ACUTE|78.39||||78.39||| 33234|EAP|0481|PACEMAKER LEAD REMOVAL SI|Humana Medicare Advantage|HUMANA MA|||||103.18||| 33234|EAP|0481|PACEMAKER LEAD REMOVAL SI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10,833.90||||10,833.90||| 33234|EAP|0481|PACEMAKER LEAD REMOVAL SI|Medicare|MEDICARE ACUTE|10,833.90||||10,575.95||| 33234|EAP|0481|PACEMAKER LEAD REMOVAL SI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||103.18||| 33241|EAP|0481|REMOVAL CARDIOVERTER DEFI|Managed Medicare|BCBS MEDICARE PPO MA|||||103.18||| 33241|EAP|0481|REMOVAL CARDIOVERTER DEFI|Veterans Affairs|VETERANS ADMINISTRATION|103.18||||10,833.90||| 33241|EAP|0481|REMOVAL CARDIOVERTER DEFI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.18||||||| 33241|EAP|0481|REMOVAL CARDIOVERTER DEFI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10,833.90||||||| 33241|EAP|0481|REMOVAL CARDIOVERTER DEFI|Humana Medicare Advantage|HUMANA MA|||||103.18||| 33241|EAP|0481|REMOVAL CARDIOVERTER DEFI|United Medicare Advantage|UHC MEDICARE GOLD MA|10,833.90||||103.18||| 33241|EAP|0481|REMOVAL CARDIOVERTER DEFI|Medicare|MEDICARE ACUTE|||||103.18||| 33241|EAP|0481|REMOVAL CARDIOVERTER DEFI|United Medicare Advantage|UHC AARP MCR HMO MA|||||10,833.90||| 33244|EAP|0481|ICD LEAD REMOVAL SINGLE/D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10,833.90||||||| 33244|EAP|0481|ICD LEAD REMOVAL SINGLE/D|United Medicare Advantage|UHC MEDICARE GOLD MA|10,833.90||||||| 33244|EAP|0481|ICD LEAD REMOVAL SINGLE/D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.18||| 33249|EAP|0481|INSRT/REP LD+ICD SINGLE C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|42,590.10||||||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Medicare|MEDICARE ACUTE|405.62||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|United Healthcare|UNITED HEALTHCARE|||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41,576.05||||405.62||| 33249|EAP|0481|INSRT/REP LD+ICD SINGLE C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|405.62||||405.62||| 33249|EAP|0481|INSRT/REP LD+ICD SINGLE C|Medicare|MEDICARE ACUTE|405.62||||41,576.05||| 33249|EAP|0481|INSRT/REP LD+ICD SINGLE C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42,590.10||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Managed Medicare|BCBS MEDICARE PPO MA|42,590.10||||405.62||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|United Healthcare|UNITED HEALTHCARE|42,590.10||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Veterans Affairs|VETERANS ADMINISTRATION|405.62||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|United Medicare Advantage|UHC AARP MCR HMO MA|42,590.10||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Managed Medicare|HEALTHSPRING MA|||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||405.62||| 33249|EAP|0481|INSRT/REP LD+ICD SINGLE C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41,576.05||||41,576.05||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|United Medicare Advantage|UHC MEDICARE GOLD MA|42,590.10||||41,576.05||| 33249|EAP|0481|INSRT/REP LD+ICD SINGLE C|Humana Medicare Advantage|HUMANA MA|405.62||||41,576.05||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Managed Medicaid|MEDICAID AMERIGROUP|||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42,590.10||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Medicaid|MEDICAID|42,590.10||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42,590.10||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Blue Cross PPO Specialty|BCBSTX PPO|41,576.05||||42,590.10||| 33249|EAP|0481|INSRT/REP LD+ICD SINGLE C|NON CONTRACTED|COMMERCIAL OTHER 1|405.62||||||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Blue Cross PPO Specialty|BCBSTX OTHER|42,590.10||||||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42,590.10||||42,590.10||| 33249|EAP|0481|INSRT/REP LD+ICD SINGLE C|United Medicare Advantage|UHC MEDICARE GOLD MA|42,590.10||||42,590.10||| 33249|EAP|0481|INSRT REP LDS+ICD DUAL CH|Humana Medicare Advantage|HUMANA MA|41,576.05||||405.62||| 33262|EAP|0481|R/R PULSE GEN ONLY SINGLE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||32,585.70||| 33262|EAP|0481|R/R PULSE GEN ONLY SINGLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||310.34||| 33262|EAP|0481|R/R PULSE GEN ONLY SINGLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|310.34||||||| 33262|EAP|0481|R/R PULSE GEN ONLY SINGLE|Medicare|MEDICARE ACUTE|||||32,585.70||| 33263|EAP|0481|R/R PULSE GEN ONLY DUAL L|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||32,585.70||| 33263|EAP|0481|R/R PULSE GEN ONLY DUAL L|Humana Medicare Advantage|HUMANA MA|||||32,585.70||| 33263|EAP|0481|R/R PULSE GEN ONLY DUAL L|Medicare|MEDICARE ACUTE|||||32,585.70||| 33263|EAP|0481|R/R PULSE GEN ONLY DUAL L|Managed Medicare|HEALTHSPRING MA|||||32,585.70||| 33264|EAP|0481|R/R PULSE GEN ONLY MULTI|Managed Medicare|BCBS MEDICARE PPO MA|||||32,585.70||| 33264|EAP|0481|R/R PULSE GEN ONLY MULTI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32,585.70||||||| 33264|EAP|0481|R/R PULSE GEN ONLY MULTI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||32,585.70||| 33264|EAP|0481|R/R PULSE GEN ONLY MULTI|Managed Medicare|HEALTHSPRING MA|||||310.34||| 33264|EAP|0481|R/R PULSE GEN ONLY MULTI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||32,585.70||| 33264|EAP|0481|R/R PULSE GEN ONLY MULTI|Humana Medicare Advantage|HUMANA MA|32,585.70||||310.34||| 33264|EAP|0481|R/R PULSE GEN ONLY MULTI|Medicare|MEDICARE ACUTE|32,585.70||||32,585.70||| 33274|EAP|0481|TCAT INSJ/RPL PERM LDLS P|United Medicare Advantage|UHC AARP MCR HMO MA|614.18||||||| 33274|EAP|0481|TCAT INSJ/RPL PERM LDLS P|Medicare|MEDICARE ACUTE|62,953.45||||614.18||| 33274|EAP|0481|TCAT INSJ/RPL PERM LDLS P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|614.18||||||| 33274|EAP|0481|TCAT INSJ/RPL PERM LDLS P|Humana Medicare Advantage|HUMANA MA|614.18||||||| 33274|EAP|0481|TCAT INSJ/RPL PERM LDLS P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|64,488.90||||64,488.90||| 33275|EAP|0481|TCAT RMVL PERM LDLS PM|Medicare|MEDICARE ACUTE|105.66||||||| 33275|EAP|0481|TCAT RMVL PERM LDLS PM|Humana Medicare Advantage|HUMANA MA|12,150.90||||||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|Blue Cross PPO Specialty|BCBSTX PPO|||||22,662.75||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|Blue Cross HMO Specialty|BCBSTX HMO|||||23,215.50||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||23,215.50||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||221.10||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||221.10||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|Medicare|MEDICARE ACUTE|221.10||||22,662.75||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|Cigna|CIGNA|||||23,215.50||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|Humana Medicare Advantage|HUMANA MA|||||221.10||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||22,662.75||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||221.10||| 33285|EAP|0481|INSJ SUBQ CARDIAC RHYTHM|United Medicare Advantage|UHC MEDICARE GOLD MA|221.10||||||| 33286|EAP|0481|REMOVAL SUBQ CARDIAC RHYT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4,556.13||| 33286|EAP|0481|REMOVAL SUBQ CARDIAC RHYT|Humana Medicare Advantage|HUMANA MA|||||44.45||| 33286|EAP|0481|REMOVAL SUBQ CARDIAC RHYT|United Medicare Advantage|UHC MEDICARE GOLD MA|4,667.25||||4,667.25||| 33286|EAP|0481|REMOVAL SUBQ CARDIAC RHYT|Blue Cross PPO Specialty|BCBSTX PPO|||||4,667.25||| 33286|EAP|0481|REMOVAL SUBQ CARDIAC RHYT|Medicare|MEDICARE ACUTE|||||4,667.25||| 33286|EAP|0481|REMOVAL SUBQ CARDIAC RHYT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||44.45||| 333|DRG||RECTAL RESECTION W CC|Blue Cross PPO Specialty|BCBSTX PPO|133,819.97|13089.76|26787.24|13089.76|||| 333|DRG||RECTAL RESECTION W CC|Humana Medicare Advantage|HUMANA MA|120,609.01|13962.33|26787.24|13089.76|||| 333|DRG||RECTAL RESECTION W CC|United Healthcare|UNITED HEALTHCARE OTHER|126,581.70|26787.24|26787.24|13089.76|||| 33340|EAP|0278|PERCUTANEOUS LEFT ATRIAL|Medicare|MEDICARE ACUTE|255.51||||||| 334|DRG||RECTAL RESECTION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|54,042.26|12505.47|12505.47|12505.47|||| 33418|EAP|0481|REPAIR MITRAL CLIP-PRIMAR|Humana Medicare Advantage|HUMANA MA|465.56||||||| 33418|EAP|0481|REPAIR MITRAL CLIP-PRIMAR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|465.56||||||| 33418|EAP|0481|REPAIR MITRAL CLIP-PRIMAR|Managed Medicare|BCBS MEDICARE PPO MA|465.56||||||| 33418|EAP|0481|REPAIR MITRAL CLIP-PRIMAR|Medicare|MEDICARE ACUTE|47,719.90||||||| 33419|EAP|0481|REPAIR MITRAL CLIP-2CLIPS|Humana Medicare Advantage|HUMANA MA|232.78||||||| 33419|EAP|0481|REPAIR MITRAL CLIP-2CLIPS|Medicare|MEDICARE ACUTE|232.78||||||| 335|DRG||PERITONEAL ADHESIOLYSIS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|87,752.47|15447.07|29967.9|15447.07|||| 335|DRG||PERITONEAL ADHESIOLYSIS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|223,004.90|17057.21|29967.9|15447.07|||| 335|DRG||PERITONEAL ADHESIOLYSIS W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|142,941.66|29967.9|29967.9|15447.07|||| 335|DRG||PERITONEAL ADHESIOLYSIS W MCC|Medicare|MEDICARE ACUTE|124,752.91|23699.535|29967.9|15447.07|||| 335|DRG||PERITONEAL ADHESIOLYSIS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|221,914.90|23480.78|29967.9|15447.07|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|Managed Medicare|HEALTHSPRING MA|89,409.71|11862.43|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|United Healthcare|UNITED HEALTHCARE|55,036.65|26822.74|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|Humana Medicare Advantage|HUMANA MA|83,790.67|13979.13|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|Cigna|CIGNA|104,574.13|22837.14|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|75,358.06|19367.3|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|107,535.85|9151.27|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98,895.57|142.88|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|86,725.90|13834.38|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|Medicare|MEDICARE ACUTE|100,737.13|13718.47|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|88,044.14|13722.39|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|United Medicare Advantage|UHC AARP MCR HMO MA|114,030.26|13699.55|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|87,395.10|17789.23|26822.74|142.88|||| 336|DRG||PERITONEAL ADHESIOLYSIS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|122,700.62|13718.47|26822.74|142.88|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|118,768.21|13979.13|15178.9|10269.325|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|79,439.60|15178.9|15178.9|10269.325|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|88,130.55|10280.67|15178.9|10269.325|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|120,692.38|10440.82|15178.9|10269.325|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|50,095.40|10886.41|15178.9|10269.325|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|84,251.03|10269.325|15178.9|10269.325|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|Medicare|MEDICARE ACUTE|85,273.31|10375.175|15178.9|10269.325|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|57,955.33|13198.44|15178.9|10269.325|||| 338|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|166,355.24|22055.15|22055.15|392.92|||| 338|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|170,826.50|392.92|22055.15|392.92|||| 339|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC|Blue Cross PPO Specialty|BCBSTX PPO|82,724.30|10046.74|10700.78|10046.74|||| 339|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|62,034.30|10696.32|10700.78|10046.74|||| 339|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|85,261.30|10672.62|10700.78|10046.74|||| 339|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|122,500.75|10700.78|10700.78|10046.74|||| 33967|EAP|0481|INTRA-AORTIC BALLOON PUMP|Humana Medicare Advantage|HUMANA MA|101.07||||||| 33967|EAP|0481|INTRA-AORTIC BALLOON PUMP|Medicare|MEDICARE ACUTE|10,359.68||||||| 33967|EAP|0481|INTRA-AORTIC BALLOON PUMP|Blue Cross PPO Specialty|BCBSTX PPO|10,612.35||||||| 33990|EAP|0481|IMPELLA INSERTION|Blue Cross HMO Specialty|BCBSTX HMO|50.67||||||| 33990|EAP|0481|IMPELLA INSERTION|Veterans Affairs|VETERANS ADMINISTRATION|5,193.68||||||| 33990|EAP|0481|IMPELLA INSERTION|Humana Medicare Advantage|HUMANA MA|5,320.35||||||| 33990|EAP|0481|IMPELLA INSERTION|Medicare|MEDICARE ACUTE|5,193.68||||||| 33990|EAP|0481|IMPELLA INSERTION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,320.35||||||| 33990|EAP|0481|IMPELLA INSERTION|Managed Medicare|HEALTHSPRING MA|50.67||||||| 34|DRG||CAROTID ARTERY STENT PROCEDURE W MCC|Medicare|MEDICARE ACUTE|223,086.76|21881.78|22313.72|21881.78|||| 34|DRG||CAROTID ARTERY STENT PROCEDURE W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|177,306.64|22313.72|22313.72|21881.78|||| 340|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|47,477.01|8215.24|14647.05|6855.98|||| 340|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|56,309.35|8073.65|14647.05|6855.98|||| 340|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Medicare|MEDICARE ACUTE|68,301.99|8215.24|14647.05|6855.98|||| 340|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|33,827.25|10047.98|14647.05|6855.98|||| 340|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC|United Healthcare|GEHA|67,666.60|14647.05|14647.05|6855.98|||| 340|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|40,049.85|8065.16|14647.05|6855.98|||| 340|DRG||APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|71,752.83|6855.98|14647.05|6855.98|||| 341|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W MCC|Tricare|TRICARE EAST REGION|72,340.61|10540.96|15467.45|10540.96|||| 341|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W MCC|Medicare|MEDICARE ACUTE|67,527.42|15467.45|15467.45|10540.96|||| 342|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|53,866.42|11658.42|20370.3|9633.65|||| 342|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC|Blue Cross PPO Specialty|BCBSTX PPO|45,635.18|9633.65|20370.3|9633.65|||| 342|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC|Humana Medicare Advantage|HUMANA MA|86,264.65|10123.96|20370.3|9633.65|||| 342|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC|Aetna|AETNA PPO|34,894.60|20370.3|20370.3|9633.65|||| 342|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|63,888.23|10092.07|20370.3|9633.65|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Medicaid|MEDICAID|55,233.40|4562.88|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Medicare|MEDICARE ACUTE|54,912.53|7668.13|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62,084.98|8456.87|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|46,877.92|7369.19|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|31,781.48|31781.48|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|51,244.33|7733.95|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|24,386.94|7254.98|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|39,325.87|13630.34|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|40,878.65|9795.61|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|77,812.20|9333.39|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|73,406.91|7714.29|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Tricare|TRICARE EAST REGION|48,313.12|6126.06|31781.48|4562.88|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|77,314.50|9333.39|31781.48|4562.88|||| 344|DRG||MINOR SMALL & LARGE BOWEL PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|174,198.96|105520.045|105520.045|17710.07|||| 344|DRG||MINOR SMALL & LARGE BOWEL PROCEDURES W MCC|Medicare|MEDICARE ACUTE|164,945.87|17710.07|105520.045|17710.07|||| 345|DRG||MINOR SMALL & LARGE BOWEL PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|96,051.85|306.18|33107.59|306.18|||| 345|DRG||MINOR SMALL & LARGE BOWEL PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|125,762.85|13153.82|33107.59|306.18|||| 345|DRG||MINOR SMALL & LARGE BOWEL PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE OTHER|33,107.59|33107.59|33107.59|306.18|||| 346|DRG||MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|51,420.97|8310.01|8310.01|8310.01|||| 347|DRG||ANAL & STOMAL PROCEDURES W MCC|Medicare|MEDICARE ACUTE|157,216.46|16053.38|16053.38|16053.38|||| 348|DRG||ANAL & STOMAL PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|57,667.05|9014.58|9177.86|8627.97|||| 348|DRG||ANAL & STOMAL PROCEDURES W CC|ChampVA|CHAMPVA CENTER|76,389.30|8627.97|9177.86|8627.97|||| 348|DRG||ANAL & STOMAL PROCEDURES W CC|Veterans Affairs|VETERANS ADMINISTRATION|98,603.94|9177.86|9177.86|8627.97|||| 349|DRG||ANAL & STOMAL PROCEDURES W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|81,205.40|81205.4|81205.4|5678.86|||| 349|DRG||ANAL & STOMAL PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|36,883.55|5678.86|81205.4|5678.86|||| 35|DRG||CAROTID ARTERY STENT PROCEDURE W CC|Medicare|MEDICARE ACUTE|75,898.45|13916.02|13916.02|34.02|||| 35|DRG||CAROTID ARTERY STENT PROCEDURE W CC|Humana Medicare Advantage|HUMANA MA|160,722.80|13914.74|13916.02|34.02|||| 35|DRG||CAROTID ARTERY STENT PROCEDURE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|114,630.45|34.02|13916.02|34.02|||| 351|DRG||INGUINAL & FEMORAL HERNIA PROCEDURES W CC|Medicaid|MEDICAID|76,399.49|5687.7|12477.71|5687.7|||| 351|DRG||INGUINAL & FEMORAL HERNIA PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|64,060.10|9270.43|12477.71|5687.7|||| 351|DRG||INGUINAL & FEMORAL HERNIA PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|64,167.05|12477.71|12477.71|5687.7|||| 352|DRG||INGUINAL & FEMORAL HERNIA PROCEDURES W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|727.49|7171.88|7253.785|7171.88|||| 352|DRG||INGUINAL & FEMORAL HERNIA PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|65,724.66|7253.785|7253.785|7171.88|||| 353|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W MCC|Tricare|TRICARE EAST REGION|67,605.77|20534.19|20534.19|20534.19|||| 354|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC|Medicare|MEDICARE ACUTE|79,329.56|10733.27|69880.37|107.16|||| 354|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|57,746.15|9097.36|69880.37|107.16|||| 354|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC|Managed Medicare|HEALTHSPRING MA|90,939.48|10930.49|69880.37|107.16|||| 354|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC|Humana Medicare Advantage|HUMANA MA|70,703.02|10721.8|69880.37|107.16|||| 354|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC|NON CONTRACTED|COMMERCIAL OTHER 1|69,880.37|69880.37|69880.37|107.16|||| 354|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|104,914.89|107.16|69880.37|107.16|||| 354|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|80,072.31|10818.02|69880.37|107.16|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|83,184.55|8799.1|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Rusk State Hospital|RUSK STATE HOSP|50,966.73|24973.7|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Medicare|MEDICARE ACUTE|87,624.54|8971.1|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|65,097.30|10705.55|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|40,972.87|8987.7|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|82,342.50|9151.27|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|65,109.98|12592.19|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|58,472.80|6814.73|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|77,882.50|9199.09|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|70,011.52|7819.91|24973.7|71.44|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|63,781.95|71.44|24973.7|71.44|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|193,181.07|24126.31|54211.38|214.32|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|176,790.53|26023.375|54211.38|214.32|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|329,809.72|54211.38|54211.38|214.32|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|Managed Medicare|HEALTHSPRING MA|110,425.30|23656.91|54211.38|214.32|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|138,451.27|214.32|54211.38|214.32|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|375,981.02|20176.18|54211.38|214.32|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|United Healthcare|UNITED HEALTHCARE|167,163.44|48257.74|54211.38|214.32|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|Medicaid|MEDICAID|311,809.23|35046.34|54211.38|214.32|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|Medicare|MEDICARE ACUTE|137,981.69|23877.53|54211.38|214.32|||| 356|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC|Medicare|MEDICARE PART B ONLY IP|788.74|8775.98|54211.38|214.32|||| 357|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC|Medicare|MEDICARE ACUTE|124,922.35|13890.61|28467.56|35.72|||| 357|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC|NON CONTRACTED|COMMERCIAL OTHER 1|202,943.74|28467.56|28467.56|35.72|||| 357|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|220,078.76|19493.46|28467.56|35.72|||| 357|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|181,274.91|17455.99|28467.56|35.72|||| 357|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|142,652.56|13890.61|28467.56|35.72|||| 357|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|156,723.12|13747.56|28467.56|35.72|||| 357|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|92,311.55|20988.63|28467.56|35.72|||| 357|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|52,433.65|35.72|28467.56|35.72|||| 357|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|125,479.25|13890.61|28467.56|35.72|||| 358|DRG||OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC|Cigna|CIGNA|30,448.65|14114.79|14114.79|14114.79|||| 36|DRG||CAROTID ARTERY STENT PROCEDURE W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|67,356.56|11103.02|20724.84|10869.98|||| 36|DRG||CAROTID ARTERY STENT PROCEDURE W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|58,159.24|20724.84|20724.84|10869.98|||| 36|DRG||CAROTID ARTERY STENT PROCEDURE W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|66,226.15|15808.125|20724.84|10869.98|||| 36|DRG||CAROTID ARTERY STENT PROCEDURE W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|72,774.20|10869.98|20724.84|10869.98|||| 36|DRG||CAROTID ARTERY STENT PROCEDURE W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|80,130.24|14710.34|20724.84|10869.98|||| 36|DRG||CAROTID ARTERY STENT PROCEDURE W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|83,375.63|11113.6|20724.84|10869.98|||| 36|DRG||CAROTID ARTERY STENT PROCEDURE W/O CC/MCC|Medicare|MEDICARE ACUTE|67,759.88|10892.29|20724.84|10869.98|||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|United Healthcare|UNITED HEALTHCARE OTHER|||||1,123.50||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Blue Cross HMO Specialty|BCBSTX HMO|10.70||||||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.70||||||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|United Medicare Advantage|UHC MEDICARE GOLD MA|1,096.75||||1,123.50||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|United Medicare Advantage|UHC AARP MCR HMO MA|1,123.50||||||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Veterans Affairs|VETERANS ADMINISTRATION|10.70||||10.70||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Blue Cross PPO Specialty|BCBSTX PPO|1,123.50||||1,123.50||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10.70||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.70||||1,123.50||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Humana Medicare Advantage|HUMANA MA|1,123.50||||1,096.75||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Medicare|MEDICARE ACUTE|10.70||||1,123.50||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Tricare|TRICARE FOR LIFE|1,123.50||||||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Managed Medicare|HEALTHSPRING MA|10.70||||1,123.50||| 36002|EAP|0361|US PSEUDOANEURYSM INJECTI|Medicare|MEDICARE ACUTE|10.70||||10.70||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,495.85||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|23.77||||||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23.77||||||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|United Healthcare|UNITED HEALTHCARE|||||2,495.85||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|NON CONTRACTED|COMMERCIAL OTHER 1|2,495.85||||||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||23.77||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,495.85||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Aenta Medicare Advantage|AETNA MEDICARE MA|2,436.43||||23.77||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Humana Medicare Advantage|HUMANA MA|23.77||||23.77||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Managed Medicare|HEALTHSPRING MA|2,495.85||||||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Blue Cross PPO Specialty|BCBSTX PPO|2,495.85||||2,436.43||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Blue Cross PPO Specialty|BCBSTX OTHER|||||2,495.85||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,495.85||||||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Blue Cross HMO Specialty|BCBSTX HMO|||||2,495.85||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||23.77||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Access Direct Platinum|HEALTHFIRST TPA|||||23.77||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|United Medicare Advantage|UHC MEDICARE GOLD MA|23.77||||23.77||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2,495.85||| 36011|EAP|0361|IR-PLACE CATHETER IN VEIN|Medicare|MEDICARE ACUTE|23.77||||2,495.85||| 36140|EAP|0481|ARTERIAL ACCESS EXTREMITY|Medicare|MEDICARE ACUTE|||||1,097.05||| 36140|EAP|0481|ARTERIAL ACCESS EXTREMITY|Humana Medicare Advantage|HUMANA MA|||||1,097.05||| 36160|EAP|0361|IR-ESTABLISH ACCESS TO AO|Managed Medicare|HEALTHSPRING MA|||||129.23||| 36160|EAP|0361|IR-ESTABLISH ACCESS TO AO|Medicare|MEDICARE ACUTE|||||13,569.15||| 36200|EAP|0481|CATH INJ INTRO OF CATH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||54.84||| 36200|EAP|0481|CATH INJ INTRO OF CATH|Medicare|MEDICARE ACUTE|54.84||||5,807.19||| 36200|EAP|0481|CATH INJ INTRO OF CATH|Aetna|AETNA PPO|||||54.84||| 36200|EAP|0481|CATH INJ INTRO OF CATH|Managed Medicaid|MEDICAID AMERIGROUP|||||54.84||| 36200|EAP|0481|CATH INJ INTRO OF CATH|Managed Medicare|HEALTHSPRING MA|54.84||||54.84||| 36200|EAP|0361|IR-AORTA/INTRO CATH|Medicare|MEDICARE ACUTE|41.29||||4,372.33||| 36200|EAP|0361|IR-AORTA/INTRO CATH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,372.33||||||| 36200|EAP|0361|IR-AORTA/INTRO CATH|Managed Medicare|HEALTHSPRING MA|||||41.29||| 36200|EAP|0481|CATH INJ INTRO OF CATH|United Healthcare|UNITED HEALTHCARE|||||54.84||| 36200|EAP|0361|IR-AORTA/INTRO CATH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|41.29||||||| 36200|EAP|0481|CATH INJ INTRO OF CATH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||54.84||| 36200|EAP|0481|CATH INJ INTRO OF CATH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||54.84||| 36200|EAP|0481|CATH INJ INTRO OF CATH|United Medicare Advantage|UHC AARP MCR HMO MA|||||5,807.19||| 36200|EAP|0481|CATH INJ INTRO OF CATH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||54.84||| 36200|EAP|0481|CATH INJ INTRO OF CATH|Humana Medicare Advantage|HUMANA MA|||||54.84||| 36200|EAP|0361|IR-AORTA/INTRO CATH|Blue Cross PPO Specialty|BCBSTX PPO|41.29||||||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|Managed Medicare|HEALTHSPRING MA|||||7,912.34||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|Managed Medicare|BCBS MEDICARE PPO MA|||||74.72||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|NON CONTRACTED|COMMERCIAL OTHER 1|||||7,912.34||| 36215|EAP|0361|IR-CEREB/LEFT SEL (COMM)|Medicaid|MEDICAID|||||5,958.61||| 36215|EAP|0361|IR-CEREB/LEFT SEL (COMM)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|56.27||||||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|Medicare|MEDICARE ACUTE|7,912.34||||7,912.34||| 36215|EAP|0361|IR-CEREB/LEFT SEL (COMM)|Aetna|AETNA QHP HMO|56.27||||||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|Humana Medicare Advantage|HUMANA MA|7,912.34||||74.72||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|Aenta Medicare Advantage|AETNA MEDICARE MA|7,912.34||||7,692.17||| 36215|EAP|0361|IR-CEREB/LEFT SEL (COMM)|Blue Cross PPO Specialty|BCBSTX PPO|56.27||||||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|Blue Cross PPO Specialty|BCBSTX PPO|||||7,912.34||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|United Medicare Advantage|UHC AARP MCR HMO MA|||||7,912.34||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|United Medicare Advantage|UHC MEDICARE GOLD MA|7,912.34||||7,912.34||| 36215|EAP|0481|CATH INJ EACH 1ST ORDER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|74.72||||||| 36215|EAP|0361|IR-CEREB/LEFT SEL (COMM)|Medicare|MEDICARE ACUTE|5,792.81||||||| 36216|EAP|0481|CATH INJ INITIAL SECOND O|United Medicare Advantage|UHC AARP MCR HMO MA|||||9,059.17||| 36216|EAP|0481|CATH INJ INITIAL SECOND O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9,059.17||| 36216|EAP|0481|CATH INJ INITIAL SECOND O|United Medicare Advantage|UHC MEDICARE GOLD MA|9,059.17||||||| 36216|EAP|0481|CATH INJ INITIAL SECOND O|Medicare|MEDICARE ACUTE|85.55||||||| 36216|EAP|0481|CATH INJ INITIAL SECOND O|Managed Medicare|BCBS MEDICARE PPO MA|||||85.55||| 36216|EAP|0481|CATH INJ INITIAL SECOND O|Managed Medicare|HEALTHSPRING MA|9,059.17||||||| 36216|EAP|0481|CATH INJ INITIAL SECOND O|Humana Medicare Advantage|HUMANA MA|8,807.09||||85.55||| 36216|EAP|0361|IR-EXTER CAROTID/LEFT-2ND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,819.53||||||| 36216|EAP|0361|IR-EXTER CAROTID/LEFT-2ND|Medicare|MEDICARE ACUTE|64.40||||||| 36217|EAP|0361|IR-EXTER CAROTID/RIGHT-3R|Medicaid|MEDICAID|||||8,097.66||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|Veterans Affairs|VETERANS ADMINISTRATION|||||13,932.38||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||13,932.38||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|131.57||||||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|Blue Cross PPO Specialty|BCBSTX PPO|13,932.38||||13,932.38||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|Humana Medicare Advantage|HUMANA MA|13,932.38||||13,544.69||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13,932.38||||||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|United Medicare Advantage|UHC AARP MCR HMO MA|13,932.38||||13,932.38||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13,932.38||||||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|United Medicare Advantage|UHC MEDICARE GOLD MA|13,932.38||||||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|United Healthcare|UNITED HEALTHCARE|||||131.57||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|NON CONTRACTED|COMMERCIAL OTHER 1|13,932.38||||||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|Managed Medicare|HEALTHSPRING MA|13,932.38||||131.57||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|PHCS|HUMANA|13,932.38||||||| 36221|EAP|0481|S&I CERVICOCEREBRAL CATHT|Medicare|MEDICARE ACUTE|13,932.38||||13,932.38||| 36222|EAP|0481|S&I CAROTID CERVICAL BILA|Medicare|MEDICARE ACUTE|13,932.38||||13,932.38||| 36222|EAP|0481|S&I CAROTID CERVICAL BILA|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||131.57||| 36222|EAP|0481|S&I CAROTID CERVICAL BILA|PHCS|HUMANA|131.57||||||| 36222|EAP|0481|S&I CAROTID CERVICAL BILA|United Healthcare|UNITED HEALTHCARE|||||131.57||| 36222|EAP|0481|S&I CAROTID CERVICAL BILA|Humana Medicare Advantage|HUMANA MA|13,932.38||||131.57||| 36222|EAP|0481|S&I CAROTID CERVICAL BILA|United Medicare Advantage|UHC MEDICARE GOLD MA|13,932.38||||||| 36222|EAP|0481|S&I CAROTID CERVICAL BILA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|131.57||||||| 36222|EAP|0481|S&I CAROTID CERVICAL BILA|Blue Cross PPO Specialty|BCBSTX PPO|||||131.57||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB BIL|Medicare|MEDICARE ACUTE|10,199.95||||10,199.95||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB BIL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||10,491.90||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB UNIL|Humana Medicare Advantage|HUMANA MA|10,491.90||||||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB UNIL|Managed Medicare|HEALTHSPRING MA|||||99.08||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB UNIL|Medicare|MEDICARE ACUTE|99.08||||10,199.95||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB UNIL|Humana Medicare Advantage|HUMANA MA|99.08||||||| 36223|EAP|0481|S&I CEREBRAL UNILATERAL|Blue Cross PPO Specialty|BCBSTX PPO|||||131.57||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB BIL|Humana Medicare Advantage|HUMANA MA|10,491.90||||||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB UNIL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.08||||||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB BIL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.08||||99.08||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB BIL|United Medicare Advantage|UHC MEDICARE GOLD MA|99.08||||||| 36223|EAP|0361|IR-ANGIO CAROT/CEREB BIL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10,491.90||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Medicaid|MEDICAID|94.34||||9,989.97||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|94.34||||||| 36224|EAP|0361|IR-CEREB/LEFT-2ND ORDER|United Healthcare|UNITED HEALTHCARE|6,819.53||||9,989.97||| 36224|EAP|0361|IR-CEREB/LEFT-2ND ORDER|Managed Medicare|HEALTHSPRING MA|||||64.40||| 36224|EAP|0361|IR-CEREB/RIGHT-3RD ORDER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|76.47||||||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|United Healthcare|UNITED HEALTHCARE|||||94.34||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|United Healthcare|UNITED HEALTHCARE|9,711.99||||9,989.97||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Medicare|MEDICARE ACUTE|94.34||||94.34||| 36224|EAP|0361|IR-CEREB/RIGHT-3RD ORDER|Medicare|MEDICARE ACUTE|76.47||||94.34||| 36224|EAP|0361|IR-CEREB/LEFT-2ND ORDER|Medicare|MEDICARE ACUTE|6,819.53||||94.34||| 36224|EAP|0361|IR-CEREB/RIGHT-3RD ORDER|United Medicare Advantage|UHC MEDICARE GOLD MA|76.47||||94.34||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|United Medicare Advantage|UHC AARP MCR HMO MA|9,989.97||||94.34||| 36224|EAP|0361|IR-CEREB/LEFT-2ND ORDER|United Medicare Advantage|UHC AARP MCR HMO MA|6,819.53||||94.34||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|United Medicare Advantage|UHC MEDICARE GOLD MA|64.40||||94.34||| 36224|EAP|0361|IR-CEREB/RIGHT-3RD ORDER|United Medicare Advantage|UHC AARP MCR HMO MA|8,097.66||||94.34||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Veterans Affairs|VETERANS ADMINISTRATION|94.34||||9,989.97||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|94.34||||94.34||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Access Direct Platinum|HEALTHFIRST TPA UMR|94.34||||||| 36224|EAP|0361|IR-CEREB/LEFT-2ND ORDER|Veterans Affairs|VETERANS ADMINISTRATION|64.40||||9,989.97||| 36224|EAP|0361|IR-CEREB/LEFT-2ND ORDER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,819.53||||9,989.97||| 36224|EAP|0361|IR-CEREB/RIGHT-3RD ORDER|Humana Medicare Advantage|HUMANA MA|76.47||||94.34||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|94.34||||9,989.97||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Managed Medicaid|MEDICAID SUPERIOR|9,989.97||||||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9,711.99||||9,989.97||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|94.34||||||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Humana Medicare Advantage|HUMANA MA|94.34||||94.34||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Managed Medicare|HEALTHSPRING MA|||||94.34||| 36224|EAP|0361|IR-CEREB/RIGHT-3RD ORDER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|76.47||||94.34||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Aetna|AETNA OTHER|9,989.97||||||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Aetna|AETNA PPO|94.34||||94.34||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Workers Compensation|WORKERS COMPENSATION OTHER|9,989.97||||||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Blue Cross HMO Specialty|BCBSTX HMO|9,989.97||||9,711.99||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Cigna|CIGNA|94.34||||||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|94.34||||9,989.97||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Blue Cross PPO Specialty|BCBSTX PPO|9,989.97||||9,989.97||| 36224|EAP|0361|IR-CEREB/LEFT-2ND ORDER|Blue Cross HMO Specialty|BCBSTX HMO|64.40||||9,711.99||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Blue Cross PPO Specialty|BCBSTX OTHER|9,989.97||||||| 36224|EAP|0361|IR-BILAT CAROTID/CEREBALI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9,989.97||||9,989.97||| 36224|EAP|0361|IR-CEREB/LEFT-2ND ORDER|Blue Cross PPO Specialty|BCBSTX PPO|6,819.53||||64.40||| 36224|EAP|0361|IR-CEREB/RIGHT-3RD ORDER|Aetna|AETNA PPO|76.47||||94.34||| 36224|EAP|0361|IR-CEREB/RIGHT-3RD ORDER|Blue Cross PPO Specialty|BCBSTX PPO|8,097.66||||64.40||| 36225|EAP|0361|IR-VERTEBRAL/RIGHT-3RD OR|Medicare|MEDICARE ACUTE|||||76.47||| 36225|EAP|0361|IR-VERTEBRAL/RIGHT-3RD OR|Veterans Affairs|VETERANS ADMINISTRATION|76.47||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.08||||10,491.90||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Blue Cross PPO Specialty|BCBSTX PPO|10,491.90||||10,491.90||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Managed Medicare|HEALTHSPRING MA|||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.08||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|United Healthcare|UNITED HEALTHCARE|99.08||||10,491.90||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Medicare|MEDICARE ACUTE|99.08||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Medicaid|SMITH COUNTY INDIGENT HEALTH|99.08||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Medicaid|MEDICAID|99.08||||10,491.90||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10,199.95||||10,491.90||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|United Healthcare|UNITED HEALTHCARE|||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Blue Cross PPO Specialty|BCBSTX PPO|99.08||||10,491.90||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.08||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.08||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Humana Medicare Advantage|HUMANA MA|99.08||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|United Medicare Advantage|UHC AARP MCR HMO MA|10,491.90||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.08||||10,491.90||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|United Medicare Advantage|UHC MEDICARE GOLD MA|99.08||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|99.08||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Blue Cross PPO Specialty|BCBSTX OTHER|10,491.90||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Aetna|AETNA OTHER|10,491.90||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Workers Compensation|WORKERS COMPENSATION OTHER|10,491.90||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Veterans Affairs|VETERANS ADMINISTRATION|99.08||||10,491.90||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Access Direct Platinum|HEALTHFIRST TPA UMR|99.08||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Cigna|CIGNA|99.08||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|United Healthcare|UNITED HEALTHCARE|10,199.95||||10,491.90||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Blue Cross HMO Specialty|BCBSTX HMO|10,491.90||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Aetna|AETNA PPO|99.08||||99.08||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Managed Medicaid|MEDICAID SUPERIOR|10,491.90||||||| 36226|EAP|0361|IR-ANGIO VERTEBRAL/CERVIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10,491.90||||10,491.90||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Humana Medicare Advantage|HUMANA MA|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Aetna|AETNA OTHER|10,491.90||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Blue Cross HMO Specialty|BCBSTX HMO|10,491.90||||10,491.90||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Managed Medicaid|MEDICAID SUPERIOR|10,491.90||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10,491.90||||10,491.90||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Blue Cross PPO Specialty|BCBSTX OTHER|10,491.90||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.08||||10,491.90||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Aetna|AETNA PPO|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Humana Medicare Advantage|HUMANA MA|10,199.95||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Blue Cross PPO Specialty|BCBSTX PPO|10,491.90||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Medicare|MEDICARE ACUTE|10,199.95||||10,491.90||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Humana Medicare Advantage|HUMANA MA|10,491.90||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Medicaid|MEDICAID|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|United Healthcare|UNITED HEALTHCARE|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|United Healthcare|UNITED HEALTHCARE|||||99.08||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Medicare|MEDICARE ACUTE|10,491.90||||10,491.90||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Blue Cross PPO Specialty|BCBSTX PPO|10,491.90||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Medicare|MEDICARE ACUTE|10,491.90||||10,491.90||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Managed Medicare|HEALTHSPRING MA|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|Veterans Affairs|VETERANS ADMINISTRATION|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Veterans Affairs|VETERANS ADMINISTRATION|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Access Direct Platinum|HEALTHFIRST TPA UMR|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10,491.90||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID BIL|United Medicare Advantage|UHC MEDICARE GOLD MA|99.08||||99.08||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.08||||||| 36227|EAP|0361|IR-ANGIO EXT CAROTID UNIL|United Medicare Advantage|UHC MEDICARE GOLD MA|99.08||||99.08||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Medicaid|MEDICAID|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Blue Cross PPO Specialty|BCBSTX PPO|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Blue Cross HMO Specialty|BCBSTX HMO|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Aetna|AETNA QHP HMO|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Aetna|AETNA PPO|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||14.18||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Humana Medicare Advantage|HUMANA MA|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Medicare|MEDICARE ACUTE|14.18||||14.18||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|United Medicare Advantage|UHC AARP MCR HMO MA|1,459.79||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|United Healthcare|UNITED HEALTHCARE|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|United Healthcare|UNITED HEALTHCARE|1,501.57||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|United Medicare Advantage|UHC MEDICARE GOLD MA|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Veterans Affairs|VETERANS ADMINISTRATION|14.18||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,459.79||||||| 36228|EAP|0361|IR-ADD 2ND OR 3RD ORDER C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|14.18||||||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,220.17||| 36245|EAP|0481|PELVIC BILATERAL ILIAC|United Medicare Advantage|UHC AARP MCR HMO MA|||||8,260.73||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6,220.17||||||| 36245|EAP|0481|PELVIC BILATERAL ILIAC|Veterans Affairs|VETERANS ADMINISTRATION|78.01||||||| 36245|EAP|0481|PELVIC BILATERAL ILIAC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8,260.73||| 36245|EAP|0481|PELVIC BILATERAL ILIAC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|78.01||||||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,220.17||| 36245|EAP|0481|PELVIC BILATERAL ILIAC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,030.87||||||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|Humana Medicare Advantage|HUMANA MA|58.74||||6,220.17||| 36245|EAP|0481|PELVIC BILATERAL ILIAC|Humana Medicare Advantage|HUMANA MA|||||78.01||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.74||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|Blue Cross PPO Specialty|BCBSTX PPO|58.74||||6,220.17||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|Rusk State Hospital|RUSK STATE HOSP|||||6,220.17||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|Medicaid|MEDICAID|6,220.17||||||| 36245|EAP|0481|PELVIC BILATERAL ILIAC|Managed Medicare|HEALTHSPRING MA|||||78.01||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,220.17||||||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|Medicare|MEDICARE ACUTE|6,220.17||||6,220.17||| 36245|EAP|0361|IR-RENAL ANGIO/SELECTIVE|Managed Medicare|BCBS MEDICARE PPO MA|6,220.17||||||| 36245|EAP|0481|PELVIC BILATERAL ILIAC|Medicare|MEDICARE ACUTE|78.01||||78.01||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|Blue Cross HMO Specialty|BCBSTX HMO|6,835.41||||||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|Medicare|MEDICARE ACUTE|6,835.41||||6,835.41||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|Blue Cross PPO Specialty|BCBSTX PPO|6,645.21||||6,835.41||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,835.41||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,835.41||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6,835.41||||||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|Veterans Affairs|VETERANS ADMINISTRATION|||||6,835.41||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|United Healthcare|TML GROUP BENEFITS|6,835.41||||||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|Managed Medicare|BCBS MEDICARE PPO MA|6,835.41||||||| 36246|EAP|0361|IR-PELVIC/EXTREM/SELECT-2|Medicaid|MEDICAID|6,835.41||||||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8,090.25||||8,090.25||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8,090.25||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8,090.25||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||76.40||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|United Medicare Advantage|UHC AARP MCR HMO MA|||||8,090.25||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,090.25||||8,090.25||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|76.40||||||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Veterans Affairs|VETERANS ADMINISTRATION|||||8,090.25||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Blue Cross PPO Specialty|BCBSTX PPO|76.40||||8,090.25||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Rusk State Hospital|RUSK STATE HOSP|||||8,090.25||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|United Healthcare|TML GROUP BENEFITS|8,090.25||||||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Medicaid|CRIME VICTIMS COMPENSATION|7,865.13||||||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Managed Medicare|HEALTHSPRING MA|76.40||||8,090.25||| 36247|EAP|0361|IR-PELVIC/EXTREM/SELECT-3|Medicare|MEDICARE ACUTE|8,090.25||||8,090.25||| 36248|EAP|0361|IR-ADD ABD/PEL/LOW EXTR-2|Medicaid|CRIME VICTIMS COMPENSATION|14.18||||||| 36248|EAP|0361|IR-ADD ABD/PEL/LOW EXTR-2|Medicare|MEDICARE ACUTE|1,501.57||||1,501.57||| 36248|EAP|0361|IR-ADD ABD/PEL/LOW EXTR-2|Blue Cross PPO Specialty|BCBSTX PPO|1,501.57||||1,501.57||| 36248|EAP|0361|IR-ADD ABD/PEL/LOW EXTR-2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14.18||| 36248|EAP|0361|IR-ADD ABD/PEL/LOW EXTR-2|Humana Medicare Advantage|HUMANA MA|||||1,501.57||| 36248|EAP|0361|IR-ADD ABD/PEL/LOW EXTR-2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,501.57||||||| 36248|EAP|0361|IR-ADD ABD/PEL/LOW EXTR-2|Rusk State Hospital|RUSK STATE HOSP|||||1,501.57||| 36251|EAP|0481|CATH PLACE UNILAT RENAL S|Aetna|AETNA PPO|||||6,233.94||| 36251|EAP|0481|CATH PLACE UNILAT RENAL S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,233.94||||||| 36251|EAP|0481|CATH PLACE UNILAT RENAL S|United Medicare Advantage|UHC MEDICARE GOLD MA|6,233.94||||6,233.94||| 36251|EAP|0361|IR-ANGIO RENAL UNILAT LT|United Healthcare|UNITED HEALTHCARE OTHER|99.08||||||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Managed Medicare|BCBS MEDICARE PPO MA|77.99||||77.99||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Managed Medicare|HEALTHSPRING MA|||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Medicaid|MEDICAID|||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|PHCS|HUMANA|77.99||||||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Medicare|MEDICARE PART B ONLY IP|77.99||||||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Medicare|MEDICARE ACUTE|8,258.62||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Blue Cross PPO Specialty|BCBSTX PPO|77.99||||77.99||| 36252|EAP|0361|IR-ANGIO RENAL BIL|UTMB|UTMB CORRECTIONAL MANAGED CARE|11,552.96||||||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|United Healthcare|UNITED HEALTHCARE|8,258.62||||||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Humana Medicare Advantage|HUMANA MA|8,258.62||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Blue Cross HMO Specialty|BCBSTX HMO|||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8,258.62||||||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,258.62||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Veterans Affairs|VETERANS ADMINISTRATION|||||8,258.62||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|United Medicare Advantage|UHC AARP MCR HMO MA|||||8,028.81||| 36252|EAP|0361|IR-ANGIO RENAL BIL|Medicare|MEDICARE ACUTE|||||109.10||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8,258.62||||||| 36252|EAP|0481|BILATERAL RENALS SELECTIV|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,258.62||||||| 36253|EAP|0361|IR-SUPESELECT-RENAL LT|Blue Cross PPO Specialty|BCBSTX PPO|13,932.38||||||| 36253|EAP|0361|IR-SUPESELECT-RENAL LT|United Healthcare|UNITED HEALTHCARE OTHER|131.57||||||| 36253|EAP|0361|IR-SUPESELECT-RENAL LT|United Medicare Advantage|UHC MEDICARE GOLD MA|131.57||||||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicare|MEDICARE PART B ONLY IP|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|CRIME VICTIMS COMPENSATION|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicare|MEDICARE ACUTE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|MEDICAID BCBSTX|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|MEDICAID HMO|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|WELLCARE CHOICE MA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|MA PART B ONLY IP|0.82||||||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|BCBS MEDICARE PPO MA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|OTHER INSTITUTIONS|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Multiplan|WEB TPA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Multiplan|NALC|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|NON CONTRACTED|COMMERCIAL OTHER 1|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|NON CONTRACTED|COMMERCIAL OTHER 4|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Multiplan|PACIFICARE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|NON CONTRACTED|COMMERCIAL OTHER 2|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.82||||||| 36415|EAP|0300|LAB PHLEBOTOMY|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|PHCS|GROUP AND PENSION|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Multiplan|TRUSTMARK|0.82||||||| 36415|EAP|0300|LAB PHLEBOTOMY|PHCS|HUMANA INSURANCE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Optum Behavioral Health|BH OPTUM UHC|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Tricare|TRICARE EAST REGION|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|PHCS|MULTIPLAN PHCS|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Healthcare|UNITED HEALTHCARE ERS|0.82||||||| 36415|EAP|0300|LAB PHLEBOTOMY|United Healthcare|GOLDEN RULE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Tricare|TRICARE FOR LIFE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Healthcare|AARP|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Healthcare|UNITED HEALTHCARE OTHER|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Healthcare|TML GROUP BENEFITS|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Healthcare|GEHA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Rusk State Hospital|RUSK STATE HOSP|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Healthcare|UNITED HEALTHCARE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Cigna|CIGNA OTHER|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Humana Medicare Advantage|HUMANA MA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|PHCS|HUMANA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Tricare|TRICARE SOUTH PHYSICIAN|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Cigna Behavioral Health|BH CIGNA|0.82||||||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicaid|MEDICAID AMERIGROUP|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicaid|MEDICAID SUPERIOR|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Cigna|CIGNA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Aetna|AETNA PPO|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Texas Workforce Commission|DIS DETER SERV (DDS)|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Aetna|AETNA QHP HMO|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Aetna|BOON CHAPMAN|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Aetna|ZZZZZ AETNA|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Aetna|BH AETNA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|LAW ENFORCEMENT OTHER|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|ETMC REHABILITATION HOSPITAL|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Aetna|AETNA OTHER|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Aetna Value Network|AETNA VALUE NETWORK|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Magellan Behavioral Health|BH MAGELLAN|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Blue Cross PPO Specialty|BCBSTX OTHER|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Blue Cross HMO Specialty|BCBSTX HMO|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Blue Cross PPO Specialty|BCBSTX PPO|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|ChampVA|CHAMPVA CENTER|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Multiplan|MUTUAL OF OMAHA|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|JACKSONVILLE ACCESS|0.82||||||| 36415|EAP|0300|LAB PHLEBOTOMY|Managed Medicare|HEALTHSPRING MA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Access Direct Platinum|ANDREWS CENTER|0.82||||||| 36415|EAP|0300|LAB PHLEBOTOMY|Aenta Medicare Advantage|AETNA MEDICARE MA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|SMITH COUNTY JAIL|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Access Direct Platinum|HEALTHFIRST TPA UMR|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Access Direct Platinum|HEALTHFIRST TPA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|ZURICH COMPANY|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Veterans Affairs|VETERANS ADMINISTRATION|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|BROOKSHIRES WORKERS COMP|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|WORKERS COMP PHYSICIAN|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|TEXAS MUTUAL INSURANCE|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|WORKERS COMPENSATION OTHER|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|UT EMPLOYEE INJURY|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicaid|MEDICAID|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Medicare|UTSW MC KIDNEY PROGRAM|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Medicare Advantage|UHC AARP MCR HMO MA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.82||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|Workers Compensation|GALLAGHER BASSETT|||||0.82||| 36415|EAP|0300|LAB PHLEBOTOMY|United Medicare Advantage|UHC MEDICARE GOLD MA|0.82||||0.82||| 36416|EAP|0300|CAPILLARY BLOOD DRAW|Managed Medicaid|MEDICAID SUPERIOR|||||36.49||| 36416|EAP|0300|CAPILLARY BLOOD DRAW|Multiplan|WEB TPA|36.49||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicaid|CRIME VICTIMS COMPENSATION|2,759.53||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Managed Medicare|OTHER INSTITUTIONS|||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Managed Medicare|HEALTHSPRING MA|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicaid|SMITH COUNTY JAIL|||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.67||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicaid|MEDICAID|25.67||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|United Healthcare|UNITED HEALTHCARE OTHER|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Tricare|TRICARE EAST REGION|||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,759.53||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicare|MEDICARE PART B ONLY IP|2,759.53||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|United Healthcare|UNITED HEALTHCARE|2,759.53||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicare|MEDICARE ACUTE|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicare|MEDICARE PART B ONLY IP|25.67||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicare|MEDICARE ACUTE|25.67||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|United Medicare Advantage|UHC MEDICARE GOLD MA|2,952.05||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|United Medicare Advantage|UHC MEDICARE GOLD MA|2,952.05||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|United Medicare Advantage|UHC AARP MCR HMO MA|2,952.05||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,759.53||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Workers Compensation|BROOKSHIRES WORKERS COMP|25.67||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|Access Direct Platinum|HEALTHFIRST TPA UMR|25.67||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicaid|MEDICAID|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Veterans Affairs|VETERANS ADMINISTRATION|2,952.05||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|United Healthcare|UNITED HEALTHCARE|2,759.53||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|25.67||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,952.05||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|Veterans Affairs|VETERANS ADMINISTRATION|2,952.05||||2,759.53||| 36430|EAP|0391|BLOOD ADMINISTRATION|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.67||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|Blue Cross PPO Specialty|BCBSTX PPO|25.67||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|United Healthcare|UNITED HEALTHCARE|||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Blue Cross HMO Specialty|BCBSTX HMO|2,759.53||||2,759.53||| 36430|EAP|0391|BLOOD ADMINISTRATION|Blue Cross PPO Specialty|BCBSTX OTHER|||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Blue Cross HMO Specialty|BCBSTX HMO|2,759.53||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,952.05||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Aetna|AETNA PPO|||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Aenta Medicare Advantage|AETNA MEDICARE MA|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Aetna|AETNA OTHER|||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Access Direct Platinum|HEALTHFIRST TPA|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Aenta Medicare Advantage|AETNA MEDICARE MA|25.67||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|Blue Cross PPO Specialty|BCBSTX PPO|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Humana Medicare Advantage|HUMANA MA|2,759.53||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Humana Medicare Advantage|HUMANA MA|2,759.53||||2,759.53||| 36430|EAP|0391|BLOOD ADMINISTRATION|Cigna|CIGNA OTHER|25.67||||||| 36430|EAP|0391|BLOOD ADMINISTRATION|Cigna|CIGNA|||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Cigna|CIGNA|2,952.05||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Managed Medicaid|MEDICAID AMERIGROUP|25.67||||25.67||| 36430|EAP|0391|BLOOD ADMINISTRATION|Managed Medicaid|MEDICAID SUPERIOR|2,759.53||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,952.05||||2,952.05||| 36430|EAP|0391|BLOOD ADMINISTRATION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.67||||25.67||| 36481|EAP|0361|IR-PORTAL VENIN CATHETERI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||18.11||| 36514|EAP|0361|APHERESIS PLASMA|UTMB|UTMB CORRECTIONAL MANAGED CARE|10,300.55||||||| 36514|EAP|0361|APHERESIS PLASMA|United Healthcare|UNITED HEALTHCARE|89.57||||||| 36514|EAP|0361|APHERESIS PLASMA|Humana Medicare Advantage|HUMANA MA|89.57||||||| 36514|EAP|0361|APHERESIS PLASMA|United Healthcare|UNITED HEALTHCARE OTHER|10,300.55||||||| 36514|EAP|0361|APHERESIS PLASMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10,300.55||||||| 36514|EAP|0361|APHERESIS PLASMA|Medicare|MEDICARE ACUTE|89.57||||||| 36514|EAP|0361|APHERESIS PLASMA|Blue Cross PPO Specialty|BCBSTX PPO|10,300.55||||||| 36514|EAP|0361|APHERESIS PLASMA|Veterans Affairs|VETERANS ADMINISTRATION|10,300.55||||||| 36514|EAP|0361|APHERESIS PLASMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10,300.55||||||| 36514|EAP|0361|APHERESIS PLASMA|Aenta Medicare Advantage|AETNA MEDICARE MA|10,300.55||||||| 36514|EAP|0361|APHERESIS PLASMA|Blue Cross HMO Specialty|BCBSTX HMO|89.57||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Aetna|AETNA PPO|3,746.38||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,076.25||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Blue Cross HMO Specialty|BCBSTX HMO|26.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Blue Cross PPO Specialty|BCBSTX PPO|34.85||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Veterans Affairs|VETERANS ADMINISTRATION|26.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Workers Compensation|TEXAS MUTUAL INSURANCE|34.85||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|34.85||||4,007.75||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Access Direct Platinum|HEALTHFIRST TPA UMR|34.85||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|United Medicare Advantage|UHC MEDICARE GOLD MA|3,076.25||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,007.75||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|United Medicare Advantage|UHC AARP MCR HMO MA|3,076.25||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Access Direct Platinum|HEALTHFIRST TPA|2,875.63||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Veterans Affairs|VETERANS ADMINISTRATION|3,746.38||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Blue Cross PPO Specialty|BCBSTX PPO|3,076.25||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|34.85||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.85||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Aenta Medicare Advantage|AETNA MEDICARE MA|26.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Aenta Medicare Advantage|AETNA MEDICARE MA|34.85||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Humana Medicare Advantage|HUMANA MA|2,875.63||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Humana Medicare Advantage|HUMANA MA|4,007.75||||3,746.38||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|PHCS|HUMANA|4,007.75||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Managed Medicaid|MEDICAID AMERIGROUP|||||34.85||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Managed Medicare|HEALTHSPRING MA|34.85||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Medicaid|SMITH COUNTY JAIL|26.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|United Healthcare|UNITED HEALTHCARE OTHER|||||34.85||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Medicaid|CRIME VICTIMS COMPENSATION|3,746.38||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Managed Medicare|HEALTHSPRING MA|26.75||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|UTMB|UTMB CORRECTIONAL MANAGED CARE|26.75||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Managed Medicare|BCBS MEDICARE PPO MA|26.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|UTMB|UTMB CORRECTIONAL MANAGED CARE|34.85||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|34.85||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.75||||3,076.25||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|United Medicare Advantage|UHC MEDICARE GOLD MA|34.85||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Managed Medicare|WELLCARE CHOICE MA|4,007.75||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|United Healthcare|UNITED HEALTHCARE OTHER|3,076.25||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Medicaid|MEDICAID|34.85||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,007.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34.85||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|United Healthcare|UNITED HEALTHCARE|26.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|NON CONTRACTED|COMMERCIAL OTHER 1|34.85||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Medicaid|MEDICAID|2,875.63||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Medicare|MEDICARE PART B ONLY IP|26.75||||||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|Medicare|MEDICARE ACUTE|26.75||||26.75||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Medicare|MEDICARE ACUTE|4,007.75||||3,746.38||| 36556|EAP|0361|IR-INS NON TUN CVAC OVR 5|NON CONTRACTED|COMMERCIAL OTHER 1|26.75||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|NON CONTRACTED|COMMERCIAL OTHER 1|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Medicare|UTSW MC KIDNEY PROGRAM|||||8,598.55||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Medicare|MEDICARE ACUTE|74.77||||8,598.55||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|UTMB|UTMB CORRECTIONAL MANAGED CARE|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|United Healthcare|UNITED HEALTHCARE OTHER|8,598.55||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|United Healthcare|UNITED HEALTHCARE|8,598.55||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,037.78||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Medicaid|MEDICAID|8,598.55||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Humana Medicare Advantage|HUMANA MA|8,598.55||||8,598.55||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Workers Compensation|WORKERS COMPENSATION OTHER|||||74.77||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Access Direct Platinum|HEALTHFIRST TPA|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8,037.78||||8,598.55||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|United Medicare Advantage|UHC AARP MCR HMO MA|||||74.77||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Medicare|MEDICARE PART B ONLY IP|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8,037.78||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Veterans Affairs|VETERANS ADMINISTRATION|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Managed Medicare|BCBS MEDICARE PPO MA|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Managed Medicare|HEALTHSPRING MA|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Blue Cross PPO Specialty|BCBSTX PPO|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|74.77||||||| 36558|EAP|0361|IR-INS TUN CVAC WO PORT O|United Medicare Advantage|UHC MEDICARE GOLD MA|8,598.55||||||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|United Medicare Advantage|UHC AARP MCR HMO MA|||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|United Medicare Advantage|UHC MEDICARE GOLD MA|||||160.08||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Veterans Affairs|VETERANS ADMINISTRATION|||||160.08||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17,208.60||||||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Access Direct Platinum|HEALTHFIRST TPA UMR|||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Blue Cross HMO Specialty|BCBSTX HMO|||||160.08||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Aetna|AETNA PPO|||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||160.08||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Managed Medicaid|MEDICAID AMERIGROUP|||||17,208.60||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Medicaid|MEDICAID|18,409.20||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||160.08||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Humana Medicare Advantage|HUMANA MA|||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Managed Medicare|HEALTHSPRING MA|160.08||||17,208.60||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Blue Cross PPO Specialty|BCBSTX PPO|160.08||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|NON CONTRACTED|COMMERCIAL OTHER 1|||||17,208.60||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|United Healthcare|UNITED HEALTHCARE OTHER|||||17,208.60||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Medicare|MEDICARE ACUTE|||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|United Healthcare|UNITED HEALTHCARE|||||18,409.20||| 36561|EAP|0361|IR-INS TUN CVAD W PORT OV|Tricare|TRICARE EAST REGION|||||160.08||| 36569|EAP|0761|INS PICC WO PORT/PUMP OVR|Medicare|MEDICARE ACUTE|3,076.25||||||| 36569|EAP|0361|IR-INS PICC WO PORT/PUMP|Managed Medicare|HEALTHSPRING MA|3,076.25||||||| 36569|EAP|0361|IR-INS PICC WO PORT/PUMP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.75||||||| 36569|EAP|0361|IR-INS PICC WO PORT/PUMP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,076.25||||3,076.25||| 36569|EAP|0361|IR-INS PICC WO PORT/PUMP|Medicare|MEDICARE ACUTE|3,076.25||||26.75||| 36569|EAP|0361|IR-INS PICC WO PORT/PUMP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,076.25||||||| 36569|EAP|0361|IR-INS PICC WO PORT/PUMP|Blue Cross PPO Specialty|BCBSTX PPO|26.75||||26.75||| 36569|EAP|0761|INS PICC WO PORT/PUMP OVR|Blue Cross PPO Specialty|BCBSTX PPO|3,076.25||||||| 36569|EAP|0361|IR-INS PICC WO PORT/PUMP|ChampVA|CHAMPVA CENTER|3,076.25||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Medicare|MEDICARE ACUTE|3,391.35||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Workers Compensation|WORKERS COMPENSATION OTHER|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Workers Compensation|BROOKSHIRES WORKERS COMP|29.49||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Veterans Affairs|VETERANS ADMINISTRATION|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|29.49||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Access Direct Platinum|HEALTHFIRST TPA UMR|29.49||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3,391.35||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Access Direct Platinum|HEALTHFIRST TPA|3,391.35||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|United Medicare Advantage|UHC AARP WELLMED HMO MA|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|United Medicare Advantage|UHC MEDICARE GOLD MA|3,391.35||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,391.35||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|United Medicare Advantage|UHC AARP MCR HMO MA|3,391.35||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Blue Cross PPO Specialty|BCBSTX PPO|3,391.35||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Managed Medicaid|MEDICAID SUPERIOR|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,391.35||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Blue Cross PPO Specialty|BCBSTX OTHER|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Aenta Medicare Advantage|AETNA MEDICARE MA|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Cigna|CIGNA|3,391.35||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|ChampVA|CHAMPVA CENTER|3,170.18||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Aetna|AETNA OTHER|3,170.18||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Aetna|BOON CHAPMAN|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Aetna|AETNA PPO|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Humana Medicare Advantage|HUMANA MA|3,391.35||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Aetna|AETNA QHP HMO|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Blue Cross HMO Specialty|BCBSTX HMO|29.49||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Cigna|CIGNA OTHER|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Cigna|CIGNA|3,391.35||||3,170.18||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Managed Medicaid|MEDICAID AMERIGROUP|29.49||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,391.35||||3,170.18||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,391.35||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Medicaid|SMITH COUNTY JAIL|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Medicaid|SMITH COUNTY INDIGENT HEALTH|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Medicaid|COUNTY INDIGENT HEALTH OTHER|3,170.18||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Medicaid|CRIME VICTIMS COMPENSATION|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Medicaid|MEDICAID|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Medicaid|MOLINA HEALTHCARE OF TEXAS|3,170.18||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Managed Medicare|HEALTHSPRING MA|29.49||||3,391.35||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Medicaid|MEDICAID HMO|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|UTMB|UTMB CORRECTIONAL MANAGED CARE|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|United Healthcare|TML GROUP BENEFITS|3,170.18||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|United Healthcare|UNITED HEALTHCARE|29.49||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Tricare|TRICARE EAST REGION|3,170.18||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|United Healthcare|UNITED HEALTHCARE OTHER|29.49||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|United Healthcare|UNITED HEALTHCARE|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|NON CONTRACTED|COMMERCIAL OTHER 1|3,391.35||||29.49||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|PHCS|HUMANA|3,391.35||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|29.49||||||| 36573|EAP|0761|PICC LINE >5YRS W/IMAGING|Managed Medicare|BCBS MEDICARE PPO MA|29.49||||||| 36581|EAP|0361|IR-RPLC CVAC TUN W/O PORT|NON CONTRACTED|COMMERCIAL OTHER 1|74.77||||||| 36581|EAP|0361|IR-RPLC CVAC TUN W/O PORT|Medicare|MEDICARE ACUTE|8,037.78||||8,598.55||| 36581|EAP|0361|IR-RPLC CVAC TUN W/O PORT|Managed Medicare|HEALTHSPRING MA|74.77||||||| 36581|EAP|0361|IR-RPLC CVAC TUN W/O PORT|Medicaid|MEDICAID|||||8,037.78||| 36581|EAP|0361|IR-RPLC CVAC TUN W/O PORT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|74.77||||74.77||| 36581|EAP|0361|IR-RPLC CVAC TUN W/O PORT|Humana Medicare Advantage|HUMANA MA|74.77||||8,598.55||| 36581|EAP|0361|IR-RPLC CVAC TUN W/O PORT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|74.77||||||| 36581|EAP|0361|IR-RPLC CVAC TUN W/O PORT|United Medicare Advantage|UHC MEDICARE GOLD MA|8,598.55||||||| 36584|EAP|0360|IR-REPLACE PICC CATH|ChampVA|CHAMPVA CENTER|5,640.75||||||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|United Healthcare|UNITED HEALTHCARE OTHER|3,076.25||||||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|Workers Compensation|WORKERS COMPENSATION OTHER|||||26.75||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|NON CONTRACTED|COMMERCIAL OTHER 1|26.75||||||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|United Medicare Advantage|UHC MEDICARE GOLD MA|3,076.25||||||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|Medicare|MEDICARE ACUTE|26.75||||3,076.25||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|Blue Cross PPO Specialty|BCBSTX PPO|26.75||||26.75||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.75||||3,076.25||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,875.63||||||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|Managed Medicaid|MEDICAID AMERIGROUP|||||26.75||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|Humana Medicare Advantage|HUMANA MA|3,076.25||||||| 36589|EAP|0361|IR-REM TUN CVC WO PORT/PU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.75||||||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Aetna|AETNA PPO|||||2,548.40||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Blue Cross PPO Specialty|BCBSTX PPO|||||2,548.40||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Blue Cross HMO Specialty|BCBSTX HMO|||||22.16||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,548.40||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||22.16||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,382.20||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||22.16||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Medicaid|LAW ENFORCEMENT OTHER|||||2,548.40||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Managed Medicare|HEALTHSPRING MA|22.16||||||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2,548.40||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|United Healthcare|UNITED HEALTHCARE|||||2,548.40||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|United Healthcare|UNITED HEALTHCARE OTHER|||||2,548.40||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Medicare|MEDICARE ACUTE|||||2,548.40||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Humana Medicare Advantage|HUMANA MA|||||2,548.40||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Tricare|TRICARE EAST REGION|||||22.16||| 36590|EAP|0361|IR-REM TUN CVAD W PORT/PU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||22.16||| 36595|EAP|0361|IR-MECH REMOV TUNNELED CV|Medicare|MEDICARE ACUTE|71.36||||||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.49||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.49||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.49||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|Blue Cross HMO Specialty|BCBSTX HMO|7.49||||793.14||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|Humana Medicare Advantage|HUMANA MA|||||793.14||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.49||||793.14||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|Blue Cross PPO Specialty|BCBSTX PPO|||||7.49||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|Medicare|MEDICARE ACUTE|||||7.49||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|United Medicare Advantage|UHC AARP MCR HMO MA|||||793.14||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.49||||771.07||| 36598|EAP|0320|XR-INJ W/FLUOR EVAL CV DE|ChampVA|CHAMPVA CENTER|793.14||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.75||||99.75||| 36600|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.75||||99.75||| 36600|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Blue Cross PPO Specialty|BCBSTX OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|99.75||||99.75||| 36600|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Brinson Benefits|THE HEALTH PLAN SMITH CO|99.75||||||| 36600|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|99.75||||||| 36600|EAP|0300||United Medicare Advantage|UHC MEDICARE GOLD MA|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|United Medicare Advantage|UHC AARP WELLMED HMO MA|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|United Medicare Advantage|UHC MEDICARE GOLD MA|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|United Medicare Advantage|UHC AARP MCR HMO MA|99.75||||99.75||| 36600|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Blue Cross HMO Specialty|BCBSTX HMO|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Blue Cross PPO Specialty|BCBSTX PPO|99.75||||99.75||| 36600|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Workers Compensation|TEXAS MUTUAL INSURANCE|99.75||||||| 36600|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.75||||99.75||| 36600|EAP|0361||Veterans Affairs|VETERANS ADMINISTRATION|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Workers Compensation|UT EMPLOYEE INJURY|99.75||||99.75||| 36600|EAP|0300||Workers Compensation|TEXAS MUTUAL INSURANCE|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Workers Compensation|WORKERS COMPENSATION OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Veterans Affairs|VETERANS ADMINISTRATION|99.75||||99.75||| 36600|EAP|0361||Aetna|AETNA PPO|99.75||||||| 36600|EAP|0361||Workers Compensation|TEXAS MUTUAL INSURANCE|99.75||||||| 36600|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Access Direct Platinum|HEALTHFIRST TPA UMR|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Access Direct Platinum|HEALTHFIRST TPA|99.75||||99.75||| 36600|EAP|0361||Workers Compensation|WORKERS COMPENSATION OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|99.75||||99.75||| 36600|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UMR|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|99.75||||||| 36600|EAP|0300||Managed Medicare|BCBS MEDICARE PPO MA|99.75||||||| 36600|EAP|0300||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicare|HEALTHSPRING MA|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicare|OTHER INSTITUTIONS|99.75||||99.75||| 36600|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|99.75||||99.75||| 36600|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicare|BCBS MEDICARE PPO MA|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicaid|MOLINA HEALTHCARE OF TEXAS|99.75||||||| 36600|EAP|0300||Medicare|MEDICARE ACUTE|99.75||||||| 36600|EAP|0361||Medicaid|COUNTY INDIGENT HEALTH OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicaid|CRIME VICTIMS COMPENSATION|99.75||||||| 36600|EAP|0361||Medicaid|SMITH COUNTY JAIL|99.75||||||| 36600|EAP|0361||Medicaid|MEDICAID|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicaid|COUNTY INDIGENT HEALTH OTHER|99.75||||||| 36600|EAP|0300||Medicaid|MEDICAID|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicaid|MEDICAID HMO|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicaid|SMITH COUNTY INDIGENT HEALTH|99.75||||||| 36600|EAP|0300||Medicaid|COUNTY INDIGENT HEALTH OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|United Healthcare|UNITED HEALTHCARE OTHER|99.75||||99.75||| 36600|EAP|0361||United Healthcare|UNITED HEALTHCARE|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|United Healthcare|UNITED HEALTHCARE|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|United Healthcare|TML GROUP BENEFITS|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|United Healthcare|UNITED HEALTHCARE|99.75||||||| 36600|EAP|0361||Tricare|TRICARE EAST REGION|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|UTMB|UTMB CORRECTIONAL MANAGED CARE|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Tricare|TRICARE EAST REGION|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|PHCS|HUMANA|99.75||||||| 36600|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|NON CONTRACTED|COMMERCIAL OTHER 2|99.75||||||| 36600|EAP|0361||Texas Workforce Commission|DIS DETER SERV (DDS)|||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicaid|LAW ENFORCEMENT OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|NON CONTRACTED|COMMERCIAL OTHER 1|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|PHCS|GROUP AND PENSION|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Rusk State Hospital|RUSK STATE HOSP|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicare|MEDICARE PART B ONLY IP|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicaid|MEDICAID|99.75||||99.75||| 36600|EAP|0361||Medicare|MEDICARE ACUTE|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicare|MEDICARE ACUTE|99.75||||99.75||| 36600|EAP|0361||Medicare|MEDICARE PART B ONLY IP|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Humana Medicare Advantage|HUMANA MA|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Medicaid|SMITH COUNTY JAIL|99.75||||99.75||| 36600|EAP|0300||Humana Medicare Advantage|HUMANA MA|99.75||||||| 36600|EAP|0361||Humana Medicare Advantage|HUMANA MA|99.75||||||| 36600|EAP|0361||Cigna|CIGNA|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Cigna|CIGNA|99.75||||99.75||| 36600|EAP|0361||Managed Medicare|HEALTHSPRING MA|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicare|ETMC AFFILIATE HOSPITALS|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|ChampVA|CHAMPVA CENTER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Cigna|CIGNA OTHER|99.75||||99.75||| 36600|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.75||||99.75||| 36600|EAP|0361||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicare|WELLCARE CHOICE MA|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicaid|MEDICAID SUPERIOR|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicaid|MEDICAID AMERIGROUP|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.75||||99.75||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Aetna|AETNA OTHER|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Aetna|AETNA PPO|99.75||||||| 36600|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Aetna|BOON CHAPMAN|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Aetna|AETNA QHP HMO|99.75||||||| 36600|EAP|0410|ARTERIAL PUNCTURE (ABG A|Aenta Medicare Advantage|AETNA MEDICARE MA|99.75||||99.75||| 36600|EAP|0300||Aetna|AETNA PPO|99.75||||||| 36600|EAP|0361||Aetna|AETNA OTHER|99.75||||||| 368|DRG||MAJOR ESOPHAGEAL DISORDERS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|77,365.82|107.16|19025.895|107.16|||| 368|DRG||MAJOR ESOPHAGEAL DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|65,181.44|11842.475|19025.895|107.16|||| 368|DRG||MAJOR ESOPHAGEAL DISORDERS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|155,397.14|19025.895|19025.895|107.16|||| 368|DRG||MAJOR ESOPHAGEAL DISORDERS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|50,570.62|9776.25|19025.895|107.16|||| 368|DRG||MAJOR ESOPHAGEAL DISORDERS W MCC|Medicare|MEDICARE ACUTE|53,611.12|11701.49|19025.895|107.16|||| 369|DRG||MAJOR ESOPHAGEAL DISORDERS W CC|United Healthcare|UNITED HEALTHCARE OTHER|40,665.55|12582.85|12582.85|7023.36|||| 369|DRG||MAJOR ESOPHAGEAL DISORDERS W CC|Medicare|MEDICARE ACUTE|50,428.60|7238.07|12582.85|7023.36|||| 369|DRG||MAJOR ESOPHAGEAL DISORDERS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|61,921.89|7023.36|12582.85|7023.36|||| 369|DRG||MAJOR ESOPHAGEAL DISORDERS W CC|Humana Medicare Advantage|HUMANA MA|71,423.00|7244.065|12582.85|7023.36|||| 369|DRG||MAJOR ESOPHAGEAL DISORDERS W CC|Blue Cross PPO Specialty|BCBSTX PPO|35,167.52|7528.75|12582.85|7023.36|||| 36901|EAP|0361|IR-INTRO CATH DIALYSIS CI|United Medicare Advantage|UHC AARP MCR HMO MA|||||28.44||| 36901|EAP|0361|IR-INTRO CATH DIALYSIS CI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,986.20||||||| 36901|EAP|0361|IR-INTRO CATH DIALYSIS CI|Humana Medicare Advantage|HUMANA MA|28.44||||||| 36901|EAP|0361|IR-INTRO CATH DIALYSIS CI|Managed Medicare|BCBS MEDICARE PPO MA|28.44||||||| 36901|EAP|0361|IR-INTRO CATH DIALYSIS CI|Medicare|MEDICARE ACUTE|28.44||||2,986.20||| 36901|EAP|0361|IR-INTRO CATH DIALYSIS CI|Medicaid|MEDICAID|||||28.44||| 36902|EAP|0361|IR-INTRO CATH DIALYSIS CI|Multiplan|WEB TPA|||||316.27||| 36902|EAP|0361|IR-INTRO CATH DIALYSIS CI|Medicare|MEDICARE PART B ONLY IP|316.27||||||| 36902|EAP|0361|IR-INTRO CATH DIALYSIS CI|Medicare|MEDICARE ACUTE|33,208.35||||32,417.68||| 36902|EAP|0361|IR-INTRO CATH DIALYSIS CI|Humana Medicare Advantage|HUMANA MA|316.27||||||| 36902|EAP|0361|IR-INTRO CATH DIALYSIS CI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||316.27||| 36905|EAP|0361|IR-THRMBC/NFS DIALYSIS CI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||376.91||| 36905|EAP|0361|ANGIOPLASTY SUBCLAVIAN|Humana Medicare Advantage|HUMANA MA|||||9,774.45||| 36905|EAP|0361|IR-THRMBC/NFS DIALYSIS CI|Managed Medicare|HEALTHSPRING MA|39,575.55||||||| 36905|EAP|0361|IR-THRMBC/NFS DIALYSIS CI|Medicare|MEDICARE ACUTE|39,575.55||||376.91||| 36906|EAP|0361|IR-THRMBC/NFS DIALYSIS CI|Managed Medicare|HEALTHSPRING MA|53,384.10||||||| 36906|EAP|0361|IR-THRMBC/NFS DIALYSIS CI|Medicare|MEDICARE ACUTE|53,384.10||||||| 36907|EAP|0361|IR-BALO ANGIOP CTR DIALYS|Medicare|MEDICARE ACUTE|||||14,371.35||| 36907|EAP|0361|IR-BALO ANGIOP CTR DIALYS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||136.87||| 37|DRG||EXTRACRANIAL PROCEDURES W MCC|Medicare|MEDICARE ACUTE|85,449.11|19453.91|19453.91|10667.71|||| 37|DRG||EXTRACRANIAL PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|138,087.42|19453.91|19453.91|10667.71|||| 37|DRG||EXTRACRANIAL PROCEDURES W MCC|Aetna|AETNA QHP HMO|181,032.74|19081.04|19453.91|10667.71|||| 37|DRG||EXTRACRANIAL PROCEDURES W MCC|Aetna|AETNA PPO|108,653.55|19081.04|19453.91|10667.71|||| 37|DRG||EXTRACRANIAL PROCEDURES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|90,413.56|10667.71|19453.91|10667.71|||| 37|DRG||EXTRACRANIAL PROCEDURES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|48,468.30|19081.04|19453.91|10667.71|||| 370|DRG||MAJOR ESOPHAGEAL DISORDERS W/O CC/MCC|Medicaid|LAW ENFORCEMENT OTHER|30,867.12|3598.82|4916.75|3598.82|||| 370|DRG||MAJOR ESOPHAGEAL DISORDERS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|35,376.35|4916.75|4916.75|3598.82|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|104,576.22|10723.98|11578.225|480.53|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|154,550.16|10949.55|11578.225|480.53|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|Medicare|MEDICARE ACUTE|74,899.66|10751.48|11578.225|480.53|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|Medicaid|MEDICAID|56,897.06|6242.77|11578.225|480.53|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|Managed Medicare|HEALTHSPRING MA|87,435.12|10752.36|11578.225|480.53|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|Managed Medicaid|MEDICAID AMERIGROUP|23,162.45|9926.01|11578.225|480.53|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|Humana Medicare Advantage|HUMANA MA|82,293.77|10747.93|11578.225|480.53|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|146,022.44|480.53|11578.225|480.53|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|68,344.33|11578.225|11578.225|480.53|||| 37182|EAP|0361|IR-INSERT TIPS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||234.94||| 37182|EAP|0361|IR-INSERT TIPS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|234.94||||||| 37182|EAP|0361|IR-INSERT TIPS|Humana Medicare Advantage|HUMANA MA|27,018.10||||||| 37182|EAP|0361|IR-INSERT TIPS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|234.94||||||| 37182|EAP|0361|IR-INSERT TIPS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|234.94||||||| 37182|EAP|0361|IR-INSERT TIPS|Medicare|MEDICARE ACUTE|234.94||||||| 37183|EAP|0361|IR-REVISION TIPS|Medicare|MEDICARE ACUTE|22,956.30||||||| 37183|EAP|0361|IR-REVISION TIPS|Managed Medicare|OTHER INSTITUTIONS|||||199.62||| 37183|EAP|0361|IR-REVISION TIPS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,956.30||||||| 37183|EAP|0361|IR-REVISION TIPS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||199.62||| 37183|EAP|0361|REMOVE HEPATIC SHUNT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||125.57||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|United Medicare Advantage|UHC AARP MCR HMO MA|136.70||||||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|136.70||||||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Managed Medicaid|MEDICAID SUPERIOR|136.70||||||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Blue Cross PPO Specialty|BCBSTX PPO|136.70||||||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Blue Cross HMO Specialty|BCBSTX HMO|||||136.70||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Aenta Medicare Advantage|AETNA MEDICARE MA|136.70||||||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|136.70||||136.70||| 37191|EAP|0481|FILTER PLACEMENT/VENA CAV|Managed Medicare|HEALTHSPRING MA|||||150.03||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Managed Medicare|BCBS MEDICARE PPO MA|||||136.70||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Managed Medicare|HEALTHSPRING MA|136.70||||136.70||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Humana Medicare Advantage|HUMANA MA|136.70||||||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|United Healthcare|UNITED HEALTHCARE OTHER|136.70||||||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||9,829.50||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Medicare|MEDICARE ACUTE|136.70||||11,749.75||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|Managed Medicaid|MEDICAID UNITED HEALTHCARE|136.70||||||| 37191|EAP|0361|IR-IVC FILTER PLACE/IVC F|United Medicare Advantage|UHC MEDICARE GOLD MA|136.70||||||| 37193|EAP|0361|IR-REMOVAL OF IVC FILTER|Medicare|MEDICARE ACUTE|||||37.03||| 37193|EAP|0361|IR-REMOVAL OF IVC FILTER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,888.15||| 37193|EAP|0361|IR-REMOVAL OF IVC FILTER|Blue Cross HMO Specialty|BCBSTX HMO|||||37.03||| 37193|EAP|0361|IR-REMOVAL OF IVC FILTER|Humana Medicare Advantage|HUMANA MA|||||37.03||| 37193|EAP|0361|IR-REMOVAL OF IVC FILTER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||37.03||| 37193|EAP|0361|IR-REMOVAL OF IVC FILTER|Workers Compensation|WORKERS COMPENSATION OTHER|||||37.03||| 37193|EAP|0361|IR-REMOVAL OF IVC FILTER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||37.03||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|United Medicare Advantage|UHC MEDICARE GOLD MA|738.15||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|United Medicare Advantage|UHC AARP MCR HMO MA|738.15||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Veterans Affairs|VETERANS ADMINISTRATION|738.15||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.03||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.03||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.03||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Humana Medicare Advantage|HUMANA MA|720.58||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Aenta Medicare Advantage|AETNA MEDICARE MA|738.15||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|720.58||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Managed Medicare|HEALTHSPRING MA|7.03||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Blue Cross HMO Specialty|BCBSTX HMO|738.15||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Tricare|TRICARE EAST REGION|738.15||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|United Healthcare|UNITED HEALTHCARE OTHER|738.15||||||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|United Healthcare|UNITED HEALTHCARE|738.15||||7.03||| 37195|EAP|0450|THROMBOLYSIS CEREBRAL IV|Medicare|MEDICARE ACUTE|7.03||||738.15||| 37197|EAP|0361|IR-FOREIGN BODY/INTRAVASC|Medicare|MEDICARE ACUTE|61.95||||||| 37197|EAP|0361|IR-TRNSCATH RET FB|Blue Cross PPO Specialty|BCBSTX PPO|||||76.42||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|110,656.26|8895.58|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|33,722.11|7010.59|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Cigna|CIGNA|99,895.10|10521.52|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Cigna|CIGNA|58,845.93|10521.52|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Humana Medicare Advantage|HUMANA MA|59,487.31|6892.22|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|128,599.83|17699.835|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Managed Medicaid|MEDICAID SUPERIOR|119,064.67|9926.01|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49,818.19|153.09|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Blue Cross PPO Specialty|BCBSTX PPO|93,402.91|7050.74|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Medicare|MEDICARE ACUTE|58,103.75|7010.59|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|72,502.96|7010.59|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|48,843.42|6890.31|17699.835|153.09|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Cigna|CIGNA OTHER|99,559.80|10521.52|17699.835|153.09|||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|Managed Medicare|HEALTHSPRING MA|76.04||||||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|76.04||||||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|76.04||||||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|Aenta Medicare Advantage|AETNA MEDICARE MA|76.04||||||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|Humana Medicare Advantage|HUMANA MA|76.04||||76.04||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||76.04||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||76.04||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|United Medicare Advantage|UHC MEDICARE GOLD MA|76.04||||76.04||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|Medicare|MEDICARE ACUTE|76.04||||76.04||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|NON CONTRACTED|COMMERCIAL OTHER 1|76.04||||||| 37200|EAP|0361|IR-TRANSCATHETER BIOPSY|Blue Cross PPO Specialty|BCBSTX OTHER|||||76.04||| 37211|EAP|0361|IR-INFUSION THROMBOLYSIS|Medicaid|SMITH COUNTY INDIGENT HEALTH|71.98||||||| 37211|EAP|0361|IR-INFUSION THROMBOLYSIS|Managed Medicare|HEALTHSPRING MA|71.98||||||| 37211|EAP|0361|IR-INFUSION THROMBOLYSIS|Medicare|MEDICARE ACUTE|71.98||||||| 37213|EAP|0361|IR-INFUSION-CATH FOLLOW U|Medicare|MEDICARE ACUTE|45.04||||||| 37214|EAP|0361|IR-EXCH PREV ART CATH|Medicare|MEDICARE ACUTE|152.70||||||| 37215|EAP|0361|IR-PLCMNT STENT CAROTID W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|238.38||||||| 37215|EAP|0361|IR-PLCMNT STENT CAROTID W|United Medicare Advantage|UHC AARP MCR HMO MA|238.38||||||| 37215|EAP|0481|PLCMNT STENT CAROTID W EM|Humana Medicare Advantage|HUMANA MA|238.38||||||| 37215|EAP|0361|IR-PLCMNT STENT CAROTID W|Humana Medicare Advantage|HUMANA MA|238.38||||||| 37215|EAP|0361|IR-PLCMNT STENT CAROTID W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|238.38||||||| 37215|EAP|0481|PLCMNT STENT CAROTID W EM|Blue Cross PPO Specialty|BCBSTX PPO|||||238.38||| 37215|EAP|0361|IR-PLCMNT STENT CAROTID W|Blue Cross PPO Specialty|BCBSTX PPO|238.38||||||| 37215|EAP|0481|PLCMNT STENT CAROTID W EM|Managed Medicare|HEALTHSPRING MA|238.38||||||| 37215|EAP|0361|IR-PLCMNT STENT CAROTID W|Medicare|MEDICARE ACUTE|238.38||||||| 37215|EAP|0481|PLCMNT STENT CAROTID W EM|Medicare|MEDICARE ACUTE|238.38||||||| 37216|EAP|0361|IR-PLCMNT STENT CAROTID W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|223.10||||||| 37216|EAP|0361|IR-PLCMNT STENT CAROTID W|Blue Cross PPO Specialty|BCBSTX PPO|223.10||||||| 37220|EAP|0481|PTA ILIAC INITIAL|Medicare|MEDICARE ACUTE|||||181.52||| 37220|EAP|0481|PTA ILIAC INITIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||181.52||| 37220|EAP|0481|PTA ILIAC INITIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||19,059.60||| 37220|EAP|0481|PTA ILIAC INITIAL|Humana Medicare Advantage|HUMANA MA|||||181.52||| 37220|EAP|0481|PTA ILIAC INITIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||181.52||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Aetna|AETNA PPO|||||11,072.05||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Blue Cross PPO Specialty|BCBSTX PPO|||||108.02||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Managed Medicaid|MEDICAID AMERIGROUP|||||108.02||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||11,342.10||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11,342.10||||||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Humana Medicare Advantage|HUMANA MA|||||108.02||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||108.02||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|United Medicare Advantage|UHC AARP MCR HMO MA|||||11,342.10||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11,342.10||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||108.02||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||108.02||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Managed Medicare|HEALTHSPRING MA|||||108.02||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|United Healthcare|UNITED HEALTHCARE|||||108.02||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Medicare|MEDICARE ACUTE|||||108.02||| 37221|EAP|0481|PTA ILIAC INITIAL W/STENT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11,342.10||| 37223|EAP|0481|PTA ILIAC EA ADDL W/STENT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13,027.35||| 37223|EAP|0481|PTA ILIAC EA ADDL W/STENT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||13,027.35||| 37223|EAP|0481|PTA ILIAC EA ADDL W/STENT|Aetna|AETNA PPO|||||124.07||| 37224|EAP|0481|PTA FEM/POP|Medicare|MEDICARE ACUTE|||||20,754.30||| 37224|EAP|0481|PTA FEM/POP|Managed Medicare|HEALTHSPRING MA|||||20,754.30||| 37224|EAP|0481|PTA FEM/POP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||197.66||| 37224|EAP|0481|PTA FEM/POP|Humana Medicare Advantage|HUMANA MA|||||197.66||| 37224|EAP|0481|PTA FEM/POP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|197.66||||20,754.30||| 37224|EAP|0481|PTA FEM/POP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||20,754.30||| 37224|EAP|0481|PTA FEM/POP|United Medicare Advantage|UHC AARP MCR HMO MA|||||20,754.30||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|Access Direct Platinum|HEALTHFIRST TPA UMR|33,352.20||||||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|United Medicare Advantage|UHC AARP MCR HMO MA|||||33,352.20||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||317.64||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|Veterans Affairs|VETERANS ADMINISTRATION|||||33,352.20||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||33,352.20||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|Aetna|AETNA PPO|||||33,352.20||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||317.64||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||33,352.20||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|Humana Medicare Advantage|HUMANA MA|||||317.64||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||317.64||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|Managed Medicare|HEALTHSPRING MA|33,352.20||||317.64||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|United Healthcare|UNITED HEALTHCARE OTHER|||||33,352.20||| 37225|EAP|0981|REVSC OPN/PRG FEM/POP W/A|Medicare|MEDICARE ACUTE|||||31.30||| 37225|EAP|0481|PTA FEM/POP W/ARTHCTMY|Medicare|MEDICARE ACUTE|33,352.20||||33,352.20||| 37226|EAP|0481|PTA FEM/POP W/STENT|NON CONTRACTED|COMMERCIAL OTHER 1|||||12,665.10||| 37226|EAP|0481|PTA FEM/POP W/STENT|Medicare|MEDICARE ACUTE|||||120.62||| 37226|EAP|0481|PTA FEM/POP W/STENT|United Healthcare|UNITED HEALTHCARE OTHER|||||12,665.10||| 37226|EAP|0481|PTA FEM/POP W/STENT|Managed Medicare|HEALTHSPRING MA|||||12,665.10||| 37226|EAP|0481|PTA FEM/POP W/STENT|Humana Medicare Advantage|HUMANA MA|||||120.62||| 37226|EAP|0481|PTA FEM/POP W/STENT|Aetna|AETNA PPO|||||120.62||| 37226|EAP|0481|PTA FEM/POP W/STENT|United Medicare Advantage|UHC AARP MCR HMO MA|||||12,665.10||| 37226|EAP|0481|PTA FEM/POP W/STENT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12,363.55||| 37227|EAP|0481|PTA FEM/POP W/ATHRCTMY W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||344.64||| 37227|EAP|0481|PTA FEM/POP W/ATHRCTMY W/|United Medicare Advantage|UHC AARP MCR HMO MA|||||36,187.20||| 37227|EAP|0481|PTA FEM/POP W/ATHRCTMY W/|Aenta Medicare Advantage|AETNA MEDICARE MA|||||35,325.60||| 37227|EAP|0481|PTA FEM/POP W/ATHRCTMY W/|Humana Medicare Advantage|HUMANA MA|||||35,325.60||| 37227|EAP|0481|PTA FEM/POP W/ATHRCTMY W/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||344.64||| 37227|EAP|0481|PTA FEM/POP W/ATHRCTMY W/|Managed Medicare|HEALTHSPRING MA|||||344.64||| 37227|EAP|0481|PTA FEM/POP W/ATHRCTMY W/|Medicare|MEDICARE ACUTE|||||344.64||| 37228|EAP|0481|PTA TIB/PER INITIAL|Medicare|MEDICARE ACUTE|||||21,827.38||| 37228|EAP|0481|PTA TIB/PER INITIAL|Humana Medicare Advantage|HUMANA MA|||||212.95||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|Access Direct Platinum|HEALTHFIRST TPA UMR|21,912.45||||||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|United Medicare Advantage|UHC AARP MCR HMO MA|||||21,912.45||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21,912.45||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|Blue Cross PPO Specialty|BCBSTX OTHER|21,912.45||||||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||208.69||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|Humana Medicare Advantage|HUMANA MA|||||208.69||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|Managed Medicare|HEALTHSPRING MA|||||21,912.45||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|United Healthcare|UNITED HEALTHCARE|||||208.69||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|United Healthcare|UNITED HEALTHCARE OTHER|||||21,912.45||| 37229|EAP|0481|PTA TIB/PER W/ARTHCTMY IN|Medicare|MEDICARE ACUTE|||||208.69||| 37231|EAP|0481|PTA TIB/PER W/ATHRCTMY W/|Medicare|MEDICARE ACUTE|||||344.64||| 37233|EAP|0481|PTA TIB/PER W/ATHRCTMY EA|Blue Cross PPO Specialty|BCBSTX OTHER|21,912.45||||||| 37233|EAP|0481|PTA TIB/PER W/ATHRCTMY EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21,912.45||| 37236|EAP|0481|S&I INTRO INTRAVASE STENT|Medicaid|MEDICAID|||||22,100.40||| 37236|EAP|0481|S&I INTRO INTRAVASE STENT|Managed Medicare|HEALTHSPRING MA|||||210.48||| 37236|EAP|0481|S&I INTRO INTRAVASE STENT|United Healthcare|UNITED HEALTHCARE|||||210.48||| 37236|EAP|0481|S&I INTRO INTRAVASE STENT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||210.48||| 37236|EAP|0481|S&I INTRO INTRAVASE STENT|Cigna|CIGNA|210.48||||||| 37236|EAP|0481|S&I INTRO INTRAVASE STENT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||22,100.40||| 37236|EAP|0481|S&I INTRO INTRAVASE STENT|Humana Medicare Advantage|HUMANA MA|||||210.48||| 37238|EAP|0361|IR-OPEN/PERQ PLACE STENT|Blue Cross PPO Specialty|BCBSTX PPO|||||261.55||| 37238|EAP|0361|IR-OPEN/PERQ PLACE STENT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||27,462.75||| 37238|EAP|0361|IR-OPEN/PERQ PLACE STENT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||261.55||| 37238|EAP|0361|IR-OPEN/PERQ PLACE STENT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||26,808.88||| 37238|EAP|0361|IR-OPEN/PERQ PLACE STENT|United Healthcare|UNITED HEALTHCARE|||||27,462.75||| 37241|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|382.01||||||| 37241|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|382.01||||||| 37242|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||382.01||| 37242|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|United Medicare Advantage|UHC AARP MCR HMO MA|||||382.01||| 37242|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Blue Cross PPO Specialty|BCBSTX PPO|382.01||||382.01||| 37242|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||382.01||| 37242|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Veterans Affairs|VETERANS ADMINISTRATION|||||382.01||| 37242|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Medicare|MEDICARE ACUTE|382.01||||382.01||| 37242|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Medicaid|MEDICAID|382.01||||||| 37242|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Managed Medicare|HEALTHSPRING MA|||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Medicaid|MEDICAID|||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Managed Medicare|HEALTHSPRING MA|||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Rusk State Hospital|RUSK STATE HOSP|||||382.01||| 37243|EAP|0361|IR-VASCULAR EMBOLIZE/OCCU|Medicare|MEDICARE ACUTE|382.01||||303.09||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Medicare|MEDICARE ACUTE|382.01||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Blue Cross PPO Specialty|BCBSTX PPO|382.01||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|United Medicare Advantage|UHC AARP MCR HMO MA|||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|United Medicare Advantage|UHC MEDICARE GOLD MA|382.01||||382.01||| 37243|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||382.01||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Medicare|MEDICARE ACUTE|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Blue Cross HMO Specialty|BCBSTX HMO|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Blue Cross PPO Specialty|BCBSTX PPO|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|United Healthcare|TML GROUP BENEFITS|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|United Healthcare|UNITED HEALTHCARE OTHER|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Medicaid|CRIME VICTIMS COMPENSATION|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Managed Medicare|HEALTHSPRING MA|382.01||||||| 37244|EAP|0361|IR-VASC EMBOLIZE/OCCLUDE|Managed Medicare|BCBS MEDICARE PPO MA|382.01||||||| 37246|EAP|0481|PTA RENAL/VISCERAL|Cigna|CIGNA|127.69||||||| 37246|EAP|0361|IR-TRLUML BALO ANGIOP 1ST|Medicare|MEDICARE ACUTE|||||66.45||| 37246|EAP|0323|CATH PLACEMENT PTA VENOUS|Medicare|MEDICARE ACUTE|||||10,018.80||| 37246|EAP|0361|IR-TRLUML BALO ANGIOP 1ST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||66.45||| 37246|EAP|0323|CATH PLACEMENT PTA VENOUS|Managed Medicare|HEALTHSPRING MA|||||10,018.80||| 37250|EAP|0361|CATH PLCMT IVUS PERIPHERA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,190.75||| 37253|EAP|0361|INTRVASC US NONCORONARY A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,190.75||| 373|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|57,678.25|8779.94|8779.94|142.88|||| 373|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC|Medicare|MEDICARE ACUTE|39,488.25|5353.59|8779.94|142.88|||| 373|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC|Medicaid|CRIME VICTIMS COMPENSATION|47,898.75|4472.88|8779.94|142.88|||| 373|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26,080.15|142.88|8779.94|142.88|||| 373|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|93,351.80|7111.88|8779.94|142.88|||| 374|DRG||DIGESTIVE MALIGNANCY W MCC|Access Direct Platinum|HEALTHFIRST TPA|104,441.06|15692.88|15887.34|42.51|||| 374|DRG||DIGESTIVE MALIGNANCY W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|233,371.20|15887.34|15887.34|42.51|||| 374|DRG||DIGESTIVE MALIGNANCY W MCC|Humana Medicare Advantage|HUMANA MA|227.25|42.51|15887.34|42.51|||| 374|DRG||DIGESTIVE MALIGNANCY W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44,193.68|14545.91|15887.34|42.51|||| 374|DRG||DIGESTIVE MALIGNANCY W MCC|Blue Cross PPO Specialty|BCBSTX PPO|124,130.14|14021.35|15887.34|42.51|||| 374|DRG||DIGESTIVE MALIGNANCY W MCC|Medicare|MEDICARE ACUTE|74,850.07|12230.4|15887.34|42.51|||| 374|DRG||DIGESTIVE MALIGNANCY W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|140,614.79|12216.76|15887.34|42.51|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|United Healthcare|TML GROUP BENEFITS|26,998.76|14289.6|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|63,541.64|7407.44|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Medicaid|MEDICAID|82,265.55|6246.13|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Medicare|MEDICARE PART B ONLY IP|14,417.15|454.5|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Blue Cross HMO Specialty|BCBSTX HMO|37,281.72|4144.89|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|206,119.05|357.2|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Blue Cross PPO Specialty|BCBSTX PPO|35,685.26|71.44|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Medicare|MEDICARE ACUTE|67,776.72|7907.94|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Managed Medicare|HEALTHSPRING MA|42,650.05|7880.66|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|114,879.05|14545.91|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18,736.80|5074.15|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Humana Medicare Advantage|HUMANA MA|55,871.80|8046.04|14545.91|71.44|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|72,549.92|10990.8|14545.91|71.44|||| 376|DRG||DIGESTIVE MALIGNANCY W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|47,280.55|6750.27|6750.27|6217.6|||| 376|DRG||DIGESTIVE MALIGNANCY W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|32,135.64|6217.6|6750.27|6217.6|||| 377|DRG||G.I. HEMORRHAGE W MCC|Medicare|MEDICARE ACUTE|737.66|10995.12|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Medicaid|MEDICAID|53,226.10|3742.15|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|4,961.75|4961.75|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|106,715.07|8493.495|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|75,788.07|10985.94|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|91,083.90|109.96|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Veterans Affairs|VETERANS ADMINISTRATION|72,010.27|11096.725|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|37,027.88|14106.14|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|177,513.69|15693.56|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Blue Cross HMO Specialty|BCBSTX HMO|106,190.25|9589.83|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|66,925.62|12145.95|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Managed Medicare|HEALTHSPRING MA|58,369.06|10554.585|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|69,324.97|13275.625|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,857.95|20804.7|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|605,303.04|32204.66|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Managed Medicare|BCBS MEDICARE PPO MA|166,659.32|11198.33|32204.66|109.96|||| 377|DRG||G.I. HEMORRHAGE W MCC|Humana Medicare Advantage|HUMANA MA|84,633.37|10999.66|32204.66|109.96|||| 378|DRG||G.I. HEMORRHAGE W CC|Humana Medicare Advantage|HUMANA MA|52,325.25|6703.46|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|47,156.45|6767.77|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|14,907.30|6817.84|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Managed Medicare|BCBS MEDICARE PPO MA|35,853.85|6823.81|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Managed Medicare|HEALTHSPRING MA|60,617.65|6817.84|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Blue Cross PPO Specialty|BCBSTX PPO|37,074.37|6724.14|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|47,294.06|71.44|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Blue Cross HMO Specialty|BCBSTX HMO|32,144.62|5428.83|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|64,499.05|6677.84|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|240.06|8655.76|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Access Direct Platinum|HEALTHFIRST TPA|80,687.57|14474.01|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Veterans Affairs|VETERANS ADMINISTRATION|40,073.38|6705.56|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|28,021.35|5716.01|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|53,939.38|6767.77|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|United Healthcare|UNITED HEALTHCARE OTHER|44,630.50|11695.15|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|137,248.81|6800.97|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|55,938.41|6677.84|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|56,903.71|6817.84|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Tricare|TRICARE EAST REGION|76,022.75|4992.08|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Medicaid|MEDICAID|45,654.77|4256.46|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Medicare|MEDICARE PART B ONLY IP|22,730.75|1686.145|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Medicaid|COUNTY INDIGENT HEALTH OTHER|41,294.25|6050.22|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|Medicare|MEDICARE ACUTE|45,222.11|67.06|14474.01|67.06|||| 378|DRG||G.I. HEMORRHAGE W CC|United Medicare Advantage|UHC AARP MCR HMO MA|37,338.06|6747.84|14474.01|67.06|||| 379|DRG||G.I. HEMORRHAGE W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|353.88|7642.51|7642.51|4435.23|||| 379|DRG||G.I. HEMORRHAGE W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|35,149.35|4788.36|7642.51|4435.23|||| 379|DRG||G.I. HEMORRHAGE W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|313.50|4907.15|7642.51|4435.23|||| 379|DRG||G.I. HEMORRHAGE W/O CC/MCC|Aetna|AETNA PPO|35,161.46|7351.29|7642.51|4435.23|||| 379|DRG||G.I. HEMORRHAGE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|13,926.97|4435.23|7642.51|4435.23|||| 379|DRG||G.I. HEMORRHAGE W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|17,807.26|4899.34|7642.51|4435.23|||| 379|DRG||G.I. HEMORRHAGE W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|51,115.40|4899.34|7642.51|4435.23|||| 379|DRG||G.I. HEMORRHAGE W/O CC/MCC|Medicare|MEDICARE ACUTE|27,045.57|4827.14|7642.51|4435.23|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|50,724.77|10571.58|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|39,236.67|15448.46|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Cigna|CIGNA OTHER|74,446.03|17237.81|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|46,086.97|10460.86|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|44,410.27|11350.84|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|85,103.53|119.07|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|43,270.79|10557.94|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|48,280.11|10455.17|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46,334.39|10474.17|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|78,070.95|10667.71|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE|49,853.95|19827.67|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Medicaid|MEDICAID|39,125.92|9716.01|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Medicaid|SMITH COUNTY INDIGENT HEALTH|85,163.42|16160.14|19827.67|119.07|||| 38|DRG||EXTRACRANIAL PROCEDURES W CC|Medicare|MEDICARE ACUTE|46,013.48|10476.33|19827.67|119.07|||| 380|DRG||COMPLICATED PEPTIC ULCER W MCC|Medicare|MEDICARE ACUTE|288,000.23|18265.085|18265.085|250.04|||| 380|DRG||COMPLICATED PEPTIC ULCER W MCC|Veterans Affairs|VETERANS ADMINISTRATION|88,190.32|11735.75|18265.085|250.04|||| 380|DRG||COMPLICATED PEPTIC ULCER W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|88,007.85|250.04|18265.085|250.04|||| 380|DRG||COMPLICATED PEPTIC ULCER W MCC|Humana Medicare Advantage|HUMANA MA|82,534.91|11617.17|18265.085|250.04|||| 380|DRG||COMPLICATED PEPTIC ULCER W MCC|Managed Medicaid|MEDICAID AMERIGROUP|159,850.47|10039.17|18265.085|250.04|||| 381|DRG||COMPLICATED PEPTIC ULCER W CC|Managed Medicare|HEALTHSPRING MA|114,879.90|7192.19|13892.66|238.14|||| 381|DRG||COMPLICATED PEPTIC ULCER W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|81,621.37|5713.47|13892.66|238.14|||| 381|DRG||COMPLICATED PEPTIC ULCER W CC|Blue Cross PPO Specialty|BCBSTX PPO|86,524.34|7096.05|13892.66|238.14|||| 381|DRG||COMPLICATED PEPTIC ULCER W CC|Aetna|AETNA OTHER|73,952.69|13892.66|13892.66|238.14|||| 381|DRG||COMPLICATED PEPTIC ULCER W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|74,955.15|238.14|13892.66|238.14|||| 381|DRG||COMPLICATED PEPTIC ULCER W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|49,763.50|7164.03|13892.66|238.14|||| 381|DRG||COMPLICATED PEPTIC ULCER W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|57,915.64|7253.23|13892.66|238.14|||| 381|DRG||COMPLICATED PEPTIC ULCER W CC|Medicare|MEDICARE ACUTE|76,967.43|7314.27|13892.66|238.14|||| 382|DRG||COMPLICATED PEPTIC ULCER W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|25,119.73|5715.72|5715.72|5715.72|||| 382|DRG||COMPLICATED PEPTIC ULCER W/O CC/MCC|Medicare|MEDICARE ACUTE|65,801.24|5715.72|5715.72|5715.72|||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Veterans Affairs|VETERANS ADMINISTRATION|4,813.90||||41.86||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|41.86||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,813.90||||4,499.95||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,813.90||||41.86||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Aenta Medicare Advantage|AETNA MEDICARE MA|41.86||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Blue Cross PPO Specialty|BCBSTX PPO|4,813.90||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Blue Cross HMO Specialty|BCBSTX HMO|4,499.95||||41.86||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,813.90||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,813.90||||41.86||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Humana Medicare Advantage|HUMANA MA|4,499.95||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|United Medicare Advantage|UHC AARP MCR HMO MA|||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Cigna|CIGNA|4,499.95||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|ChampVA|CHAMPVA CENTER|4,813.90||||||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||41.86||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Medicare|MEDICARE ACUTE|4,813.90||||41.86||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Medicare|UTSW MC KIDNEY PROGRAM|||||41.86||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|PHCS|HUMANA INSURANCE|4,813.90||||||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|NON CONTRACTED|COMMERCIAL OTHER 1|||||41.86||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Tricare|TRICARE EAST REGION|4,813.90||||||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|United Healthcare|UNITED HEALTHCARE OTHER|4,813.90||||||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|United Healthcare|UNITED HEALTHCARE|||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|41.86||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Managed Medicare|HEALTHSPRING MA|41.86||||41.86||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Medicaid|MEDICAID|41.86||||4,813.90||| 38222|EAP|0920|CT-DX BONE MARROW BX & AS|Medicaid|COUNTY INDIGENT HEALTH OTHER|4,813.90||||||| 383|DRG||UNCOMPLICATED PEPTIC ULCER W MCC|Managed Medicare|HEALTHSPRING MA|116,040.17|8712.79|8712.79|8712.79|||| 384|DRG||UNCOMPLICATED PEPTIC ULCER W/O MCC|Medicare|MEDICARE ACUTE|39,022.13|6058.61|6157.24|1617.54|||| 384|DRG||UNCOMPLICATED PEPTIC ULCER W/O MCC|Medicare|MEDICARE PART B ONLY IP|36,418.67|1617.54|6157.24|1617.54|||| 384|DRG||UNCOMPLICATED PEPTIC ULCER W/O MCC|Managed Medicare|HEALTHSPRING MA|73,732.37|6157.24|6157.24|1617.54|||| 385|DRG||INFLAMMATORY BOWEL DISEASE W MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|34,806.93|12993.48|12993.48|6305.99|||| 385|DRG||INFLAMMATORY BOWEL DISEASE W MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|399,024.91|6305.99|12993.48|6305.99|||| 385|DRG||INFLAMMATORY BOWEL DISEASE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|35,626.67|11528.74|12993.48|6305.99|||| 385|DRG||INFLAMMATORY BOWEL DISEASE W MCC|Medicare|MEDICARE ACUTE|72,571.18|10105.71|12993.48|6305.99|||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|United Healthcare|UNITED HEALTHCARE|||||22.86||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|United Healthcare|UNITED HEALTHCARE|||||2,628.90||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|United Healthcare|UNITED HEALTHCARE OTHER|||||25.66||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Tricare|TRICARE EAST REGION|2,950.90||||2,607.05||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||25.66||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|NON CONTRACTED|COMMERCIAL OTHER 1|||||22.86||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Medicare|MEDICARE ACUTE|2,950.90||||2,607.05||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|Medicare|MEDICARE ACUTE|2,950.90||||25.66||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|Medicaid|MEDICAID|2,950.90||||||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|Managed Medicare|HEALTHSPRING MA|||||2,628.90||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Managed Medicare|HEALTHSPRING MA|||||2,607.05||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|Managed Medicare|BCBS MEDICARE PPO MA|||||2,950.90||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Humana Medicare Advantage|HUMANA MA|25.66||||2,607.05||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|Humana Medicare Advantage|HUMANA MA|25.66||||25.66||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,950.90||||2,628.90||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Managed Medicaid|MEDICAID SUPERIOR|||||2,607.05||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|Humana Medicare Advantage|HUMANA MA|25.66||||2,457.45||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.66||||2,607.05||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Aetna|AETNA PPO|||||2,437.03||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Aenta Medicare Advantage|AETNA MEDICARE MA|||||22.67||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,950.90||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,950.90||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,437.03||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,628.90||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Blue Cross PPO Specialty|BCBSTX PPO|||||2,437.03||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|Medicare|MEDICARE ACUTE|2,950.90||||2,628.90||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|Blue Cross PPO Specialty|BCBSTX PPO|||||22.86||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|Blue Cross PPO Specialty|BCBSTX PPO|||||2,758.45||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|Blue Cross HMO Specialty|BCBSTX HMO|||||2,628.90||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||22.86||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,950.90||||||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,437.03||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,628.90||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,758.45||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22.67||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22.86||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,607.05||| 38505|EAP|0361|CT-BX LYMPH NODE(S) NDLE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,950.90||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,628.90||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Access Direct Platinum|HEALTHFIRST TPA|||||22.67||| 38505|EAP|0361|BC BX/EXC LYMPH NODE(S) N|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||22.67||| 38505|EAP|0361|US NEEDLE BIOPSY LYMPH NO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||22.86||| 386|DRG||INFLAMMATORY BOWEL DISEASE W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|31,599.25|8635.54|25111.9|6654.88|||| 386|DRG||INFLAMMATORY BOWEL DISEASE W CC|Blue Cross PPO Specialty|BCBSTX PPO|71,623.11|6654.88|25111.9|6654.88|||| 386|DRG||INFLAMMATORY BOWEL DISEASE W CC|Managed Medicaid|MEDICAID SUPERIOR|54,359.95|7194.41|25111.9|6654.88|||| 386|DRG||INFLAMMATORY BOWEL DISEASE W CC|Medicare|MEDICARE ACUTE|44,208.15|6689.19|25111.9|6654.88|||| 386|DRG||INFLAMMATORY BOWEL DISEASE W CC|Multiplan|NALC|339.35|25111.9|25111.9|6654.88|||| 386|DRG||INFLAMMATORY BOWEL DISEASE W CC|NON CONTRACTED|COMMERCIAL OTHER 1|80,690.75|16748.4|25111.9|6654.88|||| 386|DRG||INFLAMMATORY BOWEL DISEASE W CC|United Healthcare|UNITED HEALTHCARE OTHER|54,655.05|11660.83|25111.9|6654.88|||| 387|DRG||INFLAMMATORY BOWEL DISEASE W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|22,194.90|8293.49|8293.49|35.72|||| 387|DRG||INFLAMMATORY BOWEL DISEASE W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11,399.25|35.72|8293.49|35.72|||| 387|DRG||INFLAMMATORY BOWEL DISEASE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|51,612.64|4730.59|8293.49|35.72|||| 387|DRG||INFLAMMATORY BOWEL DISEASE W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38,177.50|6624.23|8293.49|35.72|||| 387|DRG||INFLAMMATORY BOWEL DISEASE W/O CC/MCC|Medicare|MEDICARE ACUTE|22,025.08|5116.15|8293.49|35.72|||| 387|DRG||INFLAMMATORY BOWEL DISEASE W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|19,053.85|711.46|8293.49|35.72|||| 387|DRG||INFLAMMATORY BOWEL DISEASE W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|16,265.75|8293.49|8293.49|35.72|||| 387|DRG||INFLAMMATORY BOWEL DISEASE W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41,176.93|6156.115|8293.49|35.72|||| 387|DRG||INFLAMMATORY BOWEL DISEASE W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|42,643.80|8293.49|8293.49|35.72|||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|United Medicare Advantage|UHC AARP MCR HMO MA|761.37||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|761.37||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|761.37||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Managed Medicaid|MEDICAID AMERIGROUP|||||7.19||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Humana Medicare Advantage|HUMANA MA|7.19||||740.19||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||740.19||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Blue Cross PPO Specialty|BCBSTX PPO|||||7.19||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Blue Cross HMO Specialty|BCBSTX HMO|||||740.19||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||740.19||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Aetna|AETNA PPO|||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.19||||761.37||| 38792|EAP|0340|NM RA TRACER ID OF SENTIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,167.27||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Managed Medicare|BCBS MEDICARE PPO MA|||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|United Medicare Advantage|UHC MEDICARE GOLD MA|7.19||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Managed Medicare|HEALTHSPRING MA|||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Medicaid|MEDICAID|||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|PHCS|GROUP AND PENSION|||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|NON CONTRACTED|COMMERCIAL OTHER 1|||||740.19||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Medicare|MEDICARE ACUTE|7.19||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Medicare|MEDICARE PART B ONLY IP|740.19||||||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|Tricare|TRICARE EAST REGION|||||7.19||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|United Healthcare|UNITED HEALTHCARE|||||761.37||| 38792|EAP|0361|BC INJ ID SENTINEL NODE|United Healthcare|UNITED HEALTHCARE OTHER|||||7.19||| 388|DRG||G.I. OBSTRUCTION W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.11|100.04|12438.54|100.04|||| 388|DRG||G.I. OBSTRUCTION W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|77,907.14|9630.16|12438.54|100.04|||| 388|DRG||G.I. OBSTRUCTION W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|84,201.88|9658.32|12438.54|100.04|||| 388|DRG||G.I. OBSTRUCTION W MCC|Medicare|MEDICARE ACUTE|61,850.44|9651.83|12438.54|100.04|||| 388|DRG||G.I. OBSTRUCTION W MCC|Medicaid|MEDICAID|51,801.25|4035.85|12438.54|100.04|||| 388|DRG||G.I. OBSTRUCTION W MCC|Humana Medicare Advantage|HUMANA MA|65,044.85|9835.295|12438.54|100.04|||| 388|DRG||G.I. OBSTRUCTION W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46,252.45|12438.54|12438.54|100.04|||| 388|DRG||G.I. OBSTRUCTION W MCC|Veterans Affairs|VETERANS ADMINISTRATION|91,119.95|9725.62|12438.54|100.04|||| 389|DRG||G.I. OBSTRUCTION W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|43,551.60|7645.57|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|49,113.85|7621.17|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Blue Cross HMO Specialty|BCBSTX HMO|38,234.55|4866.95|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38,860.32|5869.57|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Blue Cross PPO Specialty|BCBSTX PPO|28,974.25|5725.33|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|37,514.67|5725.33|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Managed Medicare|HEALTHSPRING MA|31,683.05|5891.69|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46,546.37|9174.56|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Humana Medicare Advantage|HUMANA MA|51,314.80|5986.35|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Medicare|MEDICARE ACUTE|39,364.24|5891.25|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Medicare|MEDICARE PART B ONLY IP|12,803.75|210.2|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|Tricare|TRICARE EAST REGION|22,553.40|3759.03|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|United Healthcare|UNITED HEALTHCARE OTHER|74,530.53|9938.69|9938.69|210.2|||| 389|DRG||G.I. OBSTRUCTION W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|56,768.75|5863.53|9938.69|210.2|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|43,661.67|7620.21|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53,956.05|7477.27|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|37,583.21|10511.98|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|41,867.56|7620.21|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|36,201.41|7620.21|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|39,897.30|34.02|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45,279.66|35.72|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|43,003.30|7491.79|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|37,398.88|9926.1|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|51,405.05|7541.92|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|39,727.13|76.89|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|44,859.75|7491.79|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39,773.29|11878.21|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47,200.57|11878.21|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Cigna|CIGNA|45,489.30|13988.39|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Medicaid|SMITH COUNTY INDIGENT HEALTH|117,155.55|9753.27|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|48,448.49|13390.07|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|143,392.67|7445.02|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|43,579.53|7620.21|13988.39|34.02|||| 39|DRG||EXTRACRANIAL PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|42,017.35|7491.79|13988.39|34.02|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|49,318.45|4012.89|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|47,938.80|5807.86|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|18,092.80|5807.86|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|45,526.88|4449.9|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Aetna|AETNA OTHER|27,128.80|7331.94|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|39,011.73|105.46|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|46,853.87|4535.98|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.02|5954.64|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32,554.05|5005.94|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Medicare|MEDICARE ACUTE|316.69|4464.42|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|37,379.75|37379.75|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Tricare|TRICARE EAST REGION|11,513.65|2761.07|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|31,242.30|6860.15|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|40,593.10|4528.98|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|35,275.30|4448.36|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33,638.40|4464.42|37379.75|105.46|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|42,528.93|4528.98|37379.75|105.46|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Managed Medicare|HEALTHSPRING MA|70,771.28|8060.82|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19,873.32|8201.23|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|73,826.01|8201.23|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|87,297.87|8049.05|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Medicare|MEDICARE PART B ONLY IP|25,299.71|833.02|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Medicare|MEDICARE ACUTE|43,406.96|8059.94|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|67,300.39|8066.44|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|77,973.88|7437.025|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|172,657.50|8059.94|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|62,883.41|8293.99|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|78,110.95|374.22|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|129,482.07|8201.23|66347.69|374.22|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|66,347.69|66347.69|66347.69|374.22|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|41,791.30|5548.18|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|34,719.28|7033.47|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|40,179.25|4360.17|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|46,386.62|5129.17|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|61,587.80|5462.57|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Managed Medicare|HEALTHSPRING MA|50,088.88|5461.69|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|58,169.22|6048.265|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Humana Medicare Advantage|HUMANA MA|32,470.57|5438.92|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Medicaid|MEDICAID|37,208.63|3547.75|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|45,793.28|5462.57|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Medicare|MEDICARE PART B ONLY IP|31,672.65|3019.065|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Medicaid|SMITH COUNTY JAIL|48,851.15|2134.54|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Tricare|TRICARE EAST REGION|39,796.80|3831.24|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|49,384.33|9013.11|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|United Healthcare|UNITED HEALTHCARE|17,818.35|9013.11|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41,652.01|5548.18|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|60,093.29|5506.78|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Cigna|CIGNA|32,699.90|7835.83|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|59,789.68|2213.11|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|42,581.36|5443.735|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35,439.42|4259.14|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35,641.91|71.44|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Aetna|BOON CHAPMAN|22,343.60|13167.74|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|39,692.78|5434.41|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|30,487.59|7075.99|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA|31,623.88|7033.47|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|62.36|7075.99|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|41,505.43|7075.99|13167.74|71.44|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33,639.35|5434.41|13167.74|71.44|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|72,315.60|10183.62|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|329,956.85|19384.82|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|115,188.16|12039.39|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|119,103.70|119103.7|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Rusk State Hospital|RUSK STATE HOSP|59,853.73|29328.33|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Tricare|TRICARE EAST REGION|26,387.25|3109.99|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|62,002.25|10198.14|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|60,274.63|82.8|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Managed Medicare|HEALTHSPRING MA|68,176.76|10197.7|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|51,512.74|11085.35|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|58,294.45|10383.64|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|52,601.71|10383.64|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30,026.63|85.9|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Blue Cross HMO Specialty|BCBSTX HMO|144,309.93|126|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|58,219.26|10197.26|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Managed Medicare|BCBS MEDICARE PPO MA|71,898.80|10169.98|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Cigna|CIGNA|19,493.35|11793.425|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Humana Medicare Advantage|HUMANA MA|67,054.22|10182.98|119103.7|82.8|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Medicare|MEDICARE PART B ONLY IP|162.05|522.54|119103.7|82.8|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Aetna|AETNA OTHER|72,586.88|11866.97|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Blue Cross HMO Specialty|BCBSTX HMO|74,809.90|5432.03|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|36,343.93|8328.09|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34,496.80|35.72|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Managed Medicare|HEALTHSPRING MA|68,115.67|6433.37|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Blue Cross PPO Specialty|BCBSTX PPO|32,494.07|6390.07|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|48,157.69|5880.195|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Managed Medicaid|MEDICAID SUPERIOR|40,710.35|4628.55|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|45,110.71|8307.18|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Veterans Affairs|VETERANS ADMINISTRATION|33,022.05|6430.77|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Managed Medicaid|MEDICAID AMERIGROUP|30,854.90|4031.51|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Cigna|CIGNA|36,861.14|9653.05|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Humana Medicare Advantage|HUMANA MA|44,282.85|6477.305|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Medicaid|COUNTY INDIGENT HEALTH OTHER|32,917.48|3904.41|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Medicaid|MEDICAID|24,797.38|2535.54|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|71,441.97|5119.755|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Medicare|MEDICARE PART B ONLY IP|5,450.80|38.57|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Medicare|MEDICARE ACUTE|47,848.33|6431.65|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Tricare|TRICARE EAST REGION|49,935.57|4861.67|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41,068.01|6537.68|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|31,418.85|6470.585|11866.97|35.72|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|35,731.65|6416.21|11866.97|35.72|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|42,410.75|4846.72|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|33,332.96|4838.18|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|37,899.03|37899.025|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Medicare|MEDICARE ACUTE|194.94|4874.88|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Medicaid|SMITH COUNTY JAIL|19,786.60|2678.7|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|33,851.52|2905.91|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|368.95|5066.31|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|21,506.10|4593.43|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|29,488.36|1108.32|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|27,749.48|4593.43|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|19,220.75|3904.76|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12,691.20|71.44|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Aetna|AETNA OTHER|9,457.95|9457.95|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Aetna|AETNA PPO|12,475.73|8278.16|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|28,905.95|4956.01|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Workers Compensation|UT EMPLOYEE INJURY|53,916.75|6969.83|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|99,708.12|4948.09|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|57,878.80|9837.99|37899.025|71.44|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22,742.27|6329.34|37899.025|71.44|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Aetna|AETNA PPO|553,301.49|241374.17|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Blue Cross HMO Specialty|BCBSTX HMO|965,158.15||||||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|454,948.47|82245.75|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Access Direct Platinum|HEALTHFIRST TPA|322,525.36|83404.42|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Aenta Medicare Advantage|AETNA MEDICARE MA|791,888.40|74836.615|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Veterans Affairs|VETERANS ADMINISTRATION|65,569.82|11205.43|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Blue Cross PPO Specialty|BCBSTX OTHER|400,980.66|11910.52|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Blue Cross PPO Specialty|BCBSTX PPO|676,846.28|2244.2|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|926,334.09|62159.83|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|832,302.91|93596.32|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Humana Medicare Advantage|HUMANA MA|774,740.17|64596.1|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Medicaid|MEDICAID|525,478.30|39215.27|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|UTMB|UTMB CORRECTIONAL MANAGED CARE|609,968.50|64438.74|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|United Medicare Advantage|UHC AARP MCR HMO MA|414,192.52|56144.97|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Rusk State Hospital|RUSK STATE HOSP|576,099.33|282288.67|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Medicare|MEDICARE ACUTE|417,909.79|59459.71|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|486,155.45|62690.29|282288.67|2244.2|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|United Medicare Advantage|UHC MEDICARE GOLD MA|509,322.83|55567.485|282288.67|2244.2|||| 405|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|230,880.20|31690.46|36524.09|464.37|||| 405|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W MCC|Medicare|MEDICARE ACUTE|125,840.70|31036.66|36524.09|464.37|||| 405|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|417,351.57|26619.32|36524.09|464.37|||| 405|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|149,261.84|12971.14|36524.09|464.37|||| 405|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|208,529.19|36524.09|36524.09|464.37|||| 405|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|274,698.96|464.37|36524.09|464.37|||| 406|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|129,229.25|19233.35|19233.35|142.88|||| 406|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|174,323.48|18444.955|19233.35|142.88|||| 406|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|186,513.90|16570.41|19233.35|142.88|||| 406|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W CC|Medicare|MEDICARE ACUTE|163,775.65|16598.57|19233.35|142.88|||| 406|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|111,572.22|17057.2|19233.35|142.88|||| 406|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|156,720.34|142.88|19233.35|142.88|||| 40650|EAP|0450|REPAIR LIP, FULL THICKNES|Managed Medicare|HEALTHSPRING MA|31.63||||||| 407|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|62,498.65|12732.18|12971.14|12732.18|||| 407|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|128,617.84|12971.14|12971.14|12732.18|||| 40800|EAP|0450|DRAIN ABSCESS CYST HEMATO|United Healthcare|UNITED HEALTHCARE OTHER|||||11.96||| 40800|EAP|0450|DRAIN ABSCESS CYST HEMATO|Managed Medicaid|MEDICAID AMERIGROUP|||||10.40||| 40800|EAP|0450|DRAIN ABSCESS CYST HEMATO|Cigna|CIGNA|||||10.40||| 40801|EAP|0981|DRAINAGE OF MOUTH LESION|ChampVA|CHAMPVA CENTER|||||12.60||| 40830|EAP|0981|CLOSURE MOUTH LAC 2.5CM O|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,089.75||| 40831|EAP|0981|CLOSURE MOUTH LAC >2.5CM|Managed Medicare|HEALTHSPRING MA|||||1,545.50||| 40831|EAP|0981|CLOSURE MOUTH LAC >2.5CM|Medicare|MEDICARE ACUTE|||||1,545.50||| 40831|EAP|0981|CLOSURE MOUTH LAC >2.5CM|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,545.50||| 40831|EAP|0981|CLOSURE MOUTH LAC >2.5CM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,545.50||| 40831|EAP|0981|CLOSURE MOUTH LAC >2.5CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,545.50||| 40831|EAP|0981|CLOSURE MOUTH LAC >2.5CM|Managed Medicaid|MEDICAID SUPERIOR|||||1,545.50||| 40831|EAP|0981|CLOSURE MOUTH LAC >2.5CM|Humana Medicare Advantage|HUMANA MA|||||1,545.50||| 40831|EAP|0981|CLOSURE MOUTH LAC >2.5CM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,545.50||| 409|DRG||BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|162,080.79|14694.08|14694.08|14694.08|||| 41|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|209,187.31|23787.03|28077.74|6466.09|||| 41|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM|United Medicare Advantage|UHC MEDICARE GOLD MA|54,081.77|14117.75|28077.74|6466.09|||| 41|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM|United Healthcare|UNITED HEALTHCARE OTHER|202,657.70|28069.07|28077.74|6466.09|||| 41|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM|Tricare|TRICARE EAST REGION|79,416.21|6466.09|28077.74|6466.09|||| 41|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM|Medicare|MEDICARE ACUTE|132,911.42|14569.14|28077.74|6466.09|||| 41|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM|Cigna|CIGNA|140,119.02|28077.74|28077.74|6466.09|||| 41|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM|Humana Medicare Advantage|HUMANA MA|184,068.39|14595.89|28077.74|6466.09|||| 41|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM|Workers Compensation|WORKERS COMPENSATION OTHER|104,103.03|20833.87|28077.74|6466.09|||| 41017|EAP|0981|DRAINAGE OF MOUTH LESION|ChampVA|CHAMPVA CENTER|||||16.66||| 41250|EAP|0450|RPR LAC TONGUE 2.5CM OR L|Medicaid|LAW ENFORCEMENT OTHER|||||752.10||| 41252|EAP|0981|RPR LAC TONGUE/MOUTH 2.6C|Managed Medicaid|MEDICAID SUPERIOR|||||22.79||| 41252|EAP|0981|RPR LAC TONGUE/MOUTH 2.6C|Humana Medicare Advantage|HUMANA MA|||||22.79||| 41252|EAP|0981|RPR LAC TONGUE/MOUTH 2.6C|Cigna|CIGNA OTHER|||||22.79||| 413|DRG||CHOLECYSTECTOMY W C.D.E. W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|87,876.05|10158.63|10158.63|10158.63|||| 414|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC|Medicare|MEDICARE ACUTE|173,108.97|20423.79|20423.79|10323.8|||| 414|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC|Blue Cross PPO Specialty|BCBSTX OTHER|125,911.74|10323.8|20423.79|10323.8|||| 414|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|108,524.55|14862.73|20423.79|10323.8|||| 414|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|290,289.17|20423.79|20423.79|10323.8|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|United Medicare Advantage|UHC AARP MCR HMO MA|145,549.41|12777.26|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|Medicare|MEDICARE ACUTE|133,059.65|12541.44|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|Managed Medicare|HEALTHSPRING MA|173,886.12|12777.26|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|Aetna|AETNA OTHER|83,079.36|259.54|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|71,148.40|142.88|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|ChampVA|CHAMPVA CENTER|81,493.79|13691.21|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|Blue Cross HMO Specialty|BCBSTX HMO|83,683.20|11652.51|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|Humana Medicare Advantage|HUMANA MA|136,954.42|12777.26|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|Blue Cross PPO Specialty|BCBSTX PPO|88,065.09|13707.65|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|72,654.80|12541.44|13707.65|142.88|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|145,194.41|12777.26|13707.65|142.88|||| 416|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|77,179.25|8665.35|30296.31|8665.35|||| 416|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|78,117.32|9459.15|30296.31|8665.35|||| 416|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC|Aetna|AETNA OTHER|109,752.90|30296.31|30296.31|8665.35|||| 416|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC|Medicare|MEDICARE ACUTE|110,789.62|8769.955|30296.31|8665.35|||| 416|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|88,541.90|8696.55|30296.31|8665.35|||| 417|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC|Blue Cross PPO Specialty|BCBSTX PPO|58,849.38|16454.89|18573.54|204.12|||| 417|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC|Medicare|MEDICARE ACUTE|111,658.10|14511.85|18573.54|204.12|||| 417|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|153,850.12|14511.41|18573.54|204.12|||| 417|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC|Humana Medicare Advantage|HUMANA MA|234,888.34|14652.24|18573.54|204.12|||| 417|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110,770.39|204.12|18573.54|204.12|||| 417|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC|Blue Cross HMO Specialty|BCBSTX HMO|105,268.55|13378.76|18573.54|204.12|||| 417|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|76,385.80|18573.54|18573.54|204.12|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Veterans Affairs|VETERANS ADMINISTRATION|138,761.03|10642.515|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Aetna|BOON CHAPMAN|187,689.15|21111.58|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Blue Cross HMO Specialty|BCBSTX HMO|126,677.54|9605.76|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|853.50|107.16|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Managed Medicare|HEALTHSPRING MA|100,318.29|10427.28|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|74,995.80|8664.06|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Humana Medicare Advantage|HUMANA MA|78,324.67|10632.42|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Medicaid|MEDICAID|93,058.50|7219.83|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Medicare|MEDICARE ACUTE|97,270.80|10441.8|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|87,958.80|13369.25|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|NON CONTRACTED|COMMERCIAL OTHER 1|32,701.05|32701.05|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|PHCS|GROUP AND PENSION|61,871.15|28371.3|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Blue Cross PPO Specialty|BCBSTX PPO|82,896.01|11299.92|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|95,723.30|10439.64|32701.05|107.16|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|United Medicare Advantage|UHC AARP MCR HMO MA|132,697.55|10441.8|32701.05|107.16|||| 41800|EAP|0450|DRAIN ABSCESS CYST HEMATO|Humana Medicare Advantage|HUMANA MA|||||848.70||| 41800|EAP|0450|DRAIN ABSCESS CYST HEMATO|Access Direct Platinum|HEALTHFIRST TPA|||||7.38||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|78,714.31|15467.28|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|83,061.64|15467.28|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|60,304.23|22215.6|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|65,761.85|10859.47|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Cigna|CIGNA|79,793.80|13446.97|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|96,061.15|11479.52|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|82,655.57|11479.52|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|74,339.59|8603.55|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|82,495.65|10877.6|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|60,283.03|8603.55|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Medicare|MEDICARE ACUTE|78,437.70|8453.95|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49,856.04|89.3|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|44,402.20|8426.67|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|51,705.47|8603.55|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|53,905.39|261.35|22215.6|89.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|46,944.92|8855.52|22215.6|89.3|||| 42|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|28,539.55|10411.97|11637.61|7839.79|||| 42|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|131,557.32|11637.61|11637.61|7839.79|||| 42|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|171,762.05|10802.3|11637.61|7839.79|||| 42|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|139,588.85|11637.61|11637.61|7839.79|||| 42|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC|Medicaid|MEDICAID|58,846.54|7839.79|11637.61|7839.79|||| 42|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC|Medicaid|LAW ENFORCEMENT OTHER|56,632.87|11426.21|11637.61|7839.79|||| 42|DRG||PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|89,883.17|11426.21|11637.61|7839.79|||| 42000|EAP|0450|DRAINAGE MOUTH LESION|Veterans Affairs|VETERANS ADMINISTRATION|||||6.34||| 421|DRG||HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|108,677.22|712.27|21792.44|712.27|||| 421|DRG||HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE OTHER|39,185.34|21792.44|21792.44|712.27|||| 421|DRG||HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC|Medicare|MEDICARE ACUTE|64,331.39|11621.64|21792.44|712.27|||| 423|DRG||OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|138,465.57|24543.11|24543.11|24543.11|||| 42400|EAP|0361|CT-BIOPSY OF SALIVARY GLA|NON CONTRACTED|COMMERCIAL OTHER 1|||||15.90||| 42400|EAP|0361|US BIOPSY OF SALIVARY GLA|Medicare|MEDICARE ACUTE|||||2,991.15||| 42400|EAP|0361|US BIOPSY OF SALIVARY GLA|Blue Cross PPO Specialty|BCBSTX PPO|||||26.01||| 42400|EAP|0361|US BIOPSY OF SALIVARY GLA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||26.01||| 42700|EAP|0450|I&D ABSCESS PERITONSILLAR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||10.19||| 42700|EAP|0450|I&D ABSCESS PERITONSILLAR|Managed Medicaid|MEDICAID SUPERIOR|||||1,171.85||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|72,778.41|15813.54|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Medicaid|MEDICAID|54,121.23|4719.235|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|49,669.55|11258.7|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|United Healthcare|UNITED HEALTHCARE OTHER|107,458.01|30167.76|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|United Healthcare|UNITED HEALTHCARE|35,363.90|21581.76|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|62,687.40|11498.1|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|67,028.22|112.95|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Medicare|MEDICARE ACUTE|65,884.97|11397.2|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|67,845.86|11520.14|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|57,805.42|11393.4|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Aetna|AETNA PPO|160,030.43|23066.01|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45,833.88|71.44|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|35,975.30|35.72|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|56,377.05|9160.58|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Managed Medicaid|MEDICAID SUPERIOR|71,212.55|17093.145|30167.76|35.72|||| 432|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC|Humana Medicare Advantage|HUMANA MA|223,125.89|11498.1|30167.76|35.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25,733.50|9160.58|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|206,002.98|6955.69|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Medicaid|MEDICAID|64,942.43|5728.72|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Medicare|MEDICARE ACUTE|43,608.31|7063.81|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|United Healthcare|UNITED HEALTHCARE|66,026.71|12214.75|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|65,713.17|7046.2|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|NON CONTRACTED|COMMERCIAL OTHER 1|16,746.05|16746.05|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|92,441.60|6918.73|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|52,105.25|7063.81|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Cigna|CIGNA OTHER|85,029.28|12394.905|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Humana Medicare Advantage|HUMANA MA|49,500.80|6937.84|16746.05|5728.72|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Managed Medicare|HEALTHSPRING MA|50,008.46|6950.69|16746.05|5728.72|||| 434|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC|Tricare|TRICARE EAST REGION|33,086.50|3315.18|6474.59|3315.18|||| 434|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|36,240.75|6474.59|6474.59|3315.18|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|78,746.12|11527.38|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|31,500.20|107.16|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|223.02|34.02|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Managed Medicaid|MEDICAID AMERIGROUP|186,611.71|18962.79|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Humana Medicare Advantage|HUMANA MA|113,199.83|10600.22|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|134,326.23|10679.395|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|24,804.55|10568.36|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|56,732.18|14017.61|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Medicaid|MEDICAID|106,115.97|7617.09|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Medicare|MEDICARE ACUTE|77,076.05|10790.43|18962.79|34.02|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|157,144.75|10790.43|18962.79|34.02|||| 436|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|70,805.81|7569.61|9141.29|136.08|||| 436|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|81,352.50|7588.83|9141.29|136.08|||| 436|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC|Medicare|MEDICARE ACUTE|46,155.13|7460.19|9141.29|136.08|||| 436|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC|Managed Medicare|HEALTHSPRING MA|124,414.51|7588.83|9141.29|136.08|||| 436|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC|Humana Medicare Advantage|HUMANA MA|145,133.69|7588.83|9141.29|136.08|||| 436|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|37,717.08|136.08|9141.29|136.08|||| 436|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC|Blue Cross PPO Specialty|BCBSTX PPO|78,052.58|7712.76|9141.29|136.08|||| 436|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|51,394.59|9141.29|9141.29|136.08|||| 437|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|91,973.50|7464.98|7464.98|6185.4|||| 437|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|68,073.57|6185.4|7464.98|6185.4|||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|Managed Medicare|HEALTHSPRING MA|15.25||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|Medicaid|MEDICAID|15.25||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|Medicare|MEDICARE ACUTE|1,753.75||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|United Healthcare|UNITED HEALTHCARE OTHER|1,639.38||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,753.75||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|Veterans Affairs|VETERANS ADMINISTRATION|1,753.75||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,753.75||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|United Medicare Advantage|UHC MEDICARE GOLD MA|15.25||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|Managed Medicaid|MEDICAID SUPERIOR|15.25||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.25||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|Blue Cross PPO Specialty|BCBSTX PPO|1,753.75||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|Humana Medicare Advantage|HUMANA MA|1,639.38||||||| 43752|EAP|0361|XR-NG TUBE PLACEMENT|United Medicare Advantage|UHC AARP MCR HMO MA|15.25||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Cigna|CIGNA|9.44||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Cigna|CIGNA|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Humana Medicare Advantage|HUMANA MA|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,085.60||||9.44||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Aetna|AETNA PPO|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Aetna|AETNA OTHER|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Blue Cross PPO Specialty|BCBSTX PPO|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.44||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|United Medicare Advantage|UHC AARP MCR HMO MA|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|United Medicare Advantage|UHC MEDICARE GOLD MA|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Access Direct Platinum|HEALTHFIRST TPA UMR|9.44||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Veterans Affairs|VETERANS ADMINISTRATION|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Workers Compensation|WORKERS COMPENSATION OTHER|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Blue Cross HMO Specialty|BCBSTX HMO|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Aenta Medicare Advantage|AETNA MEDICARE MA|9.44||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Tricare|TRICARE EAST REGION|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|United Healthcare|UNITED HEALTHCARE OTHER|1,014.80||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|United Healthcare|TML GROUP BENEFITS|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Medicare|MEDICARE ACUTE|9.44||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Medicare|MEDICARE PART B ONLY IP|9.44||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Medicaid|MEDICAID|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Medicaid|CRIME VICTIMS COMPENSATION|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Managed Medicare|HEALTHSPRING MA|9.44||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.44||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,014.80||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Managed Medicare|ETMC AFFILIATE HOSPITALS|9.44||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|NON CONTRACTED|COMMERCIAL OTHER 1|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Workers Compensation|TEXAS MUTUAL INSURANCE|1,085.60||||||| 43753|EAP|0761|TX GASTRO INTUB W/ASP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.44||||||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|Managed Medicare|BCBS MEDICARE PPO MA|6.87||||||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Medicaid|COUNTY INDIGENT HEALTH OTHER|790.05||||||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Managed Medicare|BCBS MEDICARE PPO MA|6.87||||||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Medicare|MEDICARE ACUTE|790.05||||790.05||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|Medicare|MEDICARE ACUTE|6.87||||790.05||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Tricare|TRICARE EAST REGION|||||790.05||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Veterans Affairs|VETERANS ADMINISTRATION|||||6.87||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|Workers Compensation|WORKERS COMPENSATION OTHER|||||6.87||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||6.87||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.87||||||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|6.87||||6.87||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||790.05||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.87||||790.05||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|Medicaid|MEDICAID|6.87||||||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|United Medicare Advantage|UHC AARP MCR HMO MA|||||790.05||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Managed Medicare|HEALTHSPRING MA|6.87||||||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|||||790.05||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Blue Cross PPO Specialty|BCBSTX PPO|790.05||||||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.87||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.87||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Aenta Medicare Advantage|AETNA MEDICARE MA|790.05||||6.87||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Managed Medicaid|MEDICAID SUPERIOR|790.05||||||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||790.05||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||790.05||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|Humana Medicare Advantage|HUMANA MA|||||790.05||| 43762|EAP|0450|CHANGING GASTRO TUBE W/O|Humana Medicare Advantage|HUMANA MA|790.05||||6.87||| 43762|EAP|0750|CHANGING GASTRO TUBE W/O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.87||| 43763|EAP|0750|CHANGING GASTRO TUBE REQ|Humana Medicare Advantage|HUMANA MA|7.90||||||| 43763|EAP|0750|CHANGING GASTRO TUBE REQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.90||| 43763|EAP|0750|CHANGING GASTRO TUBE REQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.90||||||| 43763|EAP|0750|CHANGING GASTRO TUBE REQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||908.50||| 43763|EAP|0750|CHANGING GASTRO TUBE REQ|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.90||| 43763|EAP|0750|CHANGING GASTRO TUBE REQ|Medicare|MEDICARE ACUTE|||||7.90||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Medicare|MEDICARE ACUTE|61,883.87|10273.43|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|103,756.45|14931.51|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Medicaid|MEDICAID|507,384.32|29621.725|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|163,316.23|10277.55|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|60,730.37|10460.97|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|34,267.80|10245.71|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|41,318.02|13187.98|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|130,935.44|10898.985|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Humana Medicare Advantage|HUMANA MA|156,225.95|10271.09|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|96,358.67|214.32|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|85,991.86|10541.03|29621.725|214.32|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43,513.91|8952.92|29621.725|214.32|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Managed Medicaid|MEDICAID AMERIGROUP|86,010.88|6634.74|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43,517.77|7364.81|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55,132.86|7364.81|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Managed Medicaid|MEDICAID SUPERIOR|21,300.69|5653.56|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Humana Medicare Advantage|HUMANA MA|59,225.67|5911.07|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Managed Medicare|HEALTHSPRING MA|227,049.13|5931.95|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Blue Cross PPO Specialty|BCBSTX PPO|46,604.71|5855.02|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Blue Cross PPO Specialty|BCBSTX OTHER|68,785.45|5855.02|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Blue Cross HMO Specialty|BCBSTX HMO|53,374.60|4977.2|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|68,404.04|178.6|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Veterans Affairs|VETERANS ADMINISTRATION|20,485.28|6028.37|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|26,489.75|5904.67|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25,272.75|8458.23|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|40,633.45|7673.46|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|71,238.05|7778.73|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Tricare|TRICARE EAST REGION|31,276.66|4517.44|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|United Medicare Advantage|UHC AARP MCR HMO MA|41,383.06|6033.485|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|73,263.84|6028.37|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|56,975.68|5904.67|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|44,550.44|3555.7|8458.23|178.6|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Medicare|MEDICARE ACUTE|33,320.44|5931.95|8458.23|178.6|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|48,653.32|141.18|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|22,967.60|4218.63|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|482.75|57.53|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|65,188.72|10273.87|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Cigna|CIGNA OTHER|38,141.30|6041.28|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|45,183.51|4655.58|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|35,108.30|67.25|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10,031.76|5653.56|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|78,346.77|7364.81|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Medicaid|MEDICAID|33,117.33|3555.7|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|25,398.62|659.79|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Medicare|MEDICARE ACUTE|35,201.87|4661.09|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|18,195.94|18195.94|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|65,048.40|4720.18|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|57,352.11|4660.89|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|26,617.05|14736.44|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|52,512.48|6543.88|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|38,084.63|4730.69|18195.94|57.53|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|43,980.15|3586.14|18195.94|57.53|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|Managed Medicaid|MEDICAID SUPERIOR|80,802.75|9108.67|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|141,403.55|21750.32|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|64,386.07|8771.21|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|Humana Medicare Advantage|HUMANA MA|128,077.32|9600.99|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|Managed Medicare|HEALTHSPRING MA|42,913.12|10681.85|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|96,808.82|214.32|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|87,309.21|11649.92|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|45,171.58|8935.325|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|United Healthcare|UNITED HEALTHCARE|221,336.96|21902.52|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|78,015.23|11618.34|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|Medicare|MEDICARE ACUTE|73,540.35|11438.28|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|Medicaid|MEDICAID|116,667.40|6502.51|21902.52|214.32|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|Medicaid|SMITH COUNTY JAIL|149,413.50|5516.49|21902.52|214.32|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Medicare|MEDICARE ACUTE|45,260.20|6407.555|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|NON CONTRACTED|COMMERCIAL OTHER 1|60,797.72|60797.72|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59,669.59|6511.34|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|56,969.30|6377.68|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Workers Compensation|WORKERS COMPENSATION OTHER|94,487.95|9311.22|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|12,935.30|8312.75|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Blue Cross PPO Specialty|BCBSTX PPO|56,913.13|6375.13|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41,221.70|89.3|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Managed Medicare|HEALTHSPRING MA|62,943.26|6405.84|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Humana Medicare Advantage|HUMANA MA|82,158.09|6409.87|60797.72|89.3|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|64,371.63|7888.24|60797.72|89.3|||| 443|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|32,110.92|3937.66|6375.13|3937.66|||| 443|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,560.70|3937.66|6375.13|3937.66|||| 443|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|48,614.30|5016.99|6375.13|3937.66|||| 443|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|64,884.50|6375.13|6375.13|3937.66|||| 443|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC/MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|71,665.56|5016.99|6375.13|3937.66|||| 443|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|7,505.75|4988.83|6375.13|3937.66|||| 44360|EAP|0750|EXTENDED EGD UPPER SMALL|Humana Medicare Advantage|HUMANA MA|4,209.09||||||| 44361|EAP|0750|EXTENDED EGD ENDOSCOPY/BI|Medicare|MEDICARE ACUTE|||||4,209.09||| 44361|EAP|0750|EXTENDED EGD ENDOSCOPY/BI|United Healthcare|UNITED HEALTHCARE OTHER|4,209.09||||||| 44361|EAP|0750|EXTENDED EGD ENDOSCOPY/BI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4,209.09||| 44366|EAP|0750|EXTENDED EGD BL W/CNTRL B|Humana Medicare Advantage|HUMANA MA|4,209.09||||||| 44366|EAP|0750|EXTENDED EGD BL W/CNTRL B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,209.09||||4,209.09||| 44366|EAP|0750|EXTENDED EGD BL W/CNTRL B|Medicare|MEDICARE ACUTE|4,209.09||||4,209.09||| 44373|EAP|0750|ENTEROSCOPY CONVERT PEG/P|Medicare|MEDICARE ACUTE|||||3,617.78||| 44373|EAP|0750|ENTEROSCOPY CONVERT PEG/P|Veterans Affairs|VETERANS ADMINISTRATION|3,617.78||||||| 44389|EAP|0750|COLONOSCOPY STOMA W/BIOPS|United Healthcare|UNITED HEALTHCARE|||||2,714.04||| 44392|EAP|0750|COLONOSCOPY STOMA W/HOT B|United Healthcare|UNITED HEALTHCARE|||||2,714.04||| 44394|EAP|0750|COLONOSCOPY STOMA W/SNARE|Blue Cross PPO Specialty|BCBSTX PPO|||||2,714.04||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Medicaid|MEDICAID|71,865.87|4835.4|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Medicare|MEDICARE ACUTE|80,687.97|10178.76|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|96,912.19|10207.2|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|52,467.87|13588.67|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Humana Medicare Advantage|HUMANA MA|86,001.10|10217.25|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|126,533.63|10805.28|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Managed Medicaid|MEDICAID SUPERIOR|55,833.99|7688.29|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|152,452.93|11906.19|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|63,234.68|178.6|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Blue Cross HMO Specialty|BCBSTX HMO|117,748.43|9840.5|13588.67|178.6|||| 444|DRG||DISORDERS OF THE BILIARY TRACT W MCC|Blue Cross PPO Specialty|BCBSTX OTHER|278,459.65|1907.57|13588.67|178.6|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Blue Cross PPO Specialty|BCBSTX PPO|103,461.76|72.49|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Aetna|AETNA PPO|85,330.96|13592.42|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|47,896.59|125.02|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Blue Cross PPO Specialty|BCBSTX OTHER|32,384.70|72.49|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Managed Medicare|HEALTHSPRING MA|54,625.50|7179.22|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Humana Medicare Advantage|HUMANA MA|55,270.14|7233.245|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|33,431.08|9743.14|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Multiplan|TRUSTMARK|15,115.10|11185.17|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|United Healthcare|UNITED HEALTHCARE OTHER|172,647.31|24165.78|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|51,861.30|7167.54|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|United Medicare Advantage|UHC AARP MCR HMO MA|70,918.26|7241.025|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Medicare|MEDICARE ACUTE|58,215.50|7301.95|24165.78|72.49|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Medicaid|SMITH COUNTY JAIL|50,630.60|4835.4|24165.78|72.49|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|Medicare|MEDICARE ACUTE|43,363.54|5743.53|7956.64|5398.05|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|57,653.94|5733.77|7956.64|5398.05|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|55,834.05|5718.36|7956.64|5398.05|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|50,099.16|5835.06|7956.64|5398.05|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|56,537.77|7788.38|7956.64|5398.05|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|62,815.90|7956.64|7956.64|5398.05|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|65,614.50|7557.37|7956.64|5398.05|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|33,490.18|5835.06|7956.64|5398.05|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|80,063.90|5743.53|7956.64|5398.05|||| 446|DRG||DISORDERS OF THE BILIARY TRACT W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|38,525.13|5398.05|7956.64|5398.05|||| 453|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,421,303.55|82187.67|82187.67|52871.58|||| 453|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC|Humana Medicare Advantage|HUMANA MA|106,650.60|52871.58|82187.67|52871.58|||| 453|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC|Veterans Affairs|VETERANS ADMINISTRATION|359,068.60|52903.31|82187.67|52871.58|||| 453|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC|Medicare|MEDICARE ACUTE|369,923.72|53989.6|82187.67|52871.58|||| 45398|EAP|0750|COLONOSCOPY W/BAND LIGATI|Humana Medicare Advantage|HUMANA MA|||||2,714.04||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|172,706.33|35600.3|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|200,417.52|34892.36|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Medicare|MEDICARE ACUTE|193,541.84|34893.44|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|148,362.44|69895.58|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|92,591.05|66486.2|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|United Healthcare|UNITED HEALTHCARE|153,432.25|72495.5|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|126,316.23|34865.72|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Veterans Affairs|VETERANS ADMINISTRATION|112,937.32|35600.3|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|136,322.90|136.08|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Blue Cross HMO Specialty|BCBSTX HMO|602,507.92|29004.005|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Aetna|AETNA PPO|155,917.41|91191.39|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Blue Cross PPO Specialty|BCBSTX PPO|166,306.50|43026.87|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Managed Medicare|BCBS MEDICARE PPO MA|194,249.60|34888.75|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Managed Medicare|HEALTHSPRING MA|177,086.42|35600.3|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Humana Medicare Advantage|HUMANA MA|124,395.20|34874.565|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|120,237.01|28717.76|91191.39|136.08|||| 454|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|272,695.24|24063.26|91191.39|136.08|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|81,492.05|24063.26|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Cigna|CIGNA|104,172.47|71641.98|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|113,180.48|27680.99|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|133,335.50|27696.15|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|167,422.08|28250.74|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|107,396.37|339.5|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Aetna|AETNA PPO|1,310.74|82927.07|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|108,568.88|40398.56|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Medicare|MEDICARE ACUTE|160,614.23|27695.71|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|Tricare|TRICARE EAST REGION|105,764.05|24299.57|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|140,212.05|27696.15|82927.07|339.5|||| 455|DRG||COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|112,817.20|42319.855|82927.07|339.5|||| 456|DRG||SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|204,535.52|52164.11|52164.11|136.08|||| 456|DRG||SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W MCC|Medicare|MEDICARE ACUTE|319,756.86|51120.83|52164.11|136.08|||| 456|DRG||SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|570,407.35|136.08|52164.11|136.08|||| 456|DRG||SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W MCC|Humana Medicare Advantage|HUMANA MA|345,376.01|51118.14|52164.11|136.08|||| 457|DRG||SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W CC|Managed Medicare|HEALTHSPRING MA|361,330.85|37023.72|37439.19|561.05|||| 457|DRG||SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W CC|Humana Medicare Advantage|HUMANA MA|241,369.79|37439.19|37439.19|561.05|||| 457|DRG||SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W CC|Blue Cross PPO Specialty|BCBSTX PPO|346,181.60|561.05|37439.19|561.05|||| 457|DRG||SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W CC|Medicare|MEDICARE ACUTE|259,976.31|37010.08|37439.19|561.05|||| 458|DRG||SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|209,223.65|27581.73|27581.73|27581.73|||| 459|DRG||SPINAL FUSION EXCEPT CERVICAL W MCC|Medicare|MEDICARE ACUTE|195,998.58|39673.74|55602.95|33952.08|||| 459|DRG||SPINAL FUSION EXCEPT CERVICAL W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|446,589.92|55602.95|55602.95|33952.08|||| 459|DRG||SPINAL FUSION EXCEPT CERVICAL W MCC|Blue Cross PPO Specialty|BCBSTX PPO|259,264.25|49728.895|55602.95|33952.08|||| 459|DRG||SPINAL FUSION EXCEPT CERVICAL W MCC|Managed Medicaid|MEDICAID SUPERIOR|243,786.24|44220.13|55602.95|33952.08|||| 459|DRG||SPINAL FUSION EXCEPT CERVICAL W MCC|Humana Medicare Advantage|HUMANA MA|194,195.33|39712.385|55602.95|33952.08|||| 459|DRG||SPINAL FUSION EXCEPT CERVICAL W MCC|Managed Medicare|BCBS MEDICARE PPO MA|179,306.51|33952.08|55602.95|33952.08|||| 459|DRG||SPINAL FUSION EXCEPT CERVICAL W MCC|Managed Medicare|HEALTHSPRING MA|344,706.79|39673.74|55602.95|33952.08|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|144,016.90|28940.425|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Managed Medicare|HEALTHSPRING MA|160,969.55|23016.01|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Humana Medicare Advantage|HUMANA MA|132,786.18|23471.88|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|165,555.05|28717.76|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|183,664.33|36468.945|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|194,662.09|34179.855|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Blue Cross PPO Specialty|BCBSTX OTHER|145,518.40|27414.62|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|123,753.35|27414.62|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|228.25|42.51|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Workers Compensation|WORKERS COMPENSATION OTHER|207,105.02|32912.265|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|132,731.55|103801.48|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|116,976.98|23004.56|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|PHCS|GROUP AND PENSION|243,184.05|167796.99|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|United Healthcare|UNITED HEALTHCARE|128,622.61|46875.29|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|135,332.05|23471.88|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|196,478.61|23471.88|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|144,324.42|20080.25|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|309,227.96|27811.4|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Medicare|MEDICARE PART B ONLY IP|118,608.56|23022.865|167796.99|42.51|||| 460|DRG||SPINAL FUSION EXCEPT CERVICAL W/O MCC|Medicare|MEDICARE ACUTE|117,709.05|23016.01|167796.99|42.51|||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Medicare|MEDICARE PART B ONLY IP|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Medicare|MEDICARE ACUTE|81.75||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Medicaid|MEDICAID|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|United Healthcare|TML GROUP BENEFITS|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|United Healthcare|UNITED HEALTHCARE|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|United Healthcare|GEHA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|PHCS|GROUP AND PENSION|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Tricare|TRICARE EAST REGION|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|PHCS|HUMANA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Veterans Affairs|VETERANS ADMINISTRATION|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Workers Compensation|TEXAS MUTUAL INSURANCE|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Workers Compensation|UT EMPLOYEE INJURY|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Workers Compensation|BROOKSHIRES WORKERS COMP|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Access Direct Platinum|HEALTHFIRST TPA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|ChampVA|CHAMPVA CENTER|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|United Healthcare|UNITED HEALTHCARE OTHER|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Blue Cross PPO Specialty|BCBSTX PPO|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Aetna|AETNA PPO|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Aetna|BOON CHAPMAN|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Aetna|AETNA OTHER|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Aetna Value Network|AETNA VALUE NETWORK|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Blue Cross HMO Specialty|BCBSTX HMO|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicaid|MEDICAID SUPERIOR|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicaid|MEDICAID AMERIGROUP|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Cigna|CIGNA OTHER|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Humana Medicare Advantage|HUMANA MA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Cigna|CIGNA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicare|BCBS MEDICARE PPO MA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicare|HEALTHSPRING MA|81.75||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||81.75||| 4601712|ERX|0250|LIDOCAINE AMPS 1.5% 20ML|Managed Medicare|OTHER INSTITUTIONS|||||81.75||| 46040|EAP|0450|INCISION RECTAL ABSCESS|United Healthcare|UNITED HEALTHCARE OTHER|5,208.35||||||| 46050|EAP|0450|I&D ABSCESS PERIANAL SIMP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,261.40||| 46050|EAP|0450|I&D ABSCESS PERIANAL SIMP|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,261.40||| 46083|EAP|0450|INCISE EXT HEMORRHOID|Managed Medicaid|MEDICAID AMERIGROUP|||||1,147.70||| 4608386|ERX|0250|BURETROL 150ML INJECTION|Medicaid|MEDICAID HMO|||||86.75||| 4608386|ERX|0250|BURETROL 150ML INJECTION|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||86.75||| 4608386|ERX|0250|BURETROL 150ML INJECTION|Medicaid|MEDICAID|||||86.75||| 4608386|ERX|0250|BURETROL 150ML INJECTION|Managed Medicaid|MEDICAID SUPERIOR|||||86.75||| 461|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W MCC|Medicare|MEDICARE ACUTE|223,987.40|30799.23|30799.23|30799.23|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|178,941.44|77774.7|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|153,323.85|68522.93|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|169,307.20|70231.85|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|185,260.24|119.92|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Aetna|AETNA PPO|159,926.43|71939.64|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|166,988.12|21687.94|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|153,735.05|18493.57|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Cigna|CIGNA|212,275.81|91836.81|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Cigna|CIGNA OTHER|142,477.30|77430.18|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Humana Medicare Advantage|HUMANA MA|164,605.68|18854.94|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|United Healthcare|GEHA|163,924.71|37122.43|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|176,988.30|18493.57|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|1,500.71|103548.99|103548.99|119.92|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Medicare|MEDICARE ACUTE|162,173.57|18494.45|103548.99|119.92|||| 46221|EAP|0750||Managed Medicare|BCBS MEDICARE PPO MA|||||19.99||| 46221|EAP|0750||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||19.99||| 46221|EAP|0750||Managed Medicare|HEALTHSPRING MA|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Managed Medicare|HEALTHSPRING MA|||||2,298.85||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|NON CONTRACTED|COMMERCIAL OTHER 1|||||832.92||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Multiplan|WEB TPA|||||832.92||| 46221|EAP|0750||Medicare|MEDICARE ACUTE|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|United Healthcare|UNITED HEALTHCARE OTHER|||||832.92||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|United Healthcare|UNITED HEALTHCARE|||||832.92||| 46221|EAP|0750||United Healthcare|UNITED HEALTHCARE|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Tricare|TRICARE EAST REGION|||||1,565.89||| 46221|EAP|0750||Humana Medicare Advantage|HUMANA MA|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Humana Medicare Advantage|HUMANA MA|||||832.92||| 46221|EAP|0750||Cigna|CIGNA OTHER|||||19.99||| 46221|EAP|0750||Cigna|CIGNA|||||19.99||| 46221|EAP|0750||Managed Medicaid|MEDICAID SUPERIOR|||||19.99||| 46221|EAP|0750||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||832.92||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||832.92||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Managed Medicaid|MEDICAID AMERIGROUP|||||832.92||| 46221|EAP|0750||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Managed Medicaid|MEDICAID SUPERIOR|||||832.92||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Medicare|MEDICARE ACUTE|||||832.92||| 46221|EAP|0750||Blue Cross PPO Specialty|BCBSTX PPO|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Blue Cross PPO Specialty|BCBSTX PPO|||||2,298.85||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Blue Cross PPO Specialty|BCBSTX OTHER|||||832.92||| 46221|EAP|0750||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||19.99||| 46221|EAP|0750||NON CONTRACTED|COMMERCIAL OTHER 1|||||19.99||| 46221|EAP|0750||Blue Cross HMO Specialty|BCBSTX HMO|||||2,148.93||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Blue Cross HMO Specialty|BCBSTX HMO|||||2,298.85||| 46221|EAP|0750||Aenta Medicare Advantage|AETNA MEDICARE MA|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||832.92||| 46221|EAP|0750||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||19.99||| 46221|EAP|0750||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,298.85||| 46221|EAP|0750||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,298.85||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Access Direct Platinum|HEALTHFIRST TPA|||||1,565.89||| 46221|EAP|0750||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2,298.85||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||832.92||| 46221|EAP|0750||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||19.99||| 46221|EAP|0510|LIGATION OF HEMORRHOID(S)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||832.92||| 46221|EAP|0750||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||19.99||| 463|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC|Humana Medicare Advantage|HUMANA MA|213,021.35|29973.01|29973.01|19401.33|||| 463|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|146,772.75|29968.49|29973.01|19401.33|||| 463|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC|Medicare|MEDICARE ACUTE|61,760.10|19401.33|29973.01|19401.33|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Medicare|MEDICARE ACUTE|76,343.17|17902.03|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|United Healthcare|UNITED HEALTHCARE|374,740.30|72918.16|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|United Medicare Advantage|UHC AARP MCR HMO MA|132,340.73|17458.25|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Workers Compensation|WORKERS COMPENSATION OTHER|295,468.50|25490.65|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|63,551.05|16541.19|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|114,385.72|428.64|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Blue Cross PPO Specialty|BCBSTX OTHER|67,639.12|19989.76|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Blue Cross PPO Specialty|BCBSTX PPO|506.90|19989.76|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Managed Medicare|HEALTHSPRING MA|264,528.54|17486.41|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Cigna|CIGNA|434,514.91|217257.45|217257.45|134.98|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Humana Medicare Advantage|HUMANA MA|143,452.38|134.98|217257.45|134.98|||| 465|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|92,829.25|18717.89|18717.89|18717.89|||| 466|DRG||REVISION OF HIP OR KNEE REPLACEMENT W MCC|Medicare|MEDICARE ACUTE|267,451.71|29273.81|29909.61|28066.43|||| 466|DRG||REVISION OF HIP OR KNEE REPLACEMENT W MCC|Humana Medicare Advantage|HUMANA MA|255,559.06|29909.61|29909.61|28066.43|||| 466|DRG||REVISION OF HIP OR KNEE REPLACEMENT W MCC|Managed Medicare|HEALTHSPRING MA|134,536.90|28066.43|29909.61|28066.43|||| 46611|EAP|0510|ANOSCOPY RMVL 1 TUM POLYP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||832.92||| 46611|EAP|0750||Blue Cross PPO Specialty|BCBSTX PPO|||||19.99||| 46611|EAP|0510|ANOSCOPY RMVL 1 TUM POLYP|Blue Cross PPO Specialty|BCBSTX PPO|||||832.92||| 46611|EAP|0510|ANOSCOPY RMVL 1 TUM POLYP|Blue Cross HMO Specialty|BCBSTX HMO|||||832.92||| 46611|EAP|0510|ANOSCOPY RMVL 1 TUM POLYP|Managed Medicaid|MEDICAID AMERIGROUP|||||832.92||| 46611|EAP|0750||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||19.99||| 46611|EAP|0750||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||19.99||| 46611|EAP|0750||Managed Medicaid|MEDICAID SUPERIOR|||||19.99||| 46611|EAP|0750||Humana Medicare Advantage|HUMANA MA|||||19.99||| 46611|EAP|0510|ANOSCOPY RMVL 1 TUM POLYP|Medicare|MEDICARE ACUTE|||||832.92||| 46611|EAP|0750||Medicare|MEDICARE ACUTE|||||19.99||| 46611|EAP|0750||United Healthcare|UNITED HEALTHCARE|||||19.99||| 46611|EAP|0510|ANOSCOPY RMVL 1 TUM POLYP|Tricare|TRICARE EAST REGION|||||832.92||| 46611|EAP|0510|ANOSCOPY RMVL 1 TUM POLYP|Managed Medicare|HEALTHSPRING MA|||||832.92||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Medicare|MEDICARE ACUTE|151,799.51|20555.15|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|United Healthcare|UNITED HEALTHCARE|168,777.32|20566.87|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|139,168.45|20564.83|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|United Medicare Advantage|UHC AARP MCR HMO MA|195,692.89|20556.03|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|PHCS|HUMANA|139,259.05|20552.54|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Humana Medicare Advantage|HUMANA MA|198,225.70|20526.54|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|157,064.22|18803.06|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|163,565.70|17264.86|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|98,089.75|18803.32|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Managed Medicare|BCBS MEDICARE PPO MA|101,710.11|19171.22|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Blue Cross HMO Specialty|BCBSTX HMO|175,761.61|71.44|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Blue Cross PPO Specialty|BCBSTX PPO|206,570.95|23564.02|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Veterans Affairs|VETERANS ADMINISTRATION|164,110.98|20556.03|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|131,168.05|53886.86|53886.86|71.44|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|202,755.10|20527.87|53886.86|71.44|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|116,289.55|16686.73|18953.61|68.04|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|202,352.89|16876.365|18953.61|68.04|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|117,529.12|18953.61|18953.61|68.04|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|140,197.27|16111.96|18953.61|68.04|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|175,840.90|68.04|18953.61|68.04|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|74,306.68|17264.86|18953.61|68.04|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|170,426.40|17037.84|18953.61|68.04|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|227,468.30|16714.89|18953.61|68.04|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Medicare|MEDICARE ACUTE|95,108.05|16714.89|18953.61|68.04|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|Medicare|MEDICARE ACUTE|129,339.15|18512.77|57991.77|442.26|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|166,904.69|18515.37|57991.77|442.26|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|United Medicare Advantage|UHC MEDICARE GOLD MA|133,953.71|18874.55|57991.77|442.26|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|United Medicare Advantage|UHC AARP MCR HMO MA|129,364.39|18874.55|57991.77|442.26|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|Aetna|AETNA QHP HMO|102,714.88|57991.77|57991.77|442.26|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|141,025.85|442.26|57991.77|442.26|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|Blue Cross PPO Specialty|BCBSTX PPO|129,989.15|21552.82|57991.77|442.26|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|99,487.39|12085.23|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|101,061.83|39378.715|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|117,750.66|42968.9|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|119,658.65|39906.48|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|109,225.35|41308.16|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|99,012.49|12064.33|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|94,727.45|12084.79|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|96,728.32|12080.49|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Cigna|CIGNA OTHER|98,212.79|47720.96|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Humana Medicare Advantage|HUMANA MA|100,534.20|12067.195|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Cigna|CIGNA|92,649.24|48801.46|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|102,943.09|18803.06|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Cigna|CIGNA|116,854.07|48588.96|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|105,353.07|17264.86|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Brinson Benefits|THE HEALTH PLAN SMITH CO|109,068.80|109068.8|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross PPO Specialty|BCBSTX OTHER|131,836.80|13521.4|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|98,382.75|13510.74|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|98,982.30|11485.13|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Aetna Value Network|AETNA VALUE NETWORK|97,040.64|38865.11|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|104,987.02|35.72|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Aetna|AETNA OTHER|103,712.03|43971.3|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicare|HEALTHSPRING MA|118,330.80|12084.35|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Aetna|AETNA PPO|97,583.24|38176.555|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|93,964.49|93964.49|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|PHCS|GROUP AND PENSION|102,113.55|70458.35|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Tricare|TRICARE EAST REGION|105,212.20|10900.41|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Healthcare|UNITED HEALTHCARE|106,996.05|23297.98|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Healthcare|UNITED HEALTHCARE|98,231.85|23297.98|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|95,757.89|23297.98|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|108,843.09|12310.54|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|101,019.69|12085.23|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|116,058.23|12084.35|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|119,117.85|18244.42|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Medicare|MEDICARE PART B ONLY IP|179,314.82|10721.11|109068.8|35.72|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Medicare|MEDICARE ACUTE|99,849.30|12085.23|109068.8|35.72|||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Medicaid|MEDICAID|31.39||||3,609.85||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||3,609.85||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Managed Medicare|HEALTHSPRING MA|3,374.43||||3,374.43||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3,374.43||||31.39||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|United Healthcare|UNITED HEALTHCARE|||||3,609.85||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|United Healthcare|UNITED HEALTHCARE|||||2,984.25||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,374.43||||||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,609.85||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Medicare|MEDICARE ACUTE|31.39||||3,609.85||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Medicare|MEDICARE ACUTE|25.95||||25.95||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Aetna|AETNA PPO|3,609.85||||3,609.85||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||25.95||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,609.85||||3,609.85||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Blue Cross HMO Specialty|BCBSTX HMO|||||25.95||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Blue Cross PPO Specialty|BCBSTX PPO|||||2,984.25||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||25.95||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Blue Cross PPO Specialty|BCBSTX PPO|3,374.43||||3,609.85||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Humana Medicare Advantage|HUMANA MA|||||2,984.25||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Humana Medicare Advantage|HUMANA MA|3,374.43||||31.39||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Cigna|CIGNA|||||25.95||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Cigna|CIGNA OTHER|||||2,984.25||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Cigna|CIGNA|||||3,609.85||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Managed Medicaid|MEDICAID AMERIGROUP|||||3,609.85||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Rusk State Hospital|RUSK STATE HOSP|||||2,984.25||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,374.43||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Managed Medicaid|MEDICAID SUPERIOR|||||31.39||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,609.85||||31.39||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Managed Medicaid|MEDICAID SUPERIOR|||||25.95||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Managed Medicaid|MEDICAID AMERIGROUP|||||25.95||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||25.95||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Veterans Affairs|VETERANS ADMINISTRATION|||||3,609.85||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Veterans Affairs|VETERANS ADMINISTRATION|||||25.95||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|United Healthcare|UNITED HEALTHCARE OTHER|3,609.85||||||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Managed Medicare|HEALTHSPRING MA|2,984.25||||25.95||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,609.85||||||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,984.25||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||31.39||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|Access Direct Platinum|HEALTHFIRST TPA|||||25.95||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,609.85||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|United Medicare Advantage|UHC MEDICARE GOLD MA|3,609.85||||3,374.43||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|United Medicare Advantage|UHC MEDICARE GOLD MA|25.95||||||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,374.43||||||| 47000|EAP|0361|US NEEDLE BIOPSY OF LIVER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,984.25||| 47000|EAP|0360|CT-NEEDLE BIOPSY OF LIVER|United Medicare Advantage|UHC AARP MCR HMO MA|||||3,609.85||| 471|DRG||CERVICAL SPINAL FUSION W MCC|Managed Medicare|HEALTHSPRING MA|388,223.90|29265.45|81344.77|18126.67|||| 471|DRG||CERVICAL SPINAL FUSION W MCC|Humana Medicare Advantage|HUMANA MA|294,315.02|29321.78|81344.77|18126.67|||| 471|DRG||CERVICAL SPINAL FUSION W MCC|Blue Cross PPO Specialty|BCBSTX PPO|129,052.87|33198.765|81344.77|18126.67|||| 471|DRG||CERVICAL SPINAL FUSION W MCC|Aetna|AETNA PPO|220,558.17|81344.77|81344.77|18126.67|||| 471|DRG||CERVICAL SPINAL FUSION W MCC|Medicaid|MEDICAID|570,449.73|18126.67|81344.77|18126.67|||| 471|DRG||CERVICAL SPINAL FUSION W MCC|Medicare|MEDICARE ACUTE|213,131.62|29265.45|81344.77|18126.67|||| 472|DRG||CERVICAL SPINAL FUSION W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|163,254.60|18271.28|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|United Healthcare|UNITED HEALTHCARE|107,999.13|35999.19|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|United Healthcare|UNITED HEALTHCARE OTHER|148,943.05|35999.19|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|92,090.43|17945.52|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107,933.91|18323.2|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|United Medicare Advantage|UHC AARP MCR HMO MA|139,763.49|18148.44|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Medicare|MEDICARE PART B ONLY IP|180,279.30|4750.79|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Medicare|MEDICARE ACUTE|124,336.26|18323.2|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Veterans Affairs|VETERANS ADMINISTRATION|88,808.97|17973.68|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|140,100.62|45073.19|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Workers Compensation|WORKERS COMPENSATION OTHER|320,143.37|25718.42|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|United Healthcare|GEHA|130,872.56|35999.19|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Blue Cross HMO Specialty|BCBSTX HMO|96,692.35|15964.77|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Aetna|AETNA PPO|134,092.20|32492.77|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Blue Cross PPO Specialty|BCBSTX PPO|123,192.60|20008.77|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|177,848.24|20193.49|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|104,402.73|20193.49|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Humana Medicare Advantage|HUMANA MA|134,194.81|18151.79|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Managed Medicare|HEALTHSPRING MA|127,476.55|17972.8|45073.19|4750.79|||| 472|DRG||CERVICAL SPINAL FUSION W CC|Managed Medicare|BCBS MEDICARE PPO MA|122,347.88|18323.2|45073.19|4750.79|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|135,788.42|153.89|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Cigna|CIGNA|1,241.59|66364.02|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|61,830.55|7542.35|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Cigna|CIGNA|88,736.13|47262.85|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|78,802.08|16111.99|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Aetna|AETNA PPO|97,484.39|43489.63|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|117,544.10|21550.6|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Medicare|MEDICARE ACUTE|131,583.30|15070.35|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|171,158.48|9565.34|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|Tricare|TRICARE EAST REGION|133,125.55|12942.81|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|PHCS|GROUP AND PENSION|128,227.14|88476.73|88476.73|153.89|||| 473|DRG||CERVICAL SPINAL FUSION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|131,778.10|15200.405|88476.73|153.89|||| 47382|EAP|0361|CT-PERCUT ABLATE LIVER RF|Medicare|MEDICARE ACUTE|||||741.27||| 47382|EAP|0361|CT-PERCUT ABLATE LIVER RF|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||741.27||| 474|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|84,843.96|39532.34|39532.34|15703.755|||| 474|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC|Humana Medicare Advantage|HUMANA MA|200,270.64|22992.81|39532.34|15703.755|||| 474|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC|Managed Medicare|HEALTHSPRING MA|212,351.57|26453.555|39532.34|15703.755|||| 474|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|208,874.83|25768.73|39532.34|15703.755|||| 474|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC|Medicare|MEDICARE ACUTE|77,437.33|15703.755|39532.34|15703.755|||| 474|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC|Medicare|MEDICARE PART B ONLY IP|136,701.50|19883.645|39532.34|15703.755|||| 47490|EAP|0361|IR-CHOLECYSTOSTOMY PERC|Medicare|MEDICARE ACUTE|86.11||||||| 47490|EAP|0361|IR-CHOLECYSTOSTOMY PERC|Medicaid|MEDICAID|86.11||||||| 47490|EAP|0361|IR-CHOLECYSTOSTOMY PERC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|86.11||||||| 47490|EAP|0361|IR-CHOLECYSTOSTOMY PERC|United Medicare Advantage|UHC AARP MCR HMO MA|86.11||||86.11||| 47490|EAP|0361|IR-CHOLECYSTOSTOMY PERC|Aenta Medicare Advantage|AETNA MEDICARE MA|86.11||||||| 47490|EAP|0361|IR-CHOLECYSTOSTOMY PERC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|86.11||||||| 47490|EAP|0361|IR-CHOLECYSTOSTOMY PERC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|86.11||||||| 47490|EAP|0361|IR-CHOLECYSTOSTOMY PERC|Humana Medicare Advantage|HUMANA MA|86.11||||||| 475|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|64,971.05|13514.91|16378.56|12784.7|||| 475|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC|Medicare|MEDICARE ACUTE|85,264.38|13053.51|16378.56|12784.7|||| 475|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|389,994.55|16378.56|16378.56|12784.7|||| 475|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|93,463.99|13053.51|16378.56|12784.7|||| 475|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|82,121.82|12784.7|16378.56|12784.7|||| 47531|EAP|0360|XR-INJECTION FOR CHOLANGI|Medicare|MEDICARE ACUTE|||||41.97||| 47531|EAP|0361|IR-INJECTION FOR CHOLANGI|Medicare|MEDICARE ACUTE|4,444.34||||||| 47531|EAP|0360|XR-INJECTION FOR CHOLANGI|United Medicare Advantage|UHC AARP MCR HMO MA|4,444.34||||||| 47531|EAP|0361|IR-INJECTION FOR CHOLANGI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,444.34||| 47531|EAP|0361|IR-INJECTION FOR CHOLANGI|Blue Cross PPO Specialty|BCBSTX PPO|41.97||||||| 47531|EAP|0360|XR-INJECTION FOR CHOLANGI|Blue Cross PPO Specialty|BCBSTX PPO|||||41.97||| 47531|EAP|0361|IR-INJECTION FOR CHOLANGI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,444.34||||||| 47531|EAP|0361|IR-INJECTION FOR CHOLANGI|Humana Medicare Advantage|HUMANA MA|||||4,444.34||| 47532|EAP|0361|IR-INJ FOR CHOLANGIOGRAM|Medicare|MEDICARE ACUTE|4,992.87||||4,992.87||| 47533|EAP|0361|IR-PLMT BILIARY DRAINAGE|Humana Medicare Advantage|HUMANA MA|||||43.63||| 47533|EAP|0361|IR-PLMT BILIARY DRAINAGE|Blue Cross HMO Specialty|BCBSTX HMO|43.63||||||| 47533|EAP|0361|IR-PLMT BILIARY DRAINAGE|Medicare|MEDICARE ACUTE|43.63||||||| 47534|EAP|0361|IR-PLMT BILIARY DRAINAGE|Medicaid|MEDICAID|43.63||||||| 47534|EAP|0361|IR-PLMT BILIARY DRAINAGE|Medicare|MEDICARE ACUTE|||||73.63||| 47534|EAP|0361|IR-PLMT BILIARY DRAINAGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||73.63||| 47534|EAP|0361|IR-PLMT BILIARY DRAINAGE|United Medicare Advantage|UHC MEDICARE GOLD MA|73.63||||||| 47534|EAP|0361|IR-PLMT BILIARY DRAINAGE|Blue Cross PPO Specialty|BCBSTX PPO|73.63||||||| 47536|EAP|0361|IR-EXCHANGE BILIARY DRG C|United Medicare Advantage|UHC AARP MCR HMO MA|43.63||||43.63||| 47536|EAP|0361|IR-EXCHANGE BILIARY DRG C|United Medicare Advantage|UHC MEDICARE GOLD MA|43.63||||||| 47536|EAP|0361|IR-EXCHANGE BILIARY DRG C|Medicare|MEDICARE ACUTE|43.63||||43.63||| 47537|EAP|0361|IR-REMOVAL BILIARY DRG CA|Medicare|MEDICARE ACUTE|||||9.92||| 47538|EAP|0361|IR-PERQ PLMT BILE DUCT-ST|Humana Medicare Advantage|HUMANA MA|59.56||||||| 47538|EAP|0361|IR-PERQ PLMT BILE DUCT-ST|Medicaid|MEDICAID|59.56||||||| 47538|EAP|0361|IR-PERQ PLMT BILE DUCT-ST|Medicare|MEDICARE ACUTE|59.56||||||| 47539|EAP|0361|IR-PERQ PLMT BILEDUCT-STN|Humana Medicare Advantage|HUMANA MA|59.56||||||| 47541|EAP|0361|IR-PLMT ACCESS BIL TREE S|Medicare|MEDICARE ACUTE|43.63||||||| 47541|EAP|0361|IR-PLMT ACCESS BIL TREE S|Managed Medicare|HEALTHSPRING MA|43.63||||||| 47541|EAP|0361|IR-PLMT ACCESS BIL TREE S|Blue Cross PPO Specialty|BCBSTX OTHER|43.63||||||| 47552|EAP|0361|IR-ENDOSCOPY BILIARY T-TU|Humana Medicare Advantage|HUMANA MA|73.32||||||| 476|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W/O CC/MCC|Medicare|MEDICARE ACUTE|35,485.10|7675.07|7807.35|7675.07|||| 476|DRG||AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|38,086.59|7807.35|7807.35|7675.07|||| 477|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|164,594.10|374.22|147746.9|374.22|||| 477|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|287,579.26|1346.52|147746.9|374.22|||| 477|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|120,801.42|16750.58|147746.9|374.22|||| 477|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|167,780.01|27381.92|147746.9|374.22|||| 477|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|214,500.72|26967.56|147746.9|374.22|||| 477|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Humana Medicare Advantage|HUMANA MA|143,760.66|19409.88|147746.9|374.22|||| 477|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|147,746.90|147746.9|147746.9|374.22|||| 477|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Medicaid|SMITH COUNTY JAIL|300,485.55|39008.89|147746.9|374.22|||| 477|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Medicare|MEDICARE ACUTE|149,042.51|19296.03|147746.9|374.22|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Medicare|MEDICARE ACUTE|115,213.63|13998.68|74051.47|5648.77|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Medicaid|SMITH COUNTY JAIL|80,234.10|5648.77|74051.47|5648.77|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|74,112.22|13998.68|74051.47|5648.77|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|147,331.82|14264.34|74051.47|5648.77|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|United Medicare Advantage|UHC AARP MCR HMO MA|104,634.11|14264.34|74051.47|5648.77|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|NON CONTRACTED|COMMERCIAL OTHER 1|74,051.47|74051.47|74051.47|5648.77|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Humana Medicare Advantage|HUMANA MA|86,267.74|12423.92|74051.47|5648.77|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|65,455.26|7360.55|74051.47|5648.77|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Managed Medicare|HEALTHSPRING MA|67,676.80|13997.8|74051.47|5648.77|||| 478|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Blue Cross PPO Specialty|BCBSTX PPO|61,993.01|15475.77|74051.47|5648.77|||| 479|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|52,742.51|12208.42|12208.42|11061.34|||| 479|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|70,714.90|11061.94|12208.42|11061.34|||| 479|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58,807.60|11061.34|12208.42|11061.34|||| 479|DRG||BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC|Medicare|MEDICARE ACUTE|121,023.83|11267.25|12208.42|11061.34|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|192,031.80|13337.85|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Medicare|MEDICARE ACUTE|115,044.42|17819.31|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|123,936.62|17866.83|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|152,523.69|18230.81|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|135,646.80|18194.32|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Managed Medicare|HEALTHSPRING MA|65,960.84|15875.575|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Managed Medicare|BCBS MEDICARE PPO MA|122,675.15|18194.32|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|126,407.31|25226.27|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Humana Medicare Advantage|HUMANA MA|99,573.24|17847.42|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|186,876.74|20576.42|25226.27|13337.85|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Blue Cross PPO Specialty|BCBSTX PPO|117,609.51|20576.42|25226.27|13337.85|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Workers Compensation|WORKERS COMPENSATION OTHER|104,768.46|18560.74|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|79,712.83|12455.295|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Veterans Affairs|VETERANS ADMINISTRATION|103,272.30|12740.42|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Aetna|AETNA PPO|94,224.05|31782.17|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|72,293.06|120.77|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Blue Cross PPO Specialty|BCBSTX PPO|113,374.84|14003.02|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|87,150.35|13894.3|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|200,060.71|13894.3|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|353,274.45|66508.89|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Humana Medicare Advantage|HUMANA MA|109,899.96|12743.96|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Cigna|CIGNA|121,895.54|32970.21|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Managed Medicare|HEALTHSPRING MA|118,408.94|12603.015|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|92,620.60|12739.54|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|PHCS|HUMANA|87,003.41|12979.54|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|NON CONTRACTED|COMMERCIAL OTHER 1|205,435.29|205435.29|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|82,255.91|12979.54|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|United Medicare Advantage|UHC AARP MCR HMO MA|83,957.08|12447.28|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|71,881.85|12447.28|205435.29|120.77|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Medicare|MEDICARE ACUTE|85,735.80|12739.54|205435.29|120.77|||| 48102|EAP|0360|CT-NEEDLE BIOPSY PANCREAS|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||50.58||| 48102|EAP|0360|CT-NEEDLE BIOPSY PANCREAS|Medicaid|MEDICAID|50.58||||||| 48102|EAP|0360|CT-NEEDLE BIOPSY PANCREAS|Medicare|MEDICARE ACUTE|50.58||||50.58||| 48102|EAP|0360|CT-NEEDLE BIOPSY PANCREAS|Humana Medicare Advantage|HUMANA MA|50.58||||||| 48102|EAP|0360|CT-NEEDLE BIOPSY PANCREAS|Blue Cross PPO Specialty|BCBSTX PPO|||||50.58||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|83,933.95|10500.19|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|52,336.12|15043.72|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|58,459.53|14745.31|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|108,178.64|9607.49|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|103,409.49|11301.95|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|70,068.97|10312.28|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|79,752.77|10314.875|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|298.88|102.9|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Cigna|CIGNA|42,691.11|24741.89|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|112,965.90|23099.77|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|129,613.47|10500.19|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|83,530.44|10392.155|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|46,697.35|46697.35|46697.35|102.9|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Medicare|MEDICARE ACUTE|66,765.30|10312.28|46697.35|102.9|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Medicaid|MOLINA HEALTHCARE OF TEXAS|125,639.54|6827.16|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Medicare|MEDICARE ACUTE|111,231.81|14410.22|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|NON CONTRACTED|COMMERCIAL OTHER 1|127,753.40|127753.4|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|United Medicare Advantage|UHC MEDICARE GOLD MA|111,707.59|14684.57|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|United Medicare Advantage|UHC AARP MCR HMO MA|103,162.64|14699.035|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|104,226.27|14410.22|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|124,472.02|15337.97|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Humana Medicare Advantage|HUMANA MA|103,042.93|14387.66|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Managed Medicare|HEALTHSPRING MA|109,184.52|14547.395|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Blue Cross PPO Specialty|BCBSTX PPO|121,804.10|16183.97|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Aetna|AETNA PPO|134,918.10|14409.34|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|100,778.31|71.44|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Blue Cross HMO Specialty|BCBSTX HMO|133,059.14|13757.56|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Aenta Medicare Advantage|AETNA MEDICARE MA|116,530.43|14684.57|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|98,186.50|40948.73|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Workers Compensation|WORKERS COMPENSATION OTHER|130,718.98|20606.61|127753.4|71.44|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Veterans Affairs|VETERANS ADMINISTRATION|129,679.86|14684.57|127753.4|71.44|||| 485|DRG||KNEE PROCEDURES W PDX OF INFECTION W MCC|Humana Medicare Advantage|HUMANA MA|345,592.78|19247.52|19247.52|19247.52|||| 486|DRG||KNEE PROCEDURES W PDX OF INFECTION W CC|United Healthcare|UNITED HEALTHCARE|239,846.95|76970.5|259498.97|13331.42|||| 486|DRG||KNEE PROCEDURES W PDX OF INFECTION W CC|NON CONTRACTED|COMMERCIAL OTHER 1|259,498.97|259498.97|259498.97|13331.42|||| 486|DRG||KNEE PROCEDURES W PDX OF INFECTION W CC|Medicare|MEDICARE ACUTE|301,098.08|13331.42|259498.97|13331.42|||| 486|DRG||KNEE PROCEDURES W PDX OF INFECTION W CC|Aetna|AETNA QHP HMO|108,796.11|37166.99|259498.97|13331.42|||| 486|DRG||KNEE PROCEDURES W PDX OF INFECTION W CC|Blue Cross PPO Specialty|BCBSTX PPO|148,439.82|15062.94|259498.97|13331.42|||| 487|DRG||KNEE PROCEDURES W PDX OF INFECTION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|75,907.75|8474.98|8474.98|8474.98|||| 488|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|160,799.35|53871.6|53871.6|68.04|||| 488|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|156,355.38|12193.35|53871.6|68.04|||| 488|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36,786.69|68.04|53871.6|68.04|||| 489|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC|Tricare|TRICARE EAST REGION|100,573.84|7994.39|8335.72|7994.39|||| 489|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|79,068.06|8335.72|8335.72|7994.39|||| 49082|EAP|0450|ER ABD PARACENTESIS W/O G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.81||||||| 49082|EAP|0761|ABD PARACENTESIS|Cigna|CIGNA OTHER|26.81||||||| 49082|EAP|0761|ABD PARACENTESIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.81||||||| 49082|EAP|0761|ABD PARACENTESIS|United Medicare Advantage|UHC AARP MCR HMO MA|26.81||||||| 49082|EAP|0761|ABD PARACENTESIS|Medicaid|SMITH COUNTY JAIL|||||26.81||| 49082|EAP|0450|ER ABD PARACENTESIS W/O G|Medicaid|SMITH COUNTY JAIL|||||18.24||| 49082|EAP|0761|ABD PARACENTESIS|Medicaid|MEDICAID|26.81||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|UTMB|UTMB CORRECTIONAL MANAGED CARE|21.41||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|United Healthcare|UNITED HEALTHCARE|21.41||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Medicare|MEDICARE PART B ONLY IP|21.41||||||| 49083|EAP|0450|ER ABD PARACENTESIS W GUI|Medicare|MEDICARE ACUTE|9.67||||9.67||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|NON CONTRACTED|COMMERCIAL OTHER 1|21.41||||21.41||| 49083|EAP|0450|ER ABD PARACENTESIS W GUI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.67||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|21.41||||||| 49083|EAP|0450|ER ABD PARACENTESIS W GUI|Medicaid|MEDICAID|||||9.67||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Medicaid|SMITH COUNTY JAIL|21.41||||21.41||| 49083|EAP|0450|ER ABD PARACENTESIS W GUI|Medicaid|SMITH COUNTY JAIL|||||9.67||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Medicaid|MEDICAID|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Veterans Affairs|VETERANS ADMINISTRATION|21.41||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21.41||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Access Direct Platinum|HEALTHFIRST TPA|21.41||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|United Medicare Advantage|UHC AARP MCR HMO MA|21.41||||||| 49083|EAP|0450|ER ABD PARACENTESIS W GUI|United Medicare Advantage|UHC MEDICARE GOLD MA|9.67||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.41||||21.41||| 49083|EAP|0450|ER ABD PARACENTESIS W GUI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.67||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|United Medicare Advantage|UHC MEDICARE GOLD MA|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Managed Medicare|HEALTHSPRING MA|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Medicare|MEDICARE ACUTE|21.41||||21.41||| 49083|EAP|0450|ER ABD PARACENTESIS W GUI|Blue Cross PPO Specialty|BCBSTX PPO|9.67||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Blue Cross PPO Specialty|BCBSTX PPO|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Blue Cross HMO Specialty|BCBSTX HMO|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Aenta Medicare Advantage|AETNA MEDICARE MA|21.41||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|United Healthcare|UNITED HEALTHCARE OTHER|||||21.41||| 49083|EAP|0350|CT-ABD PARACENTESIS W/IMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||27.60||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Humana Medicare Advantage|HUMANA MA|21.41||||21.41||| 49083|EAP|0350|CT-ABD PARACENTESIS W/IMA|Humana Medicare Advantage|HUMANA MA|||||27.60||| 49083|EAP|0450|ER ABD PARACENTESIS W GUI|Humana Medicare Advantage|HUMANA MA|||||9.67||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Cigna|CIGNA OTHER|21.41||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|ChampVA|CHAMPVA CENTER|||||21.41||| 49083|EAP|0450|ER ABD PARACENTESIS W GUI|Managed Medicaid|MEDICAID SUPERIOR|||||9.67||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Managed Medicaid|MEDICAID SUPERIOR|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Managed Medicaid|MEDICAID AMERIGROUP|21.41||||||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.41||||21.41||| 49083|EAP|0361|US ABD PARACENTESIS W/IMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.41||||21.41||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,915.75||||3,915.75||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||34.05||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Cigna|CIGNA|3,915.75||||||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Humana Medicare Advantage|HUMANA MA|2,602.38||||3,915.75||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Aenta Medicare Advantage|AETNA MEDICARE MA|34.05||||||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Blue Cross HMO Specialty|BCBSTX HMO|||||3,915.75||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Blue Cross PPO Specialty|BCBSTX PPO|3,915.75||||34.05||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||34.05||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,915.75||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,915.75||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Veterans Affairs|VETERANS ADMINISTRATION|||||34.05||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Medicaid|MEDICAID|34.05||||34.05||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||34.05||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Rusk State Hospital|RUSK STATE HOSP|||||3,915.75||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|NON CONTRACTED|COMMERCIAL OTHER 1|3,915.75||||3,915.75||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|Medicare|MEDICARE ACUTE|34.05||||3,915.75||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|United Healthcare|UNITED HEALTHCARE OTHER|||||3,915.75||| 49180|EAP|0360|CT-BIOPSY ABDOMINAL MASS|United Healthcare|UNITED HEALTHCARE|||||3,915.75||| 49185|EAP|0361|CT-SCLEROTX FLUID COLLECT|Medicare|MEDICARE ACUTE|18.54||||15.55||| 49185|EAP|0361|IR-SCLEROTX FLUID COLLECT|Medicare|MEDICARE ACUTE|18.54||||18.54||| 49185|EAP|0361|CT-SCLEROTX FLUID COLLECT|Blue Cross PPO Specialty|BCBSTX PPO|||||15.55||| 492|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|97,800.25|26253.99|27764.57|15447.56|||| 492|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W MCC|Managed Medicaid|MEDICAID SUPERIOR|233,423.02|23341.09|27764.57|15447.56|||| 492|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|97,475.94|27764.57|27764.57|15447.56|||| 492|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|57,372.25|23341.09|27764.57|15447.56|||| 492|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W MCC|Humana Medicare Advantage|HUMANA MA|142,261.35|18488.74|27764.57|15447.56|||| 492|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W MCC|Blue Cross PPO Specialty|BCBSTX PPO|108,311.99|23021.49|27764.57|15447.56|||| 492|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W MCC|Medicare|MEDICARE PART B ONLY IP|75,017.83|15447.56|27764.57|15447.56|||| 492|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W MCC|Medicare|MEDICARE ACUTE|126,743.90|20181.74|27764.57|15447.56|||| 492|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|94,824.76|24097.31|27764.57|15447.56|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|PHCS|HUMANA|181,005.90|140.43|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|94,916.81|14047.765|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|United Healthcare|UNITED HEALTHCARE OTHER|116,989.75|27246.47|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Medicare|MEDICARE PART B ONLY IP|145,615.07|5587.595|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Medicare|MEDICARE ACUTE|120,644.08|13915.81|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|163,246.15|374.22|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Blue Cross HMO Specialty|BCBSTX HMO|127,369.12|12646.815|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|146,799.35|15251.02|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Blue Cross PPO Specialty|BCBSTX PPO|230,729.64|16318.59|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Managed Medicare|HEALTHSPRING MA|158,343.15|13919.61|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Humana Medicare Advantage|HUMANA MA|150,957.90|14066.42|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Cigna|CIGNA|132,994.55|44039.21|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|170,912.48|25361.505|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Veterans Affairs|VETERANS ADMINISTRATION|124,414.12|14207.56|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|199,880.15|53366.21|53366.21|140.43|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Workers Compensation|WORKERS COMPENSATION OTHER|71,841.05|19898.35|53366.21|140.43|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|162,333.02|9960.68|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|54,287.92|16749.45|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|33,674.55|13994.6|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|174,828.31|11195.56|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|51,509.49|99.34|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|91,526.30|17610.57|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97,087.69|12369.415|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Cigna|CIGNA|227,370.90|58982.79|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|142,571.15|11222.84|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|82,725.50|11430.85|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|76,212.90|11908.98|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|158,731.13|142.88|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|109,946.12|10123.51|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Medicaid|LAW ENFORCEMENT OTHER|103,655.10|6247.8|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Medicaid|MEDICAID|121,014.75|9311.21|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|82,288.58|7779.505|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|75,880.74|358.69|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Medicare|MEDICARE ACUTE|90,947.74|11222.84|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|100,978.70|11223.28|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|52,731.30|30793.8|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Multiplan|WEB TPA|108,162.26|80040.07|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 2|110,447.10|110447.1|110447.1|99.34|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Tricare|TRICARE FOR LIFE|109,623.39|10878.59|110447.1|99.34|||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|NON CONTRACTED|COMMERCIAL OTHER 1|94.29||||||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|Medicare|MEDICARE ACUTE|94.29||||94.29||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|Medicaid|MEDICAID|94.29||||||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|Aetna|AETNA PPO|||||94.29||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|94.29||||||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|Blue Cross PPO Specialty|BCBSTX PPO|94.29||||||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|Blue Cross HMO Specialty|BCBSTX HMO|94.29||||||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|94.29||||||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|United Medicare Advantage|UHC MEDICARE GOLD MA|94.29||||||| 49405|EAP|0360|CT-IMAGE CATH FLUID COLXN|United Medicare Advantage|UHC AARP MCR HMO MA|94.29||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Veterans Affairs|VETERANS ADMINISTRATION|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|94.24||||94.24||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Cigna|CIGNA|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Cigna|CIGNA OTHER|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Humana Medicare Advantage|HUMANA MA|94.24||||94.24||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Managed Medicaid|MEDICAID SUPERIOR|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|94.24||||94.24||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Blue Cross HMO Specialty|BCBSTX HMO|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Brinson Benefits|THE HEALTH PLAN SMITH CO|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Blue Cross PPO Specialty|BCBSTX PPO|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|94.24||||94.24||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Access Direct Platinum|HEALTHFIRST TPA|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Aetna|AETNA PPO|94.24||||94.24||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Aetna|AETNA OTHER|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Managed Medicare|OTHER INSTITUTIONS|||||94.24||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Managed Medicare|HEALTHSPRING MA|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Medicaid|CRIME VICTIMS COMPENSATION|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Medicaid|MEDICAID|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Medicaid|COUNTY INDIGENT HEALTH OTHER|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|United Healthcare|UNITED HEALTHCARE OTHER|94.24||||||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|Medicare|MEDICARE ACUTE|94.24||||94.24||| 49406|EAP|0361|IR-IMAGE CATH FLUID PERI/|Medicare|MEDICARE ACUTE|70.46||||94.24||| 49406|EAP|0361|CT-IMAGE CATH FLUID PERI/|NON CONTRACTED|COMMERCIAL OTHER 1|94.24||||94.24||| 49418|EAP|0361|IR-INSERT IP CATH DRAIN/D|Medicare|MEDICARE ACUTE|17,814.65||||154.91||| 49418|EAP|0361|IR-INSERT IP CATH DRAIN/D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||154.91||| 49418|EAP|0361|IR-INSERT IP CATH DRAIN/D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17,814.65||||||| 49423|EAP|0361|IR-ABSCESS CATH CHANGE|Medicare|MEDICARE ACUTE|17.83||||17.83||| 49424|EAP|0361|IR-ABSCESS CATH INJECTION|Medicare|MEDICARE ACUTE|||||9.31||| 49440|EAP|0361|IR-INSERT GASTRO TUBE PER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|485.70||||||| 49440|EAP|0361|IR-INSERT GASTRO TUBE PER|Blue Cross PPO Specialty|BCBSTX PPO|||||42.18||| 49440|EAP|0361|IR-INSERT GASTRO TUBE PER|Medicare|MEDICARE ACUTE|2,351.85||||||| 49446|EAP|0361|IR-CONVERT G-TUBE TO GJ-T|Managed Medicare|HEALTHSPRING MA|5,525.75||||||| 49446|EAP|0361|IR-CONVERT G-TUBE TO GJ-T|Medicare|MEDICARE ACUTE|5,165.38||||||| 49446|EAP|0361|IR-CONVERT G-TUBE TO GJ-T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|48.05||||||| 49446|EAP|0361|IR-CONVERT G-TUBE TO GJ-T|Humana Medicare Advantage|HUMANA MA|48.05||||||| 49451|EAP|0361|IR-REPLACE DUODENOSTOMY/J|Humana Medicare Advantage|HUMANA MA|30.53||||||| 49452|EAP|0361|IR-RPLCMNT EXISTING G/J-T|Tricare|TRICARE EAST REGION|||||3,459.20||| 49452|EAP|0361|IR-RPLCMNT EXISTING G/J-T|Medicare|MEDICARE ACUTE|3,459.20||||3,459.20||| 49452|EAP|0361|IR-RPLCMNT EXISTING G/J-T|Medicaid|MEDICAID HMO|||||3,459.20||| 49452|EAP|0361|IR-RPLCMNT EXISTING G/J-T|Managed Medicare|HEALTHSPRING MA|3,459.20||||||| 49452|EAP|0361|IR-RPLCMNT EXISTING G/J-T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,459.20||| 49452|EAP|0361|IR-RPLCMNT EXISTING G/J-T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30.08||||||| 49452|EAP|0361|IR-RPLCMNT EXISTING G/J-T|Blue Cross PPO Specialty|BCBSTX PPO|||||30.08||| 49452|EAP|0361|IR-RPLCMNT EXISTING G/J-T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,459.20||||3,459.20||| 49452|EAP|0361|IR-RPLCMNT EXISTING G/J-T|Humana Medicare Advantage|HUMANA MA|30.08||||||| 49460|EAP|0361|IR-REMOV OBSTRUC W/FLUOR|Medicare|MEDICARE ACUTE|16.06||||||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Cigna|CIGNA OTHER|||||14.83||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Humana Medicare Advantage|HUMANA MA|1,705.45||||14.83||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,705.45||||1,705.45||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,705.45||||1,705.45||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Aenta Medicare Advantage|AETNA MEDICARE MA|||||14.83||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.83||||14.83||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Blue Cross PPO Specialty|BCBSTX PPO|14.83||||||| 49465|EAP|0361|IR-INJECT-CONTRAST G/D/J/|Blue Cross PPO Specialty|BCBSTX PPO|||||13.55||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|United Medicare Advantage|UHC MEDICARE GOLD MA|1,705.45||||14.83||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,705.45||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,705.45||| 49465|EAP|0361|IR-INJECT-CONTRAST G/D/J/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,558.25||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Veterans Affairs|VETERANS ADMINISTRATION|||||14.83||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|14.83||||||| 49465|EAP|0361|IR-INJECT-CONTRAST G/D/J/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,558.25||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|14.83||||||| 49465|EAP|0361|IR-INJECT-CONTRAST G/D/J/|Humana Medicare Advantage|HUMANA MA|13.55||||||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|14.83||||||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Managed Medicare|HEALTHSPRING MA|14.83||||14.83||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Managed Medicare|BCBS MEDICARE PPO MA|14.83||||||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,705.45||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Medicaid|MEDICAID HMO|||||14.83||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Medicaid|MEDICAID|14.83||||||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|United Healthcare|TML GROUP BENEFITS|1,705.45||||||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Tricare|TRICARE EAST REGION|||||1,705.45||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|NON CONTRACTED|COMMERCIAL OTHER 1|1,594.23||||||| 49465|EAP|0361|IR-INJECT-CONTRAST G/D/J/|Medicare|MEDICARE ACUTE|1,558.25||||||| 49465|EAP|0360|XR-FLURO EXAM OF G/COLON|Medicare|MEDICARE ACUTE|14.83||||1,705.45||| 495|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W MCC|Medicare|MEDICARE ACUTE|73,721.75|178.48|19874.66|178.48|||| 495|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W MCC|Blue Cross PPO Specialty|BCBSTX PPO|358,600.63|2580.83|19874.66|178.48|||| 495|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W MCC|Managed Medicaid|MEDICAID AMERIGROUP|157,353.05|19874.66|19874.66|178.48|||| 496|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC|Humana Medicare Advantage|HUMANA MA|75,446.54|12451.95|24151.36|11285.68|||| 496|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|78,379.30|14595.83|24151.36|11285.68|||| 496|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC|Managed Medicaid|MEDICAID AMERIGROUP|121,211.22|11828.95|24151.36|11285.68|||| 496|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC|ChampVA|CHAMPVA CENTER|54,210.57|11285.68|24151.36|11285.68|||| 496|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC|Blue Cross PPO Specialty|BCBSTX PPO|96,440.05|13314.51|24151.36|11285.68|||| 496|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC|United Healthcare|UNITED HEALTHCARE OTHER|84,725.97|24151.36|24151.36|11285.68|||| 496|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC|Medicare|MEDICARE ACUTE|126,142.96|12714.52|24151.36|11285.68|||| 497|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W/O CC/MCC|Medicare|MEDICARE ACUTE|35,754.55|9346.06|9350.28|9346.06|||| 497|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|185,911.88|9350.28|9350.28|9346.06|||| 498|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|136,275.75|15313.34|29883.88|15313.34|||| 498|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|193,437.67|29883.88|29883.88|15313.34|||| 498|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC|Humana Medicare Advantage|HUMANA MA|220,347.19|15484.07|29883.88|15313.34|||| 498|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC|Medicare|MEDICARE ACUTE|245,523.02|15644.11|29883.88|15313.34|||| 499|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|63,682.18|194.27|194.27|194.27|||| 500|DRG||SOFT TISSUE PROCEDURES W MCC|Workers Compensation|TEXAS MUTUAL INSURANCE|223,987.05|25494.73|25494.73|16451.15|||| 500|DRG||SOFT TISSUE PROCEDURES W MCC|Blue Cross HMO Specialty|BCBSTX HMO|170,362.85|16556.72|25494.73|16451.15|||| 500|DRG||SOFT TISSUE PROCEDURES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|38,942.32|19477.45|25494.73|16451.15|||| 500|DRG||SOFT TISSUE PROCEDURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|271,696.15|17828.48|25494.73|16451.15|||| 500|DRG||SOFT TISSUE PROCEDURES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|141,862.11|16451.15|25494.73|16451.15|||| 500|DRG||SOFT TISSUE PROCEDURES W MCC|Medicare|MEDICARE ACUTE|122,979.03|17871.105|25494.73|16451.15|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Medicaid|CRIME VICTIMS COMPENSATION|55,652.50|5397.18|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Medicare|MEDICARE ACUTE|60,504.50|10491.71|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|82,419.01|10654.77|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|94,979.81|10683.41|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|55,185.16|10683.41|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Cigna|CIGNA OTHER|77,227.04|17266.62|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|49,392.20|10474.735|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Managed Medicaid|MEDICAID AMERIGROUP|153,227.67|27381.92|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|142,399.23|11457.45|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|101,169.71|11118.97|27381.92|5397.18|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Workers Compensation|BROOKSHIRES WORKERS COMP|111,299.48|15001.88|27381.92|5397.18|||| 502|DRG||SOFT TISSUE PROCEDURES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|55,358.98|35.72|11828.95|35.72|||| 502|DRG||SOFT TISSUE PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|69,389.06|11828.95|11828.95|35.72|||| 502|DRG||SOFT TISSUE PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|100,256.69|8519.855|11828.95|35.72|||| 502|DRG||SOFT TISSUE PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|72,391.67|8681.42|11828.95|35.72|||| 502|DRG||SOFT TISSUE PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38,151.10|8502.92|11828.95|35.72|||| 502|DRG||SOFT TISSUE PROCEDURES W/O CC/MCC|Medicaid|SMITH COUNTY JAIL|52,775.30|5422.3|11828.95|35.72|||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||47.87||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Medicare|MEDICARE ACUTE|5,146.03||||5,505.05||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|NON CONTRACTED|COMMERCIAL OTHER 1|||||5,505.05||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Tricare|TRICARE EAST REGION|||||47.87||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|United Medicare Advantage|UHC MEDICARE GOLD MA|5,505.05||||||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5,146.03||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5,146.03||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Medicaid|MEDICAID|47.87||||||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||47.87||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||47.87||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Workers Compensation|WORKERS COMPENSATION OTHER|||||47.87||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Veterans Affairs|VETERANS ADMINISTRATION|||||47.87||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,146.03||||||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||47.87||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Cigna|CIGNA|||||5,505.05||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Humana Medicare Advantage|HUMANA MA|||||5,505.05||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Blue Cross PPO Specialty|BCBSTX PPO|47.87||||47.87||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,146.03||||||| 50200|EAP|0360|CT-RENAL BIOPSY PERQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,505.05||||47.87||| 503|DRG||FOOT PROCEDURES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|102,993.40|16502.76|16502.76|16502.76|||| 50382|EAP|0361|IR-REM/RPLC URETERAL STEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||116.42||| 50389|EAP|0361|IR-REMOVE RENAL TUBE W/FL|Medicare|MEDICARE ACUTE|26.16||||||| 504|DRG||FOOT PROCEDURES W CC|Aetna|AETNA OTHER|51,071.24|21966.72|21966.72|10811.84|||| 504|DRG||FOOT PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|30,286.14|11743.31|21966.72|10811.84|||| 504|DRG||FOOT PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|67,112.96|14565.88|21966.72|10811.84|||| 504|DRG||FOOT PROCEDURES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|22,325.71|20553.21|21966.72|10811.84|||| 504|DRG||FOOT PROCEDURES W CC|Veterans Affairs|VETERANS ADMINISTRATION|217,215.40|10812.72|21966.72|10811.84|||| 504|DRG||FOOT PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|36,286.78|13873.29|21966.72|10811.84|||| 504|DRG||FOOT PROCEDURES W CC|Medicare|MEDICARE ACUTE|129,950.17|10811.84|21966.72|10811.84|||| 504|DRG||FOOT PROCEDURES W CC|United Healthcare|UNITED HEALTHCARE OTHER|92,779.80|20553.21|21966.72|10811.84|||| 50430|EAP|0361|IR-NJX PX NFROSGRM &/URTR|Medicare|MEDICARE ACUTE|||||868.32||| 50431|EAP|0361|XR-NJX PX NFROSGRM &/URTR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.38||||||| 50431|EAP|0361|XR-NJX PX NFROSGRM &/URTR|United Medicare Advantage|UHC MEDICARE GOLD MA|993.28||||||| 50431|EAP|0361|XR-NJX PX NFROSGRM &/URTR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.38||| 50431|EAP|0361|XR-NJX PX NFROSGRM &/URTR|Humana Medicare Advantage|HUMANA MA|||||9.38||| 50431|EAP|0361|XR-NJX PX NFROSGRM &/URTR|Blue Cross PPO Specialty|BCBSTX PPO|993.28||||993.28||| 50431|EAP|0361|IR-NJX PX NFROSGRM &/URTR|Managed Medicare|BCBS MEDICARE PPO MA|||||868.32||| 50431|EAP|0361|XR-NJX PX NFROSGRM &/URTR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.38||| 50431|EAP|0361|XR-NJX PX NFROSGRM &/URTR|Medicare|MEDICARE ACUTE|993.28||||||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|NON CONTRACTED|COMMERCIAL OTHER 1|||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|PHCS|GROUP AND PENSION|21.79||||||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|Medicare|MEDICARE ACUTE|21.79||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|United Healthcare|UNITED HEALTHCARE|21.79||||||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|Blue Cross PPO Specialty|BCBSTX PPO|21.79||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|Humana Medicare Advantage|HUMANA MA|21.79||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.79||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|United Medicare Advantage|UHC MEDICARE GOLD MA|21.79||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||21.79||| 50432|EAP|0361|IR-PLMT NEPHROSTOMY CATHE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21.79||||||| 50433|EAP|0361|IR-PLMT NEPHROURETE CATHE|Blue Cross PPO Specialty|BCBSTX PPO|||||21.79||| 50433|EAP|0361|IR-PLMT NEPHROURETE CATHE|Medicare|MEDICARE ACUTE|21.79||||21.79||| 50433|EAP|0361|IR-PLMT NEPHROURETE CATHE|NON CONTRACTED|COMMERCIAL OTHER 1|||||21.79||| 50435|EAP|0361|IR-EXCHANGE NEPHROSTOMY C|Managed Medicare|BCBS MEDICARE PPO MA|||||3,539.70||| 50435|EAP|0361|IR-EXCHANGE NEPHROSTOMY C|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||30.78||| 50435|EAP|0361|IR-EXCHANGE NEPHROSTOMY C|Medicare|MEDICARE ACUTE|3,539.70||||30.78||| 50435|EAP|0510|EXCHANGE NEPHROSTOMY CATH|Medicare|MEDICARE ACUTE|||||19.95||| 50435|EAP|0361|IR-EXCHANGE NEPHROSTOMY C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||30.78||| 50435|EAP|0361|IR-EXCHANGE NEPHROSTOMY C|Blue Cross PPO Specialty|BCBSTX PPO|3,539.70||||||| 505|DRG||FOOT PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|59,551.21|10726.84|15904.71|9589.01|||| 505|DRG||FOOT PROCEDURES W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|49,586.95|15030.61|15904.71|9589.01|||| 505|DRG||FOOT PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|60,328.75|15904.71|15904.71|9589.01|||| 505|DRG||FOOT PROCEDURES W/O CC/MCC|Tricare|TRICARE EAST REGION|48,230.95|9589.01|15904.71|9589.01|||| 505|DRG||FOOT PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|96,327.30|10703.01|15904.71|9589.01|||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Managed Medicare|HEALTHSPRING MA|||||1,028.69||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|United Healthcare|UNITED HEALTHCARE|||||1,028.69||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|United Healthcare|UNITED HEALTHCARE|||||110,584.18||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Medicare|MEDICARE ACUTE|110,584.18||||118,299.35||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,028.69||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,028.69||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Tricare|TRICARE EAST REGION|||||118,299.35||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|United Medicare Advantage|UHC AARP MCR HMO MA|||||118,299.35||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|118,299.35||||118,299.35||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Access Direct Platinum|HEALTHFIRST TPA|||||1,028.69||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Access Direct Platinum|HEALTHFIRST TPA UMR|||||110,584.18||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,028.69||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||118,299.35||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118,299.35||||||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Managed Medicaid|MEDICAID SUPERIOR|||||1,028.69||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Humana Medicare Advantage|HUMANA MA|||||118,299.35||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Aetna|AETNA PPO|||||118,299.35||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||118,299.35||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Blue Cross PPO Specialty|BCBSTX PPO|||||118,299.35||| 50590|EAP|0790|ESWL EXTRACORPOREAL SHOCK|Blue Cross HMO Specialty|BCBSTX HMO|||||1,028.69||| 50592|EAP|0361|CT-PERC RF ABLATE RENAL T|Blue Cross HMO Specialty|BCBSTX HMO|||||32,135.60||| 50592|EAP|0361|CT-PERC RF ABLATE RENAL T|Blue Cross PPO Specialty|BCBSTX PPO|||||32,135.60||| 50592|EAP|0361|CT-PERC RF ABLATE RENAL T|Humana Medicare Advantage|HUMANA MA|||||279.44||| 506|DRG||MAJOR THUMB OR JOINT PROCEDURES|Medicare|MEDICARE ACUTE|77,074.85|8628.44|8629.32|8628.44|||| 506|DRG||MAJOR THUMB OR JOINT PROCEDURES|Managed Medicare|HEALTHSPRING MA|65,516.89|8629.32|8629.32|8628.44|||| 50693|EAP|0361|IR-PLMT URETERAL STENT PR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|44.94||||||| 50693|EAP|0361|IR-PLMT URETERAL STENT PR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||44.94||| 50693|EAP|0361|IR-PLMT URETERAL STENT PR|United Medicare Advantage|UHC MEDICARE GOLD MA|44.94||||||| 50693|EAP|0361|IR-PLMT URETERAL STENT PR|Humana Medicare Advantage|HUMANA MA|||||44.94||| 50693|EAP|0361|IR-PLMT URETERAL STENT PR|Medicare|MEDICARE ACUTE|44.94||||44.94||| 50694|EAP|0361|IR-PLMT URETERAL STENT PR|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||44.94||| 50694|EAP|0361|IR-PLMT URETERAL STENT PR|Medicare|MEDICARE ACUTE|||||44.94||| 50694|EAP|0361|IR-PLMT URETERAL STENT PR|Humana Medicare Advantage|HUMANA MA|||||44.94||| 50694|EAP|0361|IR-PLMT URETERAL STENT PR|Veterans Affairs|VETERANS ADMINISTRATION|||||44.94||| 50695|EAP|0361|IR-PLMT URETERAL STENT PR|United Medicare Advantage|UHC MEDICARE GOLD MA|44.94||||||| 50695|EAP|0361|IR-PLMT URETERAL STENT PR|Medicare|MEDICARE ACUTE|||||44.94||| 50695|EAP|0361|IR-PLMT URETERAL STENT PR|Managed Medicare|HEALTHSPRING MA|||||44.94||| 507|DRG||MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|298,353.77|13047.9|13047.9|13047.9|||| 510|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W MCC|Medicare|MEDICARE ACUTE|116,572.90|16902.82|16902.82|16902.82|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|Aetna|AETNA PPO|148,211.49|28266.58|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|74,856.60|35.72|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|Cigna|CIGNA|93,763.15|32776.92|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|Humana Medicare Advantage|HUMANA MA|60,582.60|7680.23|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|Managed Medicaid|MEDICAID SUPERIOR|67,893.50|7169.06|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|Workers Compensation|WORKERS COMPENSATION OTHER|52,956.69|16619.92|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|NON CONTRACTED|COMMERCIAL OTHER 1|246,669.93|34270.89|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|United Healthcare|UNITED HEALTHCARE OTHER|78,391.70|25927.39|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|130,147.85|11622.32|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|Medicare|MEDICARE ACUTE|121,531.36|11730.54|34270.89|35.72|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|Medicare|MEDICARE PART B ONLY IP|49,451.59|848.63|34270.89|35.72|||| 512|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|108,976.65|9590.7|10335.06|34.02|||| 512|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|116,194.65|9590.7|10335.06|34.02|||| 512|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|92,369.76|9569.04|10335.06|34.02|||| 512|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38,577.14|34.02|10335.06|34.02|||| 512|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|49,993.71|10335.06|10335.06|34.02|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|95,852.90|9937.16|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|60,954.55|13197.74|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|45,641.69|14468.81|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|79,983.34|11132.88|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|Humana Medicare Advantage|HUMANA MA|69,271.57|10013.965|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|Tricare|TRICARE EAST REGION|76,836.75|8233.06|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|United Healthcare|UNITED HEALTHCARE|49,607.32|18666.56|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|United Healthcare|UNITED HEALTHCARE|78,090.59|18666.56|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|Medicaid|CRIME VICTIMS COMPENSATION|140,864.25|10235.09|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|Medicaid|MEDICAID|109,793.95|5648.77|18666.56|5648.77|||| 513|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC|Medicare|MEDICARE ACUTE|63,307.12|10048.445|18666.56|5648.77|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|32,041.34|7258.8|16252.64|6788.64|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|34,122.12|7113.19|16252.64|6788.64|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47,598.80|9937.16|16252.64|6788.64|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|69,855.33|16252.64|16252.64|6788.64|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|60,321.81|7142.19|16252.64|6788.64|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|392.29|6788.64|16252.64|6788.64|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|54,038.53|10380.08|16252.64|6788.64|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|46,606.30|7136.97|16252.64|6788.64|||| 515|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118,020.72|285.76|61148.98|285.76|||| 515|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC|Blue Cross PPO Specialty|BCBSTX PPO|210,684.54|20926.78|61148.98|285.76|||| 515|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|945,045.40|61148.98|61148.98|285.76|||| 515|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC|Medicare|MEDICARE ACUTE|50,657.80|18591.02|61148.98|285.76|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Medicare|MEDICARE PART B ONLY IP|27,656.43|5017.49|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Medicare|MEDICARE ACUTE|56,509.28|11924.45|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|United Medicare Advantage|UHC AARP MCR HMO MA|59,523.80|10916.98|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|56,213.30|10889.7|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Veterans Affairs|VETERANS ADMINISTRATION|53,032.10|11924.45|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43,509.75|15285.74|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Workers Compensation|TEXAS MUTUAL INSURANCE|126,644.24|17050.7|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Managed Medicare|BCBS MEDICARE PPO MA|74,336.04|11908.49|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Managed Medicare|HEALTHSPRING MA|77,348.20|11923.57|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Humana Medicare Advantage|HUMANA MA|95,072.10|11924.35|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|64,736.66|12801.87|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Blue Cross PPO Specialty|BCBSTX PPO|82,427.65|12801.87|17050.7|34.02|||| 516|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|37,242.50|34.02|17050.7|34.02|||| 51600|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Aenta Medicare Advantage|AETNA MEDICARE MA|||||360.42||| 51600|EAP|0361|XR-INJECTION FOR BLADDER|Aetna|AETNA PPO|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Aetna|AETNA PPO|||||360.42||| 51600|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Blue Cross HMO Specialty|BCBSTX HMO|||||360.42||| 51600|EAP|0361|XR-INJECTION FOR BLADDER|Blue Cross PPO Specialty|BCBSTX PPO|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Blue Cross PPO Specialty|BCBSTX PPO|||||360.42||| 51600|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Blue Cross PPO Specialty|BCBSTX OTHER|||||360.42||| 51600|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Cigna|CIGNA OTHER|||||360.42||| 51600|EAP|0361|XR-INJECTION FOR BLADDER|Cigna|CIGNA|||||915.98||| 51600|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Managed Medicaid|MEDICAID AMERIGROUP|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||360.42||| 51600|EAP|0361|XR-INJECTION FOR BLADDER|Managed Medicaid|MEDICAID AMERIGROUP|||||915.98||| 51600|EAP|0361|XR-INJECTION FOR BLADDER|Managed Medicaid|MEDICAID SUPERIOR|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||360.42||| 51600|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Access Direct Platinum|HEALTHFIRST TPA UMR|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Access Direct Platinum|HEALTHFIRST TPA|||||360.42||| 51600|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|United Medicare Advantage|UHC MEDICARE GOLD MA|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|United Medicare Advantage|UHC AARP MCR HMO MA|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||360.42||| 51600|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Medicare|MEDICARE ACUTE|||||360.42||| 51600|EAP|0361||Medicare|MEDICARE ACUTE|||||8.65||| 51600|EAP|0361|XR-INJECTION FOR BLADDER|Medicare|UTSW MC KIDNEY PROGRAM|||||915.98||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|NON CONTRACTED|COMMERCIAL OTHER 1|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|PHCS|HUMANA INSURANCE|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Humana Medicare Advantage|HUMANA MA|||||360.42||| 51600|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|PHCS|HUMANA|||||360.42||| 51600|EAP|0361||PHCS|HUMANA|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Tricare|TRICARE FOR LIFE|||||360.42||| 51600|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||8.65||| 51600|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|United Healthcare|UNITED HEALTHCARE|||||360.42||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|United Healthcare|UNITED HEALTHCARE OTHER|||||360.42||| 51600|EAP|0361|XR-INJECTION FOR BLADDER|Managed Medicare|HEALTHSPRING MA|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Managed Medicare|HEALTHSPRING MA|||||360.42||| 51600|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.65||| 51600|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||8.65||| 51600|EAP|0510|INJECTION FOR BLADDER X-R|Medicaid|CRIME VICTIMS COMPENSATION|||||360.42||| 51600|EAP|0361|XR-INJECTION FOR BLADDER|Medicaid|CRIME VICTIMS COMPENSATION|8.65||||||| 51600|EAP|0361||Medicaid|MEDICAID|||||8.65||| 51610|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||8.65||| 51610|EAP|0361||Medicare|MEDICARE ACUTE|||||8.65||| 51610|EAP|0510|INJECTION FOR BLADDER X-R|Humana Medicare Advantage|HUMANA MA|||||360.42||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|76,107.01|25674.57|25674.57|34.02|||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|22,995.90|9376.31|25674.57|34.02|||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|66,514.94|34.02|25674.57|34.02|||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|Aetna|AETNA OTHER|53,786.01|20338.28|25674.57|34.02|||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|53,541.23|9211.47|25674.57|34.02|||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|57,022.05|9034.5|25674.57|34.02|||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|51,188.10|9049.32|25674.57|34.02|||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|60,778.56|16751.49|25674.57|34.02|||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|United Healthcare|UNITED HEALTHCARE ERS|111,653.09|16751.49|25674.57|34.02|||| 517|DRG||OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|102,498.42|9026.03|25674.57|34.02|||| 51700|EAP|0510|IRRIGATION OF BLADDER|NON CONTRACTED|COMMERCIAL OTHER 1|||||258.75||| 51700|EAP|0510|IRRIGATION OF BLADDER|Medicare|MEDICARE ACUTE|||||258.75||| 51700|EAP|0361||Medicare|MEDICARE ACUTE|6.21||||6.21||| 51700|EAP|0510|IRRIGATION OF BLADDER|United Healthcare|UNITED HEALTHCARE|||||258.75||| 51700|EAP|0510|IRRIGATION OF BLADDER|Managed Medicare|BCBS MEDICARE PPO MA|||||258.75||| 51700|EAP|0510|IRRIGATION OF BLADDER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||258.75||| 51700|EAP|0510|IRRIGATION OF BLADDER|Managed Medicare|HEALTHSPRING MA|||||258.75||| 51700|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.21||| 51700|EAP|0361||Medicaid|MEDICAID|||||6.21||| 51700|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.21||| 51700|EAP|0510|IRRIGATION OF BLADDER|Humana Medicare Advantage|HUMANA MA|||||258.75||| 51700|EAP|0510|IRRIGATION OF BLADDER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||258.75||| 51700|EAP|0510|IRRIGATION OF BLADDER|Blue Cross PPO Specialty|BCBSTX PPO|||||258.75||| 51700|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.21||| 51700|EAP|0510|IRRIGATION OF BLADDER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||258.75||| 51700|EAP|0510|IRRIGATION OF BLADDER|United Medicare Advantage|UHC AARP MCR HMO MA|||||258.75||| 51700|EAP|0510|IRRIGATION OF BLADDER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||258.75||| 51700|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||6.21||| 51700|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.21||| 51700|EAP|0510|IRRIGATION OF BLADDER|Access Direct Platinum|HEALTHFIRST TPA|||||258.75||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Veterans Affairs|VETERANS ADMINISTRATION|438.15||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Workers Compensation|WORKERS COMPENSATION OTHER|||||438.15||| 51701|EAP|0761|INSERT BLADDER CATHETER|Veterans Affairs|VETERANS ADMINISTRATION|6.10||||||| 51701|EAP|0761|INSERT BLADDER CATHETER|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.10||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|701.50||||701.50||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|438.15||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|Access Direct Platinum|HEALTHFIRST TPA|||||6.10||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Access Direct Platinum|HEALTHFIRST TPA|409.58||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.81||||3.81||| 51701|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.86||| 51701|EAP|0761|INSERT BLADDER CATHETER|United Medicare Advantage|UHC AARP MCR HMO MA|701.50||||701.50||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|438.15||||409.58||| 51701|EAP|0761|INSERT BLADDER CATHETER|United Medicare Advantage|UHC MEDICARE GOLD MA|6.10||||701.50||| 51701|EAP|0761|INSERT BLADDER CATHETER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.10||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|UHC AARP WELLMED HMO MA|438.15||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Aetna|AETNA PPO|438.15||||||| 51701|EAP|0761|INSERT BLADDER CATHETER|Aenta Medicare Advantage|AETNA MEDICARE MA|6.10||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Aetna|BOON CHAPMAN|438.15||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Aetna|AETNA OTHER|||||3.81||| 51701|EAP|0510|INSERT BLADDER CATHETER|Aenta Medicare Advantage|AETNA MEDICARE MA|||||117.17||| 51701|EAP|0761|INSERT BLADDER CATHETER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|655.75||||701.50||| 51701|EAP|0761|INSERT BLADDER CATHETER|Aetna|AETNA PPO|655.75||||||| 51701|EAP|0761|INSERT BLADDER CATHETER|Aetna|AETNA OTHER|701.50||||701.50||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross HMO Specialty|BCBSTX HMO|3.81||||438.15||| 51701|EAP|0761|INSERT BLADDER CATHETER|Blue Cross HMO Specialty|BCBSTX HMO|6.10||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross PPO Specialty|BCBSTX PPO|438.15||||438.15||| 51701|EAP|0761|INSERT BLADDER CATHETER|Blue Cross PPO Specialty|BCBSTX PPO|6.10||||701.50||| 51701|EAP|0761|INSERT BLADDER CATHETER|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.10||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|438.15||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID AMERIGROUP|3.81||||438.15||| 51701|EAP|0761|INSERT BLADDER CATHETER|Managed Medicaid|MEDICAID SUPERIOR|||||655.75||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID SUPERIOR|438.15||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|Managed Medicaid|MEDICAID AMERIGROUP|6.10||||701.50||| 51701|EAP|0761|INSERT BLADDER CATHETER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|701.50||||701.50||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|409.58||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|Cigna|CIGNA|701.50||||6.10||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Cigna|CIGNA|||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|Humana Medicare Advantage|HUMANA MA|701.50||||701.50||| 51701|EAP|0510|INSERT BLADDER CATHETER|Humana Medicare Advantage|HUMANA MA|||||117.17||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Humana Medicare Advantage|HUMANA MA|438.15||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Cigna|CIGNA OTHER|409.58||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||438.15||| 51701|EAP|0761|INSERT BLADDER CATHETER|Medicaid|MEDICAID HMO|||||6.10||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicaid|MEDICAID HMO|3.81||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicaid|MEDICAID|3.81||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.10||||701.50||| 51701|EAP|0761|INSERT BLADDER CATHETER|Medicaid|SMITH COUNTY JAIL|||||6.10||| 51701|EAP|0761|INSERT BLADDER CATHETER|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.10||||||| 51701|EAP|0761|INSERT BLADDER CATHETER|Medicaid|MEDICAID|6.10||||6.10||| 51701|EAP|0761|INSERT BLADDER CATHETER|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||6.10||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicaid|SUPERIOR HEALTHPLAN CHIP|438.15||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|438.15||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|Medicaid|MEDICAID BCBSTX|||||701.50||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicaid|SMITH COUNTY JAIL|3.81||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross PPO Specialty|BCBSTX OTHER|438.15||||409.58||| 51701|EAP|0761|INSERT BLADDER CATHETER|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||701.50||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||438.15||| 51701|EAP|0761|INSERT BLADDER CATHETER|Managed Medicare|HEALTHSPRING MA|6.10||||6.10||| 51701|EAP|0761|INSERT BLADDER CATHETER|Managed Medicare|BCBS MEDICARE PPO MA|655.75||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.81||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.81||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|HEALTHSPRING MA|3.81||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|OTHER INSTITUTIONS|||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.10||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|MA PART B ONLY IP|3.81||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|BCBS MEDICARE PPO MA|3.81||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Tricare|TRICARE EAST REGION|||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|UTMB|UTMB CORRECTIONAL MANAGED CARE|438.15||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Aenta Medicare Advantage|AETNA MEDICARE MA|3.81||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|Tricare|TRICARE EAST REGION|6.10||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Tricare|TRICARE FOR LIFE|||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|UHC AARP MCR HMO MA|438.15||||438.15||| 51701|EAP|0761|INSERT BLADDER CATHETER|UTMB|UTMB CORRECTIONAL MANAGED CARE|655.75||||||| 51701|EAP|0761|INSERT BLADDER CATHETER|United Healthcare|UNITED HEALTHCARE|6.10||||6.10||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|UHC MEDICARE GOLD MA|3.81||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|United Healthcare|UNITED HEALTHCARE|701.50||||6.10||| 51701|EAP|0761|INSERT BLADDER CATHETER|United Healthcare|GEHA|701.50||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Healthcare|UNITED HEALTHCARE OTHER|3.81||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Healthcare|UNITED HEALTHCARE|||||409.58||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Healthcare|TML GROUP BENEFITS|||||3.81||| 51701|EAP|0761|INSERT BLADDER CATHETER|United Healthcare|UNITED HEALTHCARE OTHER|6.10||||6.10||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Healthcare|UNITED HEALTHCARE|438.15||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Healthcare|GEHA|||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.81||||409.58||| 51701|EAP|0761|INSERT BLADDER CATHETER|United Healthcare|TML GROUP BENEFITS|701.50||||6.10||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicare|MEDICARE ACUTE|438.15||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Multiplan|WEB TPA|||||438.15||| 51701|EAP|0361||Medicare|MEDICARE ACUTE|||||2.86||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Workers Compensation|UT EMPLOYEE INJURY|438.15||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicare|MEDICARE PART B ONLY IP|3.81||||||| 51701|EAP|0761|INSERT BLADDER CATHETER|Medicare|MEDICARE ACUTE|701.50||||6.10||| 51701|EAP|0761|INSERT BLADDER CATHETER|Medicare|MEDICARE PART B ONLY IP|6.10||||||| 51701|EAP|0510|INSERT BLADDER CATHETER|Medicare|MEDICARE ACUTE|||||117.17||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|NON CONTRACTED|COMMERCIAL OTHER 2|||||3.81||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|NON CONTRACTED|COMMERCIAL OTHER 1|409.58||||438.15||| 51701|EAP|0761|INSERT BLADDER CATHETER|NON CONTRACTED|COMMERCIAL OTHER 1|655.75||||655.75||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|PHCS|HUMANA INSURANCE|||||438.15||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|PHCS|HUMANA|438.15||||||| 51701|EAP|0361||PHCS|HUMANA|||||2.86||| 51702|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.86||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|NON CONTRACTED|COMMERCIAL OTHER 1|119.17||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|PHCS|HUMANA|533.20||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|PHCS|GROUP AND PENSION|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|PHCS|GROUP AND PENSION|855.60||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|NON CONTRACTED|COMMERCIAL OTHER 1|533.20||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|NON CONTRACTED|COMMERCIAL OTHER 1|855.60||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicare|MEDICARE PART B ONLY IP|799.80||||||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|Medicare|MEDICARE ACUTE|||||119.17||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicare|MEDICARE ACUTE|855.60||||7.44||| 51702|EAP|0450|INSERT FOLEY SIMPL|Medicare|MEDICARE ACUTE|570.40||||570.40||| 51702|EAP|0450|INSERT FOLEY SIMPL|Medicare|MEDICARE PART B ONLY IP|4.96||||||| 51702|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||2.86||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|United Healthcare|UNITED HEALTHCARE|7.44||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Healthcare|UNITED HEALTHCARE|||||4.96||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Healthcare|UNITED HEALTHCARE OTHER|4.96||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|United Healthcare|UNITED HEALTHCARE|855.60||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|United Healthcare|UNITED HEALTHCARE OTHER|7.44||||855.60||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|United Healthcare|TML GROUP BENEFITS|119.17||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|United Healthcare|UNITED HEALTHCARE OTHER|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|United Healthcare|TML GROUP BENEFITS|855.60||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Tricare|TRICARE EAST REGION|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|UTMB|UTMB CORRECTIONAL MANAGED CARE|799.80||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Tricare|TRICARE EAST REGION|855.60||||7.44||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Managed Medicare|BCBS MEDICARE PPO MA|7.44||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Managed Medicare|ETMC AFFILIATE HOSPITALS|7.44||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicare|HEALTHSPRING MA|570.40||||570.40||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicare|BCBS MEDICARE PPO MA|570.40||||4.96||| 51702|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.86||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.44||||7.44||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Managed Medicare|HEALTHSPRING MA|799.80||||855.60||| 51702|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||2.86||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|Managed Medicare|HEALTHSPRING MA|||||119.17||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Medicaid|MOLINA HEALTHCARE OF TEXAS|119.17||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Medicaid|MEDICAID|4.96||||570.40||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicaid|SUPERIOR HEALTHPLAN CHIP|7.44||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Medicaid|MEDICAID HMO|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicaid|MEDICAID HMO|7.44||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicaid|MEDICAID|7.44||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicaid|CRIME VICTIMS COMPENSATION|7.44||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicaid|SMITH COUNTY JAIL|7.44||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.44||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Medicaid|MEDICAID|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicaid|MOLINA HEALTHCARE OF TEXAS|7.44||||||| 51702|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||2.86||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|Humana Medicare Advantage|HUMANA MA|||||119.17||| 51702|EAP|0450|INSERT FOLEY SIMPL|Humana Medicare Advantage|HUMANA MA|570.40||||4.96||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Cigna|CIGNA|855.60||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Cigna|CIGNA|7.44||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Cigna|CIGNA|119.17||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Cigna|CIGNA|570.40||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Cigna|CIGNA OTHER|855.60||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|ChampVA|CHAMPVA CENTER|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|855.60||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID AMERIGROUP|570.40||||4.96||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|855.60||||7.44||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Managed Medicaid|MEDICAID AMERIGROUP|7.44||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID SUPERIOR|570.40||||570.40||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Managed Medicaid|MEDICAID SUPERIOR|855.60||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Managed Medicaid|MEDICAID SUPERIOR|119.17||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|570.40||||570.40||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Managed Medicaid|MEDICAID AMERIGROUP|119.17||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|570.40||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Blue Cross PPO Specialty|BCBSTX PPO|570.40||||570.40||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|ChampVA|CHAMPVA CENTER|855.60||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Blue Cross PPO Specialty|BCBSTX PPO|855.60||||7.44||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Blue Cross PPO Specialty|BCBSTX OTHER|799.80||||||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|Blue Cross PPO Specialty|BCBSTX PPO|||||119.17||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|855.60||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Humana Medicare Advantage|HUMANA MA|855.60||||7.44||| 51702|EAP|0450|INSERT FOLEY SIMPL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|570.40||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Brinson Benefits|THE HEALTH PLAN SMITH CO|7.44||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|119.17||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Blue Cross PPO Specialty|BCBSTX PPO|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.44||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Blue Cross HMO Specialty|BCBSTX HMO|570.40||||||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|Blue Cross HMO Specialty|BCBSTX HMO|||||119.17||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Blue Cross HMO Specialty|BCBSTX HMO|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Blue Cross HMO Specialty|BCBSTX HMO|855.60||||7.44||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Aetna|BOON CHAPMAN|855.60||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Aetna|AETNA PPO|855.60||||855.60||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Aetna|AETNA PPO|119.17||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|119.17||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|533.20||||570.40||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Aetna|AETNA OTHER|799.80||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Aetna|AETNA QHP HMO|855.60||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|570.40||||570.40||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|855.60||||855.60||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Managed Medicare|WELLCARE CHOICE MA|855.60||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Aetna Value Network|AETNA VALUE NETWORK|855.60||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Aetna|AETNA PPO|||||570.40||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||119.17||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Aenta Medicare Advantage|AETNA MEDICARE MA|7.44||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Aetna|AETNA OTHER|||||570.40||| 51702|EAP|0450|INSERT FOLEY SIMPL|Aenta Medicare Advantage|AETNA MEDICARE MA|4.96||||570.40||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|Aetna|AETNA PPO|||||119.17||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|United Medicare Advantage|UHC AARP MCR HMO MA|||||119.17||| 51702|EAP|0450|INSERT FOLEY SIMPL|UTMB|UTMB CORRECTIONAL MANAGED CARE|570.40||||570.40||| 51702|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.86||| 51702|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||2.86||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Medicare Advantage|UHC AARP MCR HMO MA|570.40||||570.40||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||119.17||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|United Healthcare|UNITED HEALTHCARE|119.17||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Healthcare|UNITED HEALTHCARE|570.40||||||| 51702|EAP|0510|INSERT TEMP BLADDER CATH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||119.17||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|United Medicare Advantage|UHC AARP WELLMED HMO MA|855.60||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|United Medicare Advantage|UHC MEDICARE GOLD MA|7.44||||7.44||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|855.60||||7.44||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|United Medicare Advantage|UHC AARP MCR HMO MA|855.60||||855.60||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|533.20||||4.96||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Medicare Advantage|UHC MEDICARE GOLD MA|570.40||||570.40||| 51702|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.86||| 51702|EAP|0361||Medicare|MEDICARE ACUTE|||||2.86||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST TPA UMR|119.17||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|855.60||||855.60||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST TPA UMR|799.80||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Rusk State Hospital|RUSK STATE HOSP|855.60||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|570.40||||4.96||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST TPA|855.60||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.96||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|PHCS|HUMANA|855.60||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST TPA|119.17||||||| 51702|EAP|0720|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|119.17||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.44||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|855.60||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Veterans Affairs|VETERANS ADMINISTRATION|4.96||||4.96||| 51702|EAP|0450|INSERT FOLEY SIMPL|Workers Compensation|WORKERS COMPENSATION OTHER|||||4.96||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Workers Compensation|TRAVELERS INSURANCE COMPANY|7.44||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Workers Compensation|TEXAS MUTUAL INSURANCE|7.44||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Workers Compensation|WORKERS COMPENSATION OTHER|855.60||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|855.60||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|570.40||||||| 51702|EAP|0761|INSERT TEMP BLADDER CATH|Veterans Affairs|VETERANS ADMINISTRATION|799.80||||7.44||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||152.08||| 51703|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||3.65||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|United Medicare Advantage|UHC AARP MCR HMO MA|||||152.08||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||152.08||| 51703|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.65||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||152.08||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Aetna Value Network|AETNA VALUE NETWORK|||||152.08||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||152.08||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Blue Cross HMO Specialty|BCBSTX HMO|||||152.08||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Blue Cross PPO Specialty|BCBSTX OTHER|||||152.08||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||152.08||| 51703|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||3.65||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Humana Medicare Advantage|HUMANA MA|||||152.08||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Managed Medicare|HEALTHSPRING MA|||||152.08||| 51703|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||3.65||| 51703|EAP|0361||Medicare|MEDICARE ACUTE|||||3.65||| 51703|EAP|0450|INSERT CATH COMPL|Medicare|MEDICARE ACUTE|821.10||||821.10||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|Medicare|MEDICARE ACUTE|152.08||||152.08||| 51703|EAP|0510|INSERT BLADDER CATH COMPL|PHCS|HUMANA|||||152.08||| 51705|EAP|0361||Medicare|MEDICARE ACUTE|||||6.21||| 51705|EAP|0510|CHANGE OF BLADDER TUBE|Medicare|MEDICARE ACUTE|||||258.75||| 51705|EAP|0361||Medicaid|MEDICAID|||||6.21||| 51705|EAP|0510|CHANGE OF BLADDER TUBE|Medicaid|MEDICAID|||||258.75||| 51705|EAP|0510|CHANGE OF BLADDER TUBE|Humana Medicare Advantage|HUMANA MA|||||258.75||| 51705|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.21||| 51705|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.21||| 51705|EAP|0510|CHANGE OF BLADDER TUBE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||258.75||| 51705|EAP|0510|CHANGE OF BLADDER TUBE|Blue Cross PPO Specialty|BCBSTX PPO|||||258.75||| 51705|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.21||| 51705|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.21||| 51705|EAP|0510|CHANGE OF BLADDER TUBE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||258.75||| 51705|EAP|0510|CHANGE OF BLADDER TUBE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||258.75||| 51705|EAP|0510|CHANGE OF BLADDER TUBE|United Medicare Advantage|UHC AARP MCR HMO MA|||||258.75||| 51705|EAP|0450|CHANGE OF CYSTOSTOMY TUBE|Workers Compensation|WORKERS COMPENSATION OTHER|||||9.26||| 51705|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.21||| 51715|EAP|0510|ENDOSCOPIC INJECTION/IMPL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,272.92||| 51715|EAP|0510|ENDOSCOPIC INJECTION/IMPL|Medicare|MEDICARE ACUTE|||||3,272.92||| 51715|EAP|0361||Medicare|MEDICARE ACUTE|||||78.55||| 51720|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.21||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|Managed Medicare|HEALTHSPRING MA|||||258.75||| 51720|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||6.21||| 51720|EAP|0361||PHCS|HUMANA INSURANCE|||||6.21||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|Medicare|MEDICARE ACUTE|||||258.75||| 51720|EAP|0361||Medicare|MEDICARE ACUTE|||||6.21||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||258.75||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||258.75||| 51720|EAP|0361||Aetna|AETNA QHP HMO|||||6.21||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|Aetna|AETNA PPO|||||258.75||| 51720|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.21||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|Blue Cross PPO Specialty|BCBSTX PPO|||||258.75||| 51720|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.21||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|Humana Medicare Advantage|HUMANA MA|||||258.75||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|United Medicare Advantage|UHC AARP MCR HMO MA|||||258.75||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||258.75||| 51720|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.21||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||258.75||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||258.75||| 51720|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.21||| 51720|EAP|0510|TREATMENT OF BLADDER LESI|Access Direct Platinum|HEALTHFIRST TPA|||||258.75||| 51725|EAP|0510|SIMPLE CYSTOMETROGRAM|Humana Medicare Advantage|HUMANA MA|||||6.21||| 51725|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.21||| 51725|EAP|0510|SIMPLE CYSTOMETROGRAM|Blue Cross PPO Specialty|BCBSTX PPO|||||258.75||| 51725|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||6.21||| 51725|EAP|0361||Medicare|MEDICARE ACUTE|||||6.21||| 51725|EAP|0510|SIMPLE CYSTOMETROGRAM|Medicare|MEDICARE ACUTE|||||258.75||| 51728|EAP|0361||Medicaid|MEDICAID|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Managed Medicare|HEALTHSPRING MA|||||628.75||| 51728|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Tricare|TRICARE FOR LIFE|||||628.75||| 51728|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|United Healthcare|UNITED HEALTHCARE|||||628.75||| 51728|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|NON CONTRACTED|COMMERCIAL OTHER 1|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|PHCS|HUMANA INSURANCE|||||628.75||| 51728|EAP|0361||PHCS|HUMANA|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|PHCS|HUMANA|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Medicare|MEDICARE ACUTE|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Access Direct Platinum|HEALTHFIRST TPA UMR|||||628.75||| 51728|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||628.75||| 51728|EAP|0361||Medicare|MEDICARE ACUTE|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Access Direct Platinum|HEALTHFIRST TPA|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|United Medicare Advantage|UHC AARP MCR HMO MA|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||628.75||| 51728|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||628.75||| 51728|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||15.09||| 51728|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||628.75||| 51728|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Aetna|AETNA PPO|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|United Healthcare|UNITED HEALTHCARE OTHER|||||628.75||| 51728|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Blue Cross HMO Specialty|BCBSTX HMO|||||628.75||| 51728|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||15.09||| 51728|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Blue Cross PPO Specialty|BCBSTX PPO|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Blue Cross PPO Specialty|BCBSTX OTHER|||||628.75||| 51728|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||15.09||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Managed Medicaid|MEDICAID AMERIGROUP|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Cigna|CIGNA OTHER|||||628.75||| 51728|EAP|0510|CYSTOMETROGRAM W/VP|Humana Medicare Advantage|HUMANA MA|||||628.75||| 51728|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||15.09||| 51741|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Humana Medicare Advantage|HUMANA MA|||||152.08||| 51741|EAP|0361||Cigna|CIGNA OTHER|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Cigna|CIGNA OTHER|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Cigna|CIGNA|||||152.08||| 51741|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Blue Cross PPO Specialty|BCBSTX PPO|||||152.08||| 51741|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||3.65||| 51741|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Blue Cross PPO Specialty|BCBSTX OTHER|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||152.08||| 51741|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Aetna|AETNA OTHER|||||152.08||| 51741|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Aetna|AETNA PPO|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Aetna Value Network|AETNA VALUE NETWORK|||||152.08||| 51741|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||3.65||| 51741|EAP|0361||Aetna|AETNA OTHER|||||3.65||| 51741|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||152.08||| 51741|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|United Medicare Advantage|UHC AARP MCR HMO MA|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||152.08||| 51741|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3.65||| 51741|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Blue Cross HMO Specialty|BCBSTX HMO|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Access Direct Platinum|HEALTHFIRST TPA|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Medicare|MEDICARE ACUTE|||||152.08||| 51741|EAP|0361||Medicare|MEDICARE ACUTE|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|PHCS|HUMANA|||||152.08||| 51741|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Managed Medicaid|MEDICAID AMERIGROUP|||||152.08||| 51741|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|PHCS|HUMANA INSURANCE|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|NON CONTRACTED|COMMERCIAL OTHER 1|||||152.08||| 51741|EAP|0361||PHCS|HUMANA|||||3.65||| 51741|EAP|0361||Rusk State Hospital|RUSK STATE HOSP|||||3.65||| 51741|EAP|0361||PHCS|HUMANA INSURANCE|||||3.65||| 51741|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|United Healthcare|UNITED HEALTHCARE|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|United Healthcare|UNITED HEALTHCARE OTHER|||||152.08||| 51741|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||3.65||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Tricare|TRICARE FOR LIFE|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Managed Medicare|HEALTHSPRING MA|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||152.08||| 51741|EAP|0510|ELECTRO-UROFLOWMETRY FIRS|Managed Medicare|BCBS MEDICARE PPO MA|||||152.08||| 51741|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.65||| 51741|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||3.65||| 51741|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||3.65||| 51741|EAP|0361||Medicaid|MEDICAID|||||3.65||| 51784|EAP|0361||Medicaid|MEDICAID|||||3.65||| 51784|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Managed Medicare|HEALTHSPRING MA|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Tricare|TRICARE FOR LIFE|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|United Healthcare|UNITED HEALTHCARE OTHER|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|United Healthcare|UNITED HEALTHCARE|||||152.08||| 51784|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||3.65||| 51784|EAP|0361||PHCS|HUMANA|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|NON CONTRACTED|COMMERCIAL OTHER 1|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|PHCS|HUMANA|||||152.08||| 51784|EAP|0361||Medicare|MEDICARE ACUTE|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Medicare|MEDICARE ACUTE|||||152.08||| 51784|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Access Direct Platinum|HEALTHFIRST TPA|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||152.08||| 51784|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|United Medicare Advantage|UHC AARP MCR HMO MA|||||152.08||| 51784|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|PHCS|HUMANA INSURANCE|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||152.08||| 51784|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||3.65||| 51784|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Aetna|AETNA PPO|||||152.08||| 51784|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Blue Cross HMO Specialty|BCBSTX HMO|||||152.08||| 51784|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.65||| 51784|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||3.65||| 51784|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Blue Cross PPO Specialty|BCBSTX OTHER|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Blue Cross PPO Specialty|BCBSTX PPO|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Managed Medicaid|MEDICAID AMERIGROUP|||||152.08||| 51784|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||152.08||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Cigna|CIGNA OTHER|||||152.08||| 51784|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||3.65||| 51784|EAP|0510|ANAL/URINARY MUSCLE STUDY|Humana Medicare Advantage|HUMANA MA|||||152.08||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Humana Medicare Advantage|HUMANA MA|||||314.58||| 51797|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Cigna|CIGNA OTHER|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Managed Medicaid|MEDICAID AMERIGROUP|||||314.58||| 51797|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Blue Cross PPO Specialty|BCBSTX OTHER|||||314.58||| 51797|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Blue Cross PPO Specialty|BCBSTX PPO|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Aetna|AETNA PPO|||||314.58||| 51797|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.55||| 51797|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|United Medicare Advantage|UHC MEDICARE GOLD MA|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Aenta Medicare Advantage|AETNA MEDICARE MA|||||314.58||| 51797|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.55||| 51797|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Blue Cross HMO Specialty|BCBSTX HMO|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|United Medicare Advantage|UHC AARP MCR HMO MA|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Access Direct Platinum|HEALTHFIRST TPA|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||314.58||| 51797|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Access Direct Platinum|HEALTHFIRST TPA UMR|||||314.58||| 51797|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Medicare|MEDICARE ACUTE|||||314.58||| 51797|EAP|0361||Medicare|MEDICARE ACUTE|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|PHCS|HUMANA INSURANCE|||||314.58||| 51797|EAP|0361||PHCS|HUMANA|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|NON CONTRACTED|COMMERCIAL OTHER 1|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|PHCS|HUMANA|||||314.58||| 51797|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||7.55||| 51797|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|United Healthcare|UNITED HEALTHCARE OTHER|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|United Healthcare|UNITED HEALTHCARE|||||314.58||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Tricare|TRICARE FOR LIFE|||||314.58||| 51797|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.55||| 51797|EAP|0510|INTRAABDOMINAL PRESSURE T|Managed Medicare|HEALTHSPRING MA|||||314.58||| 51797|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||7.55||| 51797|EAP|0361||Medicaid|MEDICAID|||||7.55||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Managed Medicare|BCBS MEDICARE PPO MA|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||62.50||| 51798|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.50||| 51798|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||1.50||| 51798|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Tricare|TRICARE EAST REGION|||||62.50||| 51798|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| 51798|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||1.50||| 51798|EAP|0361||United Healthcare|TML GROUP BENEFITS|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|United Healthcare|TML GROUP BENEFITS|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|United Healthcare|UNITED HEALTHCARE OTHER|||||62.50||| 51798|EAP|0361||United Healthcare|AARP|||||1.50||| 51798|EAP|0361||PHCS|HUMANA INSURANCE|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|PHCS|HUMANA INSURANCE|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Rusk State Hospital|RUSK STATE HOSP|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|PHCS|HUMANA|||||62.50||| 51798|EAP|0361||PHCS|HUMANA|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|NON CONTRACTED|COMMERCIAL OTHER 1|||||62.50||| 51798|EAP|0361||Rusk State Hospital|RUSK STATE HOSP|||||1.50||| 51798|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Medicare|MEDICARE PART B ONLY IP|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Multiplan|PACIFICARE|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Medicare|MEDICARE ACUTE|||||62.50||| 51798|EAP|0361||Medicare|MEDICARE ACUTE|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Multiplan|WEB TPA|||||62.50||| 51798|EAP|0361||Multiplan|PACIFICARE|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Veterans Affairs|VETERANS ADMINISTRATION|||||62.50||| 51798|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Access Direct Platinum|HEALTHFIRST TPA|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||62.50||| 51798|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||62.50||| 51798|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|United Medicare Advantage|UHC AARP MCR HMO MA|||||62.50||| 51798|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||1.50||| 51798|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| 51798|EAP|0361||Multiplan|WEB TPA|||||1.50||| 51798|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||62.50||| 51798|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||62.50||| 51798|EAP|0361||Aetna|AETNA PPO|||||1.50||| 51798|EAP|0361||Aetna|AETNA QHP HMO|||||1.50||| 51798|EAP|0361||Aetna|AETNA OTHER|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Aetna Value Network|AETNA VALUE NETWORK|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|NON CONTRACTED|COMMERCIAL OTHER 2|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Aetna|AETNA PPO|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Aetna|AETNA OTHER|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|PHCS|GROUP AND PENSION|||||62.50||| 51798|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Aetna|BOON CHAPMAN|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Blue Cross HMO Specialty|BCBSTX HMO|||||62.50||| 51798|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Blue Cross PPO Specialty|BCBSTX OTHER|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|United Healthcare|UNITED HEALTHCARE|||||62.50||| 51798|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| 51798|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||1.50||| 51798|EAP|0361||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||62.50||| 51798|EAP|0361||Tricare|TRICARE EAST REGION|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Blue Cross PPO Specialty|BCBSTX PPO|||||62.50||| 51798|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Managed Medicaid|MEDICAID AMERIGROUP|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Managed Medicare|HEALTHSPRING MA|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||62.50||| 51798|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Medicaid|MEDICAID|||||62.50||| 51798|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Managed Medicaid|MEDICAID SUPERIOR|||||62.50||| 51798|EAP|0361||Cigna|CIGNA|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Cigna|CIGNA OTHER|||||62.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Cigna|CIGNA|||||62.50||| 51798|EAP|0361||ChampVA|CHAMPVA CENTER|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|ChampVA|CHAMPVA CENTER|||||62.50||| 51798|EAP|0361||Cigna|CIGNA OTHER|||||1.50||| 51798|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||1.50||| 51798|EAP|0510|US URINE CAPACITY MEASURE|Humana Medicare Advantage|HUMANA MA|||||62.50||| 518|DRG||BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|71,629.59|20193.49|35074.49|16336.91|||| 518|DRG||BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM|Humana Medicare Advantage|HUMANA MA|186,458.35|19958.63|35074.49|16336.91|||| 518|DRG||BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM|Cigna|CIGNA|148,296.15|35074.49|35074.49|16336.91|||| 518|DRG||BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM|Blue Cross PPO Specialty|BCBSTX PPO|184,308.88|21050.36|35074.49|16336.91|||| 518|DRG||BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM|Tricare|TRICARE EAST REGION|82,371.35|16336.91|35074.49|16336.91|||| 518|DRG||BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM|United Medicare Advantage|UHC AARP MCR HMO MA|85,372.17|20380.09|35074.49|16336.91|||| 518|DRG||BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM|United Medicare Advantage|UHC MEDICARE GOLD MA|336,986.43|20421.29|35074.49|16336.91|||| 518|DRG||BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM|Medicare|MEDICARE ACUTE|180,261.87|20380.09|35074.49|16336.91|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|Medicare|MEDICARE ACUTE|67,709.69|11757.64|34039.37|106.55|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|Medicare|MEDICARE PART B ONLY IP|167,024.23|106.55|34039.37|106.55|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|United Healthcare|UNITED HEALTHCARE|130,408.35|34039.37|34039.37|106.55|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|139,179.92|11976.04|34039.37|106.55|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|104,273.75|19844.615|34039.37|106.55|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|50,145.91|15073.8|34039.37|106.55|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|Blue Cross HMO Specialty|BCBSTX HMO|80,998.84|10747.46|34039.37|106.55|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103,074.90|10092.26|34039.37|106.55|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|Humana Medicare Advantage|HUMANA MA|113,181.14|11733.76|34039.37|106.55|||| 519|DRG||BACK & NECK PROC EXC SPINAL FUSION W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|151,208.74|11972.72|34039.37|106.55|||| 52|DRG||SPINAL DISORDERS & INJURIES W CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|45,705.50|10222.3|10222.3|10221.42|||| 52|DRG||SPINAL DISORDERS & INJURIES W CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|68,298.75|10221.42|10222.3|10221.42|||| 52|DRG||SPINAL DISORDERS & INJURIES W CC/MCC|Medicare|MEDICARE ACUTE|68,369.01|10222.3|10222.3|10221.42|||| 520|DRG||BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC|Medicare|MEDICARE ACUTE|65,625.14|8778.35|8922.74|8597.85|||| 520|DRG||BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|71,960.30|8597.85|8922.74|8597.85|||| 520|DRG||BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|89,229.96|8778.35|8922.74|8597.85|||| 520|DRG||BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|64,747.91|8922.74|8922.74|8597.85|||| 52000|EAP|0510|CYSTOURETHROSCOPY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Access Direct Platinum|HEALTHFIRST TPA|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||628.75||| 52000|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UMR|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||628.75||| 52000|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|United Medicare Advantage|UHC AARP MCR HMO MA|||||628.75||| 52000|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||15.09||| 52000|EAP|0361||Aetna|AETNA OTHER|||||15.09||| 52000|EAP|0361||Aetna|AETNA PPO|||||15.09||| 52000|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||628.75||| 52000|EAP|0361||Aetna|AETNA QHP HMO|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Aetna|BOON CHAPMAN|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Aetna|AETNA QHP HMO|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Aetna|AETNA OTHER|||||628.75||| 52000|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Blue Cross PPO Specialty|BCBSTX PPO|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Blue Cross PPO Specialty|BCBSTX OTHER|||||628.75||| 52000|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||15.09||| 52000|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Blue Cross HMO Specialty|BCBSTX HMO|||||628.75||| 52000|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||628.75||| 52000|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Managed Medicaid|MEDICAID SUPERIOR|||||628.75||| 52000|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Managed Medicaid|MEDICAID AMERIGROUP|||||628.75||| 52000|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||15.09||| 52000|EAP|0361||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Humana Medicare Advantage|HUMANA MA|||||628.75||| 52000|EAP|0361||Cigna|CIGNA OTHER|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Cigna|CIGNA OTHER|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Cigna|CIGNA|||||628.75||| 52000|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||15.09||| 52000|EAP|0361||Cigna|CIGNA|||||15.09||| 52000|EAP|0361||Medicare|MEDICARE ACUTE|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Medicare|MEDICARE ACUTE|||||628.75||| 52000|EAP|0361||PHCS|HUMANA INSURANCE|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Aetna|AETNA PPO|||||628.75||| 52000|EAP|0361||PHCS|HUMANA|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|NON CONTRACTED|COMMERCIAL OTHER 1|||||628.75||| 52000|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||15.09||| 52000|EAP|0361||Rusk State Hospital|RUSK STATE HOSP|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|PHCS|HUMANA|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|PHCS|HUMANA INSURANCE|||||628.75||| 52000|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|PHCS|GROUP AND PENSION|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|NON CONTRACTED|COMMERCIAL OTHER 2|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||628.75||| 52000|EAP|0361||Tricare|TRICARE EAST REGION|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Tricare|TRICARE EAST REGION|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Tricare|TRICARE FOR LIFE|||||628.75||| 52000|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||15.09||| 52000|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.09||| 52000|EAP|0361||United Healthcare|TML GROUP BENEFITS|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|United Healthcare|UNITED HEALTHCARE OTHER|||||628.75||| 52000|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|United Healthcare|UNITED HEALTHCARE ERS|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|United Healthcare|TML GROUP BENEFITS|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|United Healthcare|UNITED HEALTHCARE|||||628.75||| 52000|EAP|0361||United Healthcare|GEHA|||||15.09||| 52000|EAP|0361||United Healthcare|AARP|||||15.09||| 52000|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.09||||628.75||| 52000|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||15.09||| 52000|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||15.09||| 52000|EAP|0510|CYSTOURETHROSCOPY|Managed Medicare|HEALTHSPRING MA|||||628.75||| 52000|EAP|0510|CYSTOURETHROSCOPY|Managed Medicare|BCBS MEDICARE PPO MA|||||628.75||| 52001|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||78.55||| 52001|EAP|0361||Medicare|MEDICARE ACUTE|||||78.55||| 52001|EAP|0510|CYSTOSCOPY REMOVAL OF CLO|Medicare|MEDICARE ACUTE|78.55||||3,272.92||| 52001|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||78.55||| 52001|EAP|0510|CYSTOSCOPY REMOVAL OF CLO|Humana Medicare Advantage|HUMANA MA|||||3,272.92||| 52001|EAP|0510|CYSTOSCOPY REMOVAL OF CLO|Blue Cross PPO Specialty|BCBSTX PPO|||||3,272.92||| 52001|EAP|0510|CYSTOSCOPY REMOVAL OF CLO|United Medicare Advantage|UHC AARP MCR HMO MA|||||3,272.92||| 52001|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||78.55||| 52224|EAP|0510|CYSTO W/REMOVAL OF LESION|Medicare|MEDICARE ACUTE|||||19.95||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Aetna|AETNA PPO|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Blue Cross HMO Specialty|BCBSTX HMO|||||1,945.42||| 52281|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||46.69||| 52281|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||46.69||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Blue Cross PPO Specialty|BCBSTX PPO|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Cigna|CIGNA|||||1,945.42||| 52281|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||46.69||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Humana Medicare Advantage|HUMANA MA|||||1,945.42||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Managed Medicare|HEALTHSPRING MA|||||1,945.42||| 52281|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||46.69||| 52281|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||46.69||| 52281|EAP|0361||Medicare|MEDICARE ACUTE|||||46.69||| 52281|EAP|0510|CYSTOSCOPY AND TREATMENT|Medicare|MEDICARE ACUTE|||||1,945.42||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|PHCS|HUMANA|||||19.95||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|NON CONTRACTED|COMMERCIAL OTHER 1|||||19.95||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|Medicare|MEDICARE ACUTE|||||19.95||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|United Healthcare|UNITED HEALTHCARE|||||19.95||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|Managed Medicare|HEALTHSPRING MA|||||19.95||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|Managed Medicare|BCBS MEDICARE PPO MA|||||19.95||| 52287|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||47.88||| 52287|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||47.88||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|Humana Medicare Advantage|HUMANA MA|||||19.95||| 52287|EAP|0361||Cigna|CIGNA|||||47.88||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|Cigna|CIGNA OTHER|||||19.95||| 52287|EAP|0361||Medicare|MEDICARE ACUTE|||||47.88||| 52287|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||47.88||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||19.95||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|Blue Cross PPO Specialty|BCBSTX PPO|||||19.95||| 52287|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||47.88||| 52287|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||47.88||| 52287|EAP|0361||Aetna|AETNA OTHER|||||47.88||| 52287|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||47.88||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||47.88||| 52287|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||47.88||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||19.95||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|United Medicare Advantage|UHC AARP MCR HMO MA|||||19.95||| 52287|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||47.88||| 52287|EAP|0510|CYSTOSCOPY CHEMODENERVATI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||19.95||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,945.42||| 52310|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,945.42||| 52310|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,945.42||| 52310|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Aetna|AETNA PPO|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,945.42||| 52310|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Blue Cross HMO Specialty|BCBSTX HMO|||||1,945.42||| 52310|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||46.69||| 52310|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,945.42||| 52310|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||46.69||| 52310|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Managed Medicaid|MEDICAID AMERIGROUP|||||1,945.42||| 52310|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Blue Cross PPO Specialty|BCBSTX PPO|||||1,945.42||| 52310|EAP|0361||Aetna|AETNA PPO|||||46.69||| 52310|EAP|0361||Cigna|CIGNA|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Cigna|CIGNA|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Humana Medicare Advantage|HUMANA MA|||||1,945.42||| 52310|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||46.69||| 52310|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Medicaid|MEDICAID|||||46.69||| 52310|EAP|0361||Medicaid|MEDICAID|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Managed Medicare|BCBS MEDICARE PPO MA|||||1,945.42||| 52310|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||46.69||| 52310|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||46.69||| 52310|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Managed Medicare|HEALTHSPRING MA|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Tricare|TRICARE EAST REGION|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|United Healthcare|UNITED HEALTHCARE|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|United Healthcare|UNITED HEALTHCARE OTHER|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|United Healthcare|TML GROUP BENEFITS|||||1,945.42||| 52310|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Medicare|MEDICARE ACUTE|1,945.42||||1,945.42||| 52310|EAP|0361||Medicare|MEDICARE ACUTE|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|Medicare|UTSW MC KIDNEY PROGRAM|||||1,945.42||| 52310|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||46.69||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,945.42||| 52310|EAP|0510|CYSTO W/SIMPLE REMOVAL ST|PHCS|HUMANA|||||1,945.42||| 53020|EAP|0510|INCISION OF URETHRA|Blue Cross PPO Specialty|BCBSTX PPO|||||1,945.42||| 534|DRG||FRACTURES OF FEMUR W/O MCC|Medicare|MEDICARE ACUTE|31,115.53|5595.77|5595.77|5595.77|||| 535|DRG||FRACTURES OF HIP & PELVIS W MCC|Humana Medicare Advantage|HUMANA MA|46,722.90|7988.86|8017.48|7988.86|||| 535|DRG||FRACTURES OF HIP & PELVIS W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|320.35|8017.48|8017.48|7988.86|||| 535|DRG||FRACTURES OF HIP & PELVIS W MCC|Managed Medicare|HEALTHSPRING MA|25,059.85|8016.6|8017.48|7988.86|||| 535|DRG||FRACTURES OF HIP & PELVIS W MCC|Medicare|MEDICARE ACUTE|71,751.80|7989.32|8017.48|7988.86|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|115,576.97|1103.365|12603.61|1103.365|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|55,870.56|5488.295|12603.61|1103.365|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|39,616.89|12603.61|12603.61|1103.365|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|Medicare|MEDICARE ACUTE|45,800.17|5446.1|12603.61|1103.365|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|Medicare|MEDICARE PART B ONLY IP|15,696.91|4212.62|12603.61|1103.365|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|Workers Compensation|WORKERS COMPENSATION OTHER|26,987.75|7786.66|12603.61|1103.365|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|26,696.80|7044.62|12603.61|1103.365|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|49,499.75|5417.94|12603.61|1103.365|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|Aetna|AETNA OTHER|42,381.15|9786.93|12603.61|1103.365|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|Humana Medicare Advantage|HUMANA MA|617.26|5444.94|12603.61|1103.365|||| 53600|EAP|0510|DILAT URETHRAL STRIX DILA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||258.75||| 53600|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||6.21||| 53600|EAP|0510|DILAT URETHRAL STRIX DILA|Humana Medicare Advantage|HUMANA MA|||||258.75||| 53600|EAP|0510|DILAT URETHRAL STRIX DILA|Medicare|MEDICARE ACUTE|||||258.75||| 53600|EAP|0361||Medicare|MEDICARE ACUTE|||||6.21||| 53600|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.21||| 53620|EAP|0510|DILAT URETHRAL STRIX FILI|Managed Medicare|HEALTHSPRING MA|||||628.75||| 53620|EAP|0510|DILAT URETHRAL STRIX FILI|Humana Medicare Advantage|HUMANA MA|||||628.75||| 53660|EAP|0510|DILAT FEMALE URETHRA|Humana Medicare Advantage|HUMANA MA|||||152.08||| 53660|EAP|0510|DILAT FEMALE URETHRA|Medicare|MEDICARE ACUTE|||||152.08||| 53660|EAP|0361||Medicare|MEDICARE ACUTE|||||3.65||| 53661|EAP|0510|DILATION OF URETHRA|Medicare|MEDICARE ACUTE|||||1.23||| 537|DRG||SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W CC/MCC|Medicare|MEDICARE ACUTE|96,705.05|6254.22|6255.72|6254.22|||| 537|DRG||SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58,500.75|6255.72|6255.72|6254.22|||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,945.42||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,945.42||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,945.42||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|Blue Cross PPO Specialty|BCBSTX PPO|||||1,945.42||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|Cigna|CIGNA|||||1,945.42||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|Humana Medicare Advantage|HUMANA MA|||||1,945.42||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|PHCS|HUMANA|||||1,945.42||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|PHCS|HUMANA INSURANCE|||||1,945.42||| 53854|EAP|0361||PHCS|HUMANA|||||46.69||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|Medicare|MEDICARE ACUTE|||||1,945.42||| 53854|EAP|0361||Medicare|MEDICARE ACUTE|||||46.69||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|United Healthcare|UNITED HEALTHCARE OTHER|||||1,945.42||| 53854|EAP|0510|TRURL DSTRJ PRST8 TISS RF|United Healthcare|UNITED HEALTHCARE|||||1,945.42||| 539|DRG||OSTEOMYELITIS W MCC|Medicare|MEDICARE ACUTE|87,123.66|11844.36|11844.36|11633.02|||| 539|DRG||OSTEOMYELITIS W MCC|Humana Medicare Advantage|HUMANA MA|64,797.35|11633.02|11844.36|11633.02|||| 54|DRG||NERVOUS SYSTEM NEOPLASMS W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|47,895.85|11109.75|15861.42|69.74|||| 54|DRG||NERVOUS SYSTEM NEOPLASMS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|60,113.15|8710.32|15861.42|69.74|||| 54|DRG||NERVOUS SYSTEM NEOPLASMS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|55,676.92|69.74|15861.42|69.74|||| 54|DRG||NERVOUS SYSTEM NEOPLASMS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|77,774.68|11442.83|15861.42|69.74|||| 54|DRG||NERVOUS SYSTEM NEOPLASMS W MCC|Humana Medicare Advantage|HUMANA MA|69,224.35|8618.87|15861.42|69.74|||| 54|DRG||NERVOUS SYSTEM NEOPLASMS W MCC|Cigna|CIGNA|20,113.80|13789.63|15861.42|69.74|||| 54|DRG||NERVOUS SYSTEM NEOPLASMS W MCC|United Healthcare|UNITED HEALTHCARE|101,609.35|15861.42|15861.42|69.74|||| 54|DRG||NERVOUS SYSTEM NEOPLASMS W MCC|Medicare|MEDICARE ACUTE|58,876.64|8609.38|15861.42|69.74|||| 540|DRG||OSTEOMYELITIS W CC|Medicaid|MEDICAID|160,873.45|7815.93|8417.5|7485.71|||| 540|DRG||OSTEOMYELITIS W CC|Medicare|MEDICARE ACUTE|575.42|8417.5|8417.5|7485.71|||| 540|DRG||OSTEOMYELITIS W CC|Blue Cross PPO Specialty|BCBSTX PPO|47,322.23|7485.71|8417.5|7485.71|||| 541|DRG||OSTEOMYELITIS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|57,524.05|5993.53|6373.465|5993.53|||| 541|DRG||OSTEOMYELITIS W/O CC/MCC|Medicare|MEDICARE ACUTE|43,756.00|6373.465|6373.465|5993.53|||| 54150|EAP|0723|CIRCUMCISION|NON CONTRACTED|COMMERCIAL OTHER 1|4,413.95||||||| 54150|EAP|0723|CIRCUMCISION|PHCS|HUMANA INSURANCE|41.06||||||| 54150|EAP|0723|CIRCUMCISION|United Healthcare|UNITED HEALTHCARE|4,413.95||||||| 54150|EAP|0723|CIRCUMCISION|United Healthcare|UNITED HEALTHCARE OTHER|4,721.90||||||| 54150|EAP|0723|CIRCUMCISION|Tricare|TRICARE EAST REGION|4,721.90||||||| 54150|EAP|0723|CIRCUMCISION|Medicaid|MEDICAID|41.06||||||| 54150|EAP|0723|CIRCUMCISION|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|41.06||||||| 54150|EAP|0723|CIRCUMCISION|Access Direct Platinum|HEALTHFIRST TPA UMR|4,413.95||||||| 54150|EAP|0723|CIRCUMCISION|Access Direct Platinum|HEALTHFIRST TPA|41.06||||||| 54150|EAP|0723|CIRCUMCISION|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4,721.90||||||| 54150|EAP|0723|CIRCUMCISION|United Healthcare|UNITED HEALTHCARE|4,721.90||||||| 54150|EAP|0723|CIRCUMCISION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,721.90||||||| 54150|EAP|0723|CIRCUMCISION|Managed Medicaid|MEDICAID AMERIGROUP|41.06||||||| 54150|EAP|0723|CIRCUMCISION|PHCS|GROUP AND PENSION|4,413.95||||||| 54150|EAP|0723|CIRCUMCISION|Managed Medicaid|MEDICAID SUPERIOR|4,721.90||||41.06||| 54150|EAP|0723|CIRCUMCISION|ChampVA|CHAMPVA CENTER|4,721.90||||||| 54150|EAP|0723|CIRCUMCISION|Cigna|CIGNA|41.06||||||| 54150|EAP|0723|CIRCUMCISION|Cigna|CIGNA|4,413.95||||||| 54150|EAP|0723|CIRCUMCISION|Aetna Value Network|AETNA VALUE NETWORK|4,721.90||||||| 54150|EAP|0723|CIRCUMCISION|Aetna|AETNA PPO|4,721.90||||||| 54150|EAP|0723|CIRCUMCISION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41.06||||41.06||| 54150|EAP|0723|CIRCUMCISION|Blue Cross PPO Specialty|BCBSTX PPO|4,721.90||||4,721.90||| 54150|EAP|0723|CIRCUMCISION|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4,413.95||||||| 54150|EAP|0723|CIRCUMCISION|Blue Cross PPO Specialty|BCBSTX OTHER|4,413.95||||||| 54150|EAP|0723|CIRCUMCISION|Blue Cross HMO Specialty|BCBSTX HMO|4,721.90||||||| 542|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC|Aetna|AETNA PPO|34,976.32|23083.72|23083.72|9952.95|||| 542|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC|Managed Medicare|HEALTHSPRING MA|158,388.75|11297.25|23083.72|9952.95|||| 542|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC|Medicaid|MEDICAID|96,353.30|9952.95|23083.72|9952.95|||| 542|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC|Medicare|MEDICARE ACUTE|109,877.95|11505.93|23083.72|9952.95|||| 542|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|184,872.70|11269.09|23083.72|9952.95|||| 54200|EAP|0510|TREATMENT OF PENIS LESION|United Medicare Advantage|UHC AARP MCR HMO MA|||||6.35||| 54200|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.35||| 54200|EAP|0510|TREATMENT OF PENIS LESION|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.35||| 54235|EAP|0510|PENILE INJECTION|Medicare|MEDICARE ACUTE|||||264.58||| 54235|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||6.35||| 54235|EAP|0510|PENILE INJECTION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||264.58||| 54235|EAP|0510|PENILE INJECTION|Managed Medicare|HEALTHSPRING MA|||||264.58||| 54235|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.35||| 54235|EAP|0510|PENILE INJECTION|Humana Medicare Advantage|HUMANA MA|||||264.58||| 54235|EAP|0510|PENILE INJECTION|Cigna|CIGNA OTHER|||||264.58||| 54235|EAP|0510|PENILE INJECTION|Cigna|CIGNA|||||264.58||| 54235|EAP|0510|PENILE INJECTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||264.58||| 54235|EAP|0510|PENILE INJECTION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||264.58||| 54235|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.35||| 54235|EAP|0510|PENILE INJECTION|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||264.58||| 54235|EAP|0510|PENILE INJECTION|Blue Cross PPO Specialty|BCBSTX OTHER|||||264.58||| 54235|EAP|0361||Blue Cross PPO Specialty|BCBSTX OTHER|||||264.58||| 54235|EAP|0510|PENILE INJECTION|Blue Cross PPO Specialty|BCBSTX PPO|||||264.58||| 54235|EAP|0510|PENILE INJECTION|United Medicare Advantage|UHC MEDICARE GOLD MA|||||264.58||| 54235|EAP|0510|PENILE INJECTION|United Medicare Advantage|UHC AARP MCR HMO MA|||||264.58||| 54235|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.35||| 543|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC|Blue Cross PPO Specialty|BCBSTX PPO|449.10|7282.27|7282.27|216.385|||| 543|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC|Humana Medicare Advantage|HUMANA MA|53,948.70|3787.99|7282.27|216.385|||| 543|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC|Medicare|MEDICARE ACUTE|58,261.49|7079.35|7282.27|216.385|||| 543|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC|Medicare|MEDICARE PART B ONLY IP|13,653.58|216.385|7282.27|216.385|||| 543|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|91,300.05|7199.96|7282.27|216.385|||| 544|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|41,894.75|7079.35|7079.35|5453.4|||| 544|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|66,619.85|5453.4|7079.35|5453.4|||| 545|DRG||CONNECTIVE TISSUE DISORDERS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|462,490.10|22845.85|22845.85|335.01|||| 545|DRG||CONNECTIVE TISSUE DISORDERS W MCC|Medicaid|MEDICAID|180,538.43|7236.99|22845.85|335.01|||| 545|DRG||CONNECTIVE TISSUE DISORDERS W MCC|Medicare|MEDICARE ACUTE|64,037.09|13086.755|22845.85|335.01|||| 545|DRG||CONNECTIVE TISSUE DISORDERS W MCC|Medicare|MEDICARE PART B ONLY IP|71.47|335.01|22845.85|335.01|||| 546|DRG||CONNECTIVE TISSUE DISORDERS W CC|Humana Medicare Advantage|HUMANA MA|57,655.05|7869.26|7873.34|7869.26|||| 546|DRG||CONNECTIVE TISSUE DISORDERS W CC|Medicare|MEDICARE ACUTE|117,635.09|7873.34|7873.34|7869.26|||| 549|DRG||SEPTIC ARTHRITIS W CC|Medicare|MEDICARE ACUTE|86,356.62|7830.02|7834.79|7830.02|||| 549|DRG||SEPTIC ARTHRITIS W CC|Humana Medicare Advantage|HUMANA MA|58,620.50|7834.79|7834.79|7830.02|||| 55|DRG||NERVOUS SYSTEM NEOPLASMS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|66,177.55|10843.49|10843.49|561.09|||| 55|DRG||NERVOUS SYSTEM NEOPLASMS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21,063.17|6804.38|10843.49|561.09|||| 55|DRG||NERVOUS SYSTEM NEOPLASMS W/O MCC|Humana Medicare Advantage|HUMANA MA|34,408.60|6702.32|10843.49|561.09|||| 55|DRG||NERVOUS SYSTEM NEOPLASMS W/O MCC|Medicare|MEDICARE PART B ONLY IP|30,511.80|561.09|10843.49|561.09|||| 55|DRG||NERVOUS SYSTEM NEOPLASMS W/O MCC|Medicare|MEDICARE ACUTE|79,902.35|6693.6|10843.49|561.09|||| 550|DRG||SEPTIC ARTHRITIS W/O CC/MCC|Medicare|MEDICARE ACUTE|97,829.92|6122.5|6122.5|6122.5|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|75,771.10|10223.82|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|84,249.35|8679.38|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|201,234.99|11834.07|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|115,940.96|10016.37|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|Medicare|MEDICARE ACUTE|100,901.31|10005.09|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|83,976.75|238.14|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|Managed Medicare|HEALTHSPRING MA|119,490.40|11834.07|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|117,881.65|10004.65|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|Humana Medicare Advantage|HUMANA MA|77,638.13|9993.02|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|94,036.58|9186.72|14306.65|238.14|||| 551|DRG||MEDICAL BACK PROBLEMS W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|72,419.11|14306.65|14306.65|238.14|||| 55100|EAP|0510|DRAINAGE OF SCROTUM ABSCE|Humana Medicare Advantage|HUMANA MA|15.45||||15.45||| 55100|EAP|0450|DRAINAGE SCROTUM ABSCESS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||38.41||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Medicare|MEDICARE ACUTE|54,290.32|6287.87|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Medicaid|MEDICAID|99,595.25|7407.36|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|26,882.55|4071.01|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|49,784.70|6390.89|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Managed Medicare|HEALTHSPRING MA|71,776.80|6286.99|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|95,246.55|7520.56|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|65,325.54|16517.25|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|41,716.60|6472.91|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|133,812.50|6259.71|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Humana Medicare Advantage|HUMANA MA|575.36|6269.36|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|47,327.50|102.06|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63,066.65|6287.43|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32,453.30|6472.91|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|37,778.82|6117.79|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|88,349.05|5200.57|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|27,714.95|15502.3|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Workers Compensation|WORKERS COMPENSATION OTHER|42,185.70|9064.68|16517.25|102.06|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Medicare|MEDICARE PART B ONLY IP|44,229.20|699.25|16517.25|102.06|||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|United Healthcare|UNITED HEALTHCARE|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Cigna|CIGNA OTHER|||||1,945.42||| 55250|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA|||||46.69||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|PHCS|HUMANA INSURANCE|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,945.42||| 55250|EAP|0361||Managed Medicaid|MEDICAID SUPERIOR|||||46.69||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Aetna|AETNA OTHER|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Aetna|AETNA PPO|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Managed Medicaid|MEDICAID AMERIGROUP|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Blue Cross HMO Specialty|BCBSTX HMO|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,945.42||| 55250|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||46.69||| 55250|EAP|0361||Cigna|CIGNA|||||46.69||| 55250|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||46.69||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Blue Cross PPO Specialty|BCBSTX PPO|||||1,945.42||| 55250|EAP|0361||Aetna|AETNA OTHER|||||46.69||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,945.42||| 55250|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||46.69||| 55250|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||46.69||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|PHCS|GROUP AND PENSION|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,945.42||| 55250|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UMR|||||46.69||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Cigna|CIGNA|||||1,945.42||| 55250|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||46.69||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|United Healthcare|UNITED HEALTHCARE OTHER|||||1,945.42||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,945.42||| 55250|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||46.69||| 55250|EAP|0510|REMOVAL OF SPERM DUCT(S)|Tricare|TRICARE EAST REGION|||||1,945.42||| 553|DRG||BONE DISEASES & ARTHROPATHIES W MCC|Humana Medicare Advantage|HUMANA MA|100,888.11|8484.2|10729.11|8484.2|||| 553|DRG||BONE DISEASES & ARTHROPATHIES W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32,865.48|10729.11|10729.11|8484.2|||| 554|DRG||BONE DISEASES & ARTHROPATHIES W/O MCC|Humana Medicare Advantage|HUMANA MA|41,114.44|5692.18|5692.18|5139.35|||| 554|DRG||BONE DISEASES & ARTHROPATHIES W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|172.09|5139.35|5692.18|5139.35|||| 554|DRG||BONE DISEASES & ARTHROPATHIES W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|23,283.70|5692.18|5692.18|5139.35|||| 554|DRG||BONE DISEASES & ARTHROPATHIES W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|91,688.06|5692.18|5692.18|5139.35|||| 554|DRG||BONE DISEASES & ARTHROPATHIES W/O MCC|Medicare|MEDICARE PART B ONLY IP|20,555.50||||||| 554|DRG||BONE DISEASES & ARTHROPATHIES W/O MCC|Medicare|MEDICARE ACUTE|54,690.66|5603.61|5692.18|5139.35|||| 555|DRG||SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W MCC|Medicare|MEDICARE ACUTE|90,441.56|8576.315|8576.315|8576.315|||| 556|DRG||SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC|Medicare|MEDICARE ACUTE|45,987.37|5628.4|15810.46|5628.4|||| 556|DRG||SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|24,293.75|7287.23|15810.46|5628.4|||| 556|DRG||SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC|Medicare|MEDICARE PART B ONLY IP|30,676.96|5631.75|15810.46|5628.4|||| 556|DRG||SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|61,411.25|15810.46|15810.46|5628.4|||| 556|DRG||SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC|Humana Medicare Advantage|HUMANA MA|89,428.26|5717.95|15810.46|5628.4|||| 557|DRG||TENDONITIS, MYOSITIS & BURSITIS W MCC|Medicaid|MEDICAID|52,260.29|10837.06|10837.06|2131.99|||| 557|DRG||TENDONITIS, MYOSITIS & BURSITIS W MCC|Managed Medicare|HEALTHSPRING MA|62,584.09|9451.84|10837.06|2131.99|||| 557|DRG||TENDONITIS, MYOSITIS & BURSITIS W MCC|Humana Medicare Advantage|HUMANA MA|78,252.66|9451.84|10837.06|2131.99|||| 557|DRG||TENDONITIS, MYOSITIS & BURSITIS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|309,236.16|2131.99|10837.06|2131.99|||| 557|DRG||TENDONITIS, MYOSITIS & BURSITIS W MCC|Medicare|MEDICARE ACUTE|80,440.69|9285.58|10837.06|2131.99|||| 55700|EAP|0510|BIOPSY OF PROSTATE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|Cigna|CIGNA|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,945.42||| 55700|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,945.42||| 55700|EAP|0361||Cigna|CIGNA|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,945.42||| 55700|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UMR|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,945.42||| 55700|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.69||| 55700|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||46.69||| 55700|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,945.42||| 55700|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,945.42||| 55700|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||46.69||| 55700|EAP|0361||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,945.42||| 55700|EAP|0361||Aetna|AETNA PPO|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|Humana Medicare Advantage|HUMANA MA|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,945.42||| 55700|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|Aetna|AETNA PPO|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|Blue Cross HMO Specialty|BCBSTX HMO|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|Medicare|MEDICARE ACUTE|||||1,945.42||| 55700|EAP|0361||PHCS|HUMANA INSURANCE|||||46.69||| 55700|EAP|0361||Medicare|MEDICARE ACUTE|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|United Healthcare|AARP|||||1,945.42||| 55700|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||46.69||| 55700|EAP|0361||Multiplan|WEB TPA|||||46.69||| 55700|EAP|0361||PHCS|HUMANA|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|United Healthcare|UNITED HEALTHCARE OTHER|||||1,945.42||| 55700|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|PHCS|HUMANA|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,945.42||| 55700|EAP|0361||NON CONTRACTED|COMMERCIAL OTHER 1|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|United Healthcare|UNITED HEALTHCARE|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|PHCS|HUMANA INSURANCE|||||1,945.42||| 55700|EAP|0510|BIOPSY OF PROSTATE|Managed Medicare|BCBS MEDICARE PPO MA|||||1,945.42||| 55700|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||46.69||| 55700|EAP|0510|BIOPSY OF PROSTATE|Managed Medicare|HEALTHSPRING MA|||||1,945.42||| 55706|EAP|0510|PROSTATE STRTCTC SATURATI|Blue Cross PPO Specialty|BCBSTX PPO|||||33.99||| 558|DRG||TENDONITIS, MYOSITIS & BURSITIS W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|555.88|7772.45|8863.81|214.32|||| 558|DRG||TENDONITIS, MYOSITIS & BURSITIS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|36,253.43|5750.65|8863.81|214.32|||| 558|DRG||TENDONITIS, MYOSITIS & BURSITIS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|74,916.32|214.32|8863.81|214.32|||| 558|DRG||TENDONITIS, MYOSITIS & BURSITIS W/O MCC|Cigna|CIGNA|60,435.81|8863.81|8863.81|214.32|||| 558|DRG||TENDONITIS, MYOSITIS & BURSITIS W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|20,900.65|6010.76|8863.81|214.32|||| 558|DRG||TENDONITIS, MYOSITIS & BURSITIS W/O MCC|Medicare|MEDICARE ACUTE|35,214.96|6010.76|8863.81|214.32|||| 55874|EAP|0361||Medicare|MEDICARE ACUTE|||||107.91||| 55874|EAP|0510|TPRNL PLMT BIODEGRDABL MA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,496.25||| 55874|EAP|0510|TPRNL PLMT BIODEGRDABL MA|United Medicare Advantage|UHC AARP MCR HMO MA|||||4,496.25||| 55874|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||107.91||| 55874|EAP|0361||Aetna|AETNA PPO|||||107.91||| 55874|EAP|0510|TPRNL PLMT BIODEGRDABL MA|Medicare|MEDICARE ACUTE|||||4,496.25||| 55874|EAP|0510|TPRNL PLMT BIODEGRDABL MA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4,496.25||| 55874|EAP|0510|TPRNL PLMT BIODEGRDABL MA|United Healthcare|UNITED HEALTHCARE|||||4,496.25||| 55874|EAP|0510|TPRNL PLMT BIODEGRDABL MA|Humana Medicare Advantage|HUMANA MA|||||4,496.25||| 55874|EAP|0510|TPRNL PLMT BIODEGRDABL MA|Veterans Affairs|VETERANS ADMINISTRATION|||||4,496.25||| 55874|EAP|0510|TPRNL PLMT BIODEGRDABL MA|Managed Medicare|HEALTHSPRING MA|||||4,496.25||| 55874|EAP|0510|TPRNL PLMT BIODEGRDABL MA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,496.25||| 55876|EAP|0510|PLACE RT DEVICE/MARKER PR|United Healthcare|UNITED HEALTHCARE|||||1,332.92||| 55876|EAP|0510|PLACE RT DEVICE/MARKER PR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,332.92||| 55876|EAP|0361||Aetna|AETNA PPO|||||31.99||| 55876|EAP|0510|PLACE RT DEVICE/MARKER PR|Managed Medicare|HEALTHSPRING MA|||||1,332.92||| 55876|EAP|0510|PLACE RT DEVICE/MARKER PR|Veterans Affairs|VETERANS ADMINISTRATION|||||1,332.92||| 55876|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||31.99||| 55876|EAP|0510|PLACE RT DEVICE/MARKER PR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,332.92||| 55876|EAP|0510|PLACE RT DEVICE/MARKER PR|Medicare|MEDICARE ACUTE|||||1,332.92||| 55876|EAP|0510|PLACE RT DEVICE/MARKER PR|Humana Medicare Advantage|HUMANA MA|||||1,332.92||| 55876|EAP|0361||Medicare|MEDICARE ACUTE|||||31.99||| 55876|EAP|0510|PLACE RT DEVICE/MARKER PR|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,332.92||| 55876|EAP|0510|PLACE RT DEVICE/MARKER PR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,332.92||| 559|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Medicare|MEDICARE ACUTE|69,607.99|11142.88|19977.83|11142.88|||| 559|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|63,776.99|19977.83|19977.83|11142.88|||| 56|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC|Medicare|MEDICARE ACUTE|804.42|13313.51|20594.95|10005.54|||| 56|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|453,343.03|20594.95|20594.95|10005.54|||| 56|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|185,489.99|14425.35|20594.95|10005.54|||| 56|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|148,912.93|13304.57|20594.95|10005.54|||| 56|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|44,014.55|10005.54|20594.95|10005.54|||| 56|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC|Managed Medicare|HEALTHSPRING MA|195,854.50|13592.14|20594.95|10005.54|||| 560|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Managed Medicare|HEALTHSPRING MA|66,018.25|7009.99|12350.87|88.9|||| 560|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Medicare|MEDICARE ACUTE|115,618.28|6995.91|12350.87|88.9|||| 560|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Humana Medicare Advantage|HUMANA MA|8,004.25|5720.25|12350.87|88.9|||| 560|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|48,454.67|88.9|12350.87|88.9|||| 560|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|United Healthcare|UNITED HEALTHCARE OTHER|4,198.65|12350.87|12350.87|88.9|||| 561|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|9,385.60|801.27|5469.18|801.27|||| 561|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|32,275.05|5133.92|5469.18|801.27|||| 561|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|20,278.01|5469.18|5469.18|801.27|||| 561|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC|Medicare|MEDICARE ACUTE|36,081.29|5371.11|5469.18|801.27|||| 562|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W MCC|Medicare|MEDICARE ACUTE|27,045.28|5903.52|5903.52|5903.52|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Humana Medicare Advantage|HUMANA MA|60,013.78|5957.97|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Medicaid|MEDICAID|31,451.75|2270.97|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|58,086.19|5960.33|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Cigna|CIGNA|40,819.59|12462.66|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Workers Compensation|TEXAS MUTUAL INSURANCE|45,822.70|8536.06|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,310.31|5989.03|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Workers Compensation|WORKERS COMPENSATION OTHER|41,924.40|8537.31|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46,546.60|5969.27|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32,353.20|71.44|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|PHCS|HUMANA|24,142.63|145.18|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|99,039.35|10107.94|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Medicare|MEDICARE PART B ONLY IP|24,066.51|774.84|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Tricare|TRICARE EAST REGION|28,907.23|3041.52|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|55,791.31|5690.7|12462.66|71.44|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Medicare|MEDICARE ACUTE|52,431.60|5969.71|12462.66|71.44|||| 564|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|112,976.63|9515.89|10101.74|1311.91|||| 564|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|45,253.68|10101.74|10101.74|1311.91|||| 564|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,692.25|1311.91|10101.74|1311.91|||| 564|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|73,909.22|9753.29|10101.74|1311.91|||| 564|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC|Humana Medicare Advantage|HUMANA MA|77,090.17|9568.97|10101.74|1311.91|||| 56405|EAP|0450|I&D ABSCESS VULVA PERINEA|Blue Cross PPO Specialty|BCBSTX PPO|||||1,526.05||| 56405|EAP|0450|I&D ABSCESS VULVA PERINEA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.27||| 56405|EAP|0450|I&D ABSCESS VULVA PERINEA|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1,526.05||| 56405|EAP|0450|I&D ABSCESS VULVA PERINEA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||13.27||| 56420|EAP|0450|I&D BARTHOLINS GLAND|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.40||| 56420|EAP|0450|I&D BARTHOLINS GLAND|Blue Cross PPO Specialty|BCBSTX PPO|||||9.66||| 56420|EAP|0450|I&D BARTHOLINS GLAND|Managed Medicaid|MEDICAID SUPERIOR|||||9.66||| 56420|EAP|0450|I&D BARTHOLINS GLAND|Humana Medicare Advantage|HUMANA MA|||||9.66||| 565|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC|Medicare|MEDICARE ACUTE|36,386.25|6719.335|6781.185|35.72|||| 565|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12,793.91|35.72|6781.185|35.72|||| 565|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC|Veterans Affairs|VETERANS ADMINISTRATION|56,532.31|6775.26|6781.185|35.72|||| 565|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|46,975.19|6781.185|6781.185|35.72|||| 565|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC|Blue Cross PPO Specialty|BCBSTX OTHER|30,374.75|6270.67|6781.185|35.72|||| 565|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC|Managed Medicaid|MEDICAID SUPERIOR|85,368.55|5989.03|6781.185|35.72|||| 566|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|24,309.55|5429.25|5526.89|5423.56|||| 566|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC|Medicare|MEDICARE ACUTE|18,145.80|5526.89|5526.89|5423.56|||| 566|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|62,531.60|5423.56|5526.89|5423.56|||| 57|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC|Humana Medicare Advantage|HUMANA MA|55,519.42|7929.535|14331.03|7907.67|||| 57|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|47,197.33|7907.67|14331.03|7907.67|||| 57|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|50,962.67|7927.15|14331.03|7907.67|||| 57|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|137,423.40|14331.03|14331.03|7907.67|||| 570|DRG||SKIN DEBRIDEMENT W MCC|Medicaid|MEDICAID|430,563.94|12725.84|17022.02|10165.64|||| 570|DRG||SKIN DEBRIDEMENT W MCC|Medicare|MEDICARE ACUTE|99,238.43|13502.415|17022.02|10165.64|||| 570|DRG||SKIN DEBRIDEMENT W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|176,955.83|10165.64|17022.02|10165.64|||| 570|DRG||SKIN DEBRIDEMENT W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|214,982.39|17022.02|17022.02|10165.64|||| 571|DRG||SKIN DEBRIDEMENT W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|88,410.37|13272.63|13272.63|10165.64|||| 571|DRG||SKIN DEBRIDEMENT W CC|Medicare|MEDICARE ACUTE|130,015.57|10459.55|13272.63|10165.64|||| 571|DRG||SKIN DEBRIDEMENT W CC|United Medicare Advantage|UHC AARP MCR HMO MA|150,525.38|10651.47|13272.63|10165.64|||| 571|DRG||SKIN DEBRIDEMENT W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|80,540.10|10165.64|13272.63|10165.64|||| 572|DRG||SKIN DEBRIDEMENT W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|45,941.97|10637.93|11542.29|7870.245|||| 572|DRG||SKIN DEBRIDEMENT W/O CC/MCC|Cigna|CIGNA OTHER|67,380.51|11542.29|11542.29|7870.245|||| 572|DRG||SKIN DEBRIDEMENT W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|37,543.59|7870.245|11542.29|7870.245|||| 573|DRG||SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W MCC|Medicare|MEDICARE ACUTE|199,585.95|30521.18|30521.18|30521.18|||| 574|DRG||SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC|Veterans Affairs|VETERANS ADMINISTRATION|66,072.28|15657.86|32123.32|12988.38|||| 574|DRG||SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|47,981.25|12988.38|32123.32|12988.38|||| 574|DRG||SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC|NON CONTRACTED|COMMERCIAL OTHER 1|57,285.35|32123.32|32123.32|12988.38|||| 57420|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||7.33||| 57420|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.33||| 576|DRG||SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|242,437.91|28451.88|28451.88|28451.88|||| 577|DRG||SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W CC|Workers Compensation|WORKERS COMPENSATION OTHER|52,213.60|20789.73|20789.73|11295.57|||| 577|DRG||SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W CC|Tricare|TRICARE EAST REGION|60,629.85|11295.57|20789.73|11295.57|||| 578|DRG||SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W/O CC/MCC|Medicare|MEDICARE ACUTE|57,460.75|10306.525|22887.91|10306.525|||| 578|DRG||SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|103,055.15|22887.91|22887.91|10306.525|||| 579|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|91,634.63|25787.15|35343.48|16148.9|||| 579|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC|Blue Cross PPO Specialty|BCBSTX PPO|154,676.56|18997.06|35343.48|16148.9|||| 579|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC|United Healthcare|UNITED HEALTHCARE OTHER|183,938.98|35343.48|35343.48|16148.9|||| 579|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC|Medicare|MEDICARE ACUTE|72,389.20|17668.81|35343.48|16148.9|||| 579|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC|Blue Cross HMO Specialty|BCBSTX HMO|69,629.49|16148.9|35343.48|16148.9|||| 579|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|78,513.55|17660.12|35343.48|16148.9|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|50,141.80|50141.8|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Medicare|MEDICARE ACUTE|65,625.29|10203.275|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Aetna|AETNA OTHER|77,300.68|20350.06|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|44,678.90|12982.32|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|United Medicare Advantage|UHC AARP WELLMED HMO MA|52,042.17|10314.56|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|NON CONTRACTED|COMMERCIAL OTHER 1|100,678.33|100678.33|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|161,542.36|39877.01|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Blue Cross HMO Specialty|BCBSTX HMO|39,049.30|8704.7|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|59,573.82|10184.91|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|131,924.44|26284.34|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Medicare|MEDICARE PART B ONLY IP|84,154.65|10117.37|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Humana Medicare Advantage|HUMANA MA|48,001.80|10085.93|100678.33|224.53|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103,380.94|224.53|100678.33|224.53|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Tricare|TRICARE EAST REGION|132,278.92|11380.91|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|60,351.37|8168.6|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|137,713.83|12258.75|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|114,935.08|23547.005|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|93,746.60|8240.09|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|63,190.57|105.46|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Cigna|CIGNA|48,410.98|12911.89|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|80,957.60|10596.75|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|United Healthcare|TML GROUP BENEFITS|39,583.39|18477.81|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Aetna|AETNA PPO|143,369.66|25019.17|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|74,101.47|7136.5|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|47,303.16|10515.08|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|25,140.73|14851.81|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|77,346.90|8395.16|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|88,205.47|8395.16|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|138,221.59|8141.82|25019.17|105.46|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|60,836.02|8312.18|25019.17|105.46|||| 583|DRG||MASTECTOMY FOR MALIGNANCY W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|147,056.35|9469.78|9469.78|9302.27|||| 583|DRG||MASTECTOMY FOR MALIGNANCY W/O CC/MCC|Medicare|MEDICARE ACUTE|155,559.34|9302.27|9469.78|9302.27|||| 58340|EAP|0361|XR-CATHETER FOR HYSTEROGR|Managed Medicaid|MEDICAID SUPERIOR|||||5,417.50||| 58340|EAP|0361|XR-CATHETER FOR HYSTEROGR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5,417.50||| 58340|EAP|0361|XR-CATHETER FOR HYSTEROGR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,266.75||| 58340|EAP|0361|XR-CATHETER FOR HYSTEROGR|Blue Cross PPO Specialty|BCBSTX PPO|||||5,417.50||| 58340|EAP|0361|XR-CATHETER FOR HYSTEROGR|United Healthcare|UNITED HEALTHCARE|||||51.16||| 58340|EAP|0361|XR-CATHETER FOR HYSTEROGR|Medicaid|MEDICAID|||||51.16||| 584|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|203,087.49|12706.81|18124.15|11526.09|||| 584|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC|Humana Medicare Advantage|HUMANA MA|73,886.40|11526.09|18124.15|11526.09|||| 584|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|158,985.75|18124.15|18124.15|11526.09|||| 585|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC|Cigna|CIGNA|37,065.80|16721.07|41456.67|10364.64|||| 585|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|120,902.57|10694.145|41456.67|10364.64|||| 585|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|66,413.30|10631.1|41456.67|10364.64|||| 585|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|201,945.37|41456.67|41456.67|10364.64|||| 585|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|131,867.89|16007.56|41456.67|10364.64|||| 585|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|137,372.89|10364.64|41456.67|10364.64|||| 585|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|126,411.64|12280.51|41456.67|10364.64|||| 585|DRG||BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|152,625.97|12534.76|41456.67|10364.64|||| 59|DRG||MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W CC|Blue Cross PPO Specialty|BCBSTX PPO|38,954.20|7464.25|7464.25|7464.25|||| 59025|EAP|0920|NST-NON STRESS TEST|United Healthcare|UNITED HEALTHCARE OTHER|653.20||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Medicare|MEDICARE ACUTE|653.20||||||| 59025|EAP|0920|NST-NON STRESS TEST|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Medicaid|SUPERIOR HEALTHPLAN CHIP|653.20||||||| 59025|EAP|0920|NST-NON STRESS TEST|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||610.60||| 59025|EAP|0920|NST-NON STRESS TEST|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||653.20||| 59025|EAP|0920|NST-NON STRESS TEST|United Healthcare|TML GROUP BENEFITS|653.20||||||| 59025|EAP|0920|NST-NON STRESS TEST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.68||||653.20||| 59025|EAP|0920|NST-NON STRESS TEST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|653.20||||653.20||| 59025|EAP|0920|NST-NON STRESS TEST|Managed Medicare|BCBS MEDICARE PPO MA|5.68||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|United Medicare Advantage|UHC MEDICARE GOLD MA|653.20||||||| 59025|EAP|0920|NST-NON STRESS TEST|Tricare|TRICARE EAST REGION|||||653.20||| 59025|EAP|0920|NST-NON STRESS TEST|United Healthcare|UNITED HEALTHCARE|||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Cigna|CIGNA|||||610.60||| 59025|EAP|0920|NST-NON STRESS TEST|Blue Cross PPO Specialty|BCBSTX PPO|5.68||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|653.20||||610.60||| 59025|EAP|0920|NST-NON STRESS TEST|Cigna|CIGNA|||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Aetna|AETNA PPO|653.20||||||| 59025|EAP|0920|NST-NON STRESS TEST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.68||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Managed Medicaid|MEDICAID AMERIGROUP|653.20||||653.20||| 59025|EAP|0920|NST-NON STRESS TEST|Access Direct Platinum|HEALTHFIRST TPA|5.68||||||| 59025|EAP|0920|NST-NON STRESS TEST|Aetna|AETNA OTHER|||||653.20||| 59025|EAP|0920|NST-NON STRESS TEST|Aetna Value Network|AETNA VALUE NETWORK|||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Managed Medicaid|MEDICAID SUPERIOR|5.68||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|NON CONTRACTED|COMMERCIAL OTHER 1|||||653.20||| 59025|EAP|0920|NST-NON STRESS TEST|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|United Healthcare|UNITED HEALTHCARE|5.68||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Medicaid|MEDICAID|5.68||||||| 59025|EAP|0920|NST-NON STRESS TEST|Access Direct Platinum|HEALTHFIRST TPA UMR|5.68||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|653.20||||5.68||| 59025|EAP|0920|NST-NON STRESS TEST|Blue Cross HMO Specialty|BCBSTX HMO|653.20||||5.68||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Aetna|AETNA OTHER|359.95||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Blue Cross PPO Specialty|BCBSTX OTHER|3.13||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Aetna|AETNA PPO|359.95||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|359.95||||336.48||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Blue Cross PPO Specialty|BCBSTX PPO|359.95||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.13||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Blue Cross HMO Specialty|BCBSTX HMO|359.95||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|ChampVA|CHAMPVA CENTER|359.95||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|359.95||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|United Healthcare|UNITED HEALTHCARE|3.13||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Cigna|CIGNA|359.95||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.13||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.13||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|359.95||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|359.95||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Access Direct Platinum|HEALTHFIRST TPA|359.95||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Cigna|CIGNA OTHER|359.95||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|United Medicare Advantage|UHC MEDICARE GOLD MA|359.95||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Aetna Value Network|AETNA VALUE NETWORK|336.48||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Medicaid|MEDICAID|359.95||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Access Direct Platinum|HEALTHFIRST TPA UMR|3.13||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Managed Medicaid|MEDICAID AMERIGROUP|336.48||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|United Healthcare|UNITED HEALTHCARE|359.95||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Medicaid|MOLINA HEALTHCARE OF TEXAS|359.95||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Tricare|TRICARE EAST REGION|359.95||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Medicaid|MEDICAID HMO|359.95||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Managed Medicaid|MEDICAID SUPERIOR|359.95||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|United Healthcare|UNITED HEALTHCARE OTHER|359.95||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|PHCS|HUMANA INSURANCE|3.13||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|PHCS|GROUP AND PENSION|336.48||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Medicare|MEDICARE ACUTE|359.95||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|NON CONTRACTED|COMMERCIAL OTHER 1|359.95||||3.13||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Cigna|CIGNA|359.95||||359.95||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|Tricare|TRICARE FOR LIFE|359.95||||||| 59050|EAP|0720|FETAL MONITOR PER 3 HOURS|United Healthcare|TML GROUP BENEFITS|336.48||||||| 592|DRG||SKIN ULCERS W MCC|Medicare|MEDICARE ACUTE|142,245.61|11279.01|11279.01|10165.64|||| 592|DRG||SKIN ULCERS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|70,561.95|10165.64|11279.01|10165.64|||| 593|DRG||SKIN ULCERS W CC|NON CONTRACTED|COMMERCIAL OTHER 1|74,117.36|19512.6|26595.36|5851.81|||| 593|DRG||SKIN ULCERS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|64,714.20|26595.36|26595.36|5851.81|||| 593|DRG||SKIN ULCERS W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|61,147.75|7254.35|26595.36|5851.81|||| 593|DRG||SKIN ULCERS W CC|Blue Cross HMO Specialty|BCBSTX HMO|56,645.25|5851.81|26595.36|5851.81|||| 596|DRG||MAJOR SKIN DISORDERS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|773.98|6601.02|17606.99|6601.02|||| 596|DRG||MAJOR SKIN DISORDERS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|162,320.15|17606.99|17606.99|6601.02|||| 596|DRG||MAJOR SKIN DISORDERS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|218.33|6868.09|17606.99|6601.02|||| 596|DRG||MAJOR SKIN DISORDERS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13,653.80|8558.15|17606.99|6601.02|||| 597|DRG||MALIGNANT BREAST DISORDERS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|73,825.60|10571.72|11678.8|10571.72|||| 597|DRG||MALIGNANT BREAST DISORDERS W MCC|Medicare|MEDICARE ACUTE|46,506.84|10659.22|11678.8|10571.72|||| 597|DRG||MALIGNANT BREAST DISORDERS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|45,348.05|11678.8|11678.8|10571.72|||| 598|DRG||MALIGNANT BREAST DISORDERS W CC|Blue Cross PPO Specialty|BCBSTX PPO|54,200.70|7892.02|25428.25|7892.02|||| 598|DRG||MALIGNANT BREAST DISORDERS W CC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|25,428.25|25428.25|25428.25|7892.02|||| 60|DRG||MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W/O CC/MCC|Medicare|MEDICARE ACUTE|57,750.30|6121.27|7267.91|6121.27|||| 60|DRG||MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|77,408.28|7267.91|7267.91|6121.27|||| 600|DRG||NON-MALIGNANT BREAST DISORDERS W CC/MCC|Aetna|AETNA PPO|26,657.07|12133.88|12133.88|12133.88|||| 601|DRG||NON-MALIGNANT BREAST DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|44,387.16|4748.62|6367.45|4748.62|||| 601|DRG||NON-MALIGNANT BREAST DISORDERS W/O CC/MCC|Cigna|CIGNA|35,545.20|6367.45|6367.45|4748.62|||| 60100|EAP|0361|US BIOPSY OF THYROID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,667.33||| 60100|EAP|0361|US BIOPSY OF THYROID|Medicare|MEDICARE ACUTE|15.51||||1,783.65||| 60100|EAP|0361|US BIOPSY OF THYROID|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,783.65||| 60100|EAP|0361|US BIOPSY OF THYROID|Aetna|AETNA OTHER|||||15.51||| 60100|EAP|0361|US BIOPSY OF THYROID|United Healthcare|UNITED HEALTHCARE OTHER|||||15.51||| 60100|EAP|0361|US BIOPSY OF THYROID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,783.65||| 602|DRG||CELLULITIS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44,146.28|8920.97|9414.63|246.64|||| 602|DRG||CELLULITIS W MCC|Humana Medicare Advantage|HUMANA MA|66,502.62|9118.14|9414.63|246.64|||| 602|DRG||CELLULITIS W MCC|Medicare|MEDICARE ACUTE|57,118.07|9128.87|9414.63|246.64|||| 602|DRG||CELLULITIS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98,157.19|246.64|9414.63|246.64|||| 602|DRG||CELLULITIS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|56,499.20|9414.63|9414.63|246.64|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|67,879.15|5902.015|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45,346.12|107.16|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Aetna|AETNA PPO|39,008.27|6017.83|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicare|HEALTHSPRING MA|28,296.50|5912.53|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|66,435.65|6018.46|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|23,464.25|5755.88|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20,500.55|7647.66|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|17,348.88|3704.7|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Workers Compensation|WORKERS COMPENSATION OTHER|19,366.34|8168.5|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA|1,717.09|19692.94|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|101,712.62|5884.37|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|27,590.30|27590.3|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|43,077.20|5912.53|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|27,620.75|5993.23|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|16,839.49|9983.67|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|41,457.60|6007.63|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|United Healthcare|AARP|35,412.75|5912.53|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|45,632.87|3704.7|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Medicaid|MEDICAID|286.07|3861.71|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|55,550.05|5884.37|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Medicaid|SMITH COUNTY JAIL|134,086.45|3775.85|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|United Healthcare|GOLDEN RULE|71,150.76|9983.67|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54,939.98|5884.37|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Humana Medicare Advantage|HUMANA MA|23,752.87|717.98|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Medicare|MEDICARE ACUTE|41,724.55|5912.53|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|37,248.01|7647.66|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|110,838.53|17213.95|27590.3|107.16|||| 603|DRG||CELLULITIS W/O MCC|Cigna|CIGNA|45,284.67|8283.1|27590.3|107.16|||| 604|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W MCC|Medicare|MEDICARE ACUTE|85,422.04|4970.825|9320.25|4970.825|||| 604|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W MCC|Humana Medicare Advantage|HUMANA MA|54,340.03|9320.25|9320.25|4970.825|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|26,502.55|7872.15|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Workers Compensation|WORKERS COMPENSATION OTHER|18,517.85|9688.62|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31,689.50|15049.3|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Medicaid|CRIME VICTIMS COMPENSATION|132,450.30|4135.48|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|146.65|4966.81|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|121,464.63|6088.34|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|53,689.28|6067.31|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Aetna|AETNA OTHER|92,002.36|6188.05|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|197,241.45|6575.41|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 2|7,834.59|4732.81|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Medicare|MEDICARE PART B ONLY IP|6,716.40|627.21|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Medicare|MEDICARE ACUTE|38,717.50|6089.22|15049.3|627.21|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Cigna|CIGNA|55,833.53|9010.95|15049.3|627.21|||| 606|DRG||MINOR SKIN DISORDERS W MCC|Medicare|MEDICARE ACUTE|94,116.45|9462.12|9462.12|9462.12|||| 607|DRG||MINOR SKIN DISORDERS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|31,831.10|5438.79|9777.72|136.08|||| 607|DRG||MINOR SKIN DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|60,216.66|5802.98|9777.72|136.08|||| 607|DRG||MINOR SKIN DISORDERS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41,346.50|136.08|9777.72|136.08|||| 607|DRG||MINOR SKIN DISORDERS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|38,053.25|9777.72|9777.72|136.08|||| 61|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W MCC|Medicare|MEDICARE ACUTE|154,667.66|16612.83|29051.23|16584.67|||| 61|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|114,786.40|16584.67|29051.23|16584.67|||| 61|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|210,907.18|16612.83|29051.23|16584.67|||| 61|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|112,152.55|29051.23|29051.23|16584.67|||| 61|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W MCC|Managed Medicare|HEALTHSPRING MA|147,845.43|16967.42|29051.23|16584.67|||| 61050|EAP|0361|CERVICAL PUNCTURE C1-2 WO|Medicare|MEDICARE ACUTE|757.50||||||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,061.95||||||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Blue Cross HMO Specialty|BCBSTX HMO|17.93||||||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Humana Medicare Advantage|HUMANA MA|17.93||||2,061.95||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2,061.95||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,061.95||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Workers Compensation|UT EMPLOYEE INJURY|||||17.93||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Medicaid|MEDICAID|17.93||||||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2,061.95||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||17.93||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Blue Cross PPO Specialty|BCBSTX PPO|17.93||||2,061.95||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.93||||||| 61070|EAP|0361|INJECTION BRAIN CANAL SHU|Blue Cross PPO Specialty|BCBSTX PPO|17.93||||16.07||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|Medicare|MEDICARE ACUTE|17.93||||17.93||| 61070|EAP|0361|XR-BRAIN CANAL SHUNT PROC|United Medicare Advantage|UHC MEDICARE GOLD MA|2,061.95||||2,061.95||| 614|DRG||ADRENAL & PITUITARY PROCEDURES W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|65,246.93|16048.84|16048.84|14620.22|||| 614|DRG||ADRENAL & PITUITARY PROCEDURES W CC/MCC|Humana Medicare Advantage|HUMANA MA|78,123.40|14620.22|16048.84|14620.22|||| 614|DRG||ADRENAL & PITUITARY PROCEDURES W CC/MCC|Medicare|MEDICARE ACUTE|85,876.95|14915.41|16048.84|14620.22|||| 615|DRG||ADRENAL & PITUITARY PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|81,434.54|9596.97|17565.81|9596.97|||| 615|DRG||ADRENAL & PITUITARY PROCEDURES W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|66,998.76|9596.97|17565.81|9596.97|||| 615|DRG||ADRENAL & PITUITARY PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|156,564.36|17565.81|17565.81|9596.97|||| 615|DRG||ADRENAL & PITUITARY PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|108,562.60|13577.42|17565.81|9596.97|||| 615|DRG||ADRENAL & PITUITARY PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|63,058.93|12113.66|17565.81|9596.97|||| 616|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W MCC|Medicaid|MEDICAID|227,643.22|103.42|23237.25|103.42|||| 616|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|182,658.70|23236.81|23237.25|103.42|||| 616|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W MCC|Managed Medicaid|MEDICAID SUPERIOR|205,406.85|21376.91|23237.25|103.42|||| 616|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W MCC|Medicare|MEDICARE ACUTE|159,826.19|23237.25|23237.25|103.42|||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|United Medicare Advantage|UHC AARP MCR HMO MA|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|United Medicare Advantage|UHC MEDICARE GOLD MA|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Aetna|AETNA PPO|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Blue Cross HMO Specialty|BCBSTX HMO|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Blue Cross PPO Specialty|BCBSTX PPO|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Aetna|AETNA OTHER|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Aetna|AETNA QHP HMO|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Veterans Affairs|VETERANS ADMINISTRATION|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Managed Medicare|HEALTHSPRING MA|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|United Healthcare|UNITED HEALTHCARE|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Medicare|MEDICARE ACUTE|248.84||||248.84||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Medicaid|MEDICAID|248.84||||||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||248.84||| 61624|EAP|0361|IR-EMBO-AVM/ANERUYSM/SPIN|Humana Medicare Advantage|HUMANA MA|248.84||||||| 61626|EAP|0361|IR-EMBO-EXTRACRAN/BRANCHI|Humana Medicare Advantage|HUMANA MA|204.04||||||| 61626|EAP|0361|IR-EMBO-EXTRACRAN/BRANCHI|Medicare|MEDICARE ACUTE|204.04||||||| 61626|EAP|0361|IR-EMBO-EXTRACRAN/BRANCHI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|204.04||||||| 61626|EAP|0361|IR-EMBO-EXTRACRAN/BRANCHI|Workers Compensation|WORKERS COMPENSATION OTHER|204.04||||||| 61626|EAP|0361|IR-EMBO-EXTRACRAN/BRANCHI|United Medicare Advantage|UHC MEDICARE GOLD MA|204.04||||||| 61630|EAP|0361|IR-BLN ANGIOPLSTY INTRACR|Veterans Affairs|VETERANS ADMINISTRATION|137.53||||||| 61630|EAP|0361|IR-BLN ANGIOPLSTY INTRACR|Medicare|MEDICARE ACUTE|137.53||||||| 61630|EAP|0361|IR-BLN ANGIOPLSTY INTRACR|UTMB|UTMB CORRECTIONAL MANAGED CARE|137.53||||||| 61630|EAP|0361|IR-BLN ANGIOPLSTY INTRACR|Medicaid|SMITH COUNTY INDIGENT HEALTH|137.53||||||| 61635|EAP|0361|IR-TRANSCATH PLCMNT IV ST|United Healthcare|UNITED HEALTHCARE|168.08||||||| 61635|EAP|0361|IR-TRANSCATH PLCMNT IV ST|Blue Cross PPO Specialty|BCBSTX PPO|168.08||||||| 61635|EAP|0361|IR-TRANSCATH PLCMNT IV ST|Medicare|MEDICARE ACUTE|168.08||||||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Blue Cross PPO Specialty|BCBSTX PPO|85,109.70|14079.74|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Medicare|MEDICARE ACUTE|103,409.58|12775.03|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|159,269.67|12740.01|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Medicaid|MEDICAID|171,501.70|13444.6|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|United Medicare Advantage|UHC AARP MCR HMO MA|120,659.52|12540.13|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54,432.15|9074.1|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|United Healthcare|UNITED HEALTHCARE OTHER|102,317.45|24279.19|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|NON CONTRACTED|COMMERCIAL OTHER 1|63,606.27|63606.27|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|62,398.71|9833.025|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|68,740.62|21507.26|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|PHCS|HUMANA INSURANCE|48,473.32|12531.47|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|116,785.50|15321.035|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Humana Medicare Advantage|HUMANA MA|81,096.94|11682.555|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Veterans Affairs|VETERANS ADMINISTRATION|200,730.63|12775.03|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|173,873.69|12511.97|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|181,497.72|22818.565|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|65,350.35|13225.375|63606.27|142.88|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62,406.37|142.88|63606.27|142.88|||| 619|DRG||O.R. PROCEDURES FOR OBESITY W MCC|Medicare|MEDICARE ACUTE|266,546.60|18530.52|18530.52|18530.52|||| 62|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W CC|Blue Cross PPO Specialty|BCBSTX PPO|94,895.84|13197.72|23804.56|12319.21|||| 62|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W CC|Managed Medicare|HEALTHSPRING MA|91,291.37|12319.21|23804.56|12319.21|||| 62|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W CC|Veterans Affairs|VETERANS ADMINISTRATION|92,859.87|12327.5|23804.56|12319.21|||| 62|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|146,586.56|12320.09|23804.56|12319.21|||| 62|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W CC|Medicare|MEDICARE ACUTE|94,283.75|12319.21|23804.56|12319.21|||| 62|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W CC|United Healthcare|UNITED HEALTHCARE OTHER|92,246.15|23804.56|23804.56|12319.21|||| 620|DRG||O.R. PROCEDURES FOR OBESITY W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|96,785.65|11336.72|23961.83|11234.13|||| 620|DRG||O.R. PROCEDURES FOR OBESITY W CC|Medicare|MEDICARE ACUTE|104,886.65|11234.13|23961.83|11234.13|||| 620|DRG||O.R. PROCEDURES FOR OBESITY W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|135,340.83|14164.21|23961.83|11234.13|||| 620|DRG||O.R. PROCEDURES FOR OBESITY W CC|Cigna|CIGNA|778.20|23961.83|23961.83|11234.13|||| 620|DRG||O.R. PROCEDURES FOR OBESITY W CC|Blue Cross PPO Specialty|BCBSTX PPO|111,204.85|12287.18|23961.83|11234.13|||| 620|DRG||O.R. PROCEDURES FOR OBESITY W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|98,613.98|11336.72|23961.83|11234.13|||| 62000|EAP|0981|TRAUMA PHYSICIAN CHARGE|Medicare|MEDICARE ACUTE|||||33.02||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|111,790.90|115.86|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Cigna|CIGNA|86,017.10|16175.88|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Cigna|CIGNA|91,712.58|16175.88|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Aetna|AETNA PPO|109,502.87|21878.475|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|120,266.83|9999.32|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|86,287.60|34.02|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|90,797.60|10261.58|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|ChampVA|CHAMPVA CENTER|91,925.60|10393.87|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|102,291.35|10716.66|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|104,454.57|13988.645|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|97,660.27|9893.39|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|179,050.42|13779.82|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|144,884.90|12683.875|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|121,769.95|20885.43|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|107,157.19|13239.94|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|94,362.80|13283.86|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|105,672.25|9910.05|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Aetna|AETNA OTHER|111,618.10|24370.34|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|105,958.79|13239.94|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|209,069.18|10089.47|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Medicare|MEDICARE ACUTE|100,394.77|9915.84|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|92,045.57|18606.19|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|124,811.42|10089.47|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|123,171.19|9897.49|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|113,291.47|10089.47|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|100,503.10|69347.14|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|Tricare|TRICARE EAST REGION|112,541.32|9354.48|69347.14|34.02|||| 621|DRG||O.R. PROCEDURES FOR OBESITY W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|96,807.30|18606.19|69347.14|34.02|||| 622|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC|Medicare|MEDICARE ACUTE|103,723.19|22533.53|22533.53|12962.36|||| 622|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC|Medicaid|MEDICAID|209,070.36|12962.36|22533.53|12962.36|||| 62267|EAP|0361|CT-ASPIRATE IV DISC PERCU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,412.70||| 62267|EAP|0361|CT-ASPIRATE IV DISC PERCU|Humana Medicare Advantage|HUMANA MA|2,255.35||||||| 62267|EAP|0361|CT-ASPIRATE IV DISC PERCU|Medicare|MEDICARE ACUTE|20.98||||2,412.70||| 62267|EAP|0361|CT-ASPIRATE IV DISC PERCU|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,412.70||| 62268|EAP|0360|CT-DRAIN SPINAL CORD CYST|Humana Medicare Advantage|HUMANA MA|88.78||||||| 62270|EAP|0450|SPINAL TAP DX|Medicaid|MEDICAID|13.57||||||| 62270|EAP|0450|SPINAL TAP DX|Medicaid|MOLINA HEALTHCARE OF TEXAS|13.57||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Managed Medicare|ETMC AFFILIATE HOSPITALS|17.02||||||| 62270|EAP|0450|SPINAL TAP DX|Medicaid|SMITH COUNTY JAIL|13.57||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Medicaid|MEDICAID|17.02||||1,957.30||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||17.02||| 62270|EAP|0450|SPINAL TAP DX|Managed Medicare|HEALTHSPRING MA|1,560.55||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Managed Medicare|HEALTHSPRING MA|1,957.30||||1,957.30||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|United Healthcare|TML GROUP BENEFITS|||||1,957.30||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|United Healthcare|UNITED HEALTHCARE|16.89||||1,829.65||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Tricare|TRICARE FOR LIFE|1,957.30||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.02||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.02||||1,829.65||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|NON CONTRACTED|COMMERCIAL OTHER 1|17.02||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,829.65||||||| 62270|EAP|0450|SPINAL TAP DX|Veterans Affairs|VETERANS ADMINISTRATION|13.57||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.02||||17.02||| 62270|EAP|0450|SPINAL TAP DX|Medicare|MEDICARE ACUTE|13.57||||1,560.55||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|PHCS|HUMANA|17.02||||||| 62270|EAP|0450|SPINAL TAP DX|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.57||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|United Medicare Advantage|UHC MEDICARE GOLD MA|1,957.30||||1,957.30||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Veterans Affairs|VETERANS ADMINISTRATION|1,957.30||||1,957.30||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Medicare|MEDICARE ACUTE|1,957.30||||1,957.30||| 62270|EAP|0450|SPINAL TAP DX|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,560.55||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.02||||17.02||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Cigna|CIGNA|17.02||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Blue Cross HMO Specialty|BCBSTX HMO|1,957.30||||17.02||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|United Healthcare|UNITED HEALTHCARE|17.02||||1,829.65||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|United Healthcare|UNITED HEALTHCARE OTHER|1,957.30||||||| 62270|EAP|0450|SPINAL TAP DX|Blue Cross PPO Specialty|BCBSTX PPO|1,560.55||||13.57||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|ChampVA|CHAMPVA CENTER|17.02||||||| 62270|EAP|0450|SPINAL TAP DX|Cigna|CIGNA OTHER|||||13.57||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,957.30||||1,957.30||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Blue Cross PPO Specialty|BCBSTX PPO|1,957.30||||17.02||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,957.30||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,957.30||||17.02||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Medicaid|SMITH COUNTY JAIL|1,829.65||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.02||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Managed Medicaid|MEDICAID AMERIGROUP|1,957.30||||||| 62270|EAP|0450|SPINAL TAP DX|Aenta Medicare Advantage|AETNA MEDICARE MA|13.57||||||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Aetna|AETNA PPO|||||1,957.30||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.02||||17.02||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Aenta Medicare Advantage|AETNA MEDICARE MA|1,957.30||||||| 62270|EAP|0450|SPINAL TAP DX|Managed Medicaid|MEDICAID AMERIGROUP|13.57||||1,458.78||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|United Medicare Advantage|UHC AARP MCR HMO MA|1,957.30||||||| 62270|EAP|0450|SPINAL TAP DX|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.57||| 62270|EAP|0361|XR-SPINAL FLUID TAP DIAGN|Humana Medicare Advantage|HUMANA MA|1,957.30||||17.02||| 62270|EAP|0450|SPINAL TAP DX|Humana Medicare Advantage|HUMANA MA|13.57||||1,560.55||| 62270|EAP|0450|SPINAL TAP DX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.57||||||| 62273|EAP|0361|XR-INJECT-EPIDURAL PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||38.14||| 62273|EAP|0361|XR-INJECT-EPIDURAL PATCH|Cigna|CIGNA|||||38.14||| 62273|EAP|0361|IR-INJECT EPIDURAL PATCH|Managed Medicaid|MEDICAID AMERIGROUP|||||23.95||| 62273|EAP|0361|XR-INJECT-EPIDURAL PATCH|Managed Medicaid|MEDICAID AMERIGROUP|||||4,386.10||| 62273|EAP|0361|XR-INJECT-EPIDURAL PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,386.10||| 62273|EAP|0361|IR-INJECT EPIDURAL PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||23.95||| 62273|EAP|0450|TREAT EPIDURAL SPINE LESI|Blue Cross PPO Specialty|BCBSTX PPO|||||38.14||| 62273|EAP|0361|IR-INJECT EPIDURAL PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|||||23.95||| 62273|EAP|0361|XR-INJECT-EPIDURAL PATCH|Medicare|MEDICARE ACUTE|||||38.14||| 62273|EAP|0361|XR-INJECT-EPIDURAL PATCH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4,386.10||||||| 62284|EAP|0361|XR-INJECTION FOR MYELOGRA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,795.58||| 62284|EAP|0361|XR-INJECTION FOR MYELOGRA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||26.40||| 62284|EAP|0361|XR-INJECTION FOR MYELOGRA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||26.40||| 62287|EAP|0361|IR-DISC ASPIRATION|Humana Medicare Advantage|HUMANA MA|155.77||||155.77||| 62287|EAP|0361|IR-DISC ASPIRATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16,745.28||||||| 62287|EAP|0361|IR-DISC ASPIRATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17,913.55||||||| 62287|EAP|0361|IR-DISC ASPIRATION|Medicare|MEDICARE ACUTE|17,913.55||||17,913.55||| 62287|EAP|0361|IR-DISC ASPIRATION|United Medicare Advantage|UHC MEDICARE GOLD MA|||||17,913.55||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|Humana Medicare Advantage|HUMANA MA|96,978.43|12222.02|23110.97|214.32|||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|United Medicare Advantage|UHC AARP MCR HMO MA|70,049.89|12222.02|23110.97|214.32|||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|95,986.80|11970.38|23110.97|214.32|||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|92,161.42|11966.41|23110.97|214.32|||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|Medicare|MEDICARE ACUTE|101,673.22|11998.54|23110.97|214.32|||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|United Healthcare|UNITED HEALTHCARE|155,425.82|23110.97|23110.97|214.32|||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|Managed Medicare|HEALTHSPRING MA|68,657.50|12110.28|23110.97|214.32|||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99,191.30|21332.99|23110.97|214.32|||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|Blue Cross PPO Specialty|BCBSTX PPO|78,655.09|16655.19|23110.97|214.32|||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|66,393.84|214.32|23110.97|214.32|||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Aetna|AETNA PPO|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Blue Cross PPO Specialty|BCBSTX PPO|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|NON CONTRACTED|COMMERCIAL OTHER 1|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Medicare|MEDICARE ACUTE|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicare|HEALTHSPRING MA|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Humana Medicare Advantage|HUMANA MA|||||24.43||| 62302|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicare|BCBS MEDICARE PPO MA|||||24.43||| 62303|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Medicare|MEDICARE ACUTE|||||24.43||| 62303|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Humana Medicare Advantage|HUMANA MA|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|United Medicare Advantage|UHC AARP MCR HMO MA|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Medicare|MEDICARE ACUTE|24.43||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Blue Cross HMO Specialty|BCBSTX HMO|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|NON CONTRACTED|COMMERCIAL OTHER 1|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Cigna|CIGNA|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Humana Medicare Advantage|HUMANA MA|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicare|HEALTHSPRING MA|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.43||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Blue Cross PPO Specialty|BCBSTX PPO|||||24.43||| 62304|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||24.43||| 62305|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|United Healthcare|UNITED HEALTHCARE OTHER|||||44.76||| 62305|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Aetna|AETNA PPO|||||44.76||| 62305|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.76||||||| 62305|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Humana Medicare Advantage|HUMANA MA|||||44.76||| 62305|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Managed Medicare|HEALTHSPRING MA|||||44.76||| 62305|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.76||| 62305|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||44.76||| 62305|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Medicare|MEDICARE ACUTE|||||44.76||| 62305|EAP|0361|XR-INJ MYELOGRAPHY LUMBAR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||44.76||| 62329|EAP|0361|THER SPI PNXR CSF FLUOR/C|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||16.89||| 62362|EAP|0360|NJX INTERLAMINAR LMBR/SAC|Medicare|MEDICARE ACUTE|||||15.93||| 624|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|110,101.30|7330.11|15626.14|7330.11|||| 624|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|97,928.40|15626.14|15626.14|7330.11|||| 627|DRG||THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|53,151.65|7631.05|7678.46|6262.62|||| 627|DRG||THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|63,203.89|7678.46|7678.46|6262.62|||| 627|DRG||THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|76,909.32|7367.15|7678.46|6262.62|||| 627|DRG||THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|40,537.55|6262.62|7678.46|6262.62|||| 628|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|91,886.13|25713.15|25713.15|21541.97|||| 628|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W MCC|Medicare|MEDICARE ACUTE|228,807.31|21541.97|25713.15|21541.97|||| 628|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W MCC|Blue Cross PPO Specialty|BCBSTX PPO|132,867.71|24953.25|25713.15|21541.97|||| 628|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W MCC|Humana Medicare Advantage|HUMANA MA|217,617.97|21952.87|25713.15|21541.97|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|222,616.41|14220.435|142793.13|321.48|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|Cigna|CIGNA OTHER|141,772.95|23028.46|142793.13|321.48|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|Managed Medicaid|MEDICAID SUPERIOR|119,815.62|22051.16|142793.13|321.48|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|105,186.85|13225.375|142793.13|321.48|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|102,768.59|321.48|142793.13|321.48|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|Blue Cross PPO Specialty|BCBSTX PPO|118,881.69|15879.77|142793.13|321.48|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|United Medicare Advantage|UHC AARP MCR HMO MA|72,887.50|14029.94|142793.13|321.48|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|Medicare|MEDICARE ACUTE|274,749.69|14356.36|142793.13|321.48|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|PHCS|GROUP AND PENSION|206,946.57|142793.13|142793.13|321.48|||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|117,826.90|14015.42|142793.13|321.48|||| 63|DRG||ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W/O CC/MCC|Medicare|MEDICARE ACUTE|85,224.69|10603.085|10603.085|10603.085|||| 637|DRG||DIABETES W MCC|Cigna|CIGNA OTHER|71,006.40|14258.85|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|134,386.01|7972.86|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Humana Medicare Advantage|HUMANA MA|39,287.30|8968.595|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Managed Medicare|HEALTHSPRING MA|42,653.84|8087.455|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|73,749.90|9379.03|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Blue Cross HMO Specialty|BCBSTX HMO|71,988.65|7972.86|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Managed Medicare|BCBS MEDICARE PPO MA|24,921.90|7411.25|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|93,815.57|12515.185|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|119,126.48|7525.22|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|112,116.47|8966.245|17529.1|825.28|||| 637|DRG||DIABETES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|105,019.62|8864.97|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|32,934.87|8887.75|17529.1|825.28|||| 637|DRG||DIABETES W MCC|United Healthcare|UNITED HEALTHCARE OTHER|32,877.40|16401.15|17529.1|825.28|||| 637|DRG||DIABETES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|54,751.02|8886.87|17529.1|825.28|||| 637|DRG||DIABETES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|43,034.19|9008.925|17529.1|825.28|||| 637|DRG||DIABETES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|234,410.05|9045.62|17529.1|825.28|||| 637|DRG||DIABETES W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|88,336.05|17529.1|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Medicaid|MEDICAID|45,778.75|3181.73|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Medicare|MEDICARE PART B ONLY IP|25,393.60|825.28|17529.1|825.28|||| 637|DRG||DIABETES W MCC|Medicare|MEDICARE ACUTE|43,786.31|8883.16|17529.1|825.28|||| 637|DRG||DIABETES W MCC|United Healthcare|UNITED HEALTHCARE|45,564.48|12644.45|17529.1|825.28|||| 638|DRG||DIABETES W CC|NON CONTRACTED|COMMERCIAL OTHER 1|37,629.47|15029.7|15029.7|89.3|||| 638|DRG||DIABETES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41,422.16|6235.12|15029.7|89.3|||| 638|DRG||DIABETES W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|27,897.95|6108.2|15029.7|89.3|||| 638|DRG||DIABETES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|45,581.18|6107.15|15029.7|89.3|||| 638|DRG||DIABETES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|41,337.68|6235.12|15029.7|89.3|||| 638|DRG||DIABETES W CC|Medicare|MEDICARE ACUTE|45,088.95|6135.31|15029.7|89.3|||| 638|DRG||DIABETES W CC|United Healthcare|UNITED HEALTHCARE OTHER|19,920.87|10464.21|15029.7|89.3|||| 638|DRG||DIABETES W CC|Medicaid|COUNTY INDIGENT HEALTH OTHER|20,627.07|4732.84|15029.7|89.3|||| 638|DRG||DIABETES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42,523.62|7525.22|15029.7|89.3|||| 638|DRG||DIABETES W CC|Managed Medicaid|MEDICAID AMERIGROUP|38,728.57|5227.58|15029.7|89.3|||| 638|DRG||DIABETES W CC|Cigna|CIGNA OTHER|42,987.19|9097.39|15029.7|89.3|||| 638|DRG||DIABETES W CC|Cigna|CIGNA|58,187.59|9097.39|15029.7|89.3|||| 638|DRG||DIABETES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44,989.83|10895.455|15029.7|89.3|||| 638|DRG||DIABETES W CC|Humana Medicare Advantage|HUMANA MA|38,664.62|6123.4|15029.7|89.3|||| 638|DRG||DIABETES W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|68,515.20|6134.87|15029.7|89.3|||| 638|DRG||DIABETES W CC|Managed Medicare|HEALTHSPRING MA|54,600.29|6235.12|15029.7|89.3|||| 638|DRG||DIABETES W CC|Blue Cross PPO Specialty|BCBSTX PPO|32,176.26|5922.24|15029.7|89.3|||| 638|DRG||DIABETES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20,120.72|7930.71|15029.7|89.3|||| 638|DRG||DIABETES W CC|Veterans Affairs|VETERANS ADMINISTRATION|50,014.13|6185.215|15029.7|89.3|||| 638|DRG||DIABETES W CC|Managed Medicaid|MEDICAID SUPERIOR|44,420.15|7525.22|15029.7|89.3|||| 638|DRG||DIABETES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30,185.67|89.3|15029.7|89.3|||| 638|DRG||DIABETES W CC|Blue Cross HMO Specialty|BCBSTX HMO|75,659.47|5034.34|15029.7|89.3|||| 638|DRG||DIABETES W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|43,031.54|7847.75|15029.7|89.3|||| 639|DRG||DIABETES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|44,554.17|6172.48|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26,826.92|6042.11|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|26,847.88|4290.6|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34,892.62|5227.58|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|30,906.38|5227.58|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|47,447.85|7257.84|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|17,956.10|3647.33|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Medicaid|SMITH COUNTY JAIL|19,373.20|3287.79|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|12,914.46|386.66|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16,652.42|35.72|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Medicare|MEDICARE ACUTE|18,140.34|4648.8|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Medicaid|MEDICAID|11,784.00|3287.79|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Aetna|AETNA PPO|58,927.49|7756.98|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|20,168.20|7257.84|8887.75|35.72|||| 639|DRG||DIABETES W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|50,918.26|8887.75|8887.75|35.72|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Humana Medicare Advantage|HUMANA MA|91,614.38|11569.47|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Blue Cross PPO Specialty|BCBSTX PPO|156,247.05|12691.87|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Veterans Affairs|VETERANS ADMINISTRATION|93,152.05|11557.11|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Medicare|MEDICARE ACUTE|86,900.87|11571.63|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Medicaid|SMITH COUNTY INDIGENT HEALTH|147,156.17|8204.1|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|111,884.90|11786.09|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|101,105.37|11786.09|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|United Healthcare|UNITED HEALTHCARE|79,888.72|22190.13|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Managed Medicaid|MEDICAID AMERIGROUP|80,642.36|29051.23|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Managed Medicaid|MEDICAID SUPERIOR|95,902.42|20176.845|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Cigna|CIGNA|83,808.71|18832.365|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|82,767.87|15327.32|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|65,007.37|11540.79|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Managed Medicare|BCBS MEDICARE PPO MA|56,321.95|11557.11|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|124,720.58|25454.75|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|103,159.04|103159.04|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Managed Medicare|HEALTHSPRING MA|94,804.61|11678.86|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|161,612.95|11543.47|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|127,299.25|11786.09|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|PHCS|HUMANA INSURANCE|116,144.87|11575.25|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Managed Medicare|ETMC AFFILIATE HOSPITALS|435,334.62|19911.45|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Medicaid|MEDICAID|144,986.71|18271.21|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Access Direct Platinum|HEALTHFIRST TPA|1,152.84|14837.46|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|72,417.17|12691.87|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Aetna|AETNA OTHER|4,203.14|163922.46|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|126,660.42|16854.11|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|164,418.40|11786.09|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Blue Cross HMO Specialty|BCBSTX HMO|24,719.07|10789.02|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54,579.99|107.16|163922.46|107.16|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|United Healthcare|TML GROUP BENEFITS|56,317.40|22190.13|163922.46|107.16|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|146,178.84|250.04|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Aetna|AETNA OTHER|48,206.12|15359.63|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Blue Cross HMO Specialty|BCBSTX HMO|45,329.58|6869.83|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|144,075.80|11362.49|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Managed Medicare|HEALTHSPRING MA|42,841.88|7945.8|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|52,646.60|7123.87|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|196,015.53|7898.55|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|71,976.25|7945.8|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Medicare|MEDICARE ACUTE|39,402.67|7946.68|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|35,077.88|7123.87|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Managed Medicare|BCBS MEDICARE PPO MA|21,421.66|8084.69|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Humana Medicare Advantage|HUMANA MA|57,491.35|7945.345|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Medicaid|MEDICAID|43,818.01|3577.05|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|70,184.19|8023.025|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|37,119.22|4551.755|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Medicare|MEDICARE PART B ONLY IP|17,682.67|867.7|15359.63|250.04|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|651.49|7918.52|15359.63|250.04|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Managed Medicare|HEALTHSPRING MA|53,379.11|5520.73|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Medicare|MEDICARE PART B ONLY IP|27,056.70|671.53|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Medicare|MEDICARE ACUTE|31,591.62|5435.68|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|386.08|6122.64|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Medicaid|MEDICAID|40,101.96|2535.54|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41,757.10|5520.73|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|45,500.95|5520.73|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|United Healthcare|GOLDEN RULE|29,654.87|8955.12|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Cigna|CIGNA|35,180.25|7785.41|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|21,521.75|4143.97|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38,590.88|4002.555|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|45,701.95|4910.83|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Blue Cross PPO Specialty|BCBSTX OTHER|282.66|5105.4|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|20,603.32|5471.925|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|36,816.25|4339.97|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35,593.78|71.44|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|28,881.51|7926.6|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|64,743.63|7122.68|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|47,105.24|5412.935|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|22,937.53|22937.525|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|12,116.16|4467.89|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|41,676.90|5434.8|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Humana Medicare Advantage|HUMANA MA|56,809.39|824.44|22937.525|71.44|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26,720.88|4251.15|22937.525|71.44|||| 642|DRG||INBORN AND OTHER DISORDERS OF METABOLISM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11,228.85|10243.19|14013.24|6998.79|||| 642|DRG||INBORN AND OTHER DISORDERS OF METABOLISM|Blue Cross HMO Specialty|BCBSTX HMO|74,028.55|6998.79|14013.24|6998.79|||| 642|DRG||INBORN AND OTHER DISORDERS OF METABOLISM|Managed Medicare|HEALTHSPRING MA|79,763.91|7955.46|14013.24|6998.79|||| 642|DRG||INBORN AND OTHER DISORDERS OF METABOLISM|Humana Medicare Advantage|HUMANA MA|387,087.20|14013.24|14013.24|6998.79|||| 642|DRG||INBORN AND OTHER DISORDERS OF METABOLISM|Medicare|MEDICARE ACUTE|14,907.50|7954.58|14013.24|6998.79|||| 643|DRG||ENDOCRINE DISORDERS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|49,357.30|8407.13|47859.42|100.04|||| 643|DRG||ENDOCRINE DISORDERS W MCC|United Healthcare|UNITED HEALTHCARE OTHER|166,685.60|47859.42|47859.42|100.04|||| 643|DRG||ENDOCRINE DISORDERS W MCC|United Healthcare|UNITED HEALTHCARE|59,087.72|19239.42|47859.42|100.04|||| 643|DRG||ENDOCRINE DISORDERS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|89,656.02|22601.6|47859.42|100.04|||| 643|DRG||ENDOCRINE DISORDERS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|52,997.30|11095.54|47859.42|100.04|||| 643|DRG||ENDOCRINE DISORDERS W MCC|Managed Medicare|HEALTHSPRING MA|7.11|100.04|47859.42|100.04|||| 643|DRG||ENDOCRINE DISORDERS W MCC|Medicare|MEDICARE ACUTE|71,719.38|10181.46|47859.42|100.04|||| 644|DRG||ENDOCRINE DISORDERS W CC|Managed Medicare|HEALTHSPRING MA|47,068.80|6925.5|25138.25|3231.27|||| 644|DRG||ENDOCRINE DISORDERS W CC|Blue Cross HMO Specialty|BCBSTX HMO|37,797.75|5844.15|25138.25|3231.27|||| 644|DRG||ENDOCRINE DISORDERS W CC|NON CONTRACTED|COMMERCIAL OTHER 1|25,138.25|25138.25|25138.25|3231.27|||| 644|DRG||ENDOCRINE DISORDERS W CC|Medicare|MEDICARE ACUTE|49,317.39|7041.97|25138.25|3231.27|||| 644|DRG||ENDOCRINE DISORDERS W CC|Medicaid|MEDICAID|43,118.34|3231.27|25138.25|3231.27|||| 644|DRG||ENDOCRINE DISORDERS W CC|Veterans Affairs|VETERANS ADMINISTRATION|21,723.86|6925.5|25138.25|3231.27|||| 644|DRG||ENDOCRINE DISORDERS W CC|United Healthcare|UNITED HEALTHCARE OTHER|46,776.85|12168.59|25138.25|3231.27|||| 644|DRG||ENDOCRINE DISORDERS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|55,267.70|7041.97|25138.25|3231.27|||| 64400|EAP|0450|INJ FOR NERVE BLOCK TRIGE|United Healthcare|UNITED HEALTHCARE|||||14.35||| 64400|EAP|0450|INJ FOR NERVE BLOCK TRIGE|Workers Compensation|WORKERS COMPENSATION OTHER|||||14.35||| 64400|EAP|0450|INJ FOR NERVE BLOCK TRIGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,650.25||| 64405|EAP|0510|N BLOCK INJ, OCCIPITAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||309.17||| 64405|EAP|0510|N BLOCK INJ, OCCIPITAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||309.17||| 64405|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.42||| 64405|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||7.42||| 64405|EAP|0361||Blue Cross HMO Specialty|BCBSTX HMO|||||7.42||| 64405|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||7.42||| 64405|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.42||| 64405|EAP|0510|N BLOCK INJ, OCCIPITAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||309.17||| 64405|EAP|0510|N BLOCK INJ, OCCIPITAL|Managed Medicaid|MEDICAID AMERIGROUP|||||309.17||| 64405|EAP|0510|N BLOCK INJ, OCCIPITAL|Medicare|MEDICARE ACUTE|||||309.17||| 64405|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.42||| 64405|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||7.42||| 64405|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.42||| 64405|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.42||| 64405|EAP|0510|N BLOCK INJ, OCCIPITAL|Blue Cross HMO Specialty|BCBSTX HMO|||||309.17||| 64405|EAP|0361||Medicare|MEDICARE ACUTE|||||7.42||| 64405|EAP|0510|N BLOCK INJ, OCCIPITAL|Humana Medicare Advantage|HUMANA MA|||||309.17||| 64405|EAP|0361||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.42||| 64405|EAP|0510|N BLOCK INJ, OCCIPITAL|Managed Medicare|HEALTHSPRING MA|||||309.17||| 64418|EAP|0361||Tricare|TRICARE EAST REGION|||||17.96||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Tricare|TRICARE EAST REGION|||||748.33||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|United Healthcare|AARP|||||748.33||| 64418|EAP|0361||United Healthcare|UNITED HEALTHCARE OTHER|||||17.96||| 64418|EAP|0361||United Healthcare|UNITED HEALTHCARE|||||17.96||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|United Healthcare|UNITED HEALTHCARE|||||748.33||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||748.33||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Managed Medicare|HEALTHSPRING MA|||||748.33||| 64418|EAP|0361||Managed Medicaid|MEDICAID AMERIGROUP|||||17.96||| 64418|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||17.96||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||748.33||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||748.33||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||748.33||| 64418|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||17.96||| 64418|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||17.96||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Managed Medicaid|MEDICAID AMERIGROUP|||||748.33||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||748.33||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Humana Medicare Advantage|HUMANA MA|||||748.33||| 64418|EAP|0361||Aetna Value Network|AETNA VALUE NETWORK|||||17.96||| 64418|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||17.96||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Blue Cross PPO Specialty|BCBSTX PPO|||||748.33||| 64418|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||17.96||| 64418|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||17.96||| 64418|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||17.96||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||748.33||| 64418|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||17.96||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|United Medicare Advantage|UHC AARP MCR HMO MA|||||748.33||| 64418|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||17.96||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Medicare|MEDICARE ACUTE|||||748.33||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||748.33||| 64418|EAP|0361||Medicare|MEDICARE ACUTE|||||17.96||| 64418|EAP|0361||PHCS|HUMANA|||||17.96||| 64418|EAP|0510|N BLOCK INJ, SUPRASCAPULA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||748.33||| 64450|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||17.96||| 64450|EAP|0361||Aetna|BOON CHAPMAN|||||17.96||| 64450|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||17.96||| 64450|EAP|0510|N BLOCK, OTHER PERIPHERAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||748.33||| 64450|EAP|0361||Medicare|MEDICARE ACUTE|||||17.96||| 64450|EAP|0450|INJ NERVE BLOCK PERIPHERA|Managed Medicaid|MEDICAID AMERIGROUP|||||1,198.63||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|50,162.25|5588.71|7101.79|3753.96|||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37,246.01|5454.71|7101.79|3753.96|||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|39,726.11|3753.96|7101.79|3753.96|||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|570.18|5481.99|7101.79|3753.96|||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|82,599.37|5481.99|7101.79|3753.96|||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|41,955.04|7101.79|7101.79|3753.96|||| 64561|EAP|0510|IMPLANT NEUROELECTRODES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,967.50||| 64561|EAP|0510|IMPLANT NEUROELECTRODES|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,967.50||| 64561|EAP|0510|IMPLANT NEUROELECTRODES|United Healthcare|UNITED HEALTHCARE OTHER|||||6,967.50||| 64561|EAP|0510|IMPLANT NEUROELECTRODES|Managed Medicare|HEALTHSPRING MA|||||6,967.50||| 64561|EAP|0361||Medicare|MEDICARE ACUTE|||||167.22||| 64561|EAP|0510|IMPLANT NEUROELECTRODES|Humana Medicare Advantage|HUMANA MA|||||6,967.50||| 64561|EAP|0510|IMPLANT NEUROELECTRODES|Medicare|MEDICARE ACUTE|||||6,967.50||| 64561|EAP|0361||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||167.22||| 64561|EAP|0510|IMPLANT NEUROELECTRODES|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6,967.50||| 64561|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||167.22||| 64566|EAP|0361||Tricare|TRICARE EAST REGION|||||6.64||| 64566|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.64||| 64566|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||6.64||| 64566|EAP|0510|NEUROELTRD STIM POST TIBI|Blue Cross PPO Specialty|BCBSTX PPO|||||276.67||| 64566|EAP|0361||Medicare|MEDICARE ACUTE|||||6.64||| 64566|EAP|0510|NEUROELTRD STIM POST TIBI|Managed Medicare|HEALTHSPRING MA|||||276.67||| 64566|EAP|0510|NEUROELTRD STIM POST TIBI|Medicare|MEDICARE ACUTE|||||276.67||| 64566|EAP|0361||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.64||| 64566|EAP|0510|NEUROELTRD STIM POST TIBI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||276.67||| 64566|EAP|0361||Aetna|AETNA OTHER|||||6.64||| 64566|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.64||| 64566|EAP|0510|NEUROELTRD STIM POST TIBI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||276.67||| 64566|EAP|0510|NEUROELTRD STIM POST TIBI|Humana Medicare Advantage|HUMANA MA|||||276.67||| 64566|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||6.64||| 64612|EAP|0360||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.64||| 64612|EAP|0510|DESTROY NERVE,FACE MUSCLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||276.67||| 64612|EAP|0510|DESTROY NERVE,FACE MUSCLE|Aetna|AETNA PPO|||||276.67||| 64612|EAP|0360||Humana Medicare Advantage|HUMANA MA|||||6.64||| 64612|EAP|0510|DESTROY NERVE,FACE MUSCLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||276.67||| 64612|EAP|0360||Blue Cross PPO Specialty|BCBSTX PPO|||||6.64||| 64612|EAP|0510|DESTROY NERVE,FACE MUSCLE|Humana Medicare Advantage|HUMANA MA|||||276.67||| 64612|EAP|0360||Medicare|MEDICARE ACUTE|||||6.64||| 64612|EAP|0510|DESTROY NERVE,FACE MUSCLE|Blue Cross PPO Specialty|BCBSTX PPO|||||276.67||| 64612|EAP|0360||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.64||| 64612|EAP|0360||United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.64||| 64612|EAP|0510|DESTROY NERVE,FACE MUSCLE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||276.67||| 64612|EAP|0510|DESTROY NERVE,FACE MUSCLE|Medicare|MEDICARE ACUTE|||||276.67||| 64615|EAP|0510|CHEMODENERV MUSC MIGRAINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||309.17||| 64615|EAP|0510|CHEMODENERV MUSC MIGRAINE|Blue Cross PPO Specialty|BCBSTX PPO|||||309.17||| 64615|EAP|0510|CHEMODENERV MUSC MIGRAINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||309.17||| 64615|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.42||| 64616|EAP|0360||Medicare|MEDICARE ACUTE|||||7.42||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Managed Medicare|HEALTHSPRING MA|||||309.17||| 64616|EAP|0360||United Healthcare|UNITED HEALTHCARE|||||7.42||| 64616|EAP|0360||Managed Medicare|HEALTHSPRING MA|||||7.42||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|United Healthcare|UNITED HEALTHCARE OTHER|||||309.17||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||309.17||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||309.17||| 64616|EAP|0361||Medicare|MEDICARE ACUTE|||||7.42||| 64616|EAP|0360||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.42||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|United Medicare Advantage|UHC AARP MCR HMO MA|||||309.17||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Blue Cross HMO Specialty|BCBSTX HMO|||||309.17||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Aetna|AETNA OTHER|||||309.17||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||309.17||| 64616|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.42||| 64616|EAP|0360||United Medicare Advantage|UHC AARP MCR HMO MA|||||7.42||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||309.17||| 64616|EAP|0360||Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.42||| 64616|EAP|0360||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.42||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||309.17||| 64616|EAP|0360||Blue Cross HMO Specialty|BCBSTX HMO|||||7.42||| 64616|EAP|0510|CHEMODENERV MUSC NECK DYS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||309.17||| 64616|EAP|0360||Blue Cross PPO Specialty|BCBSTX OTHER|||||7.42||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Humana Medicare Advantage|HUMANA MA|||||309.17||| 64616|EAP|0360||Blue Cross PPO Specialty|BCBSTX PPO|||||7.42||| 64616|EAP|0360||Aetna|AETNA OTHER|||||7.42||| 64616|EAP|0360||ChampVA|CHAMPVA CENTER|||||7.42||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|ChampVA|CHAMPVA CENTER|||||309.17||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Medicare|MEDICARE ACUTE|||||309.17||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Blue Cross PPO Specialty|BCBSTX OTHER|||||309.17||| 64616|EAP|0360||Humana Medicare Advantage|HUMANA MA|||||7.42||| 64616|EAP|0510|CHEMODENERV MUSC NECK DYS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||309.17||| 64616|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.42||| 64616|EAP|0510|DESTROY NERVE,NECK MUSCLE|Blue Cross PPO Specialty|BCBSTX PPO|||||309.17||| 64616|EAP|0510|CHEMODENERV MUSC NECK DYS|Humana Medicare Advantage|HUMANA MA|||||309.17||| 64642|EAP|0510|CHEMODENERV 1 EXTREM 1-4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||748.33||| 64642|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||17.96||| 64642|EAP|0510|DESTROY NERVE,ONE EXTRM 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||748.33||| 64642|EAP|0360||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||17.96||| 64642|EAP|0510|DESTROY NERVE,ONE EXTRM 1|Humana Medicare Advantage|HUMANA MA|||||748.33||| 64642|EAP|0360||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||17.96||| 64642|EAP|0510|DESTROY NERVE,ONE EXTRM 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||748.33||| 64642|EAP|0360||Humana Medicare Advantage|HUMANA MA|||||17.96||| 64642|EAP|0360||Aetna|AETNA QHP HMO|||||17.96||| 64642|EAP|0510|DESTROY NERVE,ONE EXTRM 1|Aetna|AETNA QHP HMO|||||748.33||| 64642|EAP|0510|DESTROY NERVE,ONE EXTRM 1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||748.33||| 64642|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||17.96||| 64642|EAP|0360||Medicare|MEDICARE ACUTE|||||17.96||| 64642|EAP|0510|DESTROY NERVE,ONE EXTRM 1|Medicare|MEDICARE ACUTE|||||748.33||| 64642|EAP|0510|DESTROY NERVE,ONE EXTRM 1|United Healthcare|UNITED HEALTHCARE|||||748.33||| 64642|EAP|0360||Managed Medicare|HEALTHSPRING MA|||||17.96||| 64642|EAP|0510|DESTROY NERVE,ONE EXTRM 1|Managed Medicare|HEALTHSPRING MA|||||748.33||| 64642|EAP|0510|DESTROY NERVE,ONE EXTRM 1|Managed Medicare|BCBS MEDICARE PPO MA|||||748.33||| 64642|EAP|0360||United Healthcare|UNITED HEALTHCARE|||||17.96||| 64643|EAP|0510|CHEMODENERV 1 EXTREM 1-4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||340.42||| 64643|EAP|0510|DESTROY NERVE,1-4 MUSCLE|Medicare|MEDICARE ACUTE|||||340.42||| 64643|EAP|0510|DESTROY NERVE,1-4 MUSCLE|United Healthcare|UNITED HEALTHCARE|||||340.42||| 64643|EAP|0360||Medicare|MEDICARE ACUTE|||||8.17||| 64643|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.17||| 64643|EAP|0360||Aetna|AETNA QHP HMO|||||8.17||| 64643|EAP|0510|DESTROY NERVE,1-4 MUSCLE|Aetna|AETNA QHP HMO|||||340.42||| 64643|EAP|0510|DESTROY NERVE,1-4 MUSCLE|Humana Medicare Advantage|HUMANA MA|||||340.42||| 64643|EAP|0360||Humana Medicare Advantage|HUMANA MA|||||8.17||| 64643|EAP|0360||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.17||| 64643|EAP|0360||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.17||| 64643|EAP|0361||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.17||| 64643|EAP|0510|DESTROY NERVE,1-4 MUSCLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||340.42||| 64643|EAP|0510|DESTROY NERVE,1-4 MUSCLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||340.42||| 64644|EAP|0361|CHEMODENERV 1 EXTREM 5/>|United Medicare Advantage|UHC MEDICARE GOLD MA|||||16.07||| 64645|EAP|0361|CHEMODENERV 1 EXTREM 5/>|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.04||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Medicare|MEDICARE PART B ONLY IP|18,289.06|7039.73|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Medicare|MEDICARE ACUTE|59,038.50|6923.3|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Medicaid|SMITH COUNTY INDIGENT HEALTH|57,068.62|6566.37|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|UTMB|UTMB CORRECTIONAL MANAGED CARE|76,987.10|7022.19|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|United Healthcare|UNITED HEALTHCARE|58,022.02|12163.86|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|87,125.47|6983.415|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|United Medicare Advantage|UHC MEDICARE GOLD MA|86,565.16|7039.73|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|United Medicare Advantage|UHC AARP MCR HMO MA|64,083.18|7039.73|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Managed Medicare|HEALTHSPRING MA|75,827.62|6923.3|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Managed Medicare|BCBS MEDICARE PPO MA|61,041.24|6895.14|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Cigna|CIGNA|69,916.09|10575.03|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Humana Medicare Advantage|HUMANA MA|57,776.87|6927.64|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Managed Medicaid|MEDICAID AMERIGROUP|67,546.95|24130.51|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Medicaid|MEDICAID|76,010.91|6566.37|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Managed Medicaid|MEDICAID SUPERIOR|93,442.62|15327.32|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|52,929.54|10125.03|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|62,969.62|10440.52|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Cigna|CIGNA|56,316.51|10575.03|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|ChampVA|CHAMPVA CENTER|45,509.05|4020.44|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|75,068.09|6478.855|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Blue Cross PPO Specialty|BCBSTX OTHER|95,189.42|7003.89|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Blue Cross PPO Specialty|BCBSTX PPO|82,682.17|7003.89|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Blue Cross HMO Specialty|BCBSTX HMO|96,151.55|5953.82|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|81,056.67|8931.83|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Aenta Medicare Advantage|AETNA MEDICARE MA|80,964.92|7039.73|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Veterans Affairs|VETERANS ADMINISTRATION|54,449.20|7039.73|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Aetna|AETNA PPO|104,648.17|13000.41|24130.51|89.3|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|61,803.57|89.3|24130.51|89.3|||| 65205|EAP|0450|RMV FB EXT EYE SUPERFICIA|Medicare|MEDICARE ACUTE|||||2.15||| 65210|EAP|0450|RMV FB EYE EMBEDDED|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.89||| 65220|EAP|0450|RMV FB EYE CORNEAL WO SLI|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.60||| 65220|EAP|0450|RMV FB EYE CORNEAL WO SLI|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||2.60||| 65220|EAP|0450|RMV FB EYE CORNEAL WO SLI|Managed Medicaid|MEDICAID AMERIGROUP|||||2.60||| 65222|EAP|0450|RMV FB EYE EXT CORNEAL W|Medicare|MEDICARE ACUTE|||||2.41||| 65222|EAP|0450|RMV FB EYE EXT CORNEAL W|Veterans Affairs|VETERANS ADMINISTRATION|||||2.41||| 65222|EAP|0450|RMV FB EYE EXT CORNEAL W|Medicaid|SMITH COUNTY JAIL|||||2.41||| 653|DRG||MAJOR BLADDER PROCEDURES W MCC|Medicaid|MEDICAID|206,527.66|14067.92|14067.92|14067.92|||| 654|DRG||MAJOR BLADDER PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|152,512.91|16708.715|16714.56|16700.92|||| 654|DRG||MAJOR BLADDER PROCEDURES W CC|Medicare|MEDICARE ACUTE|112,807.76|16700.92|16714.56|16700.92|||| 654|DRG||MAJOR BLADDER PROCEDURES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|250,728.06|16714.56|16714.56|16700.92|||| 655|DRG||MAJOR BLADDER PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|228.25|42.51|16145.33|42.51|||| 655|DRG||MAJOR BLADDER PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|61,045.93|16145.33|16145.33|42.51|||| 656|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|126,274.95|142.88|19550.84|142.88|||| 656|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|114,448.40|19175.96|19550.84|142.88|||| 656|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC|Humana Medicare Advantage|HUMANA MA|170,675.14|19365.57|19550.84|142.88|||| 656|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC|Medicare|MEDICARE ACUTE|102,552.60|19175.08|19550.84|142.88|||| 656|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|84,249.91|19550.84|19550.84|142.88|||| 656|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|105,122.44|19168.6|19550.84|142.88|||| 657|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|127,113.27|11994.165|15251.57|11240.39|||| 657|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|106,227.34|11869.41|15251.57|11240.39|||| 657|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC|Medicare|MEDICARE ACUTE|93,120.85|12008.245|15251.57|11240.39|||| 657|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|95,687.55|15251.57|15251.57|11240.39|||| 657|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC|Humana Medicare Advantage|HUMANA MA|89,415.96|11881.67|15251.57|11240.39|||| 657|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC|Blue Cross PPO Specialty|BCBSTX PPO|100,545.21|13222.85|15251.57|11240.39|||| 657|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC|Blue Cross HMO Specialty|BCBSTX HMO|89,510.95|11240.39|15251.57|11240.39|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|104,833.82|107.16|13255.03|107.16|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|82,666.55|10635.86|13255.03|107.16|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|92,771.73|12173.73|13255.03|107.16|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|86,006.85|10077.71|13255.03|107.16|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|92,780.43|13255.03|13255.03|107.16|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|97,818.32|11039.345|13255.03|107.16|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|102,585.49|13098.05|13255.03|107.16|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|Medicare|MEDICARE ACUTE|83,350.89|9897.64|13255.03|107.16|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|84,611.30|9880.76|13255.03|107.16|||| 658|DRG||KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|86,744.51|10077.71|13255.03|107.16|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|128,965.95|16142.74|60338.11|11126.755|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|122,957.56|33899.47|60338.11|11126.755|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|United Healthcare|UNITED HEALTHCARE|437,444.62|60338.11|60338.11|11126.755|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|212,009.58|16328.97|60338.11|11126.755|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|Medicare|MEDICARE ACUTE|285,208.98|15988.48|60338.11|11126.755|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|242,226.71|21065.8|60338.11|11126.755|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|Managed Medicare|HEALTHSPRING MA|493,226.42|27570.185|60338.11|11126.755|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|Humana Medicare Advantage|HUMANA MA|57,108.12|16326.79|60338.11|11126.755|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|137,408.03|11126.755|60338.11|11126.755|||| 659|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|120,509.31|13608.76|60338.11|11126.755|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|64,320.34|4565.03|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|113,889.86|15363.265|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|79,724.81|5218.39|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|98,850.77|6765.76|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Medicare|MEDICARE ACUTE|51,926.60|5298.85|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|43,716.34|5298.85|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|55,163.72|5218.39|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63,315.07|5298.85|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|108,876.46|8486.41|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|53,421.44|5258.62|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Tricare|TRICARE EAST REGION|70,472.95|5081.63|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|122,348.42|8220.11|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|58,028.62|5190.73|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Cigna|CIGNA|128,339.61|8976.48|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|46,684.92|5218.39|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|48,967.87|5200.23|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|208,393.49|10068.22|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44,833.39|107.16|15363.265|107.16|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Aetna|AETNA PPO|36,254.65|9251.45|15363.265|107.16|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|52,096.59|9034.87|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|NON CONTRACTED|COMMERCIAL OTHER 1|33,152.84|33152.84|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|United Medicare Advantage|UHC AARP MCR HMO MA|81,228.52|9241.73|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|59,043.02|9071.16|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Medicaid|MEDICAID|67,321.18|6250.31|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Medicare|MEDICARE ACUTE|74,489.88|9079.82|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Medicare|MEDICARE PART B ONLY IP|68,887.95|9079.82|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Access Direct Platinum|HEALTHFIRST TPA|111,318.15|12133.2|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|44,198.14|12594.74|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Managed Medicare|BCBS MEDICARE PPO MA|34,919.39|9258.9|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Managed Medicare|HEALTHSPRING MA|71,905.85|9241.73|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Cigna|CIGNA|43,752.73|146.19|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Humana Medicare Advantage|HUMANA MA|70,044.54|9241.73|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|205,713.06|16187.82|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Blue Cross HMO Specialty|BCBSTX HMO|80,796.37|8355.55|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|97,463.29|250.04|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Blue Cross PPO Specialty|BCBSTX PPO|55,336.13|9829.2|33152.84|146.19|||| 660|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC|Managed Medicaid|MEDICAID AMERIGROUP|72,801.78|5481.175|33152.84|146.19|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|38,315.95|7284.31|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|60,564.87|7024.68|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|86,106.60|9707.79|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|42,502.56|9828.4|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Medicare|MEDICARE ACUTE|82,286.35|7389.35|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|37,867.90|7389.35|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|39,354.12|7389.35|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Medicaid|MEDICAID HMO|27,524.88|4418.04|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|34,831.49|7219.62|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|41,229.05|275.73|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|49,215.80|7265.7|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|71,295.19|7389.35|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|PHCS|GROUP AND PENSION|119,523.68|82471.34|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|50,421.96|5847.72|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|34,807.47|34807.47|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38,835.49|68.04|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|65,025.83|4416.165|82471.34|68.04|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|37,279.60|7403.41|82471.34|68.04|||| 663|DRG||MINOR BLADDER PROCEDURES W CC|Medicare|MEDICARE ACUTE|92,475.70|9817.17|9817.17|9817.17|||| 664|DRG||MINOR BLADDER PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|79,332.67|7355.37|7355.37|7355.37|||| 665|DRG||PROSTATECTOMY W MCC|Medicare|MEDICARE ACUTE|108,195.24|17914.18|17914.18|17914.18|||| 666|DRG||PROSTATECTOMY W CC|Medicare|MEDICARE ACUTE|239,960.80|10991.62|20939.07|10991.62|||| 666|DRG||PROSTATECTOMY W CC|United Healthcare|UNITED HEALTHCARE OTHER|107,600.45|20939.07|20939.07|10991.62|||| 668|DRG||TRANSURETHRAL PROCEDURES W MCC|Medicare|MEDICARE ACUTE|90,117.34|16749.535|16904.5|16749.535|||| 668|DRG||TRANSURETHRAL PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|74,823.75|16904.5|16904.5|16749.535|||| 669|DRG||TRANSURETHRAL PROCEDURES W CC|Medicare|MEDICARE ACUTE|507.72|9765.73|12543.11|71.44|||| 669|DRG||TRANSURETHRAL PROCEDURES W CC|Medicare|MEDICARE PART B ONLY IP|31,641.08|3812.18|12543.11|71.44|||| 669|DRG||TRANSURETHRAL PROCEDURES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|41,942.97|12543.11|12543.11|71.44|||| 669|DRG||TRANSURETHRAL PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33,308.37|71.44|12543.11|71.44|||| 669|DRG||TRANSURETHRAL PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|171,038.07|2675.83|12543.11|71.44|||| 669|DRG||TRANSURETHRAL PROCEDURES W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|135,524.54|9765.73|12543.11|71.44|||| 67|DRG||NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W MCC|Medicaid|MEDICAID|46,348.74|6572.7|9292.01|6572.7|||| 67|DRG||NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W MCC|Medicare|MEDICARE ACUTE|63,505.40|9292.01|9292.01|6572.7|||| 670|DRG||TRANSURETHRAL PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX OTHER|38,664.15|6542.16|8590.22|6542.16|||| 670|DRG||TRANSURETHRAL PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26,644.65|8590.22|8590.22|6542.16|||| 670|DRG||TRANSURETHRAL PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25,495.74|6765.16|8590.22|6542.16|||| 670|DRG||TRANSURETHRAL PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|44,539.06|6709.345|8590.22|6542.16|||| 672|DRG||URETHRAL PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|67,946.10|6925.32|6925.32|6925.32|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|United Healthcare|UNITED HEALTHCARE OTHER|113,780.89|42308.97|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|160,542.98|21310.2|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|169,264.86|130295.43|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99,302.79|20883.82|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|130,450.84|24289.87|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|Medicare|MEDICARE ACUTE|133,595.10|20898.98|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|Managed Medicare|HEALTHSPRING MA|202,116.69|20884.9|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|114,325.44|17593.68|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|218,089.88|20391.83|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|307,283.10|21310.2|130295.43|4116.64|||| 673|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC|Medicaid|MEDICAID|142,814.60|4116.64|130295.43|4116.64|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Cigna|CIGNA|99,505.75|29396.57|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|76,037.28|14700.44|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|138,346.87|13468.645|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|104,919.65|14695.22|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Managed Medicare|HEALTHSPRING MA|980.12|14695.22|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110,561.18|285.76|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Blue Cross PPO Specialty|BCBSTX PPO|80,811.50|15699.16|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|79,056.21|14976.47|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Medicare|MEDICARE ACUTE|95,761.65|14705.1|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Medicaid|MEDICAID|208,478.93|12825.05|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|NON CONTRACTED|COMMERCIAL OTHER 1|94,441.35|65164.53|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|129,652.73|14695.22|65164.53|285.76|||| 674|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|111,229.75|15699.16|65164.53|285.76|||| 675|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|139,921.90|10238.41|10240.01|10221.69|||| 675|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|101,529.65|10221.69|10240.01|10221.69|||| 675|DRG||OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|99,432.30|10240.01|10240.01|10221.69|||| 67950|EAP|0981|REVISION OF EYELID|Medicare|MEDICARE ACUTE|||||33.02||| 68|DRG||NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|325.55|8555.61|8555.61|6240.34|||| 68|DRG||NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|78,865.12|6241.22|8555.61|6240.34|||| 68|DRG||NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC|Medicare|MEDICARE ACUTE|48,350.62|6240.34|8555.61|6240.34|||| 68|DRG||NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC|Medicare|MEDICARE PART B ONLY IP|51,653.67|6241.22|8555.61|6240.34|||| 682|DRG||RENAL FAILURE W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|67,494.27|11069.21|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|87,852.05|9402.48|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|PHCS|HUMANA|60,421.61|251.26|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Medicare|MEDICARE ACUTE|72,414.10|9393.36|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|114,535.04|10402.28|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Blue Cross HMO Specialty|BCBSTX HMO|30,183.25|6207.35|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|90,085.35|9478.51|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|52,206.23|5319.43|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|123,048.88|10697.78|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Humana Medicare Advantage|HUMANA MA|68,583.63|9394.77|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Cigna|CIGNA OTHER|31,795.35|18708.67|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|135,753.29|9394.24|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62,266.01|178.6|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Medicaid|MEDICAID|326,640.40|9339.68|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Managed Medicare|BCBS MEDICARE PPO MA|41,339.65|9366.08|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Managed Medicare|HEALTHSPRING MA|40,547.89|9562.78|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Veterans Affairs|VETERANS ADMINISTRATION|96,756.47|9394.24|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|96,396.31|9562.78|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|64,308.50|9562.78|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|53,410.09|18696.7|18708.67|178.6|||| 682|DRG||RENAL FAILURE W MCC|United Healthcare|UNITED HEALTHCARE OTHER|59,428.37|17493.61|18708.67|178.6|||| 683|DRG||RENAL FAILURE W CC|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|113,860.35|9021.99|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|43,875.73|8022.73|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Veterans Affairs|VETERANS ADMINISTRATION|19,222.01|6314.505|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|41,423.37|10195.54|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|54,456.75|6206.88|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Humana Medicare Advantage|HUMANA MA|55,265.12|6205.6|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39,817.54|4042.15|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Aetna|AETNA PPO|65,823.26|11577.86|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34,772.79|71.44|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|31,771.59|6240.01|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Blue Cross PPO Specialty|BCBSTX PPO|39,011.41|6240.01|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|51,134.68|4042.15|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Managed Medicare|HEALTHSPRING MA|57,744.30|6309.08|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|15,097.72|15097.72|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Medicare|MEDICARE PART B ONLY IP|6,418.50|73.97|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Medicare|MEDICARE ACUTE|45,194.65|6309.08|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|PHCS|HUMANA INSURANCE|38,495.15|6309.08|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|26,652.52|6233.305|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|24,710.81|6235.25|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|United Medicare Advantage|UHC AARP MCR HMO MA|42,339.34|6309.08|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46,236.36|6206.88|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|United Healthcare|UNITED HEALTHCARE|96,668.40|10620.44|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|United Healthcare|UNITED HEALTHCARE|77,078.43|10620.44|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|United Healthcare|UNITED HEALTHCARE OTHER|43,287.75|10620.44|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|23,846.36|6293.77|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38,667.96|8174.02|15097.72|71.44|||| 683|DRG||RENAL FAILURE W CC|Access Direct Platinum|HEALTHFIRST TPA|51,695.94|8368.48|15097.72|71.44|||| 684|DRG||RENAL FAILURE W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|70,343.75|4573.99|6056.75|107.16|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Medicaid|MEDICAID|97,542.44|2542.23|6056.75|107.16|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Medicare|MEDICARE ACUTE|22,723.86|4659.45|6056.75|107.16|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|20,741.01|610.11|6056.75|107.16|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|41,165.63|4208.44|6056.75|107.16|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34,901.09|107.16|6056.75|107.16|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19,354.05|4042.15|6056.75|107.16|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|50,518.41|6056.75|6056.75|107.16|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|60,396.74|4729.01|6056.75|107.16|||| 686|DRG||KIDNEY & URINARY TRACT NEOPLASMS W MCC|Medicare|MEDICARE ACUTE|85,474.32|111.21|111.21|111.21|||| 687|DRG||KIDNEY & URINARY TRACT NEOPLASMS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|53,358.75|7063.45|7179.24|7063.45|||| 687|DRG||KIDNEY & URINARY TRACT NEOPLASMS W CC|Medicare|MEDICARE ACUTE|55,261.98|7179.24|7179.24|7063.45|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|67,614.76|7549.05|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Managed Medicare|HEALTHSPRING MA|67,448.85|7562.58|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|85,667.96|9629.83|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|78,966.28|232.18|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|39,091.60|7547.76|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|40,748.75|3080.99|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Humana Medicare Advantage|HUMANA MA|66,302.55|7487.745|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Managed Medicare|BCBS MEDICARE PPO MA|41,238.75|7393.94|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Medicare|MEDICARE ACUTE|54,280.16|7421.22|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|43,609.55|43609.55|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|100,922.90|7549.05|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|79,112.80|7406.94|43609.55|232.18|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|23,790.05|4522.02|43609.55|232.18|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|United Healthcare|UNITED HEALTHCARE|35,548.36|9235.63|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|78,946.32|5565.74|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Medicare|MEDICARE ACUTE|49,897.17|5564.86|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Medicare|MEDICARE PART B ONLY IP|37,157.59|1277.96|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Blue Cross PPO Specialty|BCBSTX PPO|541.16|5197.74|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|65,315.91|107.16|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Humana Medicare Advantage|HUMANA MA|52,218.77|5653.52|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|36,458.75|7207.06|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|96,220.77|7401.52|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|United Medicare Advantage|UHC AARP MCR HMO MA|57,963.37|5653.52|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Managed Medicare|HEALTHSPRING MA|84,602.37|5653.52|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Managed Medicare|BCBS MEDICARE PPO MA|47,131.25|5653.52|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|66,399.79|6957.47|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Aenta Medicare Advantage|AETNA MEDICARE MA|51,464.70|5653.52|9235.63|107.16|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Veterans Affairs|VETERANS ADMINISTRATION|60,037.54|5653.52|9235.63|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|42,228.55|7497.73|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|36,834.95|7280.26|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|21,459.60|7823.46|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|397.58|5622.48|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicare|HEALTHSPRING MA|44,800.41|5623.36|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Humana Medicare Advantage|HUMANA MA|45,345.30|5669.875|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Cigna|CIGNA|179.86|7749.84|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|41,456.45|5623.36|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|31,185.25|4898.78|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|126.22|3005.16|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|63,068.99|6151.095|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|151.72|3005.16|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|39,762.33|107.16|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|ChampVA|CHAMPVA CENTER|23,803.80|2947.82|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|23,572.40|5391.94|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Medicaid|MEDICAID|66,350.80|4656.23|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Medicare|MEDICARE PART B ONLY IP|16,703.43|812.235|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Medicare|MEDICARE ACUTE|46,897.56|5623.36|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Tricare|TRICARE EAST REGION|25,457.46|3050.995|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|26,717.10|5626.26|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|25,044.45|5712.35|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54,995.40|10543.44|10543.44|107.16|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|20,777.15|9359.91|10543.44|107.16|||| 69000|EAP|0981|DRAIN EXTERNAL EAR LESION|Medicare|MEDICARE ACUTE|||||631.50||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Humana Medicare Advantage|HUMANA MA|||||4.33||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||497.95||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Medicaid|MEDICAID|||||465.48||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.33||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Managed Medicaid|MEDICAID SUPERIOR|||||497.95||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Tricare|TRICARE FOR LIFE|||||4.33||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.33||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Medicare|MEDICARE ACUTE|||||465.48||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||497.95||| 69209|EAP|0450|REMOVAL IMPACT CERUMEN W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.24||| 69209|EAP|0450|REMOVAL IMPACT CERUMEN W/|Veterans Affairs|VETERANS ADMINISTRATION|||||2.24||| 69209|EAP|0450|REMOVAL IMPACT CERUMEN W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||257.60||| 69209|EAP|0450|REMOVAL IMPACT CERUMEN W/|Managed Medicaid|MEDICAID AMERIGROUP|||||257.60||| 69209|EAP|0450|REMOVAL IMPACT CERUMEN W/|Blue Cross PPO Specialty|BCBSTX PPO|||||240.80||| 69209|EAP|0450|REMOVAL IMPACT CERUMEN W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||257.60||| 69209|EAP|0450|REMOVAL IMPACT CERUMEN W/|Medicare|MEDICARE ACUTE|||||2.24||| 69210|EAP|0450|RMV IMPACTED EAR WAX|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||485.30||| 694|DRG||URINARY STONES W/O MCC|Medicare|MEDICARE ACUTE|32,296.87|5345.91|6496.88|4767.26|||| 694|DRG||URINARY STONES W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|141,138.05|6496.88|6496.88|4767.26|||| 694|DRG||URINARY STONES W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|382.97|4767.26|6496.88|4767.26|||| 696|DRG||KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC|Humana Medicare Advantage|HUMANA MA|33,944.80|5088.16|8301.34|454.5|||| 696|DRG||KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,648.55|8301.34|8301.34|454.5|||| 696|DRG||KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|340.76|4582.39|8301.34|454.5|||| 696|DRG||KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|36,500.44|454.5|8301.34|454.5|||| 696|DRG||KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC|Medicaid|MEDICAID|156.10|2897.23|8301.34|454.5|||| 696|DRG||KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC|Medicare|MEDICARE ACUTE|36,041.78|4998.795|8301.34|454.5|||| 697|DRG||URETHRAL STRICTURE|Medicare|MEDICARE ACUTE|32,234.24|6628.08|6628.08|136.08|||| 697|DRG||URETHRAL STRICTURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|50,045.50|136.08|6628.08|136.08|||| 697|DRG||URETHRAL STRICTURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|214.43|4606.59|6628.08|136.08|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Managed Medicare|HEALTHSPRING MA|22,271.24|10171.73|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|23,781.51|8838.76|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|59,960.30|10966.53|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|61,732.23|174.35|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|52,124.21|17593.68|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|67,873.46|20884.8|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|611.51|99.38|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|United Healthcare|UNITED HEALTHCARE OTHER|129,945.18|47777.75|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|46,375.14|10258.17|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Medicaid|MEDICAID|72,710.31|6424.67|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Humana Medicare Advantage|HUMANA MA|38,898.94|10149.99|47777.75|99.38|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|62,793.88|10165.76|47777.75|99.38|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|Medicare|MEDICARE ACUTE|39,121.64|6949.85|7067.74|99.38|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|United Medicare Advantage|UHC AARP MCR HMO MA|63,058.67|7067.74|7067.74|99.38|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|Blue Cross PPO Specialty|BCBSTX PPO|28,472.80|6979.44|7067.74|99.38|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42,880.30|99.38|7067.74|99.38|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|Humana Medicare Advantage|HUMANA MA|52,627.86|7067.74|7067.74|99.38|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35,953.82|139.48|7067.74|99.38|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|25,880.26|6933.74|7067.74|99.38|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26,045.09|4434.66|7067.74|99.38|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|86,819.01|10435.56|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|Managed Medicare|HEALTHSPRING MA|81,274.84|10654.82|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|70,043.86|142.88|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|355,458.54|13064.37|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|126,291.60|9464.09|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|76,348.67|10463.72|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|52,338.40|10555.305|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|85,173.18|10461.245|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|433,480.47|29502.415|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|Managed Medicare|BCBS MEDICARE PPO MA|33,968.76|10463.72|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|Medicare|MEDICARE ACUTE|67,154.19|10462.84|29502.415|142.88|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|Medicare|MEDICARE PART B ONLY IP|17,563.71|10654.82|29502.415|142.88|||| 700|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|40,174.95|40174.95|40174.95|35.72|||| 700|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|26,464.02|5341.72|40174.95|35.72|||| 700|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|42,404.72|5110.92|40174.95|35.72|||| 700|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC|Aetna|AETNA PPO|25,298.75|54.08|40174.95|35.72|||| 700|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33,460.15|35.72|40174.95|35.72|||| 700|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|36,252.60|5437.24|40174.95|35.72|||| 70015|EAP|0320|CISTERNOGRAM INJ.|Medicare|MEDICARE ACUTE|||||812.75||| 70100|EAP|0320|XR-JAW <4VIEWS|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 70100|EAP|0320|XR-JAW <4VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 70100|EAP|0320|XR-JAW <4VIEWS|Aetna|AETNA PPO|8.24||||||| 70100|EAP|0320|XR-JAW <4VIEWS|Medicare|MEDICARE ACUTE|||||8.24||| 70110|EAP|0320|XR-JAW 4/> VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.12||| 70110|EAP|0320|XR-JAW 4/> VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.12||| 70110|EAP|0320|XR-JAW 4/> VIEWS|Medicare|MEDICARE ACUTE|||||9.12||| 70130|EAP|0320|XR-MASTOIDS 3 VIEWS PER S|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 70140|EAP|0320|XR-FACIAL BONES < 3 VIEWS|Medicare|MEDICARE ACUTE|||||8.24||| 70140|EAP|0320|XR-FACIAL BONES < 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||8.24||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Aetna|BOON CHAPMAN|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Tricare|TRICARE EAST REGION|||||9.12||| 70150|EAP|0320|XR-FACIAL BONES 3 VIEWS|Medicare|MEDICARE ACUTE|9.12||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Medicare|MEDICARE ACUTE|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Aetna|AETNA PPO|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Cigna|CIGNA|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.12||| 70160|EAP|0320|XR-NASAL BONES 3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||9.12||| 70200|EAP|0320|XR-ORBITS 3VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|||||10.02||| 70200|EAP|0320|XR-ORBITS 3VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||10.02||| 70200|EAP|0320|XR-ORBITS 3VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|||||10.02||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Medicare|MEDICARE ACUTE|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Tricare|TRICARE EAST REGION|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Cigna|CIGNA|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.12||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.12||| 70220|EAP|0320|XR-SINUSES 3 VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|9.12||||||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.12||||||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|9.12||||||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|9.12||||||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|United Healthcare|UNITED HEALTHCARE|9.12||||||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Medicare|MEDICARE ACUTE|9.12||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Medicaid|MEDICAID HMO|||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Medicaid|MEDICAID|9.12||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Humana Medicare Advantage|HUMANA MA|9.12||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Managed Medicare|HEALTHSPRING MA|9.12||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.12||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||9.12||| 70250|EAP|0320|XR-SKULL 4/> VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.12||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|Managed Medicare|HEALTHSPRING MA|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|United Healthcare|UNITED HEALTHCARE|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|Medicare|MEDICARE ACUTE|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|Humana Medicare Advantage|HUMANA MA|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.21||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|7.21||||||| 70260|EAP|0320|XR-SKULL COMPLETE 4 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.21||| 70330|EAP|0320|XR-JAW JOINTS BILAT|Aetna|AETNA OTHER|||||10.02||| 70330|EAP|0320|XR-JAW JOINTS BILAT|Blue Cross PPO Specialty|BCBSTX PPO|||||10.02||| 70330|EAP|0320|XR-JAW JOINTS BILAT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||10.02||| 70330|EAP|0320|XR-JAW JOINTS BILAT|PHCS|HUMANA INSURANCE|||||10.02||| 70336|EAP|0610|MRI TMJ BILATERAL|United Healthcare|UNITED HEALTHCARE OTHER|||||6,370.10||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.22||||||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Veterans Affairs|VETERANS ADMINISTRATION|7.22||||||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Workers Compensation|UT EMPLOYEE INJURY|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Access Direct Platinum|HEALTHFIRST TPA|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.22||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.22||||||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Managed Medicaid|MEDICAID AMERIGROUP|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Managed Medicaid|MEDICAID SUPERIOR|7.22||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Humana Medicare Advantage|HUMANA MA|7.22||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Medicaid|SMITH COUNTY JAIL|7.22||||||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Medicaid|MEDICAID|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Medicare|MEDICARE ACUTE|7.22||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|Tricare|TRICARE EAST REGION|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|United Healthcare|UNITED HEALTHCARE OTHER|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|United Healthcare|UNITED HEALTHCARE|||||7.22||| 70355|EAP|0320|XR-PANORAMIC OF JAWS|United Healthcare|TML GROUP BENEFITS|7.22||||||| 70360|EAP|0320|XR-NECK SOFT TISSUE|United Healthcare|UNITED HEALTHCARE OTHER|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|United Healthcare|UNITED HEALTHCARE|6.42||||||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Tricare|TRICARE EAST REGION|6.42||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Medicare|MEDICARE ACUTE|6.42||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Medicaid|MEDICAID HMO|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Humana Medicare Advantage|HUMANA MA|6.42||||||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Managed Medicaid|MEDICAID SUPERIOR|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Managed Medicare|HEALTHSPRING MA|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|United Medicare Advantage|UHC AARP MCR HMO MA|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Veterans Affairs|VETERANS ADMINISTRATION|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|United Healthcare|UNITED HEALTHCARE|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|United Medicare Advantage|UHC MEDICARE GOLD MA|6.42||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Managed Medicaid|MEDICAID AMERIGROUP|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Access Direct Platinum|HEALTHFIRST TPA|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.42||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Blue Cross PPO Specialty|BCBSTX PPO|6.42||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Aetna|AETNA PPO|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Blue Cross HMO Specialty|BCBSTX HMO|||||6.42||| 70360|EAP|0320|XR-NECK SOFT TISSUE|Cigna|CIGNA|||||6.42||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Workers Compensation|UT EMPLOYEE INJURY|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Workers Compensation|TRAVELERS INSURANCE COMPANY|45.60||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Workers Compensation|WORKERS COMP PHYSICIAN|||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Workers Compensation|GALLAGHER BASSETT|||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Workers Compensation|BROOKSHIRES WORKERS COMP|45.60||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Access Direct Platinum|HEALTHFIRST TPA|4,940.55||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Workers Compensation|TEXAS MUTUAL INSURANCE|45.60||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Medicare Advantage|UHC AARP WELLMED HMO MA|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|4,940.55||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|45.60||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Cigna|CIGNA OTHER|||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|ChampVA|CHAMPVA CENTER|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Magellan Behavioral Health|BH MAGELLAN|||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Aetna|AETNA PPO|4,940.55||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Aetna|AETNA QHP HMO|4,940.55||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Aetna|BOON CHAPMAN|45.60||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Aetna|AETNA OTHER|4,940.55||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|4,750.28||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4,940.55||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|4,940.55||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|45.60||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|LAW ENFORCEMENT OTHER|4,750.28||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|MEDICAID HMO|45.60||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|MEDICAID|45.60||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|CRIME VICTIMS COMPENSATION|45.60||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|4,940.55||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|SMITH COUNTY INDIGENT HEALTH|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|4,940.55||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|MOLINA HEALTHCARE OF TEXAS|45.60||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|SMITH COUNTY JAIL|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Cigna|CIGNA|45.60||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Humana Medicare Advantage|HUMANA MA|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Cigna|CIGNA|45.60||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|BH TEXAS CHILDRENS MEDICAID|45.60||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Aetna|BH AETNA|45.60||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicaid|COUNTY INDIGENT HEALTH OTHER|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicare|WELLCARE CHOICE MA|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicare|MA PART B ONLY IP|45.60||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicare|OTHER INSTITUTIONS|||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicare|ETMC AFFILIATE HOSPITALS|45.60||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Managed Medicare|HEALTHSPRING MA|45.60||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicare|MEDICARE PART B ONLY IP|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Texas Workforce Commission|DIS DETER SERV (DDS)|||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 4|||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4,940.55||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|PHCS|HUMANA|4,940.55||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|PHCS|GROUP AND PENSION|4,940.55||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Rusk State Hospital|RUSK STATE HOSP|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Tricare|TRICARE FOR LIFE|||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 2|4,940.55||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Tricare|TRICARE EAST REGION|4,940.55||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Medicare|MEDICARE ACUTE|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|45.60||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Healthcare|TML GROUP BENEFITS|4,940.55||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Healthcare|GOLDEN RULE|||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Multiplan|WEB TPA|||||4,940.55||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Healthcare|AARP|||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Healthcare|UNITED HEALTHCARE|4,940.55||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Healthcare|UNITED HEALTHCARE ERS|45.60||||||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|4,940.55||||4,750.28||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|United Healthcare|GEHA|||||45.60||| 70450|EAP|0350|CT-HEAD/BRAIN W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|4,940.55||||45.60||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|||||6,454.13||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|United Healthcare|UNITED HEALTHCARE|6,454.13||||||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|United Healthcare|TML GROUP BENEFITS|59.57||||||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||6,454.13||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|Medicare|MEDICARE ACUTE|6,454.13||||59.57||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|6,454.13||||||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|6,205.57||||||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|59.57||||6,454.13||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|Aetna|AETNA OTHER|6,454.13||||||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|Humana Medicare Advantage|HUMANA MA|59.57||||6,205.57||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|6,454.13||||||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|59.57||||59.57||| 70460|EAP|0350|CT-HEAD/BRAIN W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|6,454.13||||||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,318.73||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|67.55||||||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|7,318.73||||7,318.73||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|67.55||||67.55||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|67.55||||||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Managed Medicaid|MEDICAID AMERIGROUP|||||7,318.73||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|67.55||||||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||67.55||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Cigna|CIGNA|7,318.73||||||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Humana Medicare Advantage|HUMANA MA|7,036.87||||7,036.87||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|67.55||||67.55||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7,036.87||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|7,318.73||||7,036.87||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|7,318.73||||7,318.73||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|||||7,318.73||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Managed Medicare|HEALTHSPRING MA|7,318.73||||7,318.73||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||67.55||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Medicaid|MEDICAID|67.55||||||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|67.55||||7,318.73||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|United Healthcare|UNITED HEALTHCARE|7,318.73||||7,318.73||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|United Healthcare|UNITED HEALTHCARE|7,318.73||||||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|United Healthcare|TML GROUP BENEFITS|67.55||||||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Tricare|TRICARE EAST REGION|||||67.55||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|7,318.73||||||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Medicare|MEDICARE ACUTE|7,318.73||||7,318.73||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|Texas Workforce Commission|DIS DETER SERV (DDS)|||||67.55||| 70470|EAP|0350|CT-HEAD/BRAIN W/O & W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|7,036.87||||7,318.73||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||45.60||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Medicare|MEDICARE ACUTE|45.60||||45.60||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|NON CONTRACTED|COMMERCIAL OTHER 1|||||45.60||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Managed Medicare|HEALTHSPRING MA|||||45.60||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Managed Medicare|BCBS MEDICARE PPO MA|||||4,940.55||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Blue Cross HMO Specialty|BCBSTX HMO|||||4,940.55||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Managed Medicaid|MEDICAID AMERIGROUP|||||45.60||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,750.28||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,940.55||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Humana Medicare Advantage|HUMANA MA|4,940.55||||||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Blue Cross PPO Specialty|BCBSTX OTHER|||||4,940.55||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Blue Cross PPO Specialty|BCBSTX PPO|||||4,750.28||| 70480|EAP|0350|CT-ORBIT/EAR/FOSSA W/O DY|Medicaid|LAW ENFORCEMENT OTHER|||||4,940.55||| 70481|EAP|0350|CT-ORBIT/EAR/FOSSA W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,454.13||| 70481|EAP|0350|CT-ORBIT/EAR/FOSSA W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6,205.57||| 70481|EAP|0350|CT-ORBIT/EAR/FOSSA W/DYE|Humana Medicare Advantage|HUMANA MA|||||59.57||| 70481|EAP|0350|CT-ORBIT/EAR/FOSSA W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|||||59.57||| 70481|EAP|0350|CT-ORBIT/EAR/FOSSA W/DYE|Medicaid|MEDICAID|||||59.57||| 70481|EAP|0350|CT-ORBIT/EAR/FOSSA W/DYE|Medicare|MEDICARE ACUTE|||||6,205.57||| 70481|EAP|0350|CT-ORBIT/EAR/FOSSA W/DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|59.57||||||| 70482|EAP|0350|CT-ORBIT/EAR/FOSSA W/O&W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||67.55||| 70482|EAP|0350|CT-ORBIT/EAR/FOSSA W/O&W/|Humana Medicare Advantage|HUMANA MA|67.55||||||| 70482|EAP|0350|CT-ORBIT/EAR/FOSSA W/O&W/|Medicare|MEDICARE ACUTE|||||7,318.73||| 70482|EAP|0350|CT-ORBIT/EAR/FOSSA W/O&W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7,318.73||| 70482|EAP|0350|CT-ORBIT/EAR/FOSSA W/O&W/|United Healthcare|UNITED HEALTHCARE|||||7,318.73||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Workers Compensation|TRAVELERS INSURANCE COMPANY|45.60||||||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|4,940.55||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|4,940.55||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Workers Compensation|TEXAS MUTUAL INSURANCE|||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4,750.28||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,940.55||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|45.60||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Access Direct Platinum|HEALTHFIRST TPA|||||4,750.28||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Workers Compensation|BROOKSHIRES WORKERS COMP|45.60||||||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|45.60||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|45.60||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|United Medicare Advantage|UHC AARP WELLMED HMO MA|4,940.55||||||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|45.60||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|4,940.55||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Cigna|CIGNA|4,940.55||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|ChampVA|CHAMPVA CENTER|||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Humana Medicare Advantage|HUMANA MA|4,940.55||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|4,750.28||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|45.60||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Cigna|CIGNA|45.60||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Cigna|CIGNA OTHER|||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|4,940.55||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4,940.55||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Aetna|AETNA OTHER|4,940.55||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|45.60||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Aetna|AETNA PPO|4,940.55||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|4,750.28||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45.60||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Managed Medicare|HEALTHSPRING MA|45.60||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|45.60||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|45.60||||||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|45.60||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicaid|CRIME VICTIMS COMPENSATION|45.60||||||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|4,940.55||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicaid|MOLINA HEALTHCARE OF TEXAS|45.60||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicaid|MEDICAID|45.60||||4,750.28||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicaid|MEDICAID HMO|||||4,750.28||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicaid|LAW ENFORCEMENT OTHER|45.60||||||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|4,750.28||||4,750.28||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Workers Compensation|UT EMPLOYEE INJURY|||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Managed Medicare|MA PART B ONLY IP|45.60||||||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 2|4,940.55||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 4|||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|4,940.55||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|PHCS|HUMANA|4,940.55||||||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicare|MEDICARE PART B ONLY IP|4,940.55||||||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicare|MEDICARE ACUTE|45.60||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|45.60||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Tricare|TRICARE EAST REGION|45.60||||4,750.28||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|United Healthcare|UNITED HEALTHCARE|45.60||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|Medicaid|SMITH COUNTY JAIL|45.60||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|United Healthcare|UNITED HEALTHCARE|||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|4,750.28||||4,940.55||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|United Healthcare|GEHA|||||45.60||| 70486|EAP|0350|CT-MAXILLOFACIAL W/O DYE|United Healthcare|GOLDEN RULE|||||4,940.55||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||59.57||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Tricare|TRICARE EAST REGION|59.57||||||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|||||59.57||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Medicaid|SMITH COUNTY JAIL|||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Medicaid|MEDICAID HMO|||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|59.57||||||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|United Healthcare|UNITED HEALTHCARE|||||59.57||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Medicare|MEDICARE ACUTE|59.57||||59.57||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Managed Medicare|HEALTHSPRING MA|||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.57||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|59.57||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|59.57||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Humana Medicare Advantage|HUMANA MA|59.57||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Managed Medicaid|MEDICAID SUPERIOR|6,454.13||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|6,454.13||||||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|59.57||||||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||59.57||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|59.57||||59.57||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||59.57||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,454.13||||6,454.13||| 70487|EAP|0350|CT-MAXILLOFACIAL W/DYE|Managed Medicaid|MEDICAID AMERIGROUP|||||6,205.57||| 70488|EAP|0350|CT-MAXILLOFACIAL W/O & W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7,318.73||| 70488|EAP|0350|CT-MAXILLOFACIAL W/O & W/|Blue Cross HMO Specialty|BCBSTX HMO|67.55||||||| 70488|EAP|0350|CT-MAXILLOFACIAL W/O & W/|Medicare|MEDICARE ACUTE|||||67.55||| 70488|EAP|0350|CT-MAXILLOFACIAL W/O & W/|Blue Cross PPO Specialty|BCBSTX PPO|||||67.55||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Medicaid|MEDICAID|4,750.28||||||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Medicaid|SMITH COUNTY JAIL|45.60||||45.60||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|United Healthcare|UNITED HEALTHCARE OTHER|45.60||||||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|NON CONTRACTED|COMMERCIAL OTHER 1|||||4,940.55||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|45.60||||4,940.55||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|45.60||||45.60||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Managed Medicare|HEALTHSPRING MA|45.60||||||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Humana Medicare Advantage|HUMANA MA|4,940.55||||4,750.28||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4,940.55||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||45.60||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Blue Cross PPO Specialty|BCBSTX OTHER|4,940.55||||||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Blue Cross PPO Specialty|BCBSTX PPO|4,750.28||||4,750.28||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|45.60||||||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|Medicare|MEDICARE ACUTE|45.60||||4,940.55||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,750.28||||45.60||| 70490|EAP|0350|CT-SOFT TISSUE NECK W/O D|United Medicare Advantage|UHC AARP MCR HMO MA|45.60||||45.60||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|6,205.57||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,454.13||||6,205.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|6,205.57||||6,205.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|59.57||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|59.57||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|59.57||||6,205.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|6,454.13||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.57||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|59.57||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Aetna|AETNA PPO|59.57||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Aetna|BH AETNA|59.57||||||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Aetna Value Network|AETNA VALUE NETWORK|||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Cigna|CIGNA OTHER|||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Cigna|CIGNA|||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Humana Medicare Advantage|HUMANA MA|6,454.13||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Blue Cross PPO Specialty|BCBSTX OTHER|||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Managed Medicaid|MEDICAID AMERIGROUP|||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|59.57||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Access Direct Platinum|HEALTHFIRST TPA|||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Managed Medicaid|MEDICAID SUPERIOR|6,454.13||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Multiplan|WEB TPA|||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Medicare|MEDICARE ACUTE|6,454.13||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|59.57||||6,205.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,454.13||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Tricare|TRICARE EAST REGION|||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|United Healthcare|TML GROUP BENEFITS|||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,454.13||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|United Healthcare|UNITED HEALTHCARE|6,454.13||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Medicaid|MEDICAID|59.57||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Medicaid|SMITH COUNTY JAIL|||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Managed Medicare|HEALTHSPRING MA|59.57||||6,205.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|59.57||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||6,454.13||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Managed Medicare|BCBS MEDICARE PPO MA|||||59.57||| 70491|EAP|0350|CT-SOFT TISSUE NECK W/DYE|Medicare|MEDICARE PART B ONLY IP|6,454.13||||||| 70492|EAP|0350|CT-SFT TSUE NCK W/O & W/D|United Healthcare|UNITED HEALTHCARE|||||67.55||| 70492|EAP|0350|CT-SFT TSUE NCK W/O & W/D|Medicare|MEDICARE ACUTE|||||67.55||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Managed Medicaid|MEDICAID AMERIGROUP|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|75.53||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Managed Medicaid|MEDICAID SUPERIOR|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Humana Medicare Advantage|HUMANA MA|8,183.32||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Cigna|CIGNA OTHER|8,183.32||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Cigna|CIGNA|75.53||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Aenta Medicare Advantage|AETNA MEDICARE MA|8,183.32||||7,868.16||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Aetna|AETNA PPO|7,868.16||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Blue Cross PPO Specialty|BCBSTX OTHER|8,183.32||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7,868.16||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Access Direct Platinum|HEALTHFIRST TPA UMR|75.53||||7,868.16||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Access Direct Platinum|HEALTHFIRST TPA|8,183.32||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|75.53||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,183.32||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|ChampVA|CHAMPVA CENTER|8,183.32||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Veterans Affairs|VETERANS ADMINISTRATION|75.53||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Workers Compensation|TEXAS MUTUAL INSURANCE|75.53||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Workers Compensation|WORKERS COMPENSATION OTHER|8,183.32||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|United Medicare Advantage|UHC AARP MCR HMO MA|8,183.32||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Blue Cross PPO Specialty|BCBSTX PPO|8,183.32||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|United Medicare Advantage|UHC AARP WELLMED HMO MA|8,183.32||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|United Medicare Advantage|UHC MEDICARE GOLD MA|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|75.53||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|75.53||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Managed Medicare|BCBS MEDICARE PPO MA|75.53||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Managed Medicare|OTHER INSTITUTIONS|||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|75.53||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Blue Cross HMO Specialty|BCBSTX HMO|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Managed Medicare|HEALTHSPRING MA|75.53||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|75.53||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Medicaid|SMITH COUNTY INDIGENT HEALTH|75.53||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Cigna|CIGNA|75.53||||7,868.16||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Aetna|AETNA QHP HMO|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Medicaid|MEDICAID|75.53||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Medicaid|SMITH COUNTY JAIL|75.53||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Medicaid|CRIME VICTIMS COMPENSATION|7,868.16||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Medicaid|MEDICAID HMO|||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|PHCS|HUMANA INSURANCE|75.53||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|PHCS|HUMANA|||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|PHCS|GROUP AND PENSION|8,183.32||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|NON CONTRACTED|COMMERCIAL OTHER 1|8,183.32||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Medicare|MEDICARE ACUTE|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Medicare|MEDICARE PART B ONLY IP|8,183.32||||||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|UTMB|UTMB CORRECTIONAL MANAGED CARE|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Tricare|TRICARE FOR LIFE|||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|Tricare|TRICARE EAST REGION|7,868.16||||7,868.16||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|United Healthcare|UNITED HEALTHCARE|75.53||||7,868.16||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|United Healthcare|UNITED HEALTHCARE|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|United Healthcare|GEHA|||||8,183.32||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|United Healthcare|UNITED HEALTHCARE OTHER|8,183.32||||75.53||| 70496|EAP|0350|CT-ANGIOGRAPHY HEAD|United Healthcare|TML GROUP BENEFITS|8,183.32||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|United Healthcare|UNITED HEALTHCARE|||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|United Healthcare|TML GROUP BENEFITS|8,183.32||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Tricare|TRICARE FOR LIFE|||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|UTMB|UTMB CORRECTIONAL MANAGED CARE|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|PHCS|HUMANA INSURANCE|75.53||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|NON CONTRACTED|COMMERCIAL OTHER 1|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|United Healthcare|UNITED HEALTHCARE|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Medicaid|SMITH COUNTY INDIGENT HEALTH|75.53||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Medicaid|MEDICAID|75.53||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Medicaid|CRIME VICTIMS COMPENSATION|7,868.16||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Medicaid|SMITH COUNTY JAIL|75.53||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Managed Medicare|OTHER INSTITUTIONS|||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|75.53||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Managed Medicare|HEALTHSPRING MA|75.53||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Managed Medicare|BCBS MEDICARE PPO MA|75.53||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Medicaid|MEDICAID HMO|||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7,868.16||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|United Medicare Advantage|UHC AARP WELLMED HMO MA|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|United Medicare Advantage|UHC AARP MCR HMO MA|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|PHCS|GROUP AND PENSION|8,183.32||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|United Medicare Advantage|UHC MEDICARE GOLD MA|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Medicare|MEDICARE PART B ONLY IP|75.53||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Workers Compensation|WORKERS COMPENSATION OTHER|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Workers Compensation|TRAVELERS INSURANCE COMPANY|8,183.32||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Workers Compensation|UT EMPLOYEE INJURY|75.53||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|75.53||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Tricare|TRICARE EAST REGION|8,183.32||||7,868.16||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Veterans Affairs|VETERANS ADMINISTRATION|75.53||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|PHCS|HUMANA|||||7,868.16||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Medicare|MEDICARE ACUTE|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Workers Compensation|TEXAS MUTUAL INSURANCE|75.53||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|75.53||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|75.53||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Access Direct Platinum|HEALTHFIRST TPA|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|United Healthcare|GEHA|||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Access Direct Platinum|HEALTHFIRST TPA UMR|75.53||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Blue Cross HMO Specialty|BCBSTX HMO|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Blue Cross PPO Specialty|BCBSTX OTHER|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Blue Cross PPO Specialty|BCBSTX PPO|8,183.32||||7,868.16||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Brinson Benefits|THE HEALTH PLAN SMITH CO|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Aetna|AETNA QHP HMO|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Aenta Medicare Advantage|AETNA MEDICARE MA|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Cigna|CIGNA OTHER|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Cigna|CIGNA|75.53||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Cigna|CIGNA|75.53||||7,868.16||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|ChampVA|CHAMPVA CENTER|8,183.32||||||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Humana Medicare Advantage|HUMANA MA|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Managed Medicaid|MEDICAID AMERIGROUP|8,183.32||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|United Healthcare|UNITED HEALTHCARE OTHER|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Managed Medicaid|MEDICAID SUPERIOR|8,183.32||||75.53||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Aetna|AETNA PPO|75.53||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|75.53||||8,183.32||| 70498|EAP|0350|CT-ANGIOGRAPHY NECK|Aetna|AETNA OTHER|||||8,183.32||| 70540|EAP|0610|MRI ORBIT/FACE/NECK W/O D|Medicare|MEDICARE ACUTE|5,422.25||||5,422.25||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Managed Medicaid|MEDICAID AMERIGROUP|||||63.79||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7,335.85||||||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7,335.85||||||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Blue Cross PPO Specialty|BCBSTX PPO|||||63.79||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Blue Cross HMO Specialty|BCBSTX HMO|||||7,335.85||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||63.79||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||63.79||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Humana Medicare Advantage|HUMANA MA|||||6,857.43||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Managed Medicaid|MEDICAID SUPERIOR|||||7,335.85||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Veterans Affairs|VETERANS ADMINISTRATION|||||7,335.85||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|United Medicare Advantage|UHC AARP MCR HMO MA|||||7,335.85||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||63.79||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63.79||||||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||7,335.85||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|Medicare|MEDICARE ACUTE|7,335.85||||63.79||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|United Healthcare|UNITED HEALTHCARE|||||63.79||| 70543|EAP|0610|MRI ORBIT/FACE/NECK W/WO|UTMB|UTMB CORRECTIONAL MANAGED CARE|63.79||||||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|PHCS|HUMANA|||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Medicare|MEDICARE ACUTE|5,422.25||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Medicare|MEDICARE PART B ONLY IP|5,068.63||||||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|United Healthcare|UNITED HEALTHCARE OTHER|||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|United Healthcare|UNITED HEALTHCARE|||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|United Healthcare|TML GROUP BENEFITS|||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|United Healthcare|UNITED HEALTHCARE|||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Managed Medicare|HEALTHSPRING MA|5,422.25||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|United Medicare Advantage|UHC AARP MCR HMO MA|5,422.25||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|5,422.25||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5,422.25||||||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Access Direct Platinum|HEALTHFIRST TPA|5,422.25||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5,068.63||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,422.25||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Blue Cross HMO Specialty|BCBSTX HMO|||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|47.15||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Blue Cross PPO Specialty|BCBSTX PPO|5,422.25||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Aenta Medicare Advantage|AETNA MEDICARE MA|47.15||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Veterans Affairs|VETERANS ADMINISTRATION|5,068.63||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Aetna|AETNA PPO|47.15||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|NON CONTRACTED|COMMERCIAL OTHER 1|47.15||||5,068.63||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47.15||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|47.15||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Aetna|AETNA OTHER|5,422.25||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Cigna|CIGNA|47.15||||||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|UTMB|UTMB CORRECTIONAL MANAGED CARE|5,422.25||||||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Humana Medicare Advantage|HUMANA MA|5,422.25||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Workers Compensation|WORKERS COMPENSATION OTHER|5,422.25||||||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5,422.25||||5,422.25||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Managed Medicaid|MEDICAID SUPERIOR|||||47.15||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Managed Medicaid|MEDICAID AMERIGROUP|5,422.25||||||| 70544|EAP|0610|MRI ANGIOGRAPHY HEAD W/O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,422.25||||5,422.25||| 70546|EAP|0610|MRI ANGIOGRAPH HEAD W/O&W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7,335.85||| 70546|EAP|0610|MRI ANGIOGRAPH HEAD W/O&W|Medicare|MEDICARE ACUTE|||||6,857.43||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Medicaid|MEDICAID|47.15||||||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Managed Medicare|HEALTHSPRING MA|5,422.25||||5,422.25||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|United Healthcare|TML GROUP BENEFITS|||||5,422.25||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Medicare|MEDICARE PART B ONLY IP|5,068.63||||||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,422.25||||||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Aetna|AETNA PPO|47.15||||5,422.25||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Aenta Medicare Advantage|AETNA MEDICARE MA|47.15||||47.15||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,068.63||||5,422.25||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5,422.25||||||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Access Direct Platinum|HEALTHFIRST TPA UMR|||||47.15||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|UTMB|UTMB CORRECTIONAL MANAGED CARE|5,422.25||||||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||47.15||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Workers Compensation|WORKERS COMPENSATION OTHER|5,422.25||||||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Blue Cross PPO Specialty|BCBSTX PPO|5,422.25||||5,422.25||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Veterans Affairs|VETERANS ADMINISTRATION|47.15||||5,422.25||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|United Medicare Advantage|UHC AARP MCR HMO MA|5,422.25||||5,422.25||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|United Medicare Advantage|UHC MEDICARE GOLD MA|5,422.25||||5,422.25||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,068.63||||5,068.63||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Humana Medicare Advantage|HUMANA MA|5,422.25||||47.15||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,068.63||||47.15||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Managed Medicaid|MEDICAID AMERIGROUP|5,422.25||||||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Managed Medicaid|MEDICAID SUPERIOR|||||47.15||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|Medicare|MEDICARE ACUTE|5,422.25||||5,422.25||| 70547|EAP|0610|MR ANGIOGRAPHY NECK W/O D|NON CONTRACTED|COMMERCIAL OTHER 1|47.15||||5,422.25||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||63.79||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|United Medicare Advantage|UHC MEDICARE GOLD MA|7,335.85||||7,335.85||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|63.79||||63.79||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,335.85||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7,335.85||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|Blue Cross HMO Specialty|BCBSTX HMO|||||7,335.85||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|Aetna|AETNA OTHER|7,335.85||||||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||63.79||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|Humana Medicare Advantage|HUMANA MA|6,857.43||||||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|Blue Cross PPO Specialty|BCBSTX PPO|||||63.79||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|Medicare|MEDICARE ACUTE|7,335.85||||63.79||| 70549|EAP|0610|MR ANGIOGRAPH NECK W/O&W/|PHCS|HUMANA|||||7,335.85||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|47.15||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|5,422.25||||5,068.63||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Aetna|AETNA OTHER|47.15||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|47.15||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Access Direct Platinum|HEALTHFIRST TPA|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|47.15||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Medicare Advantage|UHC AARP WELLMED HMO MA|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|47.15||||5,068.63||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicare|WELLCARE CHOICE MA|5,422.25||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicare|ETMC AFFILIATE HOSPITALS|47.15||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicare|MA PART B ONLY IP|47.15||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicare|HEALTHSPRING MA|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|47.15||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicaid|SMITH COUNTY INDIGENT HEALTH|47.15||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicaid|MEDICAID|47.15||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicaid|SMITH COUNTY JAIL|47.15||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicaid|COUNTY INDIGENT HEALTH OTHER|47.15||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicaid|MOLINA HEALTHCARE OF TEXAS|5,422.25||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicaid|MEDICAID HMO|||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Healthcare|GEHA|||||5,068.63||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Healthcare|UNITED HEALTHCARE|5,068.63||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Healthcare|GOLDEN RULE|5,422.25||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Healthcare|TML GROUP BENEFITS|5,422.25||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|United Healthcare|UNITED HEALTHCARE|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Tricare|TRICARE FOR LIFE|||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|47.15||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicaid|MEDICAID BCBSTX|||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Tricare|TRICARE EAST REGION|5,068.63||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|5,068.63||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|PHCS|HUMANA INSURANCE|47.15||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|PHCS|GROUP AND PENSION|5,422.25||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|PHCS|HUMANA|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicare|MEDICARE ACUTE|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Medicare|MEDICARE PART B ONLY IP|47.15||||||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|47.15||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|47.15||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Cigna|CIGNA|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Cigna|CIGNA OTHER|||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Cigna|CIGNA|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|ChampVA|CHAMPVA CENTER|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Humana Medicare Advantage|HUMANA MA|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|5,422.25||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Aetna|AETNA QHP HMO|5,422.25||||47.15||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Aetna|AETNA PPO|47.15||||5,422.25||| 70551|EAP|0610|MRI BRAIN STEM W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,422.25||||5,422.25||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|6,452.65||||||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|56.11||||6,452.65||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|56.11||||56.11||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,452.65||||6,452.65||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Access Direct Platinum|HEALTHFIRST TPA|6,452.65||||||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|6,452.65||||||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|56.11||||||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|56.11||||||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|6,452.65||||6,452.65||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6,452.65||||||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|56.11||||56.11||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Humana Medicare Advantage|HUMANA MA|56.11||||56.11||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Cigna|CIGNA|6,452.65||||||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|56.11||||56.11||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Medicare|MEDICARE ACUTE|56.11||||56.11||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Medicaid|MEDICAID|56.11||||||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Managed Medicare|HEALTHSPRING MA|||||6,452.65||| 70552|EAP|0610|MRI BRAIN STEM W/DYE|Managed Medicare|BCBS MEDICARE PPO MA|6,452.65||||||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Managed Medicare|BCBS MEDICARE PPO MA|63.79||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Managed Medicare|HEALTHSPRING MA|63.79||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|63.79||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Medicaid|MEDICAID BCBSTX|||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Medicaid|MEDICAID HMO|||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Medicaid|SMITH COUNTY JAIL|6,857.43||||||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Medicaid|MOLINA HEALTHCARE OF TEXAS|63.79||||||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|UTMB|UTMB CORRECTIONAL MANAGED CARE|63.79||||||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Tricare|TRICARE EAST REGION|||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Tricare|TRICARE FOR LIFE|7,335.85||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|United Healthcare|UNITED HEALTHCARE OTHER|7,335.85||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|United Healthcare|TML GROUP BENEFITS|63.79||||6,857.43||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|United Healthcare|GOLDEN RULE|||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|PHCS|HUMANA|||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Medicare|UTSW MC KIDNEY PROGRAM|||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Medicare|MEDICARE PART B ONLY IP|63.79||||||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Medicare|MEDICARE ACUTE|63.79||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|63.79||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7,335.85||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Managed Medicaid|MEDICAID AMERIGROUP|7,335.85||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|NON CONTRACTED|COMMERCIAL OTHER 1|6,857.43||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Managed Medicaid|MEDICAID SUPERIOR|||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|ChampVA|CHAMPVA CENTER|||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Cigna|CIGNA|||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Cigna|CIGNA|7,335.85||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|United Healthcare|UNITED HEALTHCARE|7,335.85||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Cigna|CIGNA OTHER|||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Humana Medicare Advantage|HUMANA MA|63.79||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Aenta Medicare Advantage|AETNA MEDICARE MA|63.79||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Aetna|AETNA QHP HMO|63.79||||||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7,335.85||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Aetna|AETNA PPO|63.79||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Aetna|AETNA OTHER|7,335.85||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Blue Cross PPO Specialty|BCBSTX OTHER|7,335.85||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Medicaid|MEDICAID|63.79||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6,857.43||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Blue Cross PPO Specialty|BCBSTX PPO|7,335.85||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Blue Cross HMO Specialty|BCBSTX HMO|63.79||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Veterans Affairs|VETERANS ADMINISTRATION|7,335.85||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Access Direct Platinum|HEALTHFIRST TPA UMR|63.79||||6,857.43||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Access Direct Platinum|HEALTHFIRST TPA|||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,857.43||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|63.79||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63.79||||63.79||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|United Medicare Advantage|UHC MEDICARE GOLD MA|7,335.85||||7,335.85||| 70553|EAP|0610|MRI BRAIN STEM W/O & W/DY|United Medicare Advantage|UHC AARP MCR HMO MA|7,335.85||||7,335.85||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|77,502.10|17522.95|89900.3|10339.96|||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|54,680.30|14256.03|89900.3|10339.96|||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|86,596.88|12163.61|89900.3|10339.96|||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|92,783.35|10339.96|89900.3|10339.96|||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|Aetna|AETNA PPO|99,353.05|23654.23|89900.3|10339.96|||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|Humana Medicare Advantage|HUMANA MA|99,883.63|11528.85|89900.3|10339.96|||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|89,900.30|89900.3|89900.3|10339.96|||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|101,130.74|11758.63|89900.3|10339.96|||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|Medicare|MEDICARE PART B ONLY IP|170,221.90|11758.63|89900.3|10339.96|||| 707|DRG||MAJOR MALE PELVIC PROCEDURES W CC/MCC|Medicare|MEDICARE ACUTE|98,418.74|11758.63|89900.3|10339.96|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|89,809.99|9334.335|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|149,446.03|7455.78|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|80,165.10|17185.87|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|83,453.80|17185.87|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|84,047.66|9251.57|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|81,137.83|9417.1|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Cigna|CIGNA|56,058.40|14254.8|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Aetna|AETNA PPO|86,381.40|18367.8|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|87,317.65|8118.32|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|79,288.85|71.44|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|71,299.92|9550.14|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|109,674.49|11758.63|18367.8|71.44|||| 708|DRG||MAJOR MALE PELVIC PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|66,068.68|11889.87|18367.8|71.44|||| 709|DRG||PENIS PROCEDURES W CC/MCC|Medicare|MEDICARE ACUTE|140,314.71|14760.2|14760.2|14760.2|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|Veterans Affairs|VETERANS ADMINISTRATION|49,355.31|6742.23|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|51,629.33|6854.83|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|Blue Cross PPO Specialty|BCBSTX PPO|74,631.75|6693.58|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|Managed Medicare|HEALTHSPRING MA|103,089.44|6798.09|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|64,513.25|6741.35|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|Humana Medicare Advantage|HUMANA MA|83,918.43|6741.35|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|United Medicare Advantage|UHC AARP MCR HMO MA|42,760.39|6860.845|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46,295.74|3738.22|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|45,958.67|6217.88|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|Medicare|MEDICARE PART B ONLY IP|36,125.71|4081.55|6860.845|3738.22|||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|Medicare|MEDICARE ACUTE|649.12|6741.35|6860.845|3738.22|||| 710|DRG||PENIS PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|88,717.55|9710.53|9886.65|9710.53|||| 710|DRG||PENIS PROCEDURES W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|39,223.61|9886.65|9886.65|9710.53|||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|GALLAGHER BASSETT|||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|UT EMPLOYEE INJURY|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|767.71||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|7.48||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|TRAVELERS INSURANCE COMPANY|7.48||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|7.48||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|787.41||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|787.41||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|787.41||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.48||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA|7.48||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|767.71||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Medicare Advantage|UHC AARP WELLMED HMO MA|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|787.41||||767.71||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Aetna Value Network|AETNA VALUE NETWORK|||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Aetna|BOON CHAPMAN|787.41||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Aetna|AETNA PPO|7.48||||767.71||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Aetna|BH AETNA|7.48||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Aetna|AETNA QHP HMO|787.41||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|7.48||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|7.48||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|787.41||||767.71||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Magellan Behavioral Health|BH MAGELLAN|||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Humana Medicare Advantage|HUMANA MA|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Cigna|CIGNA OTHER|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|ChampVA|CHAMPVA CENTER|767.71||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|7.48||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Cigna|CIGNA|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|PHCS|HUMANA INSURANCE|7.48||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Rusk State Hospital|RUSK STATE HOSP|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|PHCS|HUMANA|787.41||||767.71||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 2|787.41||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|PHCS|GROUP AND PENSION|767.71||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 4|||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|7.48||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Aetna|AETNA OTHER|787.41||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicare|MEDICARE ACUTE|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicare|MEDICARE PART B ONLY IP|7.48||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Multiplan|WEB TPA|||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Tricare|TRICARE FOR LIFE|787.41||||767.71||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Tricare|TRICARE EAST REGION|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Healthcare|TML GROUP BENEFITS|787.41||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Healthcare|GEHA|787.41||||767.71||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Healthcare|UNITED HEALTHCARE|787.41||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Healthcare|UNITED HEALTHCARE|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|United Healthcare|GOLDEN RULE|787.41||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.48||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.48||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicare|MA PART B ONLY IP|7.48||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicare|OTHER INSTITUTIONS|787.41||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|ZURICH COMPANY|787.41||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Workers Compensation|BROOKSHIRES WORKERS COMP|7.48||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicare|HEALTHSPRING MA|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicare|ETMC AFFILIATE HOSPITALS|7.48||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicare|WELLCARE CHOICE MA|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|7.48||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|MEDICAID HMO|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|MEDICAID|7.48||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.48||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.48||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|SMITH COUNTY JAIL|7.48||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|CRIME VICTIMS COMPENSATION|787.41||||||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|7.48||||7.48||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|LAW ENFORCEMENT OTHER|787.41||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||787.41||| 71045|EAP|0320|XR-EXAM CHEST 1 VIEW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|7.48||||787.41||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|MEDICAID CSHCN|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|MEDICAID HMO|677.93||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|CRIME VICTIMS COMPENSATION|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|SUPERIOR HEALTHPLAN CHIP|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|MOLINA HEALTHCARE OF TEXAS|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|MEDICAID BCBSTX|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|SMITH COUNTY JAIL|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|LAW ENFORCEMENT OTHER|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|MEDICAID|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicare|HEALTHSPRING MA|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicare|WELLCARE CHOICE MA|677.93||||||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicare|BCBS MEDICARE PPO MA|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Healthcare|UNITED HEALTHCARE|660.97||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Healthcare|AARP|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Healthcare|UNITED HEALTHCARE|677.93||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Healthcare|GOLDEN RULE|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Healthcare|TML GROUP BENEFITS|6.44||||660.97||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Healthcare|GEHA|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Tricare|TRICARE FOR LIFE|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|UTMB|UTMB CORRECTIONAL MANAGED CARE|677.93||||660.97||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Tricare|TRICARE EAST REGION|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Multiplan|UNION PACIFIC RAILROAD|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Multiplan|MUTUAL OF OMAHA|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Multiplan|WEB TPA|677.93||||660.97||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Multiplan|NALC|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicare|UTSW MC KIDNEY PROGRAM|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicare|MEDICARE ACUTE|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|PHCS|HUMANA|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicare|MEDICARE PART B ONLY IP|6.44||||||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|PHCS|GROUP AND PENSION|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|NON CONTRACTED|COMMERCIAL OTHER 2|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|PHCS|HUMANA INSURANCE|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Texas Workforce Commission|DIS DETER SERV (DDS)|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|NON CONTRACTED|COMMERCIAL OTHER 1|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Rusk State Hospital|RUSK STATE HOSP|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicaid|MEDICAID AMERIGROUP|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicaid|MEDICAID SUPERIOR|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Cigna|CIGNA|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Cigna|CIGNA OTHER|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Cigna|CIGNA|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|ChampVA|CHAMPVA CENTER|||||660.97||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Tricare|TRICARE SOUTH PHYSICIAN|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Healthcare|UNITED HEALTHCARE OTHER|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Healthcare|UNITED HEALTHCARE ERS|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Humana Medicare Advantage|HUMANA MA|677.93||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Blue Cross HMO Specialty|BCBSTX HMO|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Brinson Benefits|THE HEALTH PLAN SMITH CO|6.44||||660.97||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Blue Cross PPO Specialty|BCBSTX OTHER|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Blue Cross PPO Specialty|BCBSTX PPO|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|590.25||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Aetna|BOON CHAPMAN|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Aetna|AETNA QHP HMO|677.93||||||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Managed Medicare|OTHER INSTITUTIONS|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Aetna|AETNA OTHER|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Aetna|AETNA PPO|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Aenta Medicare Advantage|AETNA MEDICARE MA|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Aetna Value Network|AETNA VALUE NETWORK|||||660.97||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Medicare Advantage|UHC MEDICARE GOLD MA|677.93||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|660.97||||660.97||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Medicare Advantage|UHC AARP MCR HMO MA|677.93||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Access Direct Platinum|HEALTHFIRST TPA|6.44||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|677.93||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Access Direct Platinum|HEALTHFIRST TPA UMR|677.93||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.44||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Workers Compensation|GALLAGHER BASSETT|||||6.44||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Workers Compensation|UT EMPLOYEE INJURY|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||660.97||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Workers Compensation|WORKERS COMPENSATION OTHER|||||677.93||| 71046|EAP|0320|XR-CHEST 2VW FRONTAL&LATL|Veterans Affairs|VETERANS ADMINISTRATION|6.44||||6.44||| 71047|EAP|0320|XR-EXAM CHEST 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||787.41||| 71048|EAP|0320|XR-CHEST SPECIAL VIEWS|Medicare|MEDICARE ACUTE|7.82||||||| 71048|EAP|0320|XR-CHEST SPECIAL VIEWS|Managed Medicare|HEALTHSPRING MA|7.82||||||| 71048|EAP|0320|XR-CHEST SPECIAL VIEWS|Humana Medicare Advantage|HUMANA MA|7.82||||||| 711|DRG||TESTES PROCEDURES W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|91,730.75|14146.97|124231.45|7615.41|||| 711|DRG||TESTES PROCEDURES W CC/MCC|Cigna|CIGNA|248,462.90|124231.45|124231.45|7615.41|||| 711|DRG||TESTES PROCEDURES W CC/MCC|Medicare|MEDICARE ACUTE|153,054.10|13043.98|124231.45|7615.41|||| 711|DRG||TESTES PROCEDURES W CC/MCC|Medicaid|SMITH COUNTY JAIL|92,385.37|7615.41|124231.45|7615.41|||| 711|DRG||TESTES PROCEDURES W CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|142,948.13|13253.38|124231.45|7615.41|||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 2|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Multiplan|TRUSTMARK|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|United Healthcare|TML GROUP BENEFITS|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Tricare|TRICARE EAST REGION|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Medicaid|MEDICAID HMO|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Medicaid|MEDICAID|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Medicaid|SMITH COUNTY JAIL|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Medicare|MEDICARE ACUTE|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Humana Medicare Advantage|HUMANA MA|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Cigna|CIGNA OTHER|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|PHCS|HUMANA|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Cigna|CIGNA|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Aetna|AETNA OTHER|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Aetna|BOON CHAPMAN|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Aetna|AETNA PPO|9.12||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.12||| 71101|EAP|0320|XR-RIBS/CHEST 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|7.21||||||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||7.21||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Cigna|CIGNA|||||7.21||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Humana Medicare Advantage|HUMANA MA|||||7.21||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||7.21||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.21||||||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.21||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Access Direct Platinum|HEALTHFIRST TPA|||||7.21||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.21||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Tricare|TRICARE EAST REGION|||||7.21||| 71111|EAP|0320|XR-RIBS/CHEST4/> VIEWS|Medicare|MEDICARE ACUTE|7.21||||7.21||| 71120|EAP|0320|XR-BREASTBONE 2/>VIEWS|Medicare|MEDICARE ACUTE|||||8.24||| 71120|EAP|0320|XR-BREASTBONE 2/>VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||8.24||| 71120|EAP|0320|XR-BREASTBONE 2/>VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.24||| 71120|EAP|0320|XR-BREASTBONE 2/>VIEWS|Aetna|AETNA PPO|||||8.24||| 71120|EAP|0320|XR-BREASTBONE 2/>VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.24||| 71120|EAP|0320|XR-BREASTBONE 2/>VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||8.24||| 71120|EAP|0320|XR-BREASTBONE 2/>VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 712|DRG||TESTES PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|28,065.99|7311.47|7311.47|7311.47|||| 71250|EAP|0350|CT-THORAX W/O DYE|Medicaid|MEDICAID|42.70||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Medicaid|COUNTY INDIGENT HEALTH OTHER|42.70||||||| 71250|EAP|0350|CT-THORAX W/O DYE|Medicaid|SMITH COUNTY JAIL|42.70||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|42.70||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Managed Medicare|OTHER INSTITUTIONS|||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Managed Medicare|HEALTHSPRING MA|42.70||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Tricare|TRICARE EAST REGION|51.24||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.97||||||| 71250|EAP|0350|CT-THORAX W/O DYE|United Healthcare|GEHA|||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|51.24||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|United Healthcare|UNITED HEALTHCARE|42.70||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|United Healthcare|GOLDEN RULE|||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|United Healthcare|TML GROUP BENEFITS|||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|PHCS|HUMANA|51.24||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 2|||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Medicare|UTSW MC KIDNEY PROGRAM|||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Medicare|MEDICARE PART B ONLY IP|46.97||||||| 71250|EAP|0350|CT-THORAX W/O DYE|Medicare|MEDICARE ACUTE|42.70||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|51.24||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|51.24||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|42.70||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|42.70||||46.97||| 71250|EAP|0350|CT-THORAX W/O DYE|Workers Compensation|TEXAS MUTUAL INSURANCE|42.70||||||| 71250|EAP|0350|CT-THORAX W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|51.24||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.97||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|51.24||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Access Direct Platinum|HEALTHFIRST TPA|42.70||||||| 71250|EAP|0350|CT-THORAX W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Humana Medicare Advantage|HUMANA MA|51.24||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|United Healthcare|UNITED HEALTHCARE|||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|42.70||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Cigna|CIGNA|42.70||||||| 71250|EAP|0350|CT-THORAX W/O DYE|Cigna|CIGNA|||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Cigna|CIGNA OTHER|42.70||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|51.24||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Medicaid|CRIME VICTIMS COMPENSATION|42.70||||||| 71250|EAP|0350|CT-THORAX W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|51.24||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|42.70||||46.97||| 71250|EAP|0350|CT-THORAX W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|51.24||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42.70||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|42.70||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Aetna|AETNA OTHER|51.24||||||| 71250|EAP|0350|CT-THORAX W/O DYE|Aetna|AETNA QHP HMO|51.24||||||| 71250|EAP|0350|CT-THORAX W/O DYE|Aetna|AETNA PPO|42.70||||46.97||| 71250|EAP|0350|CT-THORAX W/O DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|42.70||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|51.24||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|42.70||||51.24||| 71250|EAP|0350|CT-THORAX W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|51.24||||42.70||| 71250|EAP|0350|CT-THORAX W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|51.24||||51.24||| 71260|EAP|0350|CT-THORAX W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Blue Cross PPO Specialty|BCBSTX OTHER|55.78||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|6,693.60||||6,135.80||| 71260|EAP|0350|CT-THORAX W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Aetna|AETNA PPO|6,135.80||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,693.60||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Managed Medicaid|MEDICAID AMERIGROUP|6,693.60||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|55.78||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55.78||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Managed Medicaid|MEDICAID SUPERIOR|6,693.60||||6,135.80||| 71260|EAP|0350|CT-THORAX W/DYE|Cigna|CIGNA|6,693.60||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Cigna|CIGNA OTHER|||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Magellan Behavioral Health|BH MAGELLAN|||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Humana Medicare Advantage|HUMANA MA|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|55.78||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|55.78||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|6,135.80||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Workers Compensation|TRAVELERS INSURANCE COMPANY|6,135.80||||||| 71260|EAP|0350|CT-THORAX W/DYE|Workers Compensation|TEXAS MUTUAL INSURANCE|55.78||||||| 71260|EAP|0350|CT-THORAX W/DYE|Workers Compensation|WORKERS COMPENSATION OTHER|55.78||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|55.78||||||| 71260|EAP|0350|CT-THORAX W/DYE|Workers Compensation|BROOKSHIRES WORKERS COMP|55.78||||||| 71260|EAP|0350|CT-THORAX W/DYE|Workers Compensation|GALLAGHER BASSETT|||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|55.78||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Workers Compensation|UT EMPLOYEE INJURY|55.78||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Access Direct Platinum|HEALTHFIRST TPA|55.78||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|United Medicare Advantage|UHC AARP WELLMED HMO MA|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Medicare|MEDICARE PART B ONLY IP|6,693.60||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Medicare|MEDICARE ACUTE|6,693.60||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Rusk State Hospital|RUSK STATE HOSP|55.78||||||| 71260|EAP|0350|CT-THORAX W/DYE|Cigna|CIGNA|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|NON CONTRACTED|COMMERCIAL OTHER 2|6,693.60||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|NON CONTRACTED|COMMERCIAL OTHER 4|||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|55.78||||6,135.80||| 71260|EAP|0350|CT-THORAX W/DYE|PHCS|HUMANA|6,693.60||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|United Healthcare|UNITED HEALTHCARE|55.78||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|United Healthcare|UNITED HEALTHCARE|6,693.60||||6,135.80||| 71260|EAP|0350|CT-THORAX W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|6,135.80||||6,135.80||| 71260|EAP|0350|CT-THORAX W/DYE|Tricare|TRICARE EAST REGION|55.78||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Aetna|AETNA OTHER|6,693.60||||||| 71260|EAP|0350|CT-THORAX W/DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6,693.60||||6,135.80||| 71260|EAP|0350|CT-THORAX W/DYE|Tricare|TRICARE FOR LIFE|||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,693.60||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|55.78||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Managed Medicare|MA PART B ONLY IP|55.78||||||| 71260|EAP|0350|CT-THORAX W/DYE|Managed Medicare|HEALTHSPRING MA|55.78||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Managed Medicare|OTHER INSTITUTIONS|||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Managed Medicare|BCBS MEDICARE PPO MA|55.78||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|55.78||||||| 71260|EAP|0350|CT-THORAX W/DYE|Medicaid|CRIME VICTIMS COMPENSATION|55.78||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Medicaid|MEDICAID|55.78||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Medicaid|SMITH COUNTY JAIL|||||55.78||| 71260|EAP|0350|CT-THORAX W/DYE|Medicaid|MEDICAID HMO|55.78||||6,693.60||| 71260|EAP|0350|CT-THORAX W/DYE|Medicaid|MOLINA HEALTHCARE OF TEXAS|55.78||||55.78||| 71270|EAP|0350|CT-THORAX W/O & W/DYE|Medicare|MEDICARE ACUTE|||||7,591.20||| 71270|EAP|0350|CT-THORAX W/O & W/DYE|ChampVA|CHAMPVA CENTER|7,591.20||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7,781.40||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|United Medicare Advantage|UHC AARP MCR HMO MA|8,488.80||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|United Medicare Advantage|UHC MEDICARE GOLD MA|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Workers Compensation|WORKERS COMPENSATION OTHER|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Veterans Affairs|VETERANS ADMINISTRATION|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Workers Compensation|UT EMPLOYEE INJURY|8,488.80||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Access Direct Platinum|HEALTHFIRST TPA UMR|7,781.40||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,488.80||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Access Direct Platinum|HEALTHFIRST TPA|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,488.80||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Aenta Medicare Advantage|AETNA MEDICARE MA|70.74||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Aetna|BOON CHAPMAN|8,488.80||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Aetna|AETNA OTHER|70.74||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Aetna|AETNA PPO|8,488.80||||7,781.40||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8,488.80||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Brinson Benefits|THE HEALTH PLAN SMITH CO|7,781.40||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Blue Cross HMO Specialty|BCBSTX HMO|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicaid|MEDICAID SUPERIOR|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicaid|MEDICAID AMERIGROUP|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,488.80||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Humana Medicare Advantage|HUMANA MA|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Cigna|CIGNA OTHER|8,488.80||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Cigna|CIGNA|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Cigna|CIGNA|8,488.80||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Blue Cross PPO Specialty|BCBSTX PPO|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicaid|SMITH COUNTY INDIGENT HEALTH|70.74||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicaid|CRIME VICTIMS COMPENSATION|8,488.80||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicaid|MOLINA HEALTHCARE OF TEXAS|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicaid|MEDICAID HMO|||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicaid|COUNTY INDIGENT HEALTH OTHER|70.74||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicaid|MEDICAID|70.74||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicaid|SMITH COUNTY JAIL|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicare|HEALTHSPRING MA|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicare|ETMC AFFILIATE HOSPITALS|70.74||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicare|BCBS MEDICARE PPO MA|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicare|MA PART B ONLY IP|70.74||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Aetna|BH AETNA|70.74||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|70.74||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|United Medicare Advantage|UHC AARP WELLMED HMO MA|8,488.80||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|UTMB|UTMB CORRECTIONAL MANAGED CARE|8,488.80||||7,781.40||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Tricare|TRICARE FOR LIFE|||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Tricare|TRICARE EAST REGION|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|United Healthcare|TML GROUP BENEFITS|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|United Healthcare|UNITED HEALTHCARE|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|United Healthcare|GOLDEN RULE|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|United Healthcare|UNITED HEALTHCARE OTHER|8,488.80||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Rusk State Hospital|RUSK STATE HOSP|8,488.80||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|NON CONTRACTED|COMMERCIAL OTHER 1|8,488.80||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|PHCS|HUMANA INSURANCE|||||8,488.80||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Texas Workforce Commission|DIS DETER SERV (DDS)|70.74||||70.74||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|NON CONTRACTED|COMMERCIAL OTHER 2|8,488.80||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicare|MEDICARE PART B ONLY IP|8,488.80||||||| 71275|EAP|0350|CT-ANGIOGRAPHY CHEST|Medicare|MEDICARE ACUTE|8,488.80||||70.74||| 713|DRG||TRANSURETHRAL PROSTATECTOMY W CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|45,845.62|248.54|9473.14|248.54|||| 713|DRG||TRANSURETHRAL PROSTATECTOMY W CC/MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|87,421.74|9473.14|9473.14|248.54|||| 713|DRG||TRANSURETHRAL PROSTATECTOMY W CC/MCC|Medicare|MEDICARE ACUTE|51,501.30|9306.46|9473.14|248.54|||| 713|DRG||TRANSURETHRAL PROSTATECTOMY W CC/MCC|Medicare|MEDICARE PART B ONLY IP|35,659.55|3751.19|9473.14|248.54|||| 713|DRG||TRANSURETHRAL PROSTATECTOMY W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|98,632.75|9373.43|9473.14|248.54|||| 713|DRG||TRANSURETHRAL PROSTATECTOMY W CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127,222.36|250.04|9473.14|248.54|||| 714|DRG||TRANSURETHRAL PROSTATECTOMY W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|32,804.90|4931.99|27930.63|3812.18|||| 714|DRG||TRANSURETHRAL PROSTATECTOMY W/O CC/MCC|Medicare|MEDICARE ACUTE|53,197.05|6278.91|27930.63|3812.18|||| 714|DRG||TRANSURETHRAL PROSTATECTOMY W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|55,716.10|3812.18|27930.63|3812.18|||| 714|DRG||TRANSURETHRAL PROSTATECTOMY W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|29,060.37|6410.5|27930.63|3812.18|||| 714|DRG||TRANSURETHRAL PROSTATECTOMY W/O CC/MCC|Multiplan|PACIFICARE|37,744.10|27930.63|27930.63|3812.18|||| 71550|EAP|0610|MRI CHEST W/O DYE|Medicare|MEDICARE ACUTE|||||6,080.55||| 71550|EAP|0610|MRI CHEST W/O DYE|United Healthcare|UNITED HEALTHCARE|||||6,370.10||| 71550|EAP|0610|MRI CHEST W/O DYE|Managed Medicare|HEALTHSPRING MA|||||6,370.10||| 71550|EAP|0610|MRI CHEST W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|6,370.10||||||| 71550|EAP|0610|MRI CHEST W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|||||6,370.10||| 71552|EAP|0610|MRI CHEST W/O & W/DYE|Managed Medicare|HEALTHSPRING MA|||||8,617.40||| 71552|EAP|0610|MRI CHEST W/O & W/DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||78.34||| 71552|EAP|0610|MRI CHEST W/O & W/DYE|Medicare|MEDICARE ACUTE|||||78.34||| 71555|EAP|0610||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8,617.40||| 71555|EAP|0610|MRA CHEST WO CONT|Medicare|MEDICARE ACUTE|57.91||||||| 71555|EAP|0610|MRA CHEST WO CONT|Medicaid|MEDICAID|6,370.10||||||| 717|DRG||OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC|Medicare|MEDICARE ACUTE|136,940.15|10954.425|22318.4|71.44|||| 717|DRG||OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC|Aetna|AETNA OTHER|80,752.42|22318.4|22318.4|71.44|||| 717|DRG||OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|52,061.30|71.44|22318.4|71.44|||| 717|DRG||OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC|Humana Medicare Advantage|HUMANA MA|68,972.80|10955.93|22318.4|71.44|||| 718|DRG||OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|92,335.84|8113.83|8113.83|8113.83|||| 72|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|50,587.80|5308.2|32864.71|34.02|||| 72|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|54,746.15|5419.3|32864.71|34.02|||| 72|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|412.09|34.02|32864.71|34.02|||| 72|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|54,235.62|5335.48|32864.71|34.02|||| 72|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|32,864.71|32864.71|32864.71|34.02|||| 72|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|91,178.59|6742.23|32864.71|34.02|||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.22||||||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Tricare|TRICARE EAST REGION|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Tricare|TRICARE FOR LIFE|||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|United Healthcare|TML GROUP BENEFITS|||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|United Healthcare|UNITED HEALTHCARE|7.22||||7.22||| 72020|EAP|0320|XR-THOR SPINE 1 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|7.22||||7.22||| 72020|EAP|0320|XR-THOR SPINE 1 VIEW|United Healthcare|UNITED HEALTHCARE|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|PHCS|GROUP AND PENSION|7.22||||||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Medicare|MEDICARE PART B ONLY IP|7.22||||||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Medicare|MEDICARE PART B ONLY IP|7.22||||||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Medicare|MEDICARE ACUTE|7.22||||7.22||| 72020|EAP|0320|XR-THOR SPINE 1 VIEW|Medicare|MEDICARE ACUTE|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Medicare|MEDICARE ACUTE|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Managed Medicare|HEALTHSPRING MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Managed Medicare|HEALTHSPRING MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Medicaid|MEDICAID|7.22||||||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|7.22||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Blue Cross PPO Specialty|BCBSTX PPO|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Aetna|AETNA PPO|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Aetna|AETNA PPO|7.22||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.22||||||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Managed Medicaid|MEDICAID AMERIGROUP|7.22||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Managed Medicaid|MEDICAID SUPERIOR|||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Blue Cross HMO Specialty|BCBSTX HMO|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.22||||||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Humana Medicare Advantage|HUMANA MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Humana Medicare Advantage|HUMANA MA|7.22||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Humana Medicare Advantage|HUMANA MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|7.22||||||| 72020|EAP|0320|XR-THOR SPINE 1 VIEW|Cigna|CIGNA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Cigna|CIGNA|7.22||||||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Medicare|MEDICARE ACUTE|7.22||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Cigna|CIGNA|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Cigna|CIGNA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Cigna|CIGNA|7.22||||7.22||| 72020|EAP|0320|XR-THOR SPINE 1 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|7.22||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|United Healthcare|UNITED HEALTHCARE|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|United Medicare Advantage|UHC AARP WELLMED HMO MA|7.22||||||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|United Healthcare|GEHA|7.22||||||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|7.22||||||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|7.22||||7.22||| 72020|EAP|0320|XR-THOR SPINE 1 VIEW|Tricare|TRICARE EAST REGION|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|7.22||||||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|7.22||||||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Workers Compensation|BROOKSHIRES WORKERS COMP|||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.22||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||7.22||| 72020|EAP|0320|XR-LUMB SPINE 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.22||| 72020|EAP|0320|XR-SPINE THOROCOLUMBAR 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.22||||7.22||| 72020|EAP|0320|XR-CERV SPINE 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.22||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Workers Compensation|TEXAS MUTUAL INSURANCE|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Cigna|CIGNA|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Cigna|CIGNA|8.24||||||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Aetna|AETNA PPO|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Aetna|AETNA OTHER|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Cigna|CIGNA OTHER|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Medicaid|MEDICAID|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Medicaid|MEDICAID HMO|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Medicare|MEDICARE ACUTE|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Medicare|MEDICARE PART B ONLY IP|8.24||||||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Multiplan|WEB TPA|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 2|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|PHCS|HUMANA INSURANCE|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|United Healthcare|GEHA|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|United Healthcare|UNITED HEALTHCARE|8.24||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|United Healthcare|TML GROUP BENEFITS|||||8.24||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||||| 72040|EAP|0320|XR-NECK SPINE 2-3 VIEWS|Tricare|TRICARE EAST REGION|8.24||||8.24||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Tricare|TRICARE EAST REGION|7.21||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Managed Medicare|HEALTHSPRING MA|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Medicaid|MEDICAID|7.21||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|7.21||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Medicare|MEDICARE ACUTE|7.21||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Aetna|AETNA PPO|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Humana Medicare Advantage|HUMANA MA|7.21||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Cigna|CIGNA|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|7.21||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.21||| 72050|EAP|0320|XR-NECK SPINE 4/5VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.21||| 72052|EAP|0320|XR-NECK SPINE 6/>VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||9.07||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Medicaid|MEDICAID HMO|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Medicare|MEDICARE ACUTE|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|NON CONTRACTED|COMMERCIAL OTHER 2|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|NON CONTRACTED|COMMERCIAL OTHER 4|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|United Healthcare|TML GROUP BENEFITS|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|United Healthcare|UNITED HEALTHCARE|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Tricare|TRICARE EAST REGION|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Workers Compensation|ZURICH COMPANY|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Multiplan|MUTUAL OF OMAHA|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Workers Compensation|TEXAS MUTUAL INSURANCE|8.24||||||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Aetna|AETNA PPO|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.24||||||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 72070|EAP|0320|XR-THORAC SPINE 2VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.12||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Cigna|CIGNA|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Humana Medicare Advantage|HUMANA MA|9.12||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|9.12||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|9.12||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|9.12||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Aetna|AETNA PPO|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 2|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.12||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Medicare|MEDICARE PART B ONLY IP|9.12||||||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Multiplan|WEB TPA|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Medicare|MEDICARE ACUTE|9.12||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Managed Medicare|HEALTHSPRING MA|9.12||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Managed Medicare|OTHER INSTITUTIONS|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||9.12||| 72072|EAP|0320|XR-THORAC SPINE 3 VIEWS|Medicaid|MEDICAID|||||9.12||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Medicare|MEDICARE ACUTE|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Medicare|MEDICARE PART B ONLY IP|8.24||||||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Tricare|TRICARE EAST REGION|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|United Healthcare|UNITED HEALTHCARE|8.24||||||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Medicaid|MEDICAID|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 72080|EAP|0320|XR-THORACOLMB 2/> VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||8.24||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Managed Medicaid|MEDICAID AMERIGROUP|||||0.97||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Managed Medicaid|MEDICAID SUPERIOR|||||0.97||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Humana Medicare Advantage|HUMANA MA|0.97||||||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Blue Cross HMO Specialty|BCBSTX HMO|||||0.97||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Blue Cross PPO Specialty|BCBSTX PPO|||||0.97||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.97||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.97||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|United Healthcare|UNITED HEALTHCARE OTHER|||||0.97||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Tricare|TRICARE EAST REGION|||||0.97||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Medicare|MEDICARE ACUTE|0.97||||||| 72081|EAP|0320|XR-ENTIRE SPI 1 VW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.97||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Medicaid|MEDICAID HMO|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Medicaid|MEDICAID|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 2|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 4|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|PHCS|HUMANA|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Medicare|MEDICARE PART B ONLY IP|8.24||||||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Medicare|MEDICARE ACUTE|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Tricare|TRICARE EAST REGION|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Tricare|TRICARE FOR LIFE|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Healthcare|GOLDEN RULE|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Healthcare|TML GROUP BENEFITS|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Healthcare|GEHA|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Healthcare|UNITED HEALTHCARE|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Healthcare|UNITED HEALTHCARE ERS|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|PHCS|GROUP AND PENSION|8.24||||||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|NON CONTRACTED|AFLAC|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Aetna|AETNA OTHER|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Aetna|AETNA PPO|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Cigna|CIGNA|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Cigna|CIGNA OTHER|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Cigna|CIGNA|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|ChampVA|CHAMPVA CENTER|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 72100|EAP|0320|XR-L-S SPINE 2/3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||8.24||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.36||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Humana Medicare Advantage|HUMANA MA|7.36||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Cigna|CIGNA|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|7.36||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Aetna|AETNA PPO|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|7.36||||||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|7.36||||||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|7.36||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.36||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|United Healthcare|UNITED HEALTHCARE|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Medicare|MEDICARE ACUTE|7.36||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|7.36||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|PHCS|HUMANA|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Managed Medicare|HEALTHSPRING MA|7.36||||7.36||| 72110|EAP|0320|XR-L-2 SPINE 4/>VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|7.36||||||| 72114|EAP|0320|XR-L-S SPINE BENDING 6 VI|Medicare|MEDICARE ACUTE|||||9.52||| 72114|EAP|0320|XR-L-S SPINE BENDING 6 VI|United Healthcare|UNITED HEALTHCARE OTHER|||||9.52||| 72114|EAP|0320|XR-L-S SPINE BENDING 6 VI|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.52||| 72114|EAP|0320|XR-L-S SPINE BENDING 6 VI|Blue Cross HMO Specialty|BCBSTX HMO|||||9.52||| 72114|EAP|0320|XR-L-S SPINE BENDING 6 VI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.52||| 72120|EAP|0320|XR-BEND ONLY L-S SPINE 2/|Medicare|MEDICARE ACUTE|||||7.21||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Cigna|CIGNA OTHER|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Cigna|CIGNA|45.60||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Cigna|CIGNA|4,940.55||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Humana Medicare Advantage|HUMANA MA|4,940.55||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|45.60||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|4,940.55||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|45.60||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Aetna|AETNA OTHER|4,940.55||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|45.60||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45.60||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|4,940.55||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4,940.55||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|4,940.55||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|45.60||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Workers Compensation|GALLAGHER BASSETT|||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|4,940.55||||4,750.28||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Workers Compensation|BROOKSHIRES WORKERS COMP|45.60||||||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Workers Compensation|UT EMPLOYEE INJURY|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|45.60||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA|||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|45.60||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,940.55||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4,940.55||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Medicare Advantage|UHC AARP WELLMED HMO MA|4,940.55||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|4,940.55||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Workers Compensation|WORKERS COMP PHYSICIAN|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|45.60||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|4,940.55||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicare|HEALTHSPRING MA|45.60||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Workers Compensation|TRAVELERS INSURANCE COMPANY|4,750.28||||||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|45.60||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicare|MA PART B ONLY IP|45.60||||||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|45.60||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicare|OTHER INSTITUTIONS|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Workers Compensation|TEXAS MUTUAL INSURANCE|45.60||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicaid|SMITH COUNTY JAIL|45.60||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicaid|MOLINA HEALTHCARE OF TEXAS|45.60||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicaid|MEDICAID HMO|45.60||||4,750.28||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicaid|MEDICAID|45.60||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicaid|CRIME VICTIMS COMPENSATION|45.60||||||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Aetna|AETNA PPO|4,940.55||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|4,940.55||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicaid|LAW ENFORCEMENT OTHER|45.60||||||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Tricare|TRICARE EAST REGION|45.60||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|4,940.55||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Tricare|TRICARE FOR LIFE|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Magellan Behavioral Health|BH MAGELLAN|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE|45.60||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|4,940.55||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE|||||4,750.28||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Healthcare|GEHA|||||4,750.28||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|United Healthcare|AARP|||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|PHCS|HUMANA|4,940.55||||||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|4,750.28||||45.60||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Rusk State Hospital|RUSK STATE HOSP|45.60||||||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 2|4,940.55||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 4|||||4,750.28||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Multiplan|WEB TPA|||||4,940.55||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicare|MEDICARE PART B ONLY IP|4,940.55||||||| 72125|EAP|0350|CT-NECK SPINE W/O DYE|Medicare|MEDICARE ACUTE|45.60||||45.60||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Medicare|MEDICARE ACUTE|6,454.13||||59.57||| 72126|EAP|0350|CT-NECK SPINE W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|||||6,454.13||| 72126|EAP|0350|CT-NECK SPINE W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|||||6,454.13||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||59.57||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Managed Medicare|BCBS MEDICARE PPO MA|||||6,454.13||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Managed Medicare|HEALTHSPRING MA|||||6,454.13||| 72126|EAP|0350|CT-NECK SPINE W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,205.57||| 72126|EAP|0350|CT-NECK SPINE W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||59.57||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,454.13||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||59.57||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|||||59.57||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|59.57||||6,454.13||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||59.57||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||59.57||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Aetna|AETNA PPO|||||6,454.13||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|59.57||||6,454.13||| 72126|EAP|0350|CT-NECK SPINE W/DYE|Humana Medicare Advantage|HUMANA MA|||||6,454.13||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Cigna|CIGNA|42.70||||46.97||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Cigna|CIGNA|||||46.97||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.97||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|46.97||||||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Aetna|AETNA PPO|||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Aetna Value Network|AETNA VALUE NETWORK|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.97||||46.97||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|51.24||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|51.24||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Workers Compensation|UT EMPLOYEE INJURY|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Workers Compensation|TRAVELERS INSURANCE COMPANY|51.24||||||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|42.70||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|46.97||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|42.70||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|51.24||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Medicaid|SMITH COUNTY JAIL|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Medicaid|MEDICAID|42.70||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|42.70||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Humana Medicare Advantage|HUMANA MA|42.70||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Managed Medicare|HEALTHSPRING MA|51.24||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|51.24||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.97||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|United Healthcare|AARP|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 2|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|51.24||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|PHCS|HUMANA|||||42.70||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Medicare|MEDICARE ACUTE|42.70||||51.24||| 72128|EAP|0350|CT-CHEST SPINE W/O DYE|Medicare|MEDICARE PART B ONLY IP|51.24||||||| 72129|EAP|0350|CT-CHEST SPINE W/DYE|Medicare|MEDICARE ACUTE|6,135.80||||55.78||| 72129|EAP|0350|CT-CHEST SPINE W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|||||6,693.60||| 72129|EAP|0350|CT-CHEST SPINE W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,693.60||||6,693.60||| 72129|EAP|0350|CT-CHEST SPINE W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55.78||||55.78||| 72129|EAP|0350|CT-CHEST SPINE W/DYE|Humana Medicare Advantage|HUMANA MA|||||6,693.60||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.70||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|42.70||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|42.70||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Workers Compensation|GALLAGHER BASSETT|||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Workers Compensation|TRAVELERS INSURANCE COMPANY|51.24||||||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Cigna|CIGNA|42.70||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Cigna|CIGNA|||||46.97||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Humana Medicare Advantage|HUMANA MA|42.70||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|42.70||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|51.24||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|51.24||||||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42.70||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|42.70||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Aetna|AETNA PPO|||||46.97||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|51.24||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Aetna|AETNA OTHER|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|51.24||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Aetna Value Network|AETNA VALUE NETWORK|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|42.70||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|51.24||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Managed Medicare|HEALTHSPRING MA|42.70||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Medicaid|COUNTY INDIGENT HEALTH OTHER|42.70||||||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Medicaid|SMITH COUNTY JAIL|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Workers Compensation|UT EMPLOYEE INJURY|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Medicaid|MEDICAID|42.70||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Tricare|TRICARE EAST REGION|||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|51.24||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Tricare|TRICARE FOR LIFE|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.97||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|United Healthcare|TML GROUP BENEFITS|51.24||||||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|||||51.24||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|United Healthcare|AARP|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE|42.70||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 2|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|46.97||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|PHCS|HUMANA|||||42.70||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Medicare|MEDICARE PART B ONLY IP|51.24||||||| 72131|EAP|0350|CT-LUMBAR SPINE W/O DYE|Medicare|MEDICARE ACUTE|42.70||||51.24||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|||||6,135.80||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Tricare|TRICARE EAST REGION|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Managed Medicare|BCBS MEDICARE PPO MA|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||55.78||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Managed Medicare|HEALTHSPRING MA|||||55.78||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,693.60||||6,135.80||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Aetna|AETNA PPO|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||55.78||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Medicare|MEDICARE ACUTE|6,693.60||||55.78||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55.78||||55.78||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Humana Medicare Advantage|HUMANA MA|55.78||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Cigna|CIGNA|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Cigna|CIGNA|55.78||||||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||55.78||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|55.78||||6,693.60||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|6,693.60||||6,135.80||| 72132|EAP|0350|CT-LUMBAR SPINE W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,693.60||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|United Medicare Advantage|UHC AARP WELLMED HMO MA|5,422.25||||||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|5,068.63||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,422.25||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|47.15||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Workers Compensation|TEXAS MUTUAL INSURANCE|47.15||||||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|5,422.25||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5,422.25||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA|||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|47.15||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Cigna|CIGNA|47.15||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|ChampVA|CHAMPVA CENTER|47.15||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Humana Medicare Advantage|HUMANA MA|5,068.63||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|5,068.63||||5,068.63||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,422.25||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|5,422.25||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Cigna|CIGNA|||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|5,422.25||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,422.25||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|5,422.25||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|47.15||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Aetna|AETNA PPO|47.15||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,422.25||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|47.15||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Managed Medicare|HEALTHSPRING MA|5,422.25||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Workers Compensation|UT EMPLOYEE INJURY|||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|47.15||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Medicaid|MEDICAID|47.15||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Medicaid|MOLINA HEALTHCARE OF TEXAS|47.15||||||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|5,422.25||||||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Tricare|TRICARE EAST REGION|5,422.25||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|United Healthcare|GEHA|||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE|47.15||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|5,422.25||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE|||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|47.15||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|United Healthcare|TML GROUP BENEFITS|||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|PHCS|HUMANA INSURANCE|||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|PHCS|GROUP AND PENSION|||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|5,422.25||||47.15||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Medicare|MEDICARE ACUTE|47.15||||5,422.25||| 72141|EAP|0610|MRI NECK SPINE W/O DYE|Medicare|MEDICARE PART B ONLY IP|5,068.63||||||| 72142|EAP|0610|MRI NECK SPINE W/DYE|Medicare|MEDICARE ACUTE|56.11||||||| 72142|EAP|0610|MRI NECK SPINE W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||56.11||| 72142|EAP|0610|MRI NECK SPINE W/DYE|Humana Medicare Advantage|HUMANA MA|56.11||||56.11||| 72142|EAP|0610|MRI NECK SPINE W/DYE|Cigna|CIGNA|6,452.65||||||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6,370.10||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA|||||6,080.55||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Workers Compensation|TEXAS MUTUAL INSURANCE|57.91||||||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|57.91||||6,080.55||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|57.91||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|57.91||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|6,370.10||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Aetna|AETNA PPO|||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|57.91||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|6,370.10||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|6,370.10||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6,370.10||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,370.10||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|6,370.10||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|ChampVA|CHAMPVA CENTER|57.91||||||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Cigna|CIGNA|57.91||||||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Cigna|CIGNA|||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Workers Compensation|UT EMPLOYEE INJURY|||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Humana Medicare Advantage|HUMANA MA|57.91||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,370.10||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|57.91||||||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|57.91||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|57.91||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|6,370.10||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Medicaid|MEDICAID|57.91||||||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Managed Medicare|HEALTHSPRING MA|57.91||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|57.91||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|6,370.10||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|United Healthcare|GOLDEN RULE|||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE|||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE|57.91||||57.91||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Tricare|TRICARE EAST REGION|||||6,370.10||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,370.10||||||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|57.91||||||| 72146|EAP|0610|MRI CHEST SPINE W/O DYE|Medicare|MEDICARE ACUTE|6,370.10||||57.91||| 72147|EAP|0610|MRI CHEST SPINE W/DYE|Humana Medicare Advantage|HUMANA MA|68.91||||||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Medicare|MEDICARE PART B ONLY IP|6,370.10||||||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Medicare|MEDICARE ACUTE|6,370.10||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|6,080.55||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|PHCS|HUMANA INSURANCE|6,370.10||||||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|PHCS|HUMANA INSURANCE|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|PHCS|HUMANA|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Tricare|TRICARE FOR LIFE|||||6,080.55||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,370.10||||||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Tricare|TRICARE EAST REGION|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|United Healthcare|AARP|||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|United Healthcare|UNITED HEALTHCARE|57.91||||6,080.55||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|57.91||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|57.91||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Managed Medicare|HEALTHSPRING MA|57.91||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Medicaid|MEDICAID HMO|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Medicaid|COUNTY INDIGENT HEALTH OTHER|57.91||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Medicaid|MEDICAID|57.91||||||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|57.91||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|57.91||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|57.91||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Workers Compensation|UT EMPLOYEE INJURY|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Workers Compensation|TEXAS MUTUAL INSURANCE|57.91||||||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|57.91||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|United Healthcare|TML GROUP BENEFITS|6,370.10||||6,080.55||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|United Healthcare|GEHA|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA|||||6,080.55||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Aetna Value Network|AETNA VALUE NETWORK|||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Aetna|AETNA PPO|57.91||||6,080.55||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,370.10||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|57.91||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|6,370.10||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,080.55||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Cigna|CIGNA OTHER|||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Cigna|CIGNA|57.91||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Cigna|CIGNA|57.91||||57.91||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|ChampVA|CHAMPVA CENTER|57.91||||6,370.10||| 72148|EAP|0610|MRI LUMBAR SPINE W/O DYE|Humana Medicare Advantage|HUMANA MA|57.91||||6,370.10||| 72149|EAP|0610|MRI LUMBAR SPINE W/DYE|Humana Medicare Advantage|HUMANA MA|68.91||||||| 72149|EAP|0610|MRI LUMBAR SPINE W/DYE|Medicare|MEDICARE ACUTE|||||7,580.10||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Medicaid|MEDICAID|63.79||||||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Managed Medicare|HEALTHSPRING MA|63.79||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|63.79||||||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|United Healthcare|UNITED HEALTHCARE|||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|United Healthcare|GEHA|||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|United Healthcare|UNITED HEALTHCARE|63.79||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|United Healthcare|TML GROUP BENEFITS|63.79||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|PHCS|HUMANA|63.79||||||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|NON CONTRACTED|COMMERCIAL OTHER 1|63.79||||||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|PHCS|GROUP AND PENSION|||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Medicare|MEDICARE ACUTE|7,335.85||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Medicare|MEDICARE PART B ONLY IP|63.79||||||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|63.79||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7,335.85||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Veterans Affairs|VETERANS ADMINISTRATION|6,857.43||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|United Medicare Advantage|UHC MEDICARE GOLD MA|7,335.85||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|UTMB|UTMB CORRECTIONAL MANAGED CARE|7,335.85||||||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,857.43||||6,857.43||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|United Medicare Advantage|UHC AARP MCR HMO MA|7,335.85||||6,857.43||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Aetna|AETNA QHP HMO|63.79||||||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Aetna|AETNA PPO|63.79||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|United Healthcare|UNITED HEALTHCARE OTHER|||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Managed Medicare|BCBS MEDICARE PPO MA|||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7,335.85||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Aenta Medicare Advantage|AETNA MEDICARE MA|63.79||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Blue Cross PPO Specialty|BCBSTX PPO|63.79||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Blue Cross HMO Specialty|BCBSTX HMO|63.79||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7,335.85||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Managed Medicaid|MEDICAID AMERIGROUP|63.79||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|63.79||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Cigna|CIGNA OTHER|||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Cigna|CIGNA|||||7,335.85||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|ChampVA|CHAMPVA CENTER|63.79||||||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Cigna|CIGNA|||||63.79||| 72156|EAP|0610|MRI NECK SPINE W/O & W/DY|Humana Medicare Advantage|HUMANA MA|63.79||||6,857.43||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Humana Medicare Advantage|HUMANA MA|78.34||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Cigna|CIGNA|8,617.40||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|ChampVA|CHAMPVA CENTER|78.34||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Cigna|CIGNA OTHER|||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8,617.40||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Managed Medicaid|MEDICAID AMERIGROUP|78.34||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|78.34||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Blue Cross HMO Specialty|BCBSTX HMO|78.34||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Blue Cross PPO Specialty|BCBSTX PPO|8,225.70||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Aetna|AETNA PPO|||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,617.40||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Aetna|AETNA QHP HMO|78.34||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|United Medicare Advantage|UHC AARP MCR HMO MA|8,617.40||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|United Medicare Advantage|UHC MEDICARE GOLD MA|78.34||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8,225.70||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Veterans Affairs|VETERANS ADMINISTRATION|8,225.70||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Workers Compensation|WORKERS COMPENSATION OTHER|78.34||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|78.34||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Managed Medicaid|MEDICAID SUPERIOR|||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,617.40||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Medicare|MEDICARE ACUTE|8,617.40||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|PHCS|HUMANA|78.34||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|NON CONTRACTED|COMMERCIAL OTHER 1|78.34||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|UTMB|UTMB CORRECTIONAL MANAGED CARE|8,617.40||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|United Healthcare|TML GROUP BENEFITS|78.34||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|United Healthcare|UNITED HEALTHCARE|||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|United Healthcare|UNITED HEALTHCARE|78.34||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|United Healthcare|UNITED HEALTHCARE OTHER|||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|United Healthcare|GEHA|||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Managed Medicare|BCBS MEDICARE PPO MA|||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|78.34||||||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Managed Medicare|HEALTHSPRING MA|8,617.40||||78.34||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Medicaid|MEDICAID|78.34||||8,617.40||| 72157|EAP|0610|MRI CHEST SPINE W/O & W/D|Medicaid|COUNTY INDIGENT HEALTH OTHER|78.34||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Medicaid|MEDICAID|78.34||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Managed Medicare|HEALTHSPRING MA|78.34||||8,225.70||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Managed Medicare|BCBS MEDICARE PPO MA|||||78.34||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||78.34||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|United Healthcare|GEHA|||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|United Healthcare|TML GROUP BENEFITS|78.34||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|United Healthcare|GOLDEN RULE|8,617.40||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|United Healthcare|UNITED HEALTHCARE|78.34||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Tricare|TRICARE EAST REGION|||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|UTMB|UTMB CORRECTIONAL MANAGED CARE|8,617.40||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|NON CONTRACTED|COMMERCIAL OTHER 1|78.34||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Medicare|MEDICARE ACUTE|8,617.40||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Medicare|MEDICARE PART B ONLY IP|8,617.40||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|78.34||||78.34||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,617.40||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|United Healthcare|UNITED HEALTHCARE|78.34||||8,225.70||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Veterans Affairs|VETERANS ADMINISTRATION|8,617.40||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Workers Compensation|WORKERS COMPENSATION OTHER|78.34||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|78.34||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|78.34||||78.34||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|United Medicare Advantage|UHC MEDICARE GOLD MA|78.34||||8,225.70||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|United Medicare Advantage|UHC AARP MCR HMO MA|8,617.40||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Aenta Medicare Advantage|AETNA MEDICARE MA|8,225.70||||78.34||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Medicaid|COUNTY INDIGENT HEALTH OTHER|78.34||||||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,617.40||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Blue Cross PPO Specialty|BCBSTX PPO|8,225.70||||78.34||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Blue Cross PPO Specialty|BCBSTX OTHER|||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Blue Cross HMO Specialty|BCBSTX HMO|78.34||||78.34||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8,225.70||||8,225.70||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|78.34||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Managed Medicaid|MEDICAID AMERIGROUP|78.34||||8,617.40||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|ChampVA|CHAMPVA CENTER|78.34||||78.34||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Cigna|CIGNA|||||78.34||| 72158|EAP|0610|MRI LUMBAR SPINE W/O & W/|Humana Medicare Advantage|HUMANA MA|78.34||||8,617.40||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Cigna|CIGNA|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Cigna|CIGNA OTHER|||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|ChampVA|CHAMPVA CENTER|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Aetna Value Network|AETNA VALUE NETWORK|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Aetna|AETNA PPO|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Workers Compensation|BROOKSHIRES WORKERS COMP|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Workers Compensation|TRAVELERS INSURANCE COMPANY|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Aetna|AETNA OTHER|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Medicare|MEDICARE PART B ONLY IP|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Medicare|MEDICARE ACUTE|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|PHCS|GROUP AND PENSION|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|PHCS|HUMANA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Tricare|TRICARE FOR LIFE|||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Tricare|TRICARE EAST REGION|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|United Healthcare|UNITED HEALTHCARE|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|United Healthcare|TML GROUP BENEFITS|||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Cigna|CIGNA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Medicaid|CRIME VICTIMS COMPENSATION|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|8.24||||||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Medicaid|MEDICAID HMO|8.24||||8.24||| 72170|EAP|0320|XR-PELVIS 1/2 VIEWS|Medicaid|MEDICAID|8.24||||8.24||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Medicaid|CRIME VICTIMS COMPENSATION|10.02||||||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Medicaid|MEDICAID|10.02||||||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Managed Medicare|HEALTHSPRING MA|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|United Healthcare|TML GROUP BENEFITS|10.02||||||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|10.02||||||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Medicare|MEDICARE ACUTE|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Medicare|MEDICARE PART B ONLY IP|10.02||||||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Workers Compensation|WORKERS COMP PHYSICIAN|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Managed Medicare|OTHER INSTITUTIONS|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Workers Compensation|TEXAS MUTUAL INSURANCE|10.02||||||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Aetna|AETNA PPO|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.02||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|ChampVA|CHAMPVA CENTER|||||10.02||| 72190|EAP|0320|XR-PELVIS 3 VIEWS|Humana Medicare Advantage|HUMANA MA|10.02||||10.02||| 72191|EAP|0350|CT-ANGIOGRAPH PELV W/O&W/|Blue Cross PPO Specialty|BCBSTX PPO|70.74||||||| 72192|EAP|0350|CT-PELVIS W/O DYE|Medicare|MEDICARE ACUTE|42.70||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|Tricare|TRICARE EAST REGION|||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|42.70||||||| 72192|EAP|0350|CT-PELVIS W/O DYE|United Healthcare|UNITED HEALTHCARE|||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|42.70||||46.97||| 72192|EAP|0350|CT-PELVIS W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|Managed Medicare|HEALTHSPRING MA|42.70||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|Medicaid|CRIME VICTIMS COMPENSATION|42.70||||||| 72192|EAP|0350|CT-PELVIS W/O DYE|Medicaid|MEDICAID|46.97||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.70||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|46.97||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|51.24||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|Workers Compensation|UT EMPLOYEE INJURY|||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|46.97||||||| 72192|EAP|0350|CT-PELVIS W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|51.24||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|51.24||||||| 72192|EAP|0350|CT-PELVIS W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|51.24||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|Humana Medicare Advantage|HUMANA MA|42.70||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|Cigna|CIGNA|||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.97||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|51.24||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42.70||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|51.24||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|Aetna|AETNA PPO|51.24||||42.70||| 72192|EAP|0350|CT-PELVIS W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|51.24||||46.97||| 72192|EAP|0350|CT-PELVIS W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|||||51.24||| 72192|EAP|0350|CT-PELVIS W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|51.24||||42.70||| 72193|EAP|0350|CT-PELVIS W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|6,693.60||||55.78||| 72193|EAP|0350|CT-PELVIS W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,693.60||||6,693.60||| 72193|EAP|0350|CT-PELVIS W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,693.60||||||| 72193|EAP|0350|CT-PELVIS W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55.78||||||| 72193|EAP|0350|CT-PELVIS W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|55.78||||6,693.60||| 72193|EAP|0350|CT-PELVIS W/DYE|Cigna|CIGNA|6,693.60||||||| 72193|EAP|0350|CT-PELVIS W/DYE|Humana Medicare Advantage|HUMANA MA|||||6,693.60||| 72193|EAP|0350|CT-PELVIS W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||55.78||| 72193|EAP|0350|CT-PELVIS W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|||||55.78||| 72193|EAP|0350|CT-PELVIS W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,693.60||||55.78||| 72193|EAP|0350|CT-PELVIS W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,693.60||| 72193|EAP|0350|CT-PELVIS W/DYE|Managed Medicare|HEALTHSPRING MA|6,693.60||||6,693.60||| 72193|EAP|0350|CT-PELVIS W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|6,693.60||||||| 72193|EAP|0350|CT-PELVIS W/DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||6,693.60||| 72193|EAP|0350|CT-PELVIS W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|6,693.60||||||| 72193|EAP|0350|CT-PELVIS W/DYE|Medicare|MEDICARE ACUTE|6,693.60||||6,693.60||| 72194|EAP|0350|CT-PELVIS W/O & W/DYE|Medicare|MEDICARE ACUTE|||||63.26||| 72194|EAP|0350|CT-PELVIS W/O & W/DYE|Managed Medicare|HEALTHSPRING MA|||||6,958.60||| 72194|EAP|0350|CT-PELVIS W/O & W/DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||63.26||| 72195|EAP|0610|MRI PELVIS W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,370.10||||||| 72195|EAP|0610|MRI PELVIS W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|||||6,370.10||| 72195|EAP|0610|MRI PELVIS W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,370.10||| 72195|EAP|0610|MRI PELVIS W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|||||57.91||| 72195|EAP|0610|MRI PELVIS W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|57.91||||6,370.10||| 72195|EAP|0610|MRI PELVIS W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||57.91||| 72195|EAP|0610|MRI PELVIS W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|6,370.10||||6,080.55||| 72195|EAP|0610|MRI PELVIS W/O DYE|Workers Compensation|WORKERS COMPENSATION OTHER|||||57.91||| 72195|EAP|0610|MRI PELVIS W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||57.91||| 72195|EAP|0610|MRI PELVIS W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,080.55||| 72195|EAP|0610|MRI PELVIS W/O DYE|Medicaid|MEDICAID|6,080.55||||||| 72195|EAP|0610|MRI PELVIS W/O DYE|Humana Medicare Advantage|HUMANA MA|57.91||||6,080.55||| 72195|EAP|0610|MRI PELVIS W/O DYE|Managed Medicare|HEALTHSPRING MA|||||57.91||| 72195|EAP|0610|MRI PELVIS W/O DYE|United Healthcare|UNITED HEALTHCARE|||||6,370.10||| 72195|EAP|0610|MRI PELVIS W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|6,370.10||||||| 72195|EAP|0610|MRI PELVIS W/O DYE|Medicare|MEDICARE ACUTE|6,370.10||||57.91||| 72197|EAP|0610|MRI PELVIS W WO CONT|PHCS|HUMANA|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|NON CONTRACTED|COMMERCIAL OTHER 1|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|United Healthcare|UNITED HEALTHCARE OTHER|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|United Healthcare|UNITED HEALTHCARE|78.34||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|United Healthcare|UNITED HEALTHCARE|||||8,225.70||| 72197|EAP|0610|MRI PELVIS W WO CONT|Managed Medicare|BCBS MEDICARE PPO MA|||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|Managed Medicare|HEALTHSPRING MA|78.34||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|Medicaid|MEDICAID|8,617.40||||||| 72197|EAP|0610|MRI PELVIS W WO CONT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,617.40||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Access Direct Platinum|HEALTHFIRST TPA|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Veterans Affairs|VETERANS ADMINISTRATION|||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8,617.40||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|United Medicare Advantage|UHC AARP MCR HMO MA|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Medicare|MEDICARE ACUTE|8,617.40||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8,225.70||| 72197|EAP|0610|MRI PELVIS W WO CONT|Blue Cross PPO Specialty|BCBSTX PPO|8,225.70||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Blue Cross HMO Specialty|BCBSTX HMO|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Aetna|AETNA OTHER|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,617.40||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Aetna|AETNA PPO|||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Managed Medicaid|MEDICAID AMERIGROUP|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Managed Medicaid|MEDICAID SUPERIOR|||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|Cigna|CIGNA|||||8,617.40||| 72197|EAP|0610|MRI PELVIS W WO CONT|Cigna|CIGNA OTHER|||||78.34||| 72197|EAP|0610|MRI PELVIS W WO CONT|Humana Medicare Advantage|HUMANA MA|8,617.40||||8,617.40||| 72198|EAP|0610|MRI ANGIO PELVIS W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|||||57.91||| 72202|EAP|0320|XR-SI JOINTS 3/> VIEWS|Medicare|MEDICARE ACUTE|||||9.12||| 72202|EAP|0320|XR-SI JOINTS 3/> VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.12||| 72202|EAP|0320|XR-SI JOINTS 3/> VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.12||| 72202|EAP|0320|XR-SI JOINTS 3/> VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||9.12||| 72202|EAP|0320|XR-SI JOINTS 3/> VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.12||| 72202|EAP|0320|XR-SI JOINTS 3/> VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 72202|EAP|0320|XR-SI JOINTS 3/> VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||9.12||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Cigna Behavioral Health|BH CIGNA|8.24||||||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|ChampVA|CHAMPVA CENTER|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Medicaid|MEDICAID|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Managed Medicare|HEALTHSPRING MA|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Tricare|TRICARE EAST REGION|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.24||| 72220|EAP|0320|XR-SACRUM TAILBONE 2 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 72285|EAP|0320|DISCOGRAPHY CERV/THORAC R|Medicare|MEDICARE ACUTE|||||78.58||| 72285|EAP|0320|DISCOGRAPHY CERV/THORAC R|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||78.58||| 72285|EAP|0320|DISCOGRAPHY CERV/THORAC R|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||78.58||| 72285|EAP|0320|DISCOGRAPHY CERV/THORAC R|Humana Medicare Advantage|HUMANA MA|||||78.58||| 72285|EAP|0320|DISCOGRAPHY CERV/THORAC R|Blue Cross HMO Specialty|BCBSTX HMO|||||78.58||| 72285|EAP|0320|DISCOGRAPHY CERV/THORAC R|Blue Cross PPO Specialty|BCBSTX PPO|||||78.58||| 72295|EAP|0320|DISCOVERY LUMBAR SPINE RA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||70.41||| 72295|EAP|0320|DISCOVERY LUMBAR SPINE RA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||70.41||| 72295|EAP|0320|DISCOVERY LUMBAR SPINE RA|Blue Cross PPO Specialty|BCBSTX PPO|||||70.41||| 72295|EAP|0320|DISCOVERY LUMBAR SPINE RA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||70.41||| 72295|EAP|0320|DISCOVERY LUMBAR SPINE RA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||70.41||| 72295|EAP|0320|DISCOVERY LUMBAR SPINE RA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||70.41||| 72295|EAP|0320|DISCOVERY LUMBAR SPINE RA|Managed Medicare|HEALTHSPRING MA|||||70.41||| 72295|EAP|0320|DISCOVERY LUMBAR SPINE RA|Tricare|TRICARE EAST REGION|||||70.41||| 72295|EAP|0320|DISCOVERY LUMBAR SPINE RA|Medicare|MEDICARE ACUTE|||||70.41||| 723|DRG||MALIGNANCY, MALE REPRODUCTIVE SYSTEM W CC|Medicare|MEDICARE ACUTE|13,546.60|7486.28|7486.28|7486.28|||| 723|DRG||MALIGNANCY, MALE REPRODUCTIVE SYSTEM W CC|Humana Medicare Advantage|HUMANA MA|77,315.71|7486.28|7486.28|7486.28|||| 725|DRG||BENIGN PROSTATIC HYPERTROPHY W MCC|Humana Medicare Advantage|HUMANA MA|38,401.55|8157.14|8177.39|8157.14|||| 725|DRG||BENIGN PROSTATIC HYPERTROPHY W MCC|Medicare|MEDICARE ACUTE|78,777.09|8177.39|8177.39|8157.14|||| 726|DRG||BENIGN PROSTATIC HYPERTROPHY W/O MCC|Medicare|MEDICARE ACUTE|93,470.68|5566.12|5566.12|5457.735|||| 726|DRG||BENIGN PROSTATIC HYPERTROPHY W/O MCC|Humana Medicare Advantage|HUMANA MA|35,818.50|5457.735|5566.12|5457.735|||| 727|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC|Blue Cross PPO Specialty|BCBSTX PPO|134,890.77|9764.02|9764.02|9087.87|||| 727|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|138,345.75|9087.87|9764.02|9087.87|||| 727|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC|Medicare|MEDICARE ACUTE|50,974.85|9115.15|9764.02|9087.87|||| 728|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC|Medicare|MEDICARE ACUTE|382.28|5687.56|8257.73|35.72|||| 728|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|34,478.10|5764.22|8257.73|35.72|||| 728|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|29,377.75|5777.92|8257.73|35.72|||| 728|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC|Managed Medicare|HEALTHSPRING MA|228.25|42.51|8257.73|35.72|||| 728|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC|Humana Medicare Advantage|HUMANA MA|35,181.22|5777.92|8257.73|35.72|||| 728|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC|Cigna|CIGNA|58,106.79|8257.73|8257.73|35.72|||| 728|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,774.91|35.72|8257.73|35.72|||| 729|DRG||OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|87,215.26|6245.3|6245.3|6245.3|||| 73|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|64,317.42|9051.83|12934.85|8529.6|||| 73|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W MCC|Medicare|MEDICARE ACUTE|46,438.21|9213.16|12934.85|8529.6|||| 73|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|99,029.50|9050.95|12934.85|8529.6|||| 73|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|66,685.82|8529.6|12934.85|8529.6|||| 73|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|59,538.40|9023.14|12934.85|8529.6|||| 73|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|89,963.56|12934.85|12934.85|8529.6|||| 730|DRG||OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W/O CC/MCC|Medicare|MEDICARE ACUTE|19,143.77|4820.35|4820.35|4820.35|||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Aetna|AETNA PPO|8.24||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Blue Cross HMO Specialty|BCBSTX HMO|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Cigna|CIGNA|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Workers Compensation|WORKERS COMPENSATION OTHER|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Humana Medicare Advantage|HUMANA MA|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Access Direct Platinum|HEALTHFIRST TPA|8.24||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|PHCS|GROUP AND PENSION|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Tricare|TRICARE EAST REGION|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|United Healthcare|UNITED HEALTHCARE OTHER|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Medicaid|MEDICAID|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Medicaid|MEDICAID HMO|||||8.24||| 73000|EAP|0320|XR-COLLAR BONE COMPLETE|Medicaid|SMITH COUNTY JAIL|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Tricare|TRICARE EAST REGION|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Medicare|MEDICARE ACUTE|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Medicare|MEDICARE PART B ONLY IP|8.24||||||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Medicaid|MEDICAID|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Humana Medicare Advantage|HUMANA MA|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Cigna|CIGNA|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Managed Medicaid|MEDICAID AMERIGROUP|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Blue Cross PPO Specialty|BCBSTX PPO|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.24||| 73010|EAP|0320|XR-SHOULDER BLADE COMPLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.24||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Aetna|AETNA PPO|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Blue Cross HMO Specialty|BCBSTX HMO|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Blue Cross PPO Specialty|BCBSTX PPO|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Managed Medicaid|MEDICAID SUPERIOR|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Cigna|CIGNA|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Humana Medicare Advantage|HUMANA MA|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Veterans Affairs|VETERANS ADMINISTRATION|7.22||||||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Managed Medicaid|MEDICAID AMERIGROUP|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|United Medicare Advantage|UHC AARP MCR HMO MA|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|NON CONTRACTED|COMMERCIAL OTHER 1|7.22||||||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Medicare|MEDICARE ACUTE|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|United Healthcare|UNITED HEALTHCARE OTHER|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|United Healthcare|UNITED HEALTHCARE|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|United Healthcare|UNITED HEALTHCARE|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Tricare|TRICARE EAST REGION|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Managed Medicare|BCBS MEDICARE PPO MA|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Managed Medicare|HEALTHSPRING MA|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Medicaid|MEDICAID|7.22||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Medicaid|SMITH COUNTY JAIL|||||7.22||| 73020|EAP|0320|XR-SHOULDER 1 VIEW LT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7.22||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicaid|MOLINA HEALTHCARE OF TEXAS|8.24||||||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Medicaid|MEDICAID|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicaid|SMITH COUNTY JAIL|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Medicaid|MEDICAID HMO|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicaid|LAW ENFORCEMENT OTHER|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Tricare|TRICARE EAST REGION|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Tricare|TRICARE FOR LIFE|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Tricare|TRICARE FOR LIFE|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Tricare|TRICARE EAST REGION|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|United Healthcare|UNITED HEALTHCARE|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicare|MEDICARE PART B ONLY IP|8.24||||||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Multiplan|TRUSTMARK|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Multiplan|WEB TPA|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|NON CONTRACTED|COMMERCIAL OTHER 2|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|PHCS|GROUP AND PENSION|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|PHCS|HUMANA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|PHCS|HUMANA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Access Direct Platinum|HEALTHFIRST TPA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Access Direct Platinum|HEALTHFIRST TPA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Workers Compensation|TEXAS MUTUAL INSURANCE|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Cigna|CIGNA|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Cigna|CIGNA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|ChampVA|CHAMPVA CENTER|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Cigna|CIGNA|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Cigna|CIGNA OTHER|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|ChampVA|CHAMPVA CENTER|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|United Healthcare|UNITED HEALTHCARE|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Cigna|CIGNA OTHER|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Cigna|CIGNA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicaid|MEDICAID HMO|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicaid|MEDICAID|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Medicaid|BH TEXAS CHILDRENS MEDICAID|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Aetna Value Network|AETNA VALUE NETWORK|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Aetna|AETNA OTHER|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Aetna|AETNA PPO|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Aetna|AETNA OTHER|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEW LT|Aetna|BOON CHAPMAN|||||8.24||| 73030|EAP|0320|XR-SHOULDER 2 VIEWS RT|Aetna|AETNA PPO|8.24||||8.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Aetna|AETNA PPO|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Blue Cross HMO Specialty|BCBSTX HMO|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,698.62||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||16.50||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Managed Medicaid|MEDICAID SUPERIOR|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Cigna|CIGNA|||||16.50||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Humana Medicare Advantage|HUMANA MA|||||16.50||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Blue Cross PPO Specialty|BCBSTX PPO|||||16.50||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Workers Compensation|UT EMPLOYEE INJURY|||||1,698.62||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||16.50||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Veterans Affairs|VETERANS ADMINISTRATION|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Workers Compensation|WORKERS COMPENSATION OTHER|||||16.50||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.50||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||16.50||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Medicare|MEDICARE ACUTE|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|United Healthcare|UNITED HEALTHCARE|||||1,698.62||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|United Healthcare|UNITED HEALTHCARE|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|United Healthcare|UNITED HEALTHCARE OTHER|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Tricare|TRICARE EAST REGION|||||1,747.24||| 73040|EAP|0320|XR-CONTRAST OF SHOULDER|Managed Medicare|HEALTHSPRING MA|||||1,747.24||| 73050|EAP|0320|XR-AC JOINTS W/WO WEIGHTS|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 73050|EAP|0320|XR-AC JOINTS W/WO WEIGHTS|Aetna|AETNA PPO|||||9.12||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Medicaid|SMITH COUNTY JAIL|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Medicaid|MEDICAID|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Medicaid|MEDICAID HMO|||||8.24||| 73060|EAP|0320|XR HUMERUS 1 VIEW|Medicaid|CRIME VICTIMS COMPENSATION|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 2|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Rusk State Hospital|RUSK STATE HOSP|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Medicare|MEDICARE PART B ONLY IP|8.24||||||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Multiplan|TRUSTMARK|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|PHCS|HUMANA|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Workers Compensation|WORKERS COMP PHYSICIAN|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Workers Compensation|BROOKSHIRES WORKERS COMP|8.24||||||| 73060|EAP|0320|XR HUMERUS 1 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|8.24||||||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Managed Medicare|HEALTHSPRING MA|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|8.24||||||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Cigna|CIGNA|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Medicaid|CRIME VICTIMS COMPENSATION|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73060|EAP|0320|XR HUMERUS 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73060|EAP|0320|XR HUMERUS 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.24||| 73060|EAP|0320|XR HUMERUS 1 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Aetna|AETNA PPO|8.24||||8.24||| 73060|EAP|0320|XR HUMERUS 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73060|EAP|0320|XR-HUMERUS 1 OR 2 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Aetna|AETNA PPO|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Aetna Value Network|AETNA VALUE NETWORK|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Cigna|CIGNA|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Cigna|CIGNA OTHER|8.24||||||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 VIEW|Medicare|MEDICARE PART B ONLY IP|8.24||||||| 73070|EAP|0320|XR-ELBOW 1 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Medicare|MEDICARE PART B ONLY IP|8.24||||||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Multiplan|TRUSTMARK|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|United Healthcare|AARP|8.24||||||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Aetna|AETNA OTHER|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|United Healthcare|GOLDEN RULE|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Tricare|TRICARE EAST REGION|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Medicaid|SMITH COUNTY JAIL|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Medicaid|MEDICAID HMO|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 VIEW|Medicaid|SMITH COUNTY JAIL|||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Medicaid|MEDICAID|8.24||||8.24||| 73070|EAP|0320|XR-ELBOW 1 OR 2 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73080|EAP|0320|XR ELBOW 3V LT.|Managed Medicaid|MEDICAID SUPERIOR|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Managed Medicaid|MEDICAID AMERIGROUP|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Managed Medicaid|MEDICAID AMERIGROUP|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Managed Medicaid|MEDICAID SUPERIOR|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Aetna|AETNA PPO|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Aetna|AETNA PPO|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Aetna|AETNA OTHER|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Blue Cross PPO Specialty|BCBSTX PPO|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Blue Cross PPO Specialty|BCBSTX PPO|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Blue Cross HMO Specialty|BCBSTX HMO|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Blue Cross HMO Specialty|BCBSTX HMO|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Cigna|CIGNA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Workers Compensation|WORKERS COMPENSATION OTHER|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Managed Medicare|HEALTHSPRING MA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Medicare|MEDICARE ACUTE|7.87||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Tricare|TRICARE EAST REGION|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|PHCS|HUMANA INSURANCE|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|United Healthcare|UNITED HEALTHCARE ERS|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Workers Compensation|TEXAS MUTUAL INSURANCE|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Humana Medicare Advantage|HUMANA MA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Medicaid|MEDICAID HMO|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Cigna|CIGNA OTHER|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|United Healthcare|UNITED HEALTHCARE|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Medicaid|MEDICAID|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Medicare|MEDICARE ACUTE|7.87||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.87||| 73080|EAP|0320|XR ELBOW 3V RT.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|United Healthcare|UNITED HEALTHCARE OTHER|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|United Healthcare|UNITED HEALTHCARE|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Humana Medicare Advantage|HUMANA MA|||||7.87||| 73080|EAP|0320|XR ELBOW 3V LT.|Medicaid|MEDICAID|||||7.87||| 73085|EAP|0320|XR-ELBOW ARTHROGRAM|Aetna|AETNA PPO|||||16.50||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73090|EAP|0320|XR-FOREMAN 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Cigna|CIGNA OTHER|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Medicaid|SMITH COUNTY JAIL|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73090|EAP|0320|XR-FOREMAN 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73090|EAP|0320|XR-FOREMAN 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Cigna|CIGNA|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73090|EAP|0320|XR-FOREMAN 1 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Multiplan|TRUSTMARK|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.24||||||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE ERS|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 2|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Medicaid|MEDICAID HMO|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Medicaid|MEDICAID|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Tricare|TRICARE EAST REGION|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Aetna|AETNA PPO|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Aetna|AETNA OTHER|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.24||| 73090|EAP|0320|XR-FOREMAN 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73090|EAP|0320|XR-FOREARM 1 OR 2 VIEW|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73092|EAP|0320|XR UPPER EXTREMITY INFANT|Managed Medicaid|MEDICAID SUPERIOR|||||1.90||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.31||||||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 2|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Medicare|MEDICARE PART B ONLY IP|6.31||||||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Workers Compensation|ZURICH COMPANY|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Aetna|AETNA PPO|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Humana Medicare Advantage|HUMANA MA|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|PHCS|HUMANA|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Aetna|AETNA OTHER|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 1 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|6.31||||||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Cigna|CIGNA OTHER|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Cigna|CIGNA|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Managed Medicare|HEALTHSPRING MA|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|6.31||||||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Medicare|MEDICARE ACUTE|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Workers Compensation|TEXAS MUTUAL INSURANCE|6.31||||||| 73100|EAP|0320|XR-EXAM OF WRIST 1 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.31||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Tricare|TRICARE EAST REGION|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Medicaid|MEDICAID|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||6.31||| 73100|EAP|0320|XR-EXAM OF WRIST 2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.31||| 73110|EAP|0320|XR-WRIST 3VIEW|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Blue Cross PPO Specialty|BCBSTX PPO|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Cigna|CIGNA|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Humana Medicare Advantage|HUMANA MA|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Aetna|BOON CHAPMAN|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|PHCS|HUMANA|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Multiplan|TRUSTMARK|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|United Healthcare|AARP|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Workers Compensation|BROOKSHIRES WORKERS COMP|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicare|MEDICARE PART B ONLY IP|9.12||||||| 73110|EAP|0320|XR-WRIST 3VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicaid|MEDICAID HMO|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|NON CONTRACTED|COMMERCIAL OTHER 2|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|PHCS|HUMANA INSURANCE|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|ChampVA|CHAMPVA CENTER|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Managed Medicare|HEALTHSPRING MA|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|United Healthcare|UNITED HEALTHCARE OTHER|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Aetna|AETNA PPO|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|United Healthcare|UNITED HEALTHCARE ERS|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicaid|CRIME VICTIMS COMPENSATION|9.12||||||| 73110|EAP|0320|XR-WRIST 3VIEW|United Healthcare|GEHA|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Tricare|TRICARE EAST REGION|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicaid|MEDICAID|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Tricare|TRICARE FOR LIFE|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|United Healthcare|UNITED HEALTHCARE|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Managed Medicare|OTHER INSTITUTIONS|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicaid|SMITH COUNTY JAIL|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Cigna|CIGNA OTHER|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Veterans Affairs|VETERANS ADMINISTRATION|9.12||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Aetna|AETNA OTHER|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|United Healthcare|GOLDEN RULE|||||9.12||| 73110|EAP|0320|XR-WRIST 3VIEW|Medicare|MEDICARE ACUTE|9.12||||9.12||| 73115|EAP|0320|IR-IR-WRIST ARTHROGRAM|Workers Compensation|WORKERS COMPENSATION OTHER|||||12.42||| 73115|EAP|0320|IR-IR-WRIST ARTHROGRAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12.42||| 73115|EAP|0320|IR-IR-WRIST ARTHROGRAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.42||| 73115|EAP|0320|IR-IR-WRIST ARTHROGRAM|Workers Compensation|UT EMPLOYEE INJURY|||||1,315.19||| 73115|EAP|0320|IR-IR-WRIST ARTHROGRAM|Blue Cross PPO Specialty|BCBSTX PPO|||||1,315.19||| 73115|EAP|0320|IR-IR-WRIST ARTHROGRAM|Managed Medicaid|MEDICAID AMERIGROUP|||||12.42||| 73115|EAP|0320|IR-IR-WRIST ARTHROGRAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,315.19||| 73115|EAP|0320|IR-IR-WRIST ARTHROGRAM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.42||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73120|EAP|0320|XR HAND 1 VIEW|Medicaid|MEDICAID|8.24||||||| 73120|EAP|0320|XR HAND 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Medicaid|SMITH COUNTY JAIL|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Medicaid|MEDICAID|8.24||||||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Medicaid|LAW ENFORCEMENT OTHER|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73120|EAP|0320|XR HAND 1 VIEW|Cigna|CIGNA|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|PHCS|HUMANA|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73120|EAP|0320|XR HAND 1 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Cigna|CIGNA|||||8.24||| 73120|EAP|0320|XR HAND 1 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||||| 73120|EAP|0320|XR HAND 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73120|EAP|0320|XR HAND 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|8.24||||||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Managed Medicare|HEALTHSPRING MA|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||||| 73120|EAP|0320|XR-HAND 1 OR 2 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||||| 73130|EAP|0320|XR-HAND 3VIEW|Managed Medicare|HEALTHSPRING MA|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Managed Medicare|OTHER INSTITUTIONS|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicaid|SMITH COUNTY JAIL|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicaid|MEDICAID|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicaid|CRIME VICTIMS COMPENSATION|9.12||||||| 73130|EAP|0320|XR-HAND 3VIEW|United Healthcare|TML GROUP BENEFITS|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicaid|MEDICAID HMO|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|United Healthcare|UNITED HEALTHCARE OTHER|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicaid|MEDICAID BCBSTX|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|9.12||||||| 73130|EAP|0320|XR-HAND 3VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|United Healthcare|UNITED HEALTHCARE ERS|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Workers Compensation|GALLAGHER BASSETT|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Blue Cross PPO Specialty|BCBSTX PPO|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Aetna|BOON CHAPMAN|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Workers Compensation|BROOKSHIRES WORKERS COMP|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Aetna|AETNA PPO|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Managed Medicaid|MEDICAID SUPERIOR|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicare|MEDICARE PART B ONLY IP|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Medicare|MEDICARE ACUTE|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Cigna|CIGNA OTHER|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Aetna|AETNA OTHER|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Multiplan|TRUSTMARK|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|PHCS|GROUP AND PENSION|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Humana Medicare Advantage|HUMANA MA|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|PHCS|HUMANA INSURANCE|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Tricare|TRICARE FOR LIFE|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Veterans Affairs|VETERANS ADMINISTRATION|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Managed Medicaid|MEDICAID AMERIGROUP|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|United Healthcare|AARP|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|United Healthcare|GEHA|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|PHCS|HUMANA|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|United Healthcare|UNITED HEALTHCARE|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Tricare|TRICARE EAST REGION|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|9.12||||||| 73130|EAP|0320|XR-HAND 3VIEW|United Healthcare|GOLDEN RULE|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.12||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|NON CONTRACTED|COMMERCIAL OTHER 2|||||9.12||| 73130|EAP|0320|XR-HAND 3VIEW|Cigna|CIGNA|||||9.12||| 73140|EAP|0320|XR-FINGER 2VIEW|United Healthcare|GOLDEN RULE|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Medicaid|LAW ENFORCEMENT OTHER|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Tricare|TRICARE EAST REGION|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|United Healthcare|UNITED HEALTHCARE OTHER|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Medicaid|MEDICAID HMO|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Medicaid|SMITH COUNTY JAIL|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|PHCS|HUMANA|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|NON CONTRACTED|AFLAC|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Medicaid|MEDICAID|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Aetna|AETNA OTHER|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Tricare|TRICARE FOR LIFE|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Aetna|AETNA PPO|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Workers Compensation|BROOKSHIRES WORKERS COMP|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Blue Cross HMO Specialty|BCBSTX HMO|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Cigna|CIGNA|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|8.24||||||| 73140|EAP|0320|XR-FINGER 2VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73140|EAP|0320|XR-FINGER 2VIEW|Cigna|CIGNA OTHER|||||8.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Workers Compensation|WORKERS COMPENSATION OTHER|42.70||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|United Medicare Advantage|UHC MEDICARE GOLD MA|42.70||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Veterans Affairs|VETERANS ADMINISTRATION|51.24||||||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.70||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Workers Compensation|GALLAGHER BASSETT|||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Aenta Medicare Advantage|AETNA MEDICARE MA|51.24||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Managed Medicaid|MEDICAID AMERIGROUP|51.24||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|United Medicare Advantage|UHC AARP MCR HMO MA|||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Blue Cross PPO Specialty|BCBSTX PPO|51.24||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Managed Medicaid|MEDICAID SUPERIOR|51.24||||||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Blue Cross HMO Specialty|BCBSTX HMO|51.24||||46.97||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Aetna|AETNA PPO|||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|51.24||||46.97||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Humana Medicare Advantage|HUMANA MA|51.24||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Cigna|CIGNA|42.70||||||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Tricare|TRICARE EAST REGION|||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|PHCS|HUMANA|||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|United Healthcare|UNITED HEALTHCARE OTHER|51.24||||||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Managed Medicare|BCBS MEDICARE PPO MA|51.24||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Medicare|MEDICARE ACUTE|51.24||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|NON CONTRACTED|COMMERCIAL OTHER 1|||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Rusk State Hospital|RUSK STATE HOSP|||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Aetna|AETNA OTHER|||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Medicaid|MEDICAID|||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|United Healthcare|UNITED HEALTHCARE|||||51.24||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Managed Medicare|HEALTHSPRING MA|51.24||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Medicaid|SMITH COUNTY JAIL|||||42.70||| 73200|EAP|0350|CT-UPPER EXTREMITY W/O DY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.97||||46.97||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|||||6,693.60||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Humana Medicare Advantage|HUMANA MA|55.78||||55.78||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Managed Medicaid|MEDICAID SUPERIOR|55.78||||6,693.60||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Managed Medicare|HEALTHSPRING MA|||||6,693.60||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|55.78||||6,693.60||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,693.60||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|||||6,693.60||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||55.78||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|55.78||||||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|55.78||||||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Medicaid|SMITH COUNTY JAIL|55.78||||||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Medicare|MEDICARE ACUTE|6,135.80||||6,693.60||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,693.60||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||55.78||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55.78||||6,693.60||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,693.60||||6,135.80||| 73201|EAP|0350|CT-UPPER EXTREMITY W/DYE|Cigna|CIGNA OTHER|6,693.60||||||| 73202|EAP|0350|CT-UPPR EXTREMITY W/O&W/D|Managed Medicare|BCBS MEDICARE PPO MA|||||63.26||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|Medicaid|LAW ENFORCEMENT OTHER|8,488.80||||||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|United Medicare Advantage|UHC AARP MCR HMO MA|8,488.80||||||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|Cigna|CIGNA|8,488.80||||||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|70.74||||||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||8,488.80||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||8,488.80||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|Medicare|MEDICARE ACUTE|7,781.40||||70.74||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|Humana Medicare Advantage|HUMANA MA|7,781.40||||||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|Workers Compensation|TEXAS MUTUAL INSURANCE|70.74||||||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||70.74||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|United Medicare Advantage|UHC MEDICARE GOLD MA|8,488.80||||||| 73206|EAP|0350|CT-ANGIO UPR EXTRM W/O&W/|Managed Medicaid|MEDICAID SUPERIOR|70.74||||8,488.80||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Medicaid|SMITH COUNTY JAIL|57.91||||||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Medicare|MEDICARE ACUTE|57.91||||6,080.55||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Blue Cross PPO Specialty|BCBSTX PPO|||||6,080.55||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Blue Cross HMO Specialty|BCBSTX HMO|||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|United Healthcare|UNITED HEALTHCARE OTHER|||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|United Healthcare|UNITED HEALTHCARE|||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Medicare|MEDICARE ACUTE|6,080.55||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||57.91||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Managed Medicare|HEALTHSPRING MA|||||57.91||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||57.91||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||57.91||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Blue Cross PPO Specialty|BCBSTX PPO|||||57.91||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|Humana Medicare Advantage|HUMANA MA|6,370.10||||6,370.10||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|United Medicare Advantage|UHC MEDICARE GOLD MA|||||57.91||| 73218|EAP|0610|MRI UPPER EXTREMITY W/O D|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,370.10||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|Blue Cross PPO Specialty|BCBSTX PPO|8,225.70||||78.34||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|78.34||||||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|Blue Cross PPO Specialty|BCBSTX PPO|8,225.70||||8,617.40||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||78.34||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|United Healthcare|UNITED HEALTHCARE OTHER|||||8,617.40||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|Humana Medicare Advantage|HUMANA MA|||||8,617.40||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|78.34||||||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|Medicare|MEDICARE ACUTE|8,617.40||||78.34||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|United Medicare Advantage|UHC AARP MCR HMO MA|||||8,617.40||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|Cigna|CIGNA|78.34||||||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8,617.40||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|United Healthcare|UNITED HEALTHCARE|8,617.40||||||| 73220|EAP|0610|MRI UPPR EXTREMITY W/O&W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||8,617.40||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Medicare|MEDICARE ACUTE|57.91||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Medicare|MEDICARE ACUTE|6,370.10||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Medicaid|MEDICAID|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|NON CONTRACTED|COMMERCIAL OTHER 1|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|NON CONTRACTED|COMMERCIAL OTHER 2|6,370.10||||||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Multiplan|NALC|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Tricare|TRICARE FOR LIFE|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|United Healthcare|UNITED HEALTHCARE OTHER|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Blue Cross PPO Specialty|BCBSTX OTHER|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Tricare|TRICARE EAST REGION|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|United Healthcare|TML GROUP BENEFITS|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,370.10||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Aenta Medicare Advantage|AETNA MEDICARE MA|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Blue Cross HMO Specialty|BCBSTX HMO|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|United Healthcare|UNITED HEALTHCARE|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Rusk State Hospital|RUSK STATE HOSP|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|NON CONTRACTED|COMMERCIAL OTHER 1|||||6,080.55||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,370.10||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicaid|MEDICAID SUPERIOR|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Blue Cross PPO Specialty|BCBSTX PPO|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Blue Cross PPO Specialty|BCBSTX PPO|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Humana Medicare Advantage|HUMANA MA|6,370.10||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6,080.55||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|United Healthcare|GEHA|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Workers Compensation|WORKERS COMPENSATION OTHER|||||6,080.55||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Access Direct Platinum|HEALTHFIRST TPA|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Access Direct Platinum|HEALTHFIRST TPA UMR|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicaid|MEDICAID AMERIGROUP|||||6,080.55||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Cigna|CIGNA|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Access Direct Platinum|HEALTHFIRST TPA|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Workers Compensation|UT EMPLOYEE INJURY|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|6,370.10||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Workers Compensation|WORKERS COMPENSATION OTHER|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|United Healthcare|UNITED HEALTHCARE|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Medicaid|SMITH COUNTY JAIL|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|PHCS|GROUP AND PENSION|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|ChampVA|CHAMPVA CENTER|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Aetna|AETNA PPO|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicaid|MEDICAID AMERIGROUP|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Workers Compensation|UT EMPLOYEE INJURY|||||6,080.55||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicaid|MEDICAID SUPERIOR|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Veterans Affairs|VETERANS ADMINISTRATION|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicare|HEALTHSPRING MA|||||6,370.10||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6,370.10||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Managed Medicare|BCBS MEDICARE PPO MA|||||57.91||| 73221|EAP|0610|MRI JOINT UPR EXTREM W/O|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||57.91||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Workers Compensation|WORKERS COMPENSATION OTHER|||||68.91||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Managed Medicaid|MEDICAID AMERIGROUP|||||68.91||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7,235.55||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||68.91||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,580.10||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,580.10||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||68.91||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Workers Compensation|UT EMPLOYEE INJURY|||||7,235.55||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Workers Compensation|WORKERS COMPENSATION OTHER|||||68.91||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Workers Compensation|UT EMPLOYEE INJURY|||||7,580.10||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7,580.10||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||68.91||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Managed Medicaid|MEDICAID SUPERIOR|||||7,580.10||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Humana Medicare Advantage|HUMANA MA|||||68.91||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||68.91||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Blue Cross PPO Specialty|BCBSTX PPO|||||68.91||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Cigna|CIGNA|||||68.91||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Blue Cross HMO Specialty|BCBSTX HMO|||||7,580.10||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|United Healthcare|UNITED HEALTHCARE|||||7,235.55||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7,580.10||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7,580.10||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|United Healthcare|UNITED HEALTHCARE|||||7,580.10||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|United Healthcare|UNITED HEALTHCARE OTHER|||||7,580.10||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Blue Cross HMO Specialty|BCBSTX HMO|||||68.91||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7,580.10||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Tricare|TRICARE EAST REGION|||||7,235.55||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Aetna|AETNA PPO|||||7,235.55||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Humana Medicare Advantage|HUMANA MA|||||7,580.10||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Blue Cross PPO Specialty|BCBSTX PPO|||||7,235.55||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Medicare|MEDICARE ACUTE|||||7,580.10||| 73222|EAP|0610|MRI JOINT UPR EXTREM W/DY|Tricare|TRICARE EAST REGION|||||7,580.10||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7,235.55||| 73222|EAP|0610|MRI JOINT SHOULDER LT W C|Aetna|AETNA PPO|||||7,580.10||| 73223|EAP|0610|MRI JOINT UPR EXTR W/O&W/|Medicare|MEDICARE ACUTE|78.34||||8,617.40||| 73223|EAP|0610|MRI JOINT UPR EXTR W/O&W/|Managed Medicaid|MEDICAID AMERIGROUP|8,617.40||||||| 73223|EAP|0610|MRI JOINT UPR EXTR W/O&W/|United Medicare Advantage|UHC AARP MCR HMO MA|8,617.40||||||| 73223|EAP|0610|MRI JOINT UPR EXTR W/O&W/|Blue Cross PPO Specialty|BCBSTX PPO|78.34||||8,617.40||| 73223|EAP|0610|MRI JOINT UPR EXTR W/O&W/|Humana Medicare Advantage|HUMANA MA|||||78.34||| 73223|EAP|0610|MRI JOINT UPR EXTR W/O&W/|Blue Cross PPO Specialty|BCBSTX PPO|78.34||||8,225.70||| 73223|EAP|0610|MRI JOINT UPR EXTR W/O&W/|Texas Workforce Commission|DIS DETER SERV (DDS)|||||78.34||| 73223|EAP|0610|MRI JOINT UPR EXTR W/O&W/|Managed Medicare|HEALTHSPRING MA|78.34||||78.34||| 73223|EAP|0610|MRI JOINT UPR EXTR W/O&W/|Blue Cross HMO Specialty|BCBSTX HMO|8,617.40||||8,617.40||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Blue Cross HMO Specialty|BCBSTX HMO|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Veterans Affairs|VETERANS ADMINISTRATION|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Humana Medicare Advantage|HUMANA MA|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|United Medicare Advantage|UHC AARP MCR HMO MA|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Cigna|CIGNA|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Humana Medicare Advantage|HUMANA MA|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|United Medicare Advantage|UHC AARP MCR HMO MA|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Medicare|MEDICARE ACUTE|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Tricare|TRICARE EAST REGION|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|United Healthcare|TML GROUP BENEFITS|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|United Healthcare|UNITED HEALTHCARE OTHER|||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Tricare|TRICARE EAST REGION|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Medicare|MEDICARE PART B ONLY IP|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Managed Medicare|HEALTHSPRING MA|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Managed Medicare|HEALTHSPRING MA|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|Medicare|MEDICARE ACUTE|0.97||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Managed Medicare|BCBS MEDICARE PPO MA|||||0.97||| 73501|EAP|0320|XR-HIP UNI 1 VIEW RT|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.97||||||| 73501|EAP|0320|XR-HIP UNI 1 VIEW LT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Managed Medicare|OTHER INSTITUTIONS|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Medicaid|SMITH COUNTY JAIL|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Managed Medicare|HEALTHSPRING MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Managed Medicare|OTHER INSTITUTIONS|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Managed Medicare|HEALTHSPRING MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Managed Medicare|BCBS MEDICARE PPO MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Medicaid|MEDICAID HMO|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Medicaid|MEDICAID|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|PHCS|HUMANA INSURANCE|0.97||||||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|PHCS|HUMANA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|NON CONTRACTED|COMMERCIAL OTHER 1|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|PHCS|HUMANA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Medicare|MEDICARE PART B ONLY IP|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Medicare|MEDICARE PART B ONLY IP|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|United Healthcare|UNITED HEALTHCARE|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Medicare|MEDICARE ACUTE|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.97||||||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|United Healthcare|UNITED HEALTHCARE|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|United Healthcare|UNITED HEALTHCARE OTHER|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|United Healthcare|UNITED HEALTHCARE OTHER|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Tricare|TRICARE FOR LIFE|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Tricare|TRICARE EAST REGION|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Blue Cross HMO Specialty|BCBSTX HMO|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Blue Cross HMO Specialty|BCBSTX HMO|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|United Healthcare|UNITED HEALTHCARE|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Tricare|TRICARE FOR LIFE|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Tricare|TRICARE SOUTH PHYSICIAN|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|United Healthcare|UNITED HEALTHCARE|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Aetna|AETNA PPO|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Aetna|AETNA OTHER|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Aetna|AETNA OTHER|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|United Healthcare|GEHA|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Aetna|AETNA PPO|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Humana Medicare Advantage|HUMANA MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Humana Medicare Advantage|HUMANA MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Cigna|CIGNA OTHER|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Cigna|CIGNA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Cigna|CIGNA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Tricare|TRICARE EAST REGION|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|United Healthcare|AARP|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Managed Medicaid|MEDICAID AMERIGROUP|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Managed Medicaid|MEDICAID SUPERIOR|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Medicare|MEDICARE ACUTE|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Managed Medicare|BCBS MEDICARE PPO MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Medicaid|MEDICAID|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Access Direct Platinum|HEALTHFIRST TPA UMR|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|United Medicare Advantage|UHC AARP MCR HMO MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Rusk State Hospital|RUSK STATE HOSP|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|NON CONTRACTED|COMMERCIAL OTHER 1|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Access Direct Platinum|HEALTHFIRST TPA|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Managed Medicaid|MEDICAID SUPERIOR|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Managed Medicaid|MEDICAID AMERIGROUP|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Access Direct Platinum|HEALTHFIRST TPA UMR|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Workers Compensation|WORKERS COMPENSATION OTHER|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Workers Compensation|UT EMPLOYEE INJURY|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Veterans Affairs|VETERANS ADMINISTRATION|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Workers Compensation|UT EMPLOYEE INJURY|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.97||||||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|United Medicare Advantage|UHC AARP MCR HMO MA|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Workers Compensation|WORKERS COMPENSATION OTHER|0.97||||0.97||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS RT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.97||||||| 73502|EAP|0320|XR-HIP UNI 2-3 VIEWS LT|Veterans Affairs|VETERANS ADMINISTRATION|0.97||||0.97||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Cigna|CIGNA OTHER|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Humana Medicare Advantage|HUMANA MA|1.61||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.61||||||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Medicaid|MEDICAID HMO|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Managed Medicare|HEALTHSPRING MA|1.61||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Medicare|MEDICARE ACUTE|1.61||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.61||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||1.61||| 73521|EAP|0320|.R-HIPS BI 2 VIEWS|United Healthcare|TML GROUP BENEFITS|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Managed Medicare|HEALTHSPRING MA|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Tricare|TRICARE EAST REGION|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Medicaid|MEDICAID|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Aetna|AETNA OTHER|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Humana Medicare Advantage|HUMANA MA|1.61||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|United Healthcare|UNITED HEALTHCARE|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Cigna|CIGNA|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Cigna|CIGNA OTHER|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Access Direct Platinum|HEALTHFIRST TPA|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Medicare|MEDICARE ACUTE|1.61||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.61||| 73522|EAP|0320|XR-HIPS BI 3-4 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|1.61||||1.61||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|PHCS|HUMANA INSURANCE|3.07||||||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|Medicare|MEDICARE ACUTE|3.07||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|Managed Medicare|HEALTHSPRING MA|3.07||||||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.07||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|Humana Medicare Advantage|HUMANA MA|||||3.07||| 73523|EAP|0320|XR-HIPS BI 5/> VIEWS|Aetna|AETNA PPO|||||3.07||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Managed Medicaid|MEDICAID AMERIGROUP|||||16.50||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Blue Cross HMO Specialty|BCBSTX HMO|||||16.50||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Blue Cross PPO Specialty|BCBSTX PPO|||||16.50||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,747.24||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,698.62||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Aetna|AETNA PPO|||||16.50||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Humana Medicare Advantage|HUMANA MA|||||16.50||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Medicare|MEDICARE ACUTE|||||1,747.24||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||16.50||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.50||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||16.50||| 73525|EAP|0320|XR-HIP ARTHROGRAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||16.50||| 73525|EAP|0320|XR-HIP ARTHROGRAM|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,747.24||| 73525|EAP|0320|XR-HIP ARTHROGRAM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,747.24||| 73551|EAP|0320|XR-OF FEMUR 1 LT|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 RT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 LT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Cigna|CIGNA|||||0.97||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Aetna|AETNA PPO|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.97||| 73551|EAP|0320|XR-OF FEMUR 1 LT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.97||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Humana Medicare Advantage|HUMANA MA|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 LT|Managed Medicaid|MEDICAID AMERIGROUP|||||0.97||| 73551|EAP|0320|XR-OF FEMUR 1 LT|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Medicaid|MEDICAID|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 LT|Medicaid|MEDICAID|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Medicare|MEDICARE ACUTE|0.97||||0.97||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Managed Medicaid|MEDICAID AMERIGROUP|||||0.97||| 73551|EAP|0320|XR-OF FEMUR 1 RT|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.97||| 73551|EAP|0320|XR-OF FEMUR 1 LT|Managed Medicare|HEALTHSPRING MA|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 RT|Managed Medicare|HEALTHSPRING MA|0.97||||||| 73551|EAP|0320|XR-OF FEMUR 1 LT|Medicaid|MEDICAID HMO|||||0.97||| 73551|EAP|0320|XR-OF FEMUR 1 LT|Medicaid|CRIME VICTIMS COMPENSATION|0.97||||||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Tricare|TRICARE EAST REGION|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|United Healthcare|UNITED HEALTHCARE OTHER|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|United Healthcare|UNITED HEALTHCARE OTHER|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Managed Medicare|OTHER INSTITUTIONS|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|PHCS|HUMANA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|United Healthcare|UNITED HEALTHCARE|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|NON CONTRACTED|COMMERCIAL OTHER 1|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|NON CONTRACTED|COMMERCIAL OTHER 1|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Medicare|MEDICARE ACUTE|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Managed Medicare|HEALTHSPRING MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Managed Medicare|BCBS MEDICARE PPO MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Managed Medicare|OTHER INSTITUTIONS|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Medicare|MEDICARE ACUTE|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Managed Medicare|HEALTHSPRING MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Medicaid|MEDICAID HMO|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Rusk State Hospital|RUSK STATE HOSP|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Blue Cross HMO Specialty|BCBSTX HMO|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Blue Cross HMO Specialty|BCBSTX HMO|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Aetna|AETNA PPO|0.97||||||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Medicaid|MEDICAID|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Managed Medicaid|MEDICAID AMERIGROUP|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Aetna|AETNA PPO|0.97||||||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Cigna|CIGNA OTHER|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Cigna|CIGNA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Cigna|CIGNA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Aetna|AETNA OTHER|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Cigna|CIGNA|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Managed Medicaid|MEDICAID SUPERIOR|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Managed Medicare|BCBS MEDICARE PPO MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|United Medicare Advantage|UHC AARP MCR HMO MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Humana Medicare Advantage|HUMANA MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|United Healthcare|TML GROUP BENEFITS|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Access Direct Platinum|HEALTHFIRST TPA|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|United Medicare Advantage|UHC AARP MCR HMO MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|PHCS|HUMANA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Access Direct Platinum|HEALTHFIRST TPA|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Access Direct Platinum|HEALTHFIRST TPA UMR|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|United Healthcare|UNITED HEALTHCARE|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Workers Compensation|WORKERS COMPENSATION OTHER|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Managed Medicaid|MEDICAID SUPERIOR|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Workers Compensation|WORKERS COMPENSATION OTHER|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Veterans Affairs|VETERANS ADMINISTRATION|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Managed Medicaid|MEDICAID AMERIGROUP|||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Humana Medicare Advantage|HUMANA MA|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> LT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.97||||0.97||| 73552|EAP|0320|XR-OF FEMUR 2/> RT|Medicaid|MEDICAID HMO|0.97||||0.97||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Workers Compensation|GALLAGHER BASSETT|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Workers Compensation|BROOKSHIRES WORKERS COMP|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Cigna|CIGNA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Cigna|CIGNA OTHER|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Humana Medicare Advantage|HUMANA MA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Aetna|AETNA PPO|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Aetna|AETNA OTHER|7.22||||||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|7.22||||||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA TYLER ISD|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Aetna|AETNA QHP HMO|7.22||||||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Managed Medicaid|MEDICAID SUPERIOR|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Medicaid|MEDICAID|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Managed Medicare|HEALTHSPRING MA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|PHCS|HUMANA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Managed Medicare|OTHER INSTITUTIONS|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Medicare|MEDICARE PART B ONLY IP|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Medicare|MEDICARE ACUTE|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Medicaid|MEDICAID HMO|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|PHCS|HUMANA INSURANCE|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 2|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|United Healthcare|GEHA|7.22||||||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|United Healthcare|TML GROUP BENEFITS|||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Tricare|TRICARE FOR LIFE|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|Tricare|TRICARE EAST REGION|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.22||||7.22||| 73560|EAP|0320|XR-KNEE 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE ERS|||||7.22||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|United Healthcare|UNITED HEALTHCARE|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|United Healthcare|UNITED HEALTHCARE OTHER|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Tricare|TRICARE FOR LIFE|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Tricare|TRICARE EAST REGION|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|United Healthcare|UNITED HEALTHCARE|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|PHCS|GROUP AND PENSION|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|NON CONTRACTED|AFLAC|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|NON CONTRACTED|COMMERCIAL OTHER 2|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|United Healthcare|UNITED HEALTHCARE ERS|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Medicare|MEDICARE ACUTE|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicare|BCBS MEDICARE PPO MA|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicare|UNIVERSAL HEALTHCARE MA|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Blue Cross HMO Specialty|BCBSTX HMO|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Medicaid|MEDICAID HMO|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicare|HEALTHSPRING MA|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Medicaid|LAW ENFORCEMENT OTHER|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Blue Cross PPO Specialty|BCBSTX OTHER|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Blue Cross PPO Specialty|BCBSTX PPO|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Medicare|MEDICARE PART B ONLY IP|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|United Healthcare|AARP|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Aetna|AETNA OTHER|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Aetna|AETNA PPO|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Humana Medicare Advantage|HUMANA MA|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Access Direct Platinum|HEALTHFIRST TPA TYLER ISD|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Medicaid|MEDICAID|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicare|OTHER INSTITUTIONS|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Access Direct Platinum|HEALTHFIRST TPA|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Aetna|AETNA QHP HMO|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Cigna|CIGNA|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|ChampVA|CHAMPVA CENTER|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|PHCS|HUMANA|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|United Medicare Advantage|UHC MEDICARE GOLD MA|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Medicaid|SMITH COUNTY JAIL|9.12||||||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Cigna|CIGNA OTHER|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Veterans Affairs|VETERANS ADMINISTRATION|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Workers Compensation|WORKERS COMPENSATION OTHER|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Cigna|CIGNA|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Workers Compensation|UT EMPLOYEE INJURY|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Workers Compensation|TEXAS MUTUAL INSURANCE|||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Managed Medicaid|MEDICAID AMERIGROUP|9.12||||9.12||| 73562|EAP|0320|XR-KNEE AP LATERAL & TUNN|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||9.12||| 73564|EAP|0320|XR-KNEE 4 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10.02||| 73564|EAP|0320|XR-KNEE 4 VIEWS|Humana Medicare Advantage|HUMANA MA|||||10.02||| 73564|EAP|0320|XR-KNEE 4 VIEWS|Medicare|MEDICARE ACUTE|||||10.02||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Medicare|MEDICARE ACUTE|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Texas Workforce Commission|DIS DETER SERV (DDS)|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|United Healthcare|UNITED HEALTHCARE|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Aetna|AETNA PPO|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Blue Cross PPO Specialty|BCBSTX PPO|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Managed Medicaid|MEDICAID AMERIGROUP|9.12||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Humana Medicare Advantage|HUMANA MA|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|ChampVA|CHAMPVA CENTER|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Veterans Affairs|VETERANS ADMINISTRATION|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.12||||||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|Managed Medicare|HEALTHSPRING MA|||||9.12||| 73565|EAP|0320|XR-KNEE BIL STANDING AP|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.12||| 73580|EAP|0320|XR-KNEE ARHTROGRAM|Blue Cross PPO Specialty|BCBSTX PPO|||||20.72||| 73580|EAP|0320|XR-KNEE ARHTROGRAM|Humana Medicare Advantage|HUMANA MA|||||2,194.11||| 73580|EAP|0320|XR-KNEE ARHTROGRAM|Medicare|MEDICARE ACUTE|||||2,133.06||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.24||| 73590|EAP|0320|XR-TIBIA FIBULA 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Cigna|CIGNA|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Cigna|CIGNA OTHER|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|ChampVA|CHAMPVA CENTER|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Brinson Benefits|THE HEALTH PLAN SMITH CO|8.24||||8.24||| 73590|EAP|0320|XR-TIBIA FIBULA 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Aetna|AETNA OTHER|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Aetna|AETNA PPO|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Medicaid|MOLINA HEALTHCARE OF TEXAS|8.24||||||| 73590|EAP|0320|XR-TIBIA FIBULA 1 VIEW|Medicaid|MEDICAID|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Medicaid|LAW ENFORCEMENT OTHER|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Medicaid|CRIME VICTIMS COMPENSATION|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Medicaid|MEDICAID|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Medicaid|MEDICAID HMO|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Tricare|TRICARE EAST REGION|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|United Healthcare|UNITED HEALTHCARE|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|NON CONTRACTED|COMMERCIAL OTHER 2|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|PHCS|HUMANA|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|United Healthcare|UNITED HEALTHCARE ERS|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Multiplan|WEB TPA|8.24||||||| 73590|EAP|0320|XR-TIBIA FIBULA 1 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Access Direct Platinum|HEALTHFIRST TPA UMR|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Workers Compensation|TEXAS MUTUAL INSURANCE|8.24||||||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 73590|EAP|0320|XR-TIBIA FIBULA 1 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||8.24||| 73590|EAP|0320|XR-TIB-FIB 1 OR 2+AF38 VI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73590|EAP|0320|XR-TIBIA FIBULA 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73592|EAP|0320|XR-INFANT UNI EXTREMITY|Blue Cross PPO Specialty|BCBSTX PPO|||||9.12||| 73592|EAP|0320|XR-INFANT UNI EXTREMITY|Tricare|TRICARE EAST REGION|||||9.12||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|8.24||||||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|8.24||||||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Medicaid|MEDICAID|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Multiplan|NALC|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Multiplan|WEB TPA|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Multiplan|PACIFICARE|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Multiplan|GILSBAR INC|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|PHCS|GROUP AND PENSION|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|United Healthcare|GEHA|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Tricare|TRICARE FOR LIFE|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Tricare|TRICARE EAST REGION|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Workers Compensation|WORKERS COMP PHYSICIAN|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|United Healthcare|TML GROUP BENEFITS|8.24||||||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|PHCS|HUMANA|8.24||||||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Cigna|CIGNA|8.24||||||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|ChampVA|CHAMPVA CENTER|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Medicaid|MEDICAID|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Managed Medicaid|MEDICAID SUPERIOR|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Aetna|AETNA PPO|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Cigna|CIGNA|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Aetna|AETNA OTHER|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Aetna|AETNA OTHER|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73600|EAP|0320|XR-ANKLE 1 OR 2 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||||| 73610|EAP|0320|XR-ANKLE 3VIEW|Blue Cross PPO Specialty|BCBSTX PPO|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Blue Cross HMO Specialty|BCBSTX HMO|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Aetna|AETNA OTHER|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Aetna|AETNA PPO|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Managed Medicaid|MEDICAID AMERIGROUP|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Cigna|CIGNA OTHER|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|ChampVA|CHAMPVA CENTER|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Cigna|CIGNA|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Humana Medicare Advantage|HUMANA MA|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Veterans Affairs|VETERANS ADMINISTRATION|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Workers Compensation|GALLAGHER BASSETT|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|United Healthcare|AARP|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Cigna|CIGNA|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|United Healthcare|TML GROUP BENEFITS|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Tricare|TRICARE FOR LIFE|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|United Healthcare|UNITED HEALTHCARE OTHER|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|United Healthcare|UNITED HEALTHCARE|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|PHCS|HUMANA|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Multiplan|WEB TPA|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicare|MEDICARE PART B ONLY IP|9.12||||||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicaid|MEDICAID|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Managed Medicare|OTHER INSTITUTIONS|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Managed Medicare|HEALTHSPRING MA|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicaid|MEDICAID HMO|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Multiplan|GILSBAR INC|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicare|MEDICARE ACUTE|9.12||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Tricare|TRICARE EAST REGION|||||9.12||| 73610|EAP|0320|XR-ANKLE 3VIEW|Medicaid|MEDICAID BCBSTX|||||9.12||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Managed Medicare|HEALTHSPRING MA|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Medicaid|CRIME VICTIMS COMPENSATION|8.24||||||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Medicaid|MEDICAID|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Medicaid|SMITH COUNTY JAIL|8.24||||||| 73620|EAP|0320|XR-FOOT 1 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Medicare|MEDICARE PART B ONLY IP|8.24||||||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|PHCS|HUMANA|8.24||||||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Medicaid|CRIME VICTIMS COMPENSATION|8.24||||||| 73620|EAP|0320|XR-FOOT 1 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Tricare|TRICARE EAST REGION|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Medicaid|SMITH COUNTY INDIGENT HEALTH|8.24||||||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|PHCS|GROUP AND PENSION|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Cigna|CIGNA OTHER|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Cigna|CIGNA|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Workers Compensation|ZURICH COMPANY|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Aetna|AETNA PPO|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Aetna|AETNA PPO|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|8.24||||||| 73620|EAP|0320|XR-FOOT 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.24||| 73620|EAP|0320|XR-FOOT 1 OR 2 VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|8.24||||8.24||| 73630|EAP|0320|XR-FOOT 3VIEWS|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Aetna|AETNA OTHER|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Aetna|AETNA PPO|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Cigna|CIGNA OTHER|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Cigna|CIGNA|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Cigna|CIGNA|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Humana Medicare Advantage|HUMANA MA|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Access Direct Platinum|HEALTHFIRST TPA|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Workers Compensation|ZURICH COMPANY|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Workers Compensation|BROOKSHIRES WORKERS COMP|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Medicare Advantage|UHC AARP MCR HMO MA|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Tricare|TRICARE FOR LIFE|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Tricare|TRICARE EAST REGION|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Healthcare|TML GROUP BENEFITS|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Healthcare|UNITED HEALTHCARE ERS|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Healthcare|GEHA|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|PHCS|GROUP AND PENSION|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|ChampVA|CHAMPVA CENTER|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Managed Medicaid|MEDICAID SUPERIOR|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Healthcare|GOLDEN RULE|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|PHCS|HUMANA|9.12||||||| 73630|EAP|0320|XR-FOOT 3VIEWS|United Healthcare|UNITED HEALTHCARE|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|PHCS|MULTIPLAN PHCS OTHER|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|PHCS|HUMANA INSURANCE|9.12||||||| 73630|EAP|0320|XR-FOOT 3VIEWS|Multiplan|WEB TPA|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Medicare|MEDICARE ACUTE|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Multiplan|GILSBAR INC|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Multiplan|NALC|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Multiplan|TRUSTMARK|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Medicaid|MEDICAID|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Medicaid|MEDICAID HMO|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Medicaid|MEDICAID BCBSTX|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Managed Medicare|WELLCARE CHOICE MA|||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Managed Medicare|HEALTHSPRING MA|9.12||||9.12||| 73630|EAP|0320|XR-FOOT 3VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.12||||9.12||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Managed Medicare|HEALTHSPRING MA|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Medicaid|MEDICAID HMO|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Medicaid|MEDICAID|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|United Healthcare|UNITED HEALTHCARE OTHER|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Tricare|TRICARE FOR LIFE|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Workers Compensation|WORKERS COMPENSATION OTHER|8.24||||||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Tricare|TRICARE EAST REGION|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Workers Compensation|TEXAS MUTUAL INSURANCE|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Veterans Affairs|VETERANS ADMINISTRATION|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|United Healthcare|TML GROUP BENEFITS|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Cigna|CIGNA|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Cigna|CIGNA OTHER|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.24||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Managed Medicare|OTHER INSTITUTIONS|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Managed Medicaid|MEDICAID AMERIGROUP|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Aetna|AETNA PPO|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Aetna|AETNA OTHER|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Aetna|BOON CHAPMAN|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.24||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Blue Cross HMO Specialty|BCBSTX HMO|||||8.24||| 73650|EAP|0320|XR-OS CALCIS (HEEL) 2VW P|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Blue Cross PPO Specialty|BCBSTX PPO|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Aetna|AETNA OTHER|8.24||||||| 73660|EAP|0320|XR-TOES 2VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Cigna|CIGNA|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Access Direct Platinum|HEALTHFIRST TPA|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Workers Compensation|UT EMPLOYEE INJURY|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Tricare|TRICARE EAST REGION|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|United Healthcare|GOLDEN RULE|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Medicare|MEDICARE ACUTE|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Blue Cross HMO Specialty|BCBSTX HMO|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Medicaid|SMITH COUNTY JAIL|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|United Healthcare|UNITED HEALTHCARE|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Medicaid|MEDICAID|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Medicaid|LAW ENFORCEMENT OTHER|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Managed Medicare|HEALTHSPRING MA|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|United Healthcare|UNITED HEALTHCARE OTHER|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Humana Medicare Advantage|HUMANA MA|8.24||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|Cigna|CIGNA|||||8.24||| 73660|EAP|0320|XR-TOES 2VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|8.24||||8.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Managed Medicare|HEALTHSPRING MA|42.70||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Managed Medicare|BCBS MEDICARE PPO MA|51.24||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Medicaid|CRIME VICTIMS COMPENSATION|51.24||||||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Medicaid|MEDICAID|42.70||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Multiplan|WEB TPA|51.24||||||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Medicare|MEDICARE ACUTE|42.70||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|NON CONTRACTED|COMMERCIAL OTHER 1|51.24||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|PHCS|HUMANA|46.97||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|United Healthcare|UNITED HEALTHCARE|||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|United Healthcare|GOLDEN RULE|||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|United Healthcare|UNITED HEALTHCARE|42.70||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Tricare|TRICARE FOR LIFE|51.24||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.97||||||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Tricare|TRICARE EAST REGION|||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|United Medicare Advantage|UHC MEDICARE GOLD MA|51.24||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|United Medicare Advantage|UHC AARP MCR HMO MA|51.24||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.70||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Veterans Affairs|VETERANS ADMINISTRATION|42.70||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|51.24||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Workers Compensation|BROOKSHIRES WORKERS COMP|42.70||||||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Workers Compensation|WORKERS COMPENSATION OTHER|42.70||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Workers Compensation|UT EMPLOYEE INJURY|||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|United Healthcare|TML GROUP BENEFITS|51.24||||||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|United Healthcare|UNITED HEALTHCARE OTHER|42.70||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Access Direct Platinum|HEALTHFIRST TPA UMR|42.70||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Access Direct Platinum|HEALTHFIRST TPA|||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Medicaid|MEDICAID HMO|||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.97||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Humana Medicare Advantage|HUMANA MA|51.24||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Cigna|CIGNA|51.24||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Managed Medicaid|MEDICAID SUPERIOR|||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Managed Medicaid|MEDICAID AMERIGROUP|||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.97||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|51.24||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Aetna|AETNA PPO|||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Aenta Medicare Advantage|AETNA MEDICARE MA|51.24||||46.97||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Aetna|AETNA OTHER|51.24||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42.70||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Blue Cross HMO Specialty|BCBSTX HMO|51.24||||42.70||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||51.24||| 73700|EAP|0350|CT-LOWER EXTREMITY W/O DY|Blue Cross PPO Specialty|BCBSTX PPO|51.24||||51.24||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,693.60||||6,693.60||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|6,693.60||||6,135.80||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6,693.60||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||55.78||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|6,693.60||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|55.78||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6,135.80||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,135.80||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Managed Medicaid|MEDICAID AMERIGROUP|6,693.60||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Cigna|CIGNA OTHER|55.78||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Cigna|CIGNA|6,693.60||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Humana Medicare Advantage|HUMANA MA|6,693.60||||55.78||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|55.78||||6,693.60||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|6,693.60||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Workers Compensation|WORKERS COMPENSATION OTHER|6,693.60||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,693.60||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|55.78||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||55.78||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|55.78||||6,693.60||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|United Healthcare|UNITED HEALTHCARE|6,693.60||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|United Healthcare|UNITED HEALTHCARE|55.78||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Medicare|MEDICARE ACUTE|55.78||||55.78||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Medicaid|MEDICAID|55.78||||55.78||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Managed Medicare|BCBS MEDICARE PPO MA|55.78||||||| 73701|EAP|0350|CT-LOWER EXTREMITY W/DYE|Managed Medicare|HEALTHSPRING MA|6,135.80||||||| 73702|EAP|0350|CT-LWR EXTREMITY W/O&W/DY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|63.26||||||| 73702|EAP|0350|CT-LWR EXTREMITY W/O&W/DY|Medicare|MEDICARE ACUTE|||||6,958.60||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|United Medicare Advantage|UHC AARP MCR HMO MA|8,488.80||||70.74||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|United Medicare Advantage|UHC MEDICARE GOLD MA|70.74||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|70.74||||70.74||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Workers Compensation|ZURICH COMPANY|||||70.74||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Workers Compensation|WORKERS COMPENSATION OTHER|7,781.40||||8,488.80||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Veterans Affairs|VETERANS ADMINISTRATION|||||7,781.40||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Access Direct Platinum|HEALTHFIRST TPA UMR|70.74||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Aenta Medicare Advantage|AETNA MEDICARE MA|8,488.80||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Blue Cross HMO Specialty|BCBSTX HMO|||||70.74||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Humana Medicare Advantage|HUMANA MA|8,488.80||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Managed Medicaid|MEDICAID SUPERIOR|70.74||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Managed Medicaid|MEDICAID AMERIGROUP|||||70.74||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Managed Medicare|BCBS MEDICARE PPO MA|70.74||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|PHCS|HUMANA|8,488.80||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Workers Compensation|UT EMPLOYEE INJURY|||||70.74||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Medicare|MEDICARE ACUTE|70.74||||70.74||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|UTMB|UTMB CORRECTIONAL MANAGED CARE|70.74||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|NON CONTRACTED|COMMERCIAL OTHER 1|70.74||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|United Healthcare|UNITED HEALTHCARE|8,488.80||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Managed Medicare|HEALTHSPRING MA|70.74||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||70.74||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|70.74||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Medicaid|MEDICAID|70.74||||||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Blue Cross PPO Specialty|BCBSTX PPO|8,488.80||||8,488.80||| 73706|EAP|0350|CT-ANGIO LWR EXTR W/O&W/D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|70.74||||70.74||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Medicare|MEDICARE ACUTE|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Medicare|MEDICARE ACUTE|57.91||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,370.10||||||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|UTMB|UTMB CORRECTIONAL MANAGED CARE|57.91||||||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|United Healthcare|UNITED HEALTHCARE|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|United Healthcare|UNITED HEALTHCARE OTHER|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|United Healthcare|TML GROUP BENEFITS|||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Managed Medicare|HEALTHSPRING MA|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Managed Medicare|HEALTHSPRING MA|6,370.10||||6,080.55||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,370.10||||6,080.55||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Cigna|CIGNA|||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,370.10||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Cigna|CIGNA OTHER|||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Cigna|CIGNA|||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Humana Medicare Advantage|HUMANA MA|6,370.10||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|57.91||||||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Humana Medicare Advantage|HUMANA MA|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Managed Medicaid|MEDICAID AMERIGROUP|6,370.10||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Medicaid|SMITH COUNTY JAIL|57.91||||||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Blue Cross PPO Specialty|BCBSTX PPO|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Blue Cross PPO Specialty|BCBSTX PPO|6,080.55||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Blue Cross HMO Specialty|BCBSTX HMO|57.91||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Blue Cross HMO Specialty|BCBSTX HMO|57.91||||6,080.55||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,080.55||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Medicaid|MEDICAID|57.91||||||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|United Healthcare|GOLDEN RULE|||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Aetna|AETNA OTHER|||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Aenta Medicare Advantage|AETNA MEDICARE MA|57.91||||||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Aenta Medicare Advantage|AETNA MEDICARE MA|6,080.55||||||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,370.10||||6,080.55||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Tricare|TRICARE EAST REGION|||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Access Direct Platinum|HEALTHFIRST TPA|||||6,080.55||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|United Healthcare|UNITED HEALTHCARE|||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Access Direct Platinum|HEALTHFIRST TPA UMR|57.91||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Veterans Affairs|VETERANS ADMINISTRATION|57.91||||||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Veterans Affairs|VETERANS ADMINISTRATION|6,370.10||||||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|Workers Compensation|UT EMPLOYEE INJURY|||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,080.55||||6,080.55||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|United Medicare Advantage|UHC AARP MCR HMO MA|6,370.10||||6,370.10||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|57.91||||57.91||| 73718|EAP|0610|MRI LOWER EXTREMITY W/O D|United Medicare Advantage|UHC MEDICARE GOLD MA|57.91||||||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Access Direct Platinum|HEALTHFIRST TPA UMR|78.34||||8,617.40||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|United Medicare Advantage|UHC MEDICARE GOLD MA|78.34||||||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8,617.40||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||78.34||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,617.40||||78.34||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Blue Cross PPO Specialty|BCBSTX PPO|8,225.70||||78.34||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Blue Cross PPO Specialty|BCBSTX OTHER|8,617.40||||||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Blue Cross PPO Specialty|BCBSTX PPO|78.34||||78.34||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,225.70||||78.34||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Humana Medicare Advantage|HUMANA MA|8,617.40||||78.34||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Cigna|CIGNA|||||8,617.40||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8,617.40||||||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Managed Medicaid|MEDICAID SUPERIOR|78.34||||||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,617.40||||78.34||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Managed Medicaid|MEDICAID AMERIGROUP|||||8,617.40||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Managed Medicare|HEALTHSPRING MA|||||78.34||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|78.34||||||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Medicaid|MEDICAID|78.34||||||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Medicare|MEDICARE ACUTE|8,617.40||||8,617.40||| 73720|EAP|0610|MRI LWR EXTREMITY W/O&W/D|Medicare|MEDICARE ACUTE|78.34||||8,617.40||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Healthcare|UNITED HEALTHCARE|57.91||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Healthcare|UNITED HEALTHCARE|6,370.10||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Healthcare|UNITED HEALTHCARE|6,370.10||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Healthcare|GEHA|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Healthcare|UNITED HEALTHCARE|6,370.10||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Healthcare|UNITED HEALTHCARE OTHER|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Healthcare|TML GROUP BENEFITS|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Tricare|TRICARE EAST REGION|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|NON CONTRACTED|COMMERCIAL OTHER 1|6,370.10||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|NON CONTRACTED|COMMERCIAL OTHER 1|6,370.10||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Medicare|MEDICARE ACUTE|57.91||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Multiplan|GILSBAR INC|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Medicaid|MEDICAID|6,370.10||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Medicaid|MEDICAID HMO|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicare|HEALTHSPRING MA|57.91||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicare|BCBS MEDICARE PPO MA|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicaid|MEDICAID AMERIGROUP|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicaid|MEDICAID SUPERIOR|6,370.10||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,370.10||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicaid|MEDICAID AMERIGROUP|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicare|BCBS MEDICARE PPO MA|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Cigna|CIGNA OTHER|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|57.91||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Cigna|CIGNA|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|ChampVA|CHAMPVA CENTER|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Cigna|CIGNA|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|57.91||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Humana Medicare Advantage|HUMANA MA|57.91||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Humana Medicare Advantage|HUMANA MA|57.91||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Blue Cross HMO Specialty|BCBSTX HMO|57.91||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Blue Cross HMO Specialty|BCBSTX HMO|57.91||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Blue Cross PPO Specialty|BCBSTX OTHER|||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Blue Cross PPO Specialty|BCBSTX PPO|6,080.55||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Blue Cross PPO Specialty|BCBSTX PPO|6,370.10||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Blue Cross PPO Specialty|BCBSTX OTHER|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Aetna|AETNA PPO|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Aetna|AETNA PPO|||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Workers Compensation|UT EMPLOYEE INJURY|||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Veterans Affairs|VETERANS ADMINISTRATION|57.91||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Veterans Affairs|VETERANS ADMINISTRATION|57.91||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Medicare|MEDICARE ACUTE|57.91||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Tricare|TRICARE FOR LIFE|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Workers Compensation|WORKERS COMP PHYSICIAN|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Workers Compensation|UT EMPLOYEE INJURY|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Aenta Medicare Advantage|AETNA MEDICARE MA|6,370.10||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Workers Compensation|WORKERS COMPENSATION OTHER|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Workers Compensation|BROOKSHIRES WORKERS COMP|57.91||||||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Access Direct Platinum|HEALTHFIRST TPA UMR|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Access Direct Platinum|HEALTHFIRST TPA|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|57.91||||6,080.55||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,370.10||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|United Medicare Advantage|UHC AARP MCR HMO MA|6,370.10||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Aetna|AETNA OTHER|||||6,370.10||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||57.91||| 73721|EAP|0610|MRI JNT OF LWR EXTRE W/O|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6,080.55||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||68.91||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Blue Cross PPO Specialty|BCBSTX PPO|||||68.91||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Blue Cross HMO Specialty|BCBSTX HMO|||||68.91||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||68.91||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Managed Medicaid|MEDICAID AMERIGROUP|||||68.91||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Aetna|AETNA PPO|||||68.91||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Medicare|MEDICARE ACUTE|||||7,580.10||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Blue Cross PPO Specialty|BCBSTX OTHER|||||7,580.10||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7,580.10||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|United Medicare Advantage|UHC AARP MCR HMO MA|7,580.10||||7,580.10||| 73722|EAP|0610|MRI JOINT OF LWR EXTR W/D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,580.10||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Managed Medicare|HEALTHSPRING MA|78.34||||||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|United Healthcare|UNITED HEALTHCARE|78.34||||||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Medicare|MEDICARE ACUTE|8,617.40||||78.34||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Medicare|MEDICARE ACUTE|8,617.40||||8,617.40||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Humana Medicare Advantage|HUMANA MA|8,617.40||||||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|78.34||||||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8,617.40||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Blue Cross PPO Specialty|BCBSTX PPO|78.34||||8,225.70||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Aenta Medicare Advantage|AETNA MEDICARE MA|78.34||||||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,617.40||||8,617.40||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|United Medicare Advantage|UHC AARP MCR HMO MA|8,617.40||||||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8,617.40||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|NON CONTRACTED|COMMERCIAL OTHER 1|78.34||||||| 73723|EAP|0610|MRI JOINT LWR EXTR W/O&W/|Blue Cross PPO Specialty|BCBSTX PPO|8,225.70||||8,225.70||| 73725|EAP|0610|MR ANG LWR EXT W DYE RT|Blue Cross PPO Specialty|BCBSTX PPO|||||7,580.10||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|58,170.90|6760.84|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|67,599.14|6817.84|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|40,305.20|6817.84|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|52,673.71|6705.56|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA|58,256.96|8655.76|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Humana Medicare Advantage|HUMANA MA|121,888.63|6817.84|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|94,899.64|85549.835|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|37,102.95|6333.79|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36,108.25|142.88|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|31,968.30|5621.35|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Aetna|AETNA QHP HMO|205,453.47|19130.06|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|379.46|6612.78|85549.835|142.88|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|14,919.75|5621.35|85549.835|142.88|||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Brinson Benefits|THE HEALTH PLAN SMITH CO|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Aetna|BOON CHAPMAN|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Aetna|AETNA OTHER|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Aetna|AETNA PPO|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Humana Medicare Advantage|HUMANA MA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Cigna|CIGNA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|ChampVA|CHAMPVA CENTER|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Cigna|CIGNA|||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|United Medicare Advantage|UHC AARP WELLMED HMO MA|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|United Medicare Advantage|UHC AARP MCR HMO MA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Workers Compensation|ZURICH COMPANY|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Workers Compensation|BROOKSHIRES WORKERS COMP|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Workers Compensation|TEXAS MUTUAL INSURANCE|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicare|WELLCARE CHOICE MA|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Cigna|CIGNA OTHER|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicare|ETMC AFFILIATE HOSPITALS|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicare|HEALTHSPRING MA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicare|OTHER INSTITUTIONS|||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicare|ETMC REHABILITATION HOSPITAL|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicaid|MEDICAID HMO|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicaid|SMITH COUNTY JAIL|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicaid|CRIME VICTIMS COMPENSATION|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Aetna|AETNA QHP HMO|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Tricare|TRICARE EAST REGION|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|United Healthcare|TML GROUP BENEFITS|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|United Healthcare|UNITED HEALTHCARE|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|PHCS|HUMANA|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|PHCS|GROUP AND PENSION|||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 2|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.45||||7.45||| 74018|EAP|0320|XR-EXAM OF ABDOMEN|Medicare|MEDICARE ACUTE|6.42||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicare|MEDICARE ACUTE|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicare|MEDICARE PART B ONLY IP|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Multiplan|WEB TPA|||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|7.45||||7.45||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Rusk State Hospital|RUSK STATE HOSP|7.45||||||| 74018|EAP|0320|XR-EXAM ABDOMEN 1 VIEW|Medicaid|MEDICAID|7.45||||7.45||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Medicare|MEDICARE ACUTE|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Multiplan|NALC|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|PHCS|GROUP AND PENSION|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|NON CONTRACTED|COMMERCIAL OTHER 1|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|United Healthcare|UNITED HEALTHCARE|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.32||||||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Medicaid|MEDICAID HMO|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Tricare|TRICARE EAST REGION|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Managed Medicare|BCBS MEDICARE PPO MA|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST TPA|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Veterans Affairs|VETERANS ADMINISTRATION|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|United Medicare Advantage|UHC MEDICARE GOLD MA|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Cigna|CIGNA|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Medicaid|MEDICAID|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Cigna|CIGNA OTHER|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Humana Medicare Advantage|HUMANA MA|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|United Healthcare|UNITED HEALTHCARE OTHER|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Managed Medicaid|MEDICAID SUPERIOR|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Managed Medicaid|MEDICAID AMERIGROUP|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Aetna|AETNA PPO|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Blue Cross HMO Specialty|BCBSTX HMO|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.32||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Managed Medicare|HEALTHSPRING MA|||||7.32||| 74019|EAP|0320|XR-EXAM OF ABDOMEN|Blue Cross PPO Specialty|BCBSTX PPO|7.32||||7.32||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Blue Cross PPO Specialty|BCBSTX PPO|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Blue Cross HMO Specialty|BCBSTX HMO|5.29||||||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Aetna|AETNA PPO|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Aenta Medicare Advantage|AETNA MEDICARE MA|5.29||||||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Aetna|BH AETNA|5.29||||||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Aetna|AETNA QHP HMO|5.29||||||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Managed Medicaid|MEDICAID SUPERIOR|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Humana Medicare Advantage|HUMANA MA|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Cigna|CIGNA OTHER|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Cigna|CIGNA|||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|United Medicare Advantage|UHC MEDICARE GOLD MA|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Cigna|CIGNA|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|United Medicare Advantage|UHC AARP MCR HMO MA|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Veterans Affairs|VETERANS ADMINISTRATION|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|5.29||||||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Access Direct Platinum|HEALTHFIRST TPA|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Access Direct Platinum|HEALTHFIRST TPA UMR|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Managed Medicaid|MEDICAID AMERIGROUP|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Managed Medicare|HEALTHSPRING MA|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.29||||||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Tricare|TRICARE FOR LIFE|||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Tricare|TRICARE EAST REGION|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|United Healthcare|TML GROUP BENEFITS|||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|United Healthcare|UNITED HEALTHCARE OTHER|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|United Healthcare|UNITED HEALTHCARE|||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|NON CONTRACTED|COMMERCIAL OTHER 1|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Medicaid|MEDICAID|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Medicare|MEDICARE ACUTE|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Medicaid|LAW ENFORCEMENT OTHER|||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Medicare|MEDICARE PART B ONLY IP|5.29||||||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Medicaid|MEDICAID HMO|5.29||||5.29||| 74022|EAP|0320|XR-ABDOMEN SERIES 3VW|Managed Medicare|BCBS MEDICARE PPO MA|5.29||||||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|United Healthcare|UNITED HEALTHCARE|||||51.24||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|51.24||||51.24||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|42.70||||||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Medicare|MEDICARE ACUTE|42.70||||42.70||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Managed Medicare|HEALTHSPRING MA|51.24||||51.24||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||42.70||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|||||51.24||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|United Healthcare|UNITED HEALTHCARE|51.24||||||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|51.24||||46.97||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||51.24||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Cigna|CIGNA|42.70||||||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Humana Medicare Advantage|HUMANA MA|||||51.24||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|51.24||||||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42.70||||42.70||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||42.70||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Aetna|AETNA OTHER|51.24||||||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Aetna|AETNA PPO|42.70||||51.24||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|42.70||||||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|||||51.24||| 74150|EAP|0350|CT-ABDOMEN W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||51.24||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Cigna|CIGNA OTHER|||||55.78||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Aetna|AETNA PPO|||||55.78||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||55.78||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Managed Medicaid|MEDICAID AMERIGROUP|||||6,135.80||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6,135.80||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Humana Medicare Advantage|HUMANA MA|6,693.60||||55.78||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Cigna|CIGNA|55.78||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|6,693.60||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,693.60||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|55.78||||||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|6,693.60||||||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|6,135.80||||55.78||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||55.78||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||55.78||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Managed Medicare|BCBS MEDICARE PPO MA|||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Medicare|MEDICARE ACUTE|6,693.60||||55.78||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Rusk State Hospital|RUSK STATE HOSP|55.78||||||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Tricare|TRICARE EAST REGION|||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|Managed Medicare|HEALTHSPRING MA|||||6,693.60||| 74160|EAP|0350|CT-ABDOMEN W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|6,693.60||||6,693.60||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|PHCS|HUMANA|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Managed Medicare|HEALTHSPRING MA|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Managed Medicaid|MEDICAID SUPERIOR|63.26||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Humana Medicare Advantage|HUMANA MA|63.26||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Aetna|AETNA PPO|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Aetna|AETNA OTHER|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||63.26||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|United Healthcare|UNITED HEALTHCARE|||||63.26||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|7,591.20||||6,958.60||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Medicare|MEDICARE ACUTE|63.26||||7,591.20||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Access Direct Platinum|HEALTHFIRST TPA|||||6,958.60||| 74170|EAP|0350|CT-ABDOMEN W/O & W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|7,591.20||||7,591.20||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Blue Cross PPO Specialty|BCBSTX PPO|2,766.50||||2,766.50||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Blue Cross HMO Specialty|BCBSTX HMO|30.18||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.15||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|30.18||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.15||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Cigna|CIGNA OTHER|25.15||||||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Aenta Medicare Advantage|AETNA MEDICARE MA|2,766.50||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Cigna|CIGNA|25.15||||||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Humana Medicare Advantage|HUMANA MA|25.15||||2,766.50||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|30.18||||||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|United Medicare Advantage|UHC AARP MCR HMO MA|30.18||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30.18||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|United Medicare Advantage|UHC MEDICARE GOLD MA|2,766.50||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Veterans Affairs|VETERANS ADMINISTRATION|30.18||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Cigna|CIGNA|||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Managed Medicaid|MEDICAID SUPERIOR|30.18||||||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Access Direct Platinum|HEALTHFIRST TPA|25.15||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|30.18||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Aetna|AETNA OTHER|||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Medicaid|MEDICAID|2,766.50||||2,766.50||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Managed Medicare|BCBS MEDICARE PPO MA|||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.15||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Managed Medicare|HEALTHSPRING MA|25.15||||30.18||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Tricare|TRICARE EAST REGION|25.15||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|United Healthcare|UNITED HEALTHCARE OTHER|||||25.15||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Medicare|MEDICARE ACUTE|30.18||||2,766.50||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Medicare|MEDICARE PART B ONLY IP|30.18||||||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|NON CONTRACTED|COMMERCIAL OTHER 2|30.18||||||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|NON CONTRACTED|COMMERCIAL OTHER 1|25.15||||||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|Medicare|UTSW MC KIDNEY PROGRAM|||||2,766.50||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|United Healthcare|GOLDEN RULE|30.18||||||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|United Healthcare|UNITED HEALTHCARE|||||2,766.50||| 74174|EAP|0350|CT ANGIO ABD & PEL W &/OR|UTMB|UTMB CORRECTIONAL MANAGED CARE|30.18||||||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Medicare|MEDICARE ACUTE|8,488.80||||70.74||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Managed Medicare|HEALTHSPRING MA|||||8,488.80||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Medicaid|CRIME VICTIMS COMPENSATION|8,488.80||||||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|70.74||||||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8,488.80||||||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|United Medicare Advantage|UHC AARP MCR HMO MA|8,488.80||||||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Blue Cross HMO Specialty|BCBSTX HMO|||||70.74||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Blue Cross PPO Specialty|BCBSTX PPO|||||8,488.80||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,488.80||||70.74||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8,488.80||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Humana Medicare Advantage|HUMANA MA|8,488.80||||70.74||| 74175|EAP|0350|CT-ANGIO ABDOM W/O & W/DY|Medicaid|MEDICAID|8,488.80||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|93.94||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Blue Cross PPO Specialty|BCBSTX PPO|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Blue Cross HMO Specialty|BCBSTX HMO|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Aetna|AETNA QHP HMO|102.48||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Aetna|BOON CHAPMAN|85.40||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Managed Medicaid|MEDICAID AMERIGROUP|102.48||||85.40||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Cigna|CIGNA|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Aenta Medicare Advantage|AETNA MEDICARE MA|85.40||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|ChampVA|CHAMPVA CENTER|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Cigna|CIGNA|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|United Medicare Advantage|UHC MEDICARE GOLD MA|85.40||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|United Medicare Advantage|UHC AARP MCR HMO MA|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Workers Compensation|UT EMPLOYEE INJURY|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Access Direct Platinum|HEALTHFIRST TPA|93.94||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Workers Compensation|WORKERS COMPENSATION OTHER|93.94||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Veterans Affairs|VETERANS ADMINISTRATION|102.48||||85.40||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|85.40||||85.40||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|85.40||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicaid|MEDICAID HMO|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Workers Compensation|TEXAS MUTUAL INSURANCE|85.40||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicaid|SMITH COUNTY JAIL|85.40||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Humana Medicare Advantage|HUMANA MA|85.40||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|102.48||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicaid|COUNTY INDIGENT HEALTH OTHER|85.40||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicaid|CRIME VICTIMS COMPENSATION|85.40||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Cigna|CIGNA OTHER|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||85.40||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicaid|MEDICAID|85.40||||85.40||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Managed Medicare|HEALTHSPRING MA|85.40||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Aetna|AETNA PPO|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Aetna|AETNA OTHER|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Managed Medicaid|MEDICAID SUPERIOR|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|85.40||||85.40||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||93.94||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Managed Medicare|WELLCARE CHOICE MA|102.48||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Managed Medicare|BCBS MEDICARE PPO MA|85.40||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|United Healthcare|TML GROUP BENEFITS|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|United Healthcare|UNITED HEALTHCARE|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|United Healthcare|UNITED HEALTHCARE OTHER|85.40||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Blue Cross PPO Specialty|BCBSTX OTHER|93.94||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Tricare|TRICARE FOR LIFE|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|UTMB|UTMB CORRECTIONAL MANAGED CARE|93.94||||85.40||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Tricare|TRICARE EAST REGION|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|PHCS|GROUP AND PENSION|85.40||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|NON CONTRACTED|COMMERCIAL OTHER 1|102.48||||85.40||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|PHCS|HUMANA|102.48||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicare|MEDICARE PART B ONLY IP|85.40||||||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|United Healthcare|GOLDEN RULE|||||85.40||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Managed Medicare|OTHER INSTITUTIONS|||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicare|MEDICARE ACUTE|102.48||||102.48||| 74176|EAP|0350|CT-ABD & PELVIS W/O CONTR|Medicare|UTSW MC KIDNEY PROGRAM|||||102.48||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Healthcare|TML GROUP BENEFITS|||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicare|MA PART B ONLY IP|111.57||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicare|BCBS MEDICARE PPO MA|111.57||||12,272.70||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicare|WELLCARE CHOICE MA|||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicare|HEALTHSPRING MA|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|SUPERIOR HEALTHPLAN CHIP|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|MEDICAID|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|LAW ENFORCEMENT OTHER|||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|MEDICAID BCBSTX|||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|MOLINA HEALTHCARE OF TEXAS|111.57||||12,272.70||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|SMITH COUNTY INDIGENT HEALTH|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|SMITH COUNTY JAIL|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|COUNTY INDIGENT HEALTH OTHER|13,388.40||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|MEDICAID HMO|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|12,272.70||||12,272.70||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Access Direct Platinum|HEALTHFIRST TPA|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Workers Compensation|BROOKSHIRES WORKERS COMP|111.57||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Veterans Affairs|VETERANS ADMINISTRATION|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Workers Compensation|UT EMPLOYEE INJURY|111.57||||12,272.70||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|111.57||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Workers Compensation|TRAVELERS INSURANCE COMPANY|12,272.70||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Workers Compensation|TEXAS MUTUAL INSURANCE|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Medicare Advantage|UHC AARP MCR HMO MA|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UMR|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Workers Compensation|WORKERS COMPENSATION OTHER|12,272.70||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Workers Compensation|GALLAGHER BASSETT|||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Medicare Advantage|UHC AARP WELLMED HMO MA|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Humana Medicare Advantage|HUMANA MA|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicaid|CRIME VICTIMS COMPENSATION|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Magellan Behavioral Health|BH MAGELLAN|||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Cigna|CIGNA|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|ChampVA|CHAMPVA CENTER|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Cigna|CIGNA OTHER|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|111.57||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicare|OTHER INSTITUTIONS|||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicaid|MEDICAID SUPERIOR|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Workers Compensation|ZURICH COMPANY|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Aenta Medicare Advantage|AETNA MEDICARE MA|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicare|ETMC REHABILITATION HOSPITAL|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Aetna|BOON CHAPMAN|12,272.70||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Aetna|AETNA PPO|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Aetna|BH AETNA|111.57||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Aetna|AETNA OTHER|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Healthcare|GEHA|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Blue Cross PPO Specialty|BCBSTX OTHER|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Managed Medicaid|MEDICAID AMERIGROUP|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Cigna|CIGNA|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Brinson Benefits|THE HEALTH PLAN SMITH CO|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicare|MEDICARE PART B ONLY IP|12,272.70||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Multiplan|NALC|111.57||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Medicare|MEDICARE ACUTE|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Multiplan|WEB TPA|||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Optum Behavioral Health|BH OPTUM UHC|111.57||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 1|111.57||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 4|||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|PHCS|HUMANA INSURANCE|||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 2|13,388.40||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Rusk State Hospital|RUSK STATE HOSP|111.57||||||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|PHCS|GROUP AND PENSION|||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|PHCS|MULTIPLAN PHCS|||||13,388.40||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|PHCS|HUMANA|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Tricare|TRICARE FOR LIFE|||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|UTMB|UTMB CORRECTIONAL MANAGED CARE|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|Tricare|TRICARE EAST REGION|111.57||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Healthcare|GOLDEN RULE|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Healthcare|UNITED HEALTHCARE|||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Healthcare|UNITED HEALTHCARE|13,388.40||||111.57||| 74177|EAP|0350|CT-ABD & PELV W/CONTRAST|United Healthcare|UNITED HEALTHCARE OTHER|12,272.70||||111.57||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Blue Cross PPO Specialty|BCBSTX OTHER|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Blue Cross PPO Specialty|BCBSTX PPO|15,182.40||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Blue Cross HMO Specialty|BCBSTX HMO|126.52||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Aetna|AETNA PPO|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Aetna|AETNA QHP HMO|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Cigna|CIGNA|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Humana Medicare Advantage|HUMANA MA|126.52||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|United Medicare Advantage|UHC MEDICARE GOLD MA|15,182.40||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|United Medicare Advantage|UHC AARP MCR HMO MA|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Cigna|CIGNA OTHER|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13,917.20||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Managed Medicaid|MEDICAID SUPERIOR|||||13,917.20||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|126.52||||126.52||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Access Direct Platinum|HEALTHFIRST TPA|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||126.52||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Medicaid|SMITH COUNTY JAIL|126.52||||||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Medicaid|MEDICAID|15,182.40||||||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||13,917.20||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Managed Medicare|BCBS MEDICARE PPO MA|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Managed Medicare|HEALTHSPRING MA|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|United Healthcare|GEHA|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|United Healthcare|GOLDEN RULE|||||126.52||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|United Healthcare|UNITED HEALTHCARE OTHER|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|United Healthcare|UNITED HEALTHCARE|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|United Healthcare|TML GROUP BENEFITS|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|United Healthcare|UNITED HEALTHCARE|||||13,917.20||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|PHCS|HUMANA|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|NON CONTRACTED|COMMERCIAL OTHER 1|||||15,182.40||| 74178|EAP|0350|CT-ABD & PELV 1/> REGNS|Medicare|MEDICARE ACUTE|126.52||||15,182.40||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Multiplan|TRUSTMARK|57.91||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Medicare|MEDICARE ACUTE|57.91||||6,370.10||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,370.10||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|United Healthcare|UNITED HEALTHCARE|6,370.10||||6,080.55||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|United Healthcare|UNITED HEALTHCARE OTHER|6,370.10||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Managed Medicare|BCBS MEDICARE PPO MA|||||6,370.10||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|57.91||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Medicaid|MEDICAID|57.91||||6,370.10||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||57.91||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|6,370.10||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Workers Compensation|BROOKSHIRES WORKERS COMP|57.91||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Veterans Affairs|VETERANS ADMINISTRATION|6,370.10||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|57.91||||6,080.55||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|6,370.10||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||57.91||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Access Direct Platinum|HEALTHFIRST TPA|57.91||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,370.10||||6,370.10||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|57.91||||6,080.55||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|United Medicare Advantage|UHC AARP MCR HMO MA|6,370.10||||57.91||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|57.91||||57.91||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Managed Medicare|HEALTHSPRING MA|||||6,080.55||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Humana Medicare Advantage|HUMANA MA|57.91||||57.91||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Cigna|CIGNA|6,370.10||||6,080.55||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|57.91||||6,080.55||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Managed Medicaid|MEDICAID SUPERIOR|6,080.55||||6,080.55||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,370.10||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Managed Medicaid|MEDICAID AMERIGROUP|6,080.55||||57.91||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Aetna|AETNA PPO|||||57.91||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,080.55||||6,370.10||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|NON CONTRACTED|COMMERCIAL OTHER 1|||||6,080.55||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Aetna|AETNA OTHER|57.91||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Aetna|BOON CHAPMAN|57.91||||||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|57.91||||6,370.10||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Blue Cross HMO Specialty|BCBSTX HMO|57.91||||6,370.10||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Blue Cross PPO Specialty|BCBSTX PPO|57.91||||6,080.55||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||57.91||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||57.91||| 74181|EAP|0610|MRI ABDOMEN W/O DYE|Blue Cross PPO Specialty|BCBSTX OTHER|57.91||||||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Blue Cross PPO Specialty|BCBSTX PPO|8,617.40||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Blue Cross PPO Specialty|BCBSTX OTHER|||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Aenta Medicare Advantage|AETNA MEDICARE MA|8,617.40||||8,225.70||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Aetna|BOON CHAPMAN|78.34||||||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Aetna|AETNA OTHER|8,617.40||||||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,617.40||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8,617.40||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,225.70||||||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Cigna|CIGNA|||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Cigna|CIGNA OTHER|78.34||||||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Humana Medicare Advantage|HUMANA MA|8,617.40||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|United Medicare Advantage|UHC AARP MCR HMO MA|8,617.40||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Aetna|AETNA PPO|||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|United Medicare Advantage|UHC MEDICARE GOLD MA|8,225.70||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Blue Cross HMO Specialty|BCBSTX HMO|78.34||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,617.40||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Access Direct Platinum|HEALTHFIRST TPA|||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Workers Compensation|WORKERS COMPENSATION OTHER|8,617.40||||||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Veterans Affairs|VETERANS ADMINISTRATION|78.34||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Medicaid|MEDICAID|78.34||||||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Managed Medicare|HEALTHSPRING MA|78.34||||8,225.70||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8,617.40||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Managed Medicare|BCBS MEDICARE PPO MA|||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|United Healthcare|UNITED HEALTHCARE|78.34||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|United Healthcare|UNITED HEALTHCARE OTHER|||||8,617.40||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Tricare|TRICARE EAST REGION|||||78.34||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|8,225.70||||||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|NON CONTRACTED|COMMERCIAL OTHER 1|||||8,225.70||| 74183|EAP|0610|MRI ABDOMEN W/O & W/DYE|Medicare|MEDICARE ACUTE|78.34||||8,617.40||| 74185|EAP|0610|MRI ANGIO ABDOM W OR W/O|Medicare|MEDICARE ACUTE|57.91||||57.91||| 74185|EAP|0610|MRI ANGIO ABDOM W OR W/O|United Healthcare|UNITED HEALTHCARE OTHER|||||6,370.10||| 74185|EAP|0610|MRI ANGIO ABDOM W OR W/O|United Healthcare|GEHA|||||57.91||| 74185|EAP|0610|MRI ANGIO ABDOM W OR W/O|United Medicare Advantage|UHC AARP MCR HMO MA|||||57.91||| 74185|EAP|0610|MRI ANGIO ABDOM W OR W/O|Cigna|CIGNA|||||57.91||| 74185|EAP|0610|MRI ANGIO ABDOM W OR W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,370.10||| 742|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|70,304.60|11638.06|18422.81|214.32|||| 742|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|138,148.07|214.32|18422.81|214.32|||| 742|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|149,302.81|10511.86|18422.81|214.32|||| 742|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC|Cigna|CIGNA|62,905.05|17384.96|18422.81|214.32|||| 742|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|103,624.30|14488.88|18422.81|214.32|||| 742|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC|Medicare|MEDICARE ACUTE|55,215.73|10554.82|18422.81|214.32|||| 742|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC|Texas Workforce Commission|DIS DETER SERV (DDS)|61,409.38|18422.81|18422.81|214.32|||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Tricare|TRICARE EAST REGION|||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|United Healthcare|UNITED HEALTHCARE OTHER|||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Medicare|MEDICARE ACUTE|8.46||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|PHCS|HUMANA|8.46||||||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|NON CONTRACTED|COMMERCIAL OTHER 1|8.46||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|PHCS|GROUP AND PENSION|||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Managed Medicare|HEALTHSPRING MA|8.46||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Medicaid|CRIME VICTIMS COMPENSATION|8.46||||||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Medicaid|MEDICAID|8.46||||||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|United Healthcare|UNITED HEALTHCARE|||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|United Medicare Advantage|UHC MEDICARE GOLD MA|8.46||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.46||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|United Medicare Advantage|UHC AARP MCR HMO MA|8.46||||||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Veterans Affairs|VETERANS ADMINISTRATION|8.46||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.46||||||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Humana Medicare Advantage|HUMANA MA|8.46||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Aetna|AETNA PPO|8.46||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.46||||8.46||| 74220|EAP|0320|XR-ESOPHAG B/SWAL|Blue Cross PPO Specialty|BCBSTX PPO|8.46||||8.46||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Blue Cross HMO Specialty|BCBSTX HMO|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Blue Cross PPO Specialty|BCBSTX OTHER|||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Aenta Medicare Advantage|AETNA MEDICARE MA|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Aetna|AETNA OTHER|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Aetna|AETNA PPO|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Humana Medicare Advantage|HUMANA MA|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Managed Medicaid|MEDICAID SUPERIOR|||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Access Direct Platinum|HEALTHFIRST TPA UMR|||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Access Direct Platinum|HEALTHFIRST TPA|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Workers Compensation|WORKERS COMPENSATION OTHER|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Veterans Affairs|VETERANS ADMINISTRATION|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|United Medicare Advantage|UHC MEDICARE GOLD MA|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Managed Medicaid|MEDICAID AMERIGROUP|||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|United Medicare Advantage|UHC AARP MCR HMO MA|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Medicaid|MEDICAID|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Medicaid|MEDICAID HMO|||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Medicaid|SMITH COUNTY JAIL|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Blue Cross PPO Specialty|BCBSTX PPO|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Managed Medicare|HEALTHSPRING MA|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Managed Medicare|ETMC AFFILIATE HOSPITALS|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Managed Medicare|BCBS MEDICARE PPO MA|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Managed Medicare|WELLCARE CHOICE MA|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|NON CONTRACTED|COMMERCIAL OTHER 1|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Medicare|MEDICARE PART B ONLY IP|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Medicare|MEDICARE ACUTE|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Multiplan|WEB TPA|||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|United Healthcare|UNITED HEALTHCARE|||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|United Healthcare|UNITED HEALTHCARE OTHER|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|United Healthcare|UNITED HEALTHCARE|11.20||||11.20||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.20||||||| 74230|EAP|0320|XR-CIN/VID XRAY THROAT/ES|Tricare|TRICARE EAST REGION|11.20||||11.20||| 74240|EAP|0320|XR-UPPER GI|Tricare|TRICARE EAST REGION|10.63||||10.63||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|United Healthcare|UNITED HEALTHCARE|10.63||||4.92||| 74240|EAP|0320|XR-UPPER GI|United Healthcare|UNITED HEALTHCARE|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|United Healthcare|UNITED HEALTHCARE OTHER|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|United Healthcare|UNITED HEALTHCARE|||||10.63||| 74240|EAP|0320|XR-UPPER GI|Medicare|MEDICARE PART B ONLY IP|10.63||||||| 74240|EAP|0320|XR-UPPER GI|Medicare|MEDICARE ACUTE|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|PHCS|GROUP AND PENSION|||||10.63||| 74240|EAP|0320|XR-UPPER GI|NON CONTRACTED|COMMERCIAL OTHER 1|10.63||||||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|NON CONTRACTED|COMMERCIAL OTHER 1|4.92||||||| 74240|EAP|0320|XR-UPPER GI|Managed Medicare|HEALTHSPRING MA|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|Medicaid|CRIME VICTIMS COMPENSATION|10.63||||||| 74240|EAP|0320|XR-UPPER GI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||10.63||| 74240|EAP|0320|XR-UPPER GI|United Medicare Advantage|UHC MEDICARE GOLD MA|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.63||||10.63||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|United Medicare Advantage|UHC MEDICARE GOLD MA|10.63||||4.92||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|United Medicare Advantage|UHC AARP MCR HMO MA|4.92||||4.92||| 74240|EAP|0320|XR-UPPER GI|Veterans Affairs|VETERANS ADMINISTRATION|10.63||||||| 74240|EAP|0320|XR-UPPER GI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|Access Direct Platinum|HEALTHFIRST TPA UMR|10.63||||||| 74240|EAP|0320|XR-UPPER GI|United Medicare Advantage|UHC AARP MCR HMO MA|10.63||||4.92||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|Managed Medicare|HEALTHSPRING MA|10.63||||4.92||| 74240|EAP|0320|XR-UPPER GI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10.63||||||| 74240|EAP|0320|XR-UPPER GI|Access Direct Platinum|HEALTHFIRST TPA|10.63||||||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.63||||4.92||| 74240|EAP|0320|XR-UPPER GI|Managed Medicaid|MEDICAID SUPERIOR|10.63||||10.63||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|Medicare|MEDICARE ACUTE|4.92||||4.92||| 74240|EAP|0320|XR-UPPER GI|Managed Medicaid|MEDICAID AMERIGROUP|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.63||||||| 74240|EAP|0320|XR-UPPER GI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|Cigna|CIGNA OTHER|10.63||||||| 74240|EAP|0320|XR-UPPER GI|Cigna|CIGNA|10.63||||||| 74240|EAP|0320|XR-UPPER GI|Cigna|CIGNA|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|ChampVA|CHAMPVA CENTER|10.63||||||| 74240|EAP|0320|XR-UPPER GI|Humana Medicare Advantage|HUMANA MA|10.63||||10.63||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|Humana Medicare Advantage|HUMANA MA|4.92||||4.92||| 74240|EAP|0320|XR-UPPER GI|Aenta Medicare Advantage|AETNA MEDICARE MA|10.63||||||| 74240|EAP|0320|XR-UPPER GI|Aetna|AETNA PPO|10.63||||10.63||| 74240|EAP|0320|XR-UPPER GI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.63||||10.63||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.92||||4.92||| 74240|EAP|0320|XR-UPPER GI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||10.63||| 74240|EAP|0320|XR-UPPER GI|Blue Cross PPO Specialty|BCBSTX PPO|10.63||||10.63||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|Blue Cross PPO Specialty|BCBSTX PPO|10.63||||4.92||| 74240|EAP|0320|XR XM UPR GI TRC 1CNTRST|Blue Cross HMO Specialty|BCBSTX HMO|4.92||||4.92||| 74240|EAP|0320|XR-UPPER GI|Blue Cross HMO Specialty|BCBSTX HMO|4.92||||10.63||| 74241|EAP|0320||Blue Cross HMO Specialty|BCBSTX HMO|||||10.63||| 74241|EAP|0320||Blue Cross PPO Specialty|BCBSTX PPO|10.63||||10.63||| 74241|EAP|0320||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10.63||||||| 74241|EAP|0320||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.63||||10.63||| 74241|EAP|0320||Aetna|AETNA OTHER|10.63||||||| 74241|EAP|0320||Aetna|AETNA PPO|10.63||||||| 74241|EAP|0320||Humana Medicare Advantage|HUMANA MA|10.63||||10.63||| 74241|EAP|0320||Cigna|CIGNA|10.63||||||| 74241|EAP|0320||Managed Medicaid|MEDICAID AMERIGROUP|||||10.63||| 74241|EAP|0320||Managed Medicaid|MEDICAID SUPERIOR|||||10.63||| 74241|EAP|0320||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|10.63||||||| 74241|EAP|0320||ChampVA|CHAMPVA CENTER|10.63||||||| 74241|EAP|0320||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10.63||||||| 74241|EAP|0320||Veterans Affairs|VETERANS ADMINISTRATION|10.63||||||| 74241|EAP|0320||United Medicare Advantage|UHC MEDICARE GOLD MA|10.63||||||| 74241|EAP|0320||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.63||||10.63||| 74241|EAP|0320||Medicaid|MEDICAID|10.63||||||| 74241|EAP|0320||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.63||||10.63||| 74241|EAP|0320||Managed Medicare|HEALTHSPRING MA|10.63||||10.63||| 74241|EAP|0320||Managed Medicare|OTHER INSTITUTIONS|||||10.63||| 74241|EAP|0320||Aenta Medicare Advantage|AETNA MEDICARE MA|||||10.63||| 74241|EAP|0320||NON CONTRACTED|COMMERCIAL OTHER 1|10.63||||||| 74241|EAP|0320||Medicare|MEDICARE ACUTE|10.63||||10.63||| 74241|EAP|0320||Medicare|MEDICARE PART B ONLY IP|10.63||||||| 74241|EAP|0320||Multiplan|WEB TPA|10.63||||10.63||| 74241|EAP|0320||United Healthcare|UNITED HEALTHCARE|10.63||||||| 74241|EAP|0320||United Healthcare|UNITED HEALTHCARE OTHER|10.63||||||| 74241|EAP|0320||United Healthcare|UNITED HEALTHCARE|||||10.63||| 74241|EAP|0320||UTMB|UTMB CORRECTIONAL MANAGED CARE|10.63||||||| 74241|EAP|0320||Tricare|TRICARE EAST REGION|||||10.63||| 74245|EAP|0320|XR UGI AND SM BOWEL W/O A|Medicare|MEDICARE ACUTE|||||20.43||| 74245|EAP|0320|XR UGI AND SM BOWEL W/O A|Managed Medicare|BCBS MEDICARE PPO MA|||||20.43||| 74245|EAP|0320|XR UGI AND SM BOWEL W/O A|Medicaid|MEDICAID|20.43||||||| 74245|EAP|0320|XR UGI AND SM BOWEL W/O A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.43||||||| 74245|EAP|0320|XR UGI AND SM BOWEL W/O A|Blue Cross PPO Specialty|BCBSTX PPO|||||20.43||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.92||||4.92||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.92||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|Aenta Medicare Advantage|AETNA MEDICARE MA|4.92||||||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|Managed Medicaid|MEDICAID AMERIGROUP|4.92||||||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.92||||||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|Blue Cross PPO Specialty|BCBSTX PPO|4.92||||4.92||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.92||||4.92||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|Blue Cross HMO Specialty|BCBSTX HMO|4.92||||||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|Medicare|MEDICARE ACUTE|4.92||||4.92||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.92||||||| 74246|EAP|0020|X-RAY XM UPR GI TRC 2CNTR|United Medicare Advantage|UHC MEDICARE GOLD MA|4.92||||||| 74247|EAP|0320|XR-UPPER GI W AIR-|Blue Cross PPO Specialty|BCBSTX PPO|||||12.08||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Medicare|MEDICARE ACUTE|2.50||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|United Healthcare|UNITED HEALTHCARE|||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Managed Medicare|HEALTHSPRING MA|||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 74248|EAP|0320|X-RAY SM INT F-THRU STD|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 74249|EAP|0320|XR-UPPER GI W SM BOWEL|Blue Cross PPO Specialty|BCBSTX PPO|18.42||||18.42||| 74249|EAP|0320|XR-UPPER GI W SM BOWEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||18.42||| 74249|EAP|0320|XR-UPPER GI W SM BOWEL|Humana Medicare Advantage|HUMANA MA|18.42||||||| 74249|EAP|0320|XR-UPPER GI W SM BOWEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||18.42||| 74249|EAP|0320|XR-UPPER GI W SM BOWEL|Veterans Affairs|VETERANS ADMINISTRATION|18.42||||||| 74249|EAP|0320|XR-UPPER GI W SM BOWEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|18.42||||||| 74249|EAP|0320|XR-UPPER GI W SM BOWEL|Medicaid|MEDICAID|18.42||||||| 74249|EAP|0320|XR-UPPER GI W SM BOWEL|Medicare|MEDICARE ACUTE|18.42||||18.42||| 74249|EAP|0320|XR-UPPER GI W SM BOWEL|NON CONTRACTED|COMMERCIAL OTHER 1|18.42||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Tricare|TRICARE EAST REGION|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|United Healthcare|UNITED HEALTHCARE OTHER|9.31||||9.31||| 74250|EAP|0320|XR-SMALL BOWEL SER|NON CONTRACTED|COMMERCIAL OTHER 1|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Medicare|MEDICARE ACUTE|9.31||||9.31||| 74250|EAP|0320|XR-SMALL BOWEL SER|Managed Medicare|HEALTHSPRING MA|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Managed Medicare|WELLCARE CHOICE MA|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Medicaid|COUNTY INDIGENT HEALTH OTHER|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.31||||9.31||| 74250|EAP|0320|XR-SMALL BOWEL SER|United Medicare Advantage|UHC MEDICARE GOLD MA|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|United Medicare Advantage|UHC AARP WELLMED HMO MA|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Access Direct Platinum|HEALTHFIRST TPA|||||9.31||| 74250|EAP|0320|XR-SMALL BOWEL SER|Workers Compensation|WORKERS COMPENSATION OTHER|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Medicare|MEDICARE PART B ONLY IP|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Veterans Affairs|VETERANS ADMINISTRATION|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Managed Medicaid|MEDICAID SUPERIOR|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Managed Medicaid|MEDICAID AMERIGROUP|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Humana Medicare Advantage|HUMANA MA|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Aetna|AETNA OTHER|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Aetna|BOON CHAPMAN|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Aetna|AETNA PPO|||||9.31||| 74250|EAP|0320|XR-SMALL BOWEL SER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.31||| 74250|EAP|0320|XR-SMALL BOWEL SER|Blue Cross HMO Specialty|BCBSTX HMO|9.31||||||| 74250|EAP|0320|XR-SMALL BOWEL SER|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.31||||9.31||| 74250|EAP|0320|XR-SMALL BOWEL SER|Blue Cross PPO Specialty|BCBSTX PPO|9.31||||9.31||| 74270|EAP|0320|XR-COLON BAR/ENE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|Blue Cross PPO Specialty|BCBSTX OTHER|12.21||||||| 74270|EAP|0320|XR-COLON BAR/ENE|Blue Cross HMO Specialty|BCBSTX HMO|12.21||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|Blue Cross PPO Specialty|BCBSTX PPO|12.21||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.21||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|Aetna|BOON CHAPMAN|12.21||||||| 74270|EAP|0320|XR-COLON BAR/ENE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|Cigna|CIGNA|||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|Humana Medicare Advantage|HUMANA MA|12.21||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|Managed Medicaid|MEDICAID AMERIGROUP|||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.21||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|United Medicare Advantage|UHC AARP MCR HMO MA|||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|Managed Medicare|HEALTHSPRING MA|12.21||||||| 74270|EAP|0320|XR-COLON BAR/ENE|Medicare|MEDICARE ACUTE|12.21||||12.21||| 74270|EAP|0320|XR-COLON BAR/ENE|United Healthcare|UNITED HEALTHCARE|||||12.21||| 74280|EAP|0320|XR-COLON W/DBL AIR-CONT|Medicare|MEDICARE ACUTE|||||15.98||| 74280|EAP|0320|XR-COLON W/DBL AIR-CONT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||15.98||| 74280|EAP|0320|XR-COLON W/DBL AIR-CONT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||15.98||| 74280|EAP|0320|XR-COLON W/DBL AIR-CONT|Humana Medicare Advantage|HUMANA MA|||||15.98||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49,301.99|6577.915|13593.65|5557.93|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|72,252.56|6439.24|13593.65|5557.93|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|47,593.80|7574.92|13593.65|5557.93|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Cigna|CIGNA|52,183.23|11818.07|13593.65|5557.93|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Medicaid|MEDICAID|61,583.71|5557.93|13593.65|5557.93|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|United Healthcare|TML GROUP BENEFITS|50,188.67|13593.65|13593.65|5557.93|||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|NON CONTRACTED|COMMERCIAL OTHER 1|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Texas Workforce Commission|DIS DETER SERV (DDS)|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Medicare|MEDICARE ACUTE|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|United Healthcare|UNITED HEALTHCARE|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|United Healthcare|UNITED HEALTHCARE OTHER|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Tricare|TRICARE SOUTH PHYSICIAN|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Tricare|TRICARE FOR LIFE|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Medicaid|MEDICAID|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|United Medicare Advantage|UHC MEDICARE GOLD MA|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|United Medicare Advantage|UHC AARP MCR HMO MA|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Managed Medicare|HEALTHSPRING MA|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Veterans Affairs|VETERANS ADMINISTRATION|6.93||||||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Managed Medicaid|MEDICAID AMERIGROUP|6.93||||||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Managed Medicaid|MEDICAID SUPERIOR|6.93||||||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Tricare|TRICARE EAST REGION|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Humana Medicare Advantage|HUMANA MA|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Cigna|CIGNA|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Cigna|CIGNA|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Blue Cross PPO Specialty|BCBSTX PPO|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Blue Cross PPO Specialty|BCBSTX OTHER|6.93||||||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Blue Cross HMO Specialty|BCBSTX HMO|6.93||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Aetna|BOON CHAPMAN|6.93||||||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Aetna|AETNA OTHER|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Aetna|AETNA PPO|||||6.93||| 74300|EAP|0320|XR-OR CHOLANGIOGRAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.93||||6.93||| 74329|EAP|0320|XR-ENDOSCOP PANCREAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22.51||||||| 74329|EAP|0320|XR-ENDOSCOP PANCREAT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22.51||||||| 74329|EAP|0320|XR-ENDOSCOP PANCREAT|Managed Medicaid|MEDICAID SUPERIOR|22.51||||||| 74329|EAP|0320|XR-ENDOSCOP PANCREAT|Veterans Affairs|VETERANS ADMINISTRATION|22.51||||||| 74329|EAP|0320|XR-ENDOSCOP PANCREAT|United Medicare Advantage|UHC MEDICARE GOLD MA|22.51||||||| 74329|EAP|0320|XR-ENDOSCOP PANCREAT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|22.51||||||| 74329|EAP|0320|XR-ENDOSCOP PANCREAT|Managed Medicare|HEALTHSPRING MA|22.51||||||| 74329|EAP|0320|XR-ENDOSCOP PANCREAT|UTMB|UTMB CORRECTIONAL MANAGED CARE|22.51||||||| 74329|EAP|0320|XR-ENDOSCOP PANCREAT|Medicare|MEDICARE ACUTE|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Medicare|MEDICARE ACUTE|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|United Healthcare|UNITED HEALTHCARE OTHER|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|UTMB|UTMB CORRECTIONAL MANAGED CARE|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|Medicaid|MEDICAID|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicare|WELLCARE CHOICE MA|||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicare|HEALTHSPRING MA|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|United Medicare Advantage|UHC MEDICARE GOLD MA|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|United Medicare Advantage|UHC AARP MCR HMO MA|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicare|OTHER INSTITUTIONS|||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Access Direct Platinum|HEALTHFIRST TPA UMR|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|United Healthcare|UNITED HEALTHCARE|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Workers Compensation|BROOKSHIRES WORKERS COMP|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|Veterans Affairs|VETERANS ADMINISTRATION|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|Cigna|CIGNA|||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Humana Medicare Advantage|HUMANA MA|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicaid|MEDICAID AMERIGROUP|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Managed Medicaid|MEDICAID SUPERIOR|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Blue Cross HMO Specialty|BCBSTX HMO|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Blue Cross PPO Specialty|BCBSTX PPO|22.51||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Blue Cross PPO Specialty|BCBSTX OTHER|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||22.51||| 74330|EAP|0320|XR ERCP GUIDANCE|Aetna|AETNA PPO|22.51||||||| 74330|EAP|0320|XR ERCP GUIDANCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22.51||||22.51||| 744|DRG||D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W CC/MCC|Medicare|MEDICARE ACUTE|107,500.03|10933.7|11033.6|10933.7|||| 744|DRG||D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|55,037.72|11033.6|11033.6|10933.7|||| 74400|EAP|0320|XR-UROGRAM IVP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.08||| 74400|EAP|0320|XR-UROGRAM IVP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||12.08||| 74400|EAP|0320|XR-UROGRAM IVP|Blue Cross PPO Specialty|BCBSTX PPO|||||12.08||| 74400|EAP|0320|XR-UROGRAM IVP|Blue Cross HMO Specialty|BCBSTX HMO|||||12.08||| 74400|EAP|0320|XR-UROGRAM IVP|Humana Medicare Advantage|HUMANA MA|||||12.08||| 74400|EAP|0320|XR-UROGRAM IVP|Veterans Affairs|VETERANS ADMINISTRATION|||||12.08||| 74400|EAP|0320|XR-UROGRAM IVP|Medicare|MEDICARE ACUTE|||||12.08||| 74400|EAP|0320|XR-UROGRAM IVP|United Healthcare|UNITED HEALTHCARE OTHER|||||12.08||| 74420|EAP|0320|XR-URETHROGRAM - RETROGR|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.82||||||| 74420|EAP|0320|XR-URETHROGRAM - RETROGR|Blue Cross PPO Specialty|BCBSTX PPO|18.82||||||| 74430|EAP|0320|XR-CYSTOGRAM|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|Access Direct Platinum|HEALTHFIRST TPA|7.51||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|Managed Medicaid|MEDICAID AMERIGROUP|||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|Humana Medicare Advantage|HUMANA MA|7.51||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|Blue Cross HMO Specialty|BCBSTX HMO|7.51||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|Blue Cross PPO Specialty|BCBSTX PPO|||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|Medicaid|CRIME VICTIMS COMPENSATION|7.51||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|Medicare|MEDICARE ACUTE|7.51||||7.51||| 74430|EAP|0320|XR-CYSTOGRAM|United Healthcare|UNITED HEALTHCARE OTHER|7.51||||7.51||| 74450|EAP|0320|XR URETHRA/BLADDER RETROG|Medicare|MEDICARE ACUTE|||||13.84||| 74450|EAP|0320|XR URETHRA/BLADDER RETROG|Managed Medicare|HEALTHSPRING MA|||||13.84||| 74450|EAP|0320|XR URETHRA/BLADDER RETROG|Blue Cross HMO Specialty|BCBSTX HMO|||||13.84||| 74450|EAP|0320|XR URETHRA/BLADDER RETROG|Humana Medicare Advantage|HUMANA MA|||||13.84||| 74450|EAP|0320|XR URETHRA/BLADDER RETROG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||13.84||| 74450|EAP|0320|XR URETHRA/BLADDER RETROG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||13.84||| 74450|EAP|0320|XR URETHRA/BLADDER RETROG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||13.84||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|United Medicare Advantage|UHC AARP MCR HMO MA|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Managed Medicaid|MEDICAID AMERIGROUP|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Managed Medicaid|MEDICAID SUPERIOR|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Cigna|CIGNA OTHER|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Cigna|CIGNA|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Humana Medicare Advantage|HUMANA MA|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Aetna|AETNA PPO|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Blue Cross PPO Specialty|BCBSTX PPO|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Blue Cross PPO Specialty|BCBSTX OTHER|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Blue Cross HMO Specialty|BCBSTX HMO|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Medicaid|MEDICAID|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Managed Medicare|HEALTHSPRING MA|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Tricare|TRICARE FOR LIFE|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|United Healthcare|UNITED HEALTHCARE|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|United Healthcare|UNITED HEALTHCARE OTHER|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|PHCS|HUMANA|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|NON CONTRACTED|COMMERCIAL OTHER 1|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Medicare|UTSW MC KIDNEY PROGRAM|||||11.28||| 74455|EAP|0320|XR-VOIDING CYSTOURETH|Medicare|MEDICARE ACUTE|||||11.28||| 746|DRG||VAGINA, CERVIX & VULVA PROCEDURES W CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|374,529.12|964.44|964.44|964.44|||| 747|DRG||VAGINA, CERVIX & VULVA PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21,262.80|6398.39|6504.63|5530.73|||| 747|DRG||VAGINA, CERVIX & VULVA PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|56,473.86|6504.63|6504.63|5530.73|||| 747|DRG||VAGINA, CERVIX & VULVA PROCEDURES W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|88,973.77|5530.73|6504.63|5530.73|||| 74742|EAP|0320|XR-TRANSCERVCAL CATH FALL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.31||| 74742|EAP|0320|XR-TRANSCERVCAL CATH FALL|Managed Medicaid|MEDICAID SUPERIOR|||||9.31||| 74742|EAP|0320|XR-TRANSCERVCAL CATH FALL|Blue Cross PPO Specialty|BCBSTX PPO|||||9.31||| 74742|EAP|0320|XR-TRANSCERVCAL CATH FALL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.31||| 74742|EAP|0320|XR-TRANSCERVCAL CATH FALL|Medicaid|MEDICAID|||||9.31||| 74742|EAP|0320|XR-TRANSCERVCAL CATH FALL|United Healthcare|UNITED HEALTHCARE|||||9.31||| 748|DRG||FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES|Medicare|MEDICARE PART B ONLY IP|144,159.79|6426.935|13701.13|6426.935|||| 748|DRG||FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|86,496.79|13701.13|13701.13|6426.935|||| 754|DRG||MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W MCC|Blue Cross PPO Specialty|BCBSTX PPO|44,400.80|11785.07|14205.04|8946.93|||| 754|DRG||MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|245,362.35|8946.93|14205.04|8946.93|||| 754|DRG||MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|54,207.34|14205.04|14205.04|8946.93|||| 755|DRG||MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC|Medicare|MEDICARE ACUTE|107,737.10|6901.89|7029.42|392.92|||| 755|DRG||MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC|Managed Medicare|HEALTHSPRING MA|48,653.73|7017.86|7029.42|392.92|||| 755|DRG||MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC|Humana Medicare Advantage|HUMANA MA|43,341.66|7029.42|7029.42|392.92|||| 755|DRG||MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|91,381.74|392.92|7029.42|392.92|||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|United Medicare Advantage|UHC MEDICARE GOLD MA|4,118.40||||37.44||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,118.40||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Blue Cross PPO Specialty|BCBSTX OTHER|||||4,118.40||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||4,118.40||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Blue Cross PPO Specialty|BCBSTX PPO|||||37.44||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,118.40||||37.44||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Humana Medicare Advantage|HUMANA MA|3,931.20||||4,118.40||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||37.44||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Medicare|MEDICARE ACUTE|4,118.40||||4,118.40||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|United Healthcare|UNITED HEALTHCARE|||||37.44||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|United Healthcare|UNITED HEALTHCARE OTHER|||||37.44||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Managed Medicare|HEALTHSPRING MA|||||4,118.40||| 75561|EAP|0610|MRI CARDIAC FOR MORPH W/D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||37.44||| 75571|EAP|0350|CT CALCIUM SCREEN W/CHEST|United Healthcare|UNITED HEALTHCARE|||||0.75||| 75571|EAP|0350|CT CALCIUM SCREEN W/CHEST|Medicare|MEDICARE ACUTE|||||0.75||| 75571|EAP|0350|CT CALCIUM SCREEN W/CHEST|Humana Medicare Advantage|HUMANA MA|||||0.75||| 75571|EAP|0350|CT CALCIUM SCREEN W/CHEST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.75||| 75571|EAP|0350|CT CALCIUM SCREEN W/CHEST|Blue Cross PPO Specialty|BCBSTX PPO|||||0.75||| 75571|EAP|0350|CT CALCIUM SCREEN W/CHEST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.75||| 75571|EAP|0350|CT CALCIUM SCREEN W/CHEST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.75||| 75571|EAP|0350|CT CALCIUM SCREEN W/CHEST|Access Direct Platinum|HEALTHFIRST TPA|||||0.75||| 75571|EAP|0350|CT CALCIUM SCREEN W/CHEST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.75||| 75572|EAP|0350|CT-HRT W/3D IMAGE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5,572.80||| 75572|EAP|0350|CT-HRT W/3D IMAGE|United Medicare Advantage|UHC AARP MCR HMO MA|||||5,572.80||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Veterans Affairs|VETERANS ADMINISTRATION|||||5,572.80||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5,108.40||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||46.44||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5,572.80||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Aetna|AETNA OTHER|||||5,572.80||| 75572|EAP|0350|CT-HRT W/3D IMAGE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5,108.40||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Aetna|AETNA PPO|||||46.44||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.44||||46.44||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Blue Cross PPO Specialty|BCBSTX PPO|46.44||||5,572.80||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.44||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,572.80||||||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Cigna|CIGNA|||||5,572.80||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Humana Medicare Advantage|HUMANA MA|5,572.80||||5,572.80||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Managed Medicare|BCBS MEDICARE PPO MA|||||46.44||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Managed Medicare|HEALTHSPRING MA|||||46.44||| 75572|EAP|0350|CT-HRT W/3D IMAGE|Medicare|MEDICARE ACUTE|5,572.80||||46.44||| 75572|EAP|0350|CT-HRT W/3D IMAGE|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.44||||||| 75572|EAP|0350|CT-HRT W/3D IMAGE|United Healthcare|UNITED HEALTHCARE|||||5,572.80||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|United Healthcare|UNITED HEALTHCARE|||||46.44||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.44||||||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|PHCS|HUMANA|5,572.80||||||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Medicare|MEDICARE ACUTE|||||46.44||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Managed Medicare|HEALTHSPRING MA|46.44||||||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Humana Medicare Advantage|HUMANA MA|46.44||||46.44||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.44||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|United Healthcare|UNITED HEALTHCARE|||||5,572.80||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Managed Medicaid|MEDICAID SUPERIOR|||||46.44||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Managed Medicaid|MEDICAID AMERIGROUP|46.44||||||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Blue Cross HMO Specialty|BCBSTX HMO|||||46.44||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Blue Cross PPO Specialty|BCBSTX PPO|||||5,572.80||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.44||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|Access Direct Platinum|HEALTHFIRST TPA|||||46.44||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||46.44||| 75574|EAP|0350|CT-ANGIO HRT W/3D IMAGE|United Medicare Advantage|UHC AARP MCR HMO MA|||||5,572.80||| 756|DRG||MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC|Medicare|MEDICARE ACUTE|27,761.82|6194.22|6194.22|6194.22|||| 75605|EAP|0320|AORTOGRAPHY THORACIC|United Medicare Advantage|UHC AARP MCR HMO MA|||||13,932.38||| 75625|EAP|0320|ABD AORTOGRAPHY|Medicare|UTSW MC KIDNEY PROGRAM|||||13,932.38||| 75625|EAP|0320|IR-AGRAM ABD|Medicare|MEDICARE ACUTE|99.08||||13,932.38||| 75625|EAP|0320|ABD AORTOGRAPHY|United Healthcare|UNITED HEALTHCARE|||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|Managed Medicare|HEALTHSPRING MA|13,544.69||||13,544.69||| 75625|EAP|0320|ABD AORTOGRAPHY|Managed Medicare|BCBS MEDICARE PPO MA|131.57||||||| 75625|EAP|0320|ABD AORTOGRAPHY|Medicare|MEDICARE ACUTE|13,932.38||||13,932.38||| 75625|EAP|0320|ABD AORTOGRAPHY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|Aetna|AETNA PPO|||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|131.57||||13,932.38||| 75625|EAP|0320|IR-AGRAM ABD|Blue Cross PPO Specialty|BCBSTX PPO|99.08||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|Blue Cross PPO Specialty|BCBSTX PPO|131.57||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13,932.38||| 75625|EAP|0320|ABD AORTOGRAPHY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|Humana Medicare Advantage|HUMANA MA|||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|Veterans Affairs|VETERANS ADMINISTRATION|||||13,932.38||| 75625|EAP|0320|ABD AORTOGRAPHY|United Medicare Advantage|UHC AARP MCR HMO MA|||||13,932.38||| 75625|EAP|0320|ABD AORTOGRAPHY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||131.57||| 75625|EAP|0320|ABD AORTOGRAPHY|United Medicare Advantage|UHC MEDICARE GOLD MA|131.57||||131.57||| 75630|EAP|0320|ABD AORTOGRAPHY W/RUNOFFS|United Medicare Advantage|UHC AARP MCR HMO MA|||||14,524.32||| 75630|EAP|0320|ABD AORTOGRAPHY W/RUNOFFS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||137.16||| 75630|EAP|0320|ABD AORTOGRAPHY W/RUNOFFS|Humana Medicare Advantage|HUMANA MA|14,120.16||||14,524.32||| 75630|EAP|0320|ABD AORTOGRAPHY W/RUNOFFS|Managed Medicaid|MEDICAID AMERIGROUP|||||137.16||| 75630|EAP|0320|ABD AORTOGRAPHY W/RUNOFFS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14,524.32||||||| 75630|EAP|0320|ABD AORTOGRAPHY W/RUNOFFS|Blue Cross PPO Specialty|BCBSTX PPO|||||137.16||| 75630|EAP|0320|ABD AORTOGRAPHY W/RUNOFFS|Aetna|AETNA PPO|||||14,524.32||| 75630|EAP|0320|ABD AORTOGRAPHY W/RUNOFFS|Managed Medicare|HEALTHSPRING MA|14,524.32||||14,524.32||| 75630|EAP|0320|ABD AORTOGRAPHY W/RUNOFFS|Medicare|MEDICARE ACUTE|14,524.32||||137.16||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|UTMB|UTMB CORRECTIONAL MANAGED CARE|7,781.40||||||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|United Healthcare|UNITED HEALTHCARE OTHER|||||8,488.80||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|PHCS|HUMANA|||||8,488.80||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Medicare|MEDICARE ACUTE|8,488.80||||8,488.80||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Medicare|UTSW MC KIDNEY PROGRAM|||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Medicaid|MEDICAID|70.74||||||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Managed Medicare|HEALTHSPRING MA|8,488.80||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7,781.40||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Medicare|MEDICARE PART B ONLY IP|70.74||||||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Aenta Medicare Advantage|AETNA MEDICARE MA|7,781.40||||||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Aetna|AETNA PPO|70.74||||||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Blue Cross HMO Specialty|BCBSTX HMO|8,488.80||||8,488.80||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Blue Cross PPO Specialty|BCBSTX PPO|7,781.40||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,488.80||||7,781.40||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Managed Medicaid|MEDICAID AMERIGROUP|70.74||||||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|United Healthcare|UNITED HEALTHCARE|||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Managed Medicaid|MEDICAID SUPERIOR|8,488.80||||||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Cigna|CIGNA|7,781.40||||||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Humana Medicare Advantage|HUMANA MA|70.74||||8,488.80||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|Veterans Affairs|VETERANS ADMINISTRATION|8,488.80||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|70.74||||70.74||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|United Medicare Advantage|UHC MEDICARE GOLD MA|70.74||||7,781.40||| 75635|EAP|0350|CT-ANGIO ABDOMINAL ARTERI|United Medicare Advantage|UHC AARP MCR HMO MA|8,488.80||||8,488.80||| 75705|EAP|0320|IR-ANGIO SPINAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10,491.90||||||| 75705|EAP|0320|IR-ANGIO SPINAL|Blue Cross PPO Specialty|BCBSTX PPO|99.08||||||| 75705|EAP|0320|IR-ANGIO SPINAL|Aetna|AETNA QHP HMO|99.08||||||| 75705|EAP|0320|IR-ANGIO SPINAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.08||||||| 75705|EAP|0320|IR-ANGIO SPINAL|Managed Medicare|BCBS MEDICARE PPO MA|99.08||||||| 75705|EAP|0320|IR-ANGIO SPINAL|Medicare|MEDICARE ACUTE|10,199.95||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|United Healthcare|TML GROUP BENEFITS|99.08||||99.08||| 75710|EAP|0320|XR-OR ARTERIOGRAM|United Healthcare|UNITED HEALTHCARE|10,199.95||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|United Healthcare|UNITED HEALTHCARE|99.08||||99.08||| 75710|EAP|0320|EXTREMITY UNILATERAL ANGI|United Healthcare|UNITED HEALTHCARE|99.08||||13,932.38||| 75710|EAP|0320|XR-OR ARTERIOGRAM|UTMB|UTMB CORRECTIONAL MANAGED CARE|10,491.90||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Texas Workforce Commission|DIS DETER SERV (DDS)|||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|NON CONTRACTED|COMMERCIAL OTHER 2|10,491.90||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|NON CONTRACTED|COMMERCIAL OTHER 1|99.08||||99.08||| 75710|EAP|0320|ARTERIAL ACCESS|Medicare|MEDICARE ACUTE|131.57||||5,788.13||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Medicare|MEDICARE ACUTE|99.08||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Medicaid|SMITH COUNTY JAIL|99.08||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||99.08||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.08||||99.08||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Managed Medicare|HEALTHSPRING MA|99.08||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||99.08||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Managed Medicare|BCBS MEDICARE PPO MA|99.08||||||| 75710|EAP|0320|EXTREMITY UNILATERAL ANGI|United Medicare Advantage|UHC AARP MCR HMO MA|10,491.90||||13,932.38||| 75710|EAP|0320|XR-OR ARTERIOGRAM|United Medicare Advantage|UHC AARP MCR HMO MA|10,491.90||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|United Medicare Advantage|UHC MEDICARE GOLD MA|10,199.95||||99.08||| 75710|EAP|0320|XR-OR ARTERIOGRAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.08||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Veterans Affairs|VETERANS ADMINISTRATION|99.08||||99.08||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Medicaid|MEDICAID|99.08||||||| 75710|EAP|0320|EXTREMITY UNILATERAL ANGI|Veterans Affairs|VETERANS ADMINISTRATION|99.08||||13,932.38||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Access Direct Platinum|HEALTHFIRST TPA|10,491.90||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Access Direct Platinum|HEALTHFIRST TPA UMR|99.08||||99.08||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.08||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Medicare|MEDICARE PART B ONLY IP|10,491.90||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Tricare|TRICARE EAST REGION|10,491.90||||10,199.95||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||99.08||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10,199.95||||10,491.90||| 75710|EAP|0320|EXTREMITY UNILATERAL ANGI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10,199.95||||13,932.38||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Aetna|AETNA PPO|10,491.90||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Aenta Medicare Advantage|AETNA MEDICARE MA|13,932.38||||10,199.95||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Aenta Medicare Advantage|AETNA MEDICARE MA|10,491.90||||10,199.95||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Blue Cross HMO Specialty|BCBSTX HMO|99.08||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Blue Cross PPO Specialty|BCBSTX PPO|10,491.90||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10,491.90||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Humana Medicare Advantage|HUMANA MA|99.08||||10,491.90||| 75710|EAP|0320|EXTREMITY UNILATERAL ANGI|Humana Medicare Advantage|HUMANA MA|13,932.38||||13,932.38||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Cigna|CIGNA|10,491.90||||99.08||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Managed Medicaid|MEDICAID AMERIGROUP|99.08||||10,491.90||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10,491.90||||10,491.90||| 75710|EAP|0320|EXTREMITY UNILATERAL ANGI|Managed Medicaid|MEDICAID AMERIGROUP|99.08||||131.57||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Managed Medicaid|MEDICAID SUPERIOR|10,491.90||||||| 75710|EAP|0320|XR-OR ARTERIOGRAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99.08||||10,199.95||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13,932.38||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Cigna|CIGNA|131.57||||13,932.38||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Blue Cross PPO Specialty|BCBSTX OTHER|13,932.38||||||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Blue Cross PPO Specialty|BCBSTX PPO|131.57||||13,544.69||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Blue Cross HMO Specialty|BCBSTX HMO|||||13,932.38||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Aetna|AETNA PPO|||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|131.57||||||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Veterans Affairs|VETERANS ADMINISTRATION|13,932.38||||13,932.38||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Humana Medicare Advantage|HUMANA MA|13,932.38||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|United Medicare Advantage|UHC AARP MCR HMO MA|13,932.38||||13,932.38||| 75716|EAP|0320|EXTREMITY BIL ANGIO|United Medicare Advantage|UHC MEDICARE GOLD MA|131.57||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13,544.69||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Managed Medicare|HEALTHSPRING MA|131.57||||13,932.38||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Managed Medicare|BCBS MEDICARE PPO MA|131.57||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|Medicare|MEDICARE ACUTE|131.57||||13,932.38||| 75716|EAP|0320|EXTREMITY BIL ANGIO|NON CONTRACTED|COMMERCIAL OTHER 1|||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|United Healthcare|UNITED HEALTHCARE|||||131.57||| 75716|EAP|0320|EXTREMITY BIL ANGIO|United Healthcare|UNITED HEALTHCARE OTHER|||||13,932.38||| 75726|EAP|0320|IR-ANGIO VISCERAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|10,491.90||||||| 75726|EAP|0320|IR-ANGIO VISCERAL|United Healthcare|TML GROUP BENEFITS|10,491.90||||||| 75726|EAP|0320|IR-ANGIO VISCERAL|Medicare|MEDICARE ACUTE|10,491.90||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|Medicaid|CRIME VICTIMS COMPENSATION|10,199.95||||||| 75726|EAP|0320|IR-ANGIO VISCERAL|Medicaid|MEDICAID|10,491.90||||||| 75726|EAP|0320|IR-ANGIO VISCERAL|Rusk State Hospital|RUSK STATE HOSP|||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|Managed Medicare|HEALTHSPRING MA|99.08||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|Managed Medicare|BCBS MEDICARE PPO MA|10,491.90||||||| 75726|EAP|0320|IR-ANGIO VISCERAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10,491.90||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|Veterans Affairs|VETERANS ADMINISTRATION|||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||99.08||| 75726|EAP|0320|IR-ANGIO VISCERAL|Blue Cross HMO Specialty|BCBSTX HMO|10,491.90||||||| 75726|EAP|0320|IR-ANGIO VISCERAL|Blue Cross PPO Specialty|BCBSTX PPO|99.08||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|Humana Medicare Advantage|HUMANA MA|99.08||||||| 75726|EAP|0320|IR-ANGIO VISCERAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10,491.90||||10,491.90||| 75726|EAP|0320|IR-ANGIO VISCERAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.08||||||| 75736|EAP|0320|IR-ANGIO PELVIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10,491.90||||||| 75736|EAP|0320|IR-ANGIO PELVIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||99.08||| 75736|EAP|0320|IR-ANGIO PELVIC|Medicare|MEDICARE ACUTE|10,491.90||||||| 75743|EAP|0320|IR-ANGIO PULMONARY BIL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.08||||||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|Veterans Affairs|VETERANS ADMINISTRATION|||||4,616.95||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|Workers Compensation|WORKERS COMPENSATION OTHER|4,616.95||||||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,616.95||||||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4,616.95||||||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|United Medicare Advantage|UHC AARP MCR HMO MA|||||4,616.95||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4,616.95||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,616.95||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|Blue Cross PPO Specialty|BCBSTX PPO|43.60||||4,488.48||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||43.60||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|United Healthcare|TML GROUP BENEFITS|4,616.95||||||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|Medicare|MEDICARE ACUTE|4,616.95||||4,616.95||| 75774|EAP|0320|SELECTIVE IMAGING AFTER E|Medicare|MEDICARE ACUTE|4,616.95||||5,650.46||| 75774|EAP|0320|IR-ANGIO SELECT-EA ADD VE|Medicaid|MEDICAID|||||4,616.95||| 75809|EAP|0320|XR-SHUNTOGRAM|Medicaid|MEDICAID|10.49||||||| 75809|EAP|0320|XR-SHUNTOGRAM|Medicare|MEDICARE ACUTE|10.49||||10.49||| 75809|EAP|0320|XR-SHUNTOGRAM|Humana Medicare Advantage|HUMANA MA|10.49||||10.49||| 75809|EAP|0320|XR-SHUNTOGRAM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.49||||||| 75809|EAP|0320|XR-SHUNTOGRAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||10.49||| 75809|EAP|0320|XR-SHUNTOGRAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10.49||| 75809|EAP|0320|XR-SHUNTOGRAM|Blue Cross HMO Specialty|BCBSTX HMO|10.49||||||| 75809|EAP|0320|XR-SHUNTOGRAM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||10.49||| 75809|EAP|0323|NON VASCULAR SHUNT XRAY S|Blue Cross PPO Specialty|BCBSTX PPO|||||3.02||| 75809|EAP|0320|XR-SHUNTOGRAM|Blue Cross PPO Specialty|BCBSTX PPO|10.49||||10.49||| 75809|EAP|0320|XR-SHUNTOGRAM|United Medicare Advantage|UHC MEDICARE GOLD MA|10.49||||10.49||| 75809|EAP|0320|XR-SHUNTOGRAM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||10.49||| 75809|EAP|0320|XR-SHUNTOGRAM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|10.49||||||| 75809|EAP|0320|XR-SHUNTOGRAM|Workers Compensation|UT EMPLOYEE INJURY|||||10.49||| 75820|EAP|0320|IR-VENOGRAM - UNILAT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||30.51||| 75820|EAP|0320|IR-VENOGRAM - UNILAT|United Medicare Advantage|UHC AARP MCR HMO MA|||||3,230.80||| 75820|EAP|0320|IR-VENOGRAM - UNILAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,230.80||||||| 75820|EAP|0320|IR-VENOGRAM - UNILAT|Medicare|MEDICARE ACUTE|3,230.80||||||| 75825|EAP|0320|IR-VGRAM IVC|Medicare|MEDICARE ACUTE|99.08||||||| 75825|EAP|0320|IR-VGRAM IVC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||99.08||| 75825|EAP|0320|VENA CAVA ANGIO|Humana Medicare Advantage|HUMANA MA|48.71||||||| 75825|EAP|0320|VENA CAVA ANGIO|United Medicare Advantage|UHC AARP MCR HMO MA|||||5,158.06||| 75831|EAP|0320|IR-RENAL VEIN - UNILAT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.08||||||| 75860|EAP|0320|IR-VENOGRAPHY VENOUS SINU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||36.92||| 75860|EAP|0320|IR-VENOGRAPHY VENOUS SINU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,909.58||| 75860|EAP|0320|IR-VENOGRAPHY VENOUS SINU|Blue Cross PPO Specialty|BCBSTX PPO|||||3,800.79||| 75860|EAP|0320|IR-VENOGRAPHY VENOUS SINU|Blue Cross HMO Specialty|BCBSTX HMO|||||3,909.58||| 75870|EAP|0320|IR-VGRAM SUP SAG SINUS|United Healthcare|UNITED HEALTHCARE|||||10,491.90||| 75870|EAP|0320|IR-VGRAM SUP SAG SINUS|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||99.08||| 75870|EAP|0320|IR-VGRAM SUP SAG SINUS|Blue Cross PPO Specialty|BCBSTX PPO|10,491.90||||||| 75891|EAP|0320|IR-VGRAM HEP WO EVAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|149.65||||||| 75891|EAP|0320|IR-VGRAM HEP WO EVAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||149.65||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Medicaid|MEDICAID|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Managed Medicare|HEALTHSPRING MA|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|United Healthcare|UNITED HEALTHCARE|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|United Medicare Advantage|UHC MEDICARE GOLD MA|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Medicare|MEDICARE ACUTE|172.35||||172.35||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|United Medicare Advantage|UHC AARP MCR HMO MA|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Workers Compensation|WORKERS COMPENSATION OTHER|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Veterans Affairs|VETERANS ADMINISTRATION|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Blue Cross HMO Specialty|BCBSTX HMO|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||172.35||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Blue Cross PPO Specialty|BCBSTX PPO|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Aetna|AETNA OTHER|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Aetna|AETNA PPO|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Aetna|AETNA QHP HMO|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Humana Medicare Advantage|HUMANA MA|172.35||||||| 75894|EAP|0320|IR-TRANSCATH THPY EMOLIZ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|172.35||||||| 759|DRG||INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44,727.07|107.16|39147.8|107.16|||| 759|DRG||INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|39,147.80|39147.8|39147.8|107.16|||| 75901|EAP|0320|IR-MECH REM OBSTR CVD SEP|Medicare|MEDICARE ACUTE|21.25||||||| 75945|EAP|0320|S&I IVUS PERIPHERAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,279.75||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|Managed Medicare|HEALTHSPRING MA|82.45||||||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|NON CONTRACTED|COMMERCIAL OTHER 1|82.45||||||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|Medicare|MEDICARE ACUTE|82.45||||82.45||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|United Medicare Advantage|UHC MEDICARE GOLD MA|82.45||||82.45||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||82.45||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|Blue Cross PPO Specialty|BCBSTX OTHER|||||82.45||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|Aenta Medicare Advantage|AETNA MEDICARE MA|82.45||||||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||82.45||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|Humana Medicare Advantage|HUMANA MA|82.45||||82.45||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|82.45||||||| 75970|EAP|0320|IR-TRANSCATH BX LIVER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|82.45||||||| 75989|EAP|0350|CT-ABSCESS DRAINAGE UNDER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58.94||||||| 75989|EAP|0350|CT-ABSCESS DRAINAGE UNDER|United Healthcare|UNITED HEALTHCARE|||||58.94||| 75989|EAP|0350|CT-ABSCESS DRAINAGE UNDER|Medicare|MEDICARE ACUTE|58.94||||||| 760|DRG||MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W CC/MCC|Medicare|MEDICARE ACUTE|33,722.09|6338.22|7844.26|6338.22|||| 760|DRG||MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|27,123.60|7844.26|7844.26|6338.22|||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicaid|MEDICAID AMERIGROUP|1,324.72||||12.51||| 76000|EAP|0320|XR-FLUORO 0 - 30 MIN.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,324.72||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicaid|MEDICAID SUPERIOR|12.51||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Cigna|CIGNA|1,324.72||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Cigna|CIGNA|12.51||||1,324.72||| 76000|EAP|0320|XR-CHEST X-RAY AND FLUORO|Humana Medicare Advantage|HUMANA MA|1,085.41||||944.57||| 76000|EAP|0320|XR-FLUORO 0 - 30 MIN.|Humana Medicare Advantage|HUMANA MA|8.92||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Humana Medicare Advantage|HUMANA MA|12.51||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Blue Cross HMO Specialty|BCBSTX HMO|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Brinson Benefits|THE HEALTH PLAN SMITH CO|8.92||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Blue Cross PPO Specialty|BCBSTX PPO|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Blue Cross PPO Specialty|BCBSTX OTHER|1,287.86||||1,324.72||| 76000|EAP|0320|XR-FLUORO 0 - 30 MIN.|Blue Cross PPO Specialty|BCBSTX PPO|944.57||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Aetna|AETNA OTHER|||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Aetna|AETNA PPO|12.51||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Aenta Medicare Advantage|AETNA MEDICARE MA|1,324.72||||1,324.72||| 76000|EAP|0320|XR-CHEST X-RAY AND FLUORO|Aenta Medicare Advantage|AETNA MEDICARE MA|1,324.72||||918.29||| 76000|EAP|0320|XR-FLUORO 0 - 30 MIN.|Aenta Medicare Advantage|AETNA MEDICARE MA|1,324.72||||1,324.72||| 76000|EAP|0320|XR-CHEST X-RAY AND FLUORO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|944.57||||944.57||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.51||||1,324.72||| 76000|EAP|0320|XR-FLUORO 0 - 30 MIN.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.51||||12.51||| 76000|EAP|0320|XR-FLUORO 0 - 30 MIN.|United Medicare Advantage|UHC AARP MCR HMO MA|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|United Medicare Advantage|UHC AARP WELLMED HMO MA|1,324.72||||||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|United Medicare Advantage|UHC MEDICARE GOLD MA|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|WORKERS COMP PHYSICIAN|||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|ZURICH COMPANY|||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|WORKERS COMPENSATION OTHER|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|TEXAS MUTUAL INSURANCE|12.51||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|BROOKSHIRES WORKERS COMP|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Veterans Affairs|VETERANS ADMINISTRATION|1,324.72||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|UT EMPLOYEE INJURY|||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|TRAVELERS INSURANCE COMPANY|12.51||||12.51||| 76000|EAP|0320|XR-CHEST X-RAY AND FLUORO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.51||||8.92||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Access Direct Platinum|HEALTHFIRST TPA|||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Access Direct Platinum|HEALTHFIRST TPA UMR|12.51||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.51||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,287.86||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|12.51||||||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|PHCS|HUMANA|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|PHCS|GROUP AND PENSION|12.51||||1,287.86||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|NON CONTRACTED|COMMERCIAL OTHER 2|||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Rusk State Hospital|RUSK STATE HOSP|12.51||||||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|United Medicare Advantage|UHC AARP MCR HMO MA|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|NON CONTRACTED|COMMERCIAL OTHER 1|1,324.72||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Texas Workforce Commission|DIS DETER SERV (DDS)|||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Multiplan|WEB TPA|1,324.72||||||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicare|MEDICARE PART B ONLY IP|12.51||||||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicare|MEDICARE ACUTE|12.51||||12.51||| 76000|EAP|0320|XR-FLUORO 0 - 30 MIN.|Medicare|MEDICARE ACUTE|12.51||||1,324.72||| 76000|EAP|0320|XR-CHEST X-RAY AND FLUORO|Medicare|MEDICARE ACUTE|8.92||||8.92||| 76000|EAP|0320|IR-FLUORO 0-1 HOUR|Medicare|MEDICARE ACUTE|10.25||||1,085.41||| 76000|EAP|0320|XR-CHEST X-RAY AND FLUORO|Aetna|AETNA PPO|12.51||||8.92||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Aetna|BOON CHAPMAN|12.51||||||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Tricare|TRICARE FOR LIFE|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Tricare|TRICARE EAST REGION|1,324.72||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.51||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|United Healthcare|TML GROUP BENEFITS|1,324.72||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.51||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|United Healthcare|UNITED HEALTHCARE OTHER|12.51||||1,324.72||| 76000|EAP|0320|XR-CHEST X-RAY AND FLUORO|United Healthcare|UNITED HEALTHCARE OTHER|12.51||||944.57||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|United Healthcare|UNITED HEALTHCARE|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|United Healthcare|GEHA|1,324.72||||||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.51||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Cigna|CIGNA OTHER|||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicare|BCBS MEDICARE PPO MA|12.51||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicare|HEALTHSPRING MA|1,324.72||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicare|BCBS MEDICARE PPO MA|8.92||||12.51||| 76000|EAP|0320|XR-CHEST X-RAY AND FLUORO|Managed Medicare|HEALTHSPRING MA|1,324.72||||944.57||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|SMITH COUNTY JAIL|||||1,287.86||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,324.72||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|MEDICAID|12.51||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|MEDICAID HMO|1,324.72||||1,287.86||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|MEDICAID BCBSTX|||||1,324.72||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|LAW ENFORCEMENT OTHER|12.51||||||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|MOLINA HEALTHCARE OF TEXAS|12.51||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|CRIME VICTIMS COMPENSATION|12.51||||||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||12.51||| 76000|EAP|0320|XR-OR FLUORO 1ST HOUR|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||12.51||| 76010|EAP|0320|XR-INFANT FOREIGN BODY|Blue Cross PPO Specialty|BCBSTX PPO|||||8.90||| 76010|EAP|0320|XR-INFANT FOREIGN BODY|Cigna|CIGNA OTHER|||||8.90||| 76010|EAP|0320|XR-INFANT FOREIGN BODY|Managed Medicaid|MEDICAID SUPERIOR|||||8.90||| 76080|EAP|0320|XR-FISTULA INJECT-|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.51||||||| 76080|EAP|0320|XR-FISTULA INJECT-|Medicaid|MEDICAID|7.51||||||| 76080|EAP|0320|XR-FISTULA INJECT-|Managed Medicare|HEALTHSPRING MA|||||7.51||| 76080|EAP|0320|IR-X-RAY EXAM OF FISTULA|Medicare|MEDICARE ACUTE|||||12.21||| 76080|EAP|0320|XR-FISTULA INJECT-|Humana Medicare Advantage|HUMANA MA|7.51||||7.51||| 76080|EAP|0320|XR-FISTULA INJECT-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.51||| 76080|EAP|0320|XR-FISTULA INJECT-|Blue Cross HMO Specialty|BCBSTX HMO|7.51||||||| 76080|EAP|0320|XR-FISTULA INJECT-|Blue Cross PPO Specialty|BCBSTX PPO|||||7.51||| 761|DRG||MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|25,884.81|3730.43|3837.15|3730.43|||| 761|DRG||MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|39,404.32|3837.15|3837.15|3730.43|||| 76376|EAP|0402|3D RENDERING|United Healthcare|UNITED HEALTHCARE|1,962.20||||||| 76376|EAP|0402|3D RENDERING|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1,907.60||| 76376|EAP|0402|3D RENDERING|Medicare|MEDICARE ACUTE|1,962.20||||1,962.20||| 76376|EAP|0402|3D RENDERING|Managed Medicare|HEALTHSPRING MA|1,907.60||||1,962.20||| 76376|EAP|0402|3D RENDERING|Managed Medicare|BCBS MEDICARE PPO MA|18.53||||||| 76376|EAP|0402|3D RENDERING|Medicaid|SMITH COUNTY INDIGENT HEALTH|18.53||||||| 76376|EAP|0402|3D RENDERING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||18.53||| 76376|EAP|0402|3D RENDERING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.53||||||| 76376|EAP|0402|3D RENDERING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,962.20||||18.53||| 76376|EAP|0402|3D RENDERING|Humana Medicare Advantage|HUMANA MA|1,907.60||||18.53||| 76376|EAP|0402|3D RENDERING|Aetna|AETNA OTHER|1,962.20||||||| 76376|EAP|0402|3D RENDERING|Aenta Medicare Advantage|AETNA MEDICARE MA|18.53||||||| 76376|EAP|0402|3D RENDERING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,907.60||||18.53||| 76376|EAP|0402|3D RENDERING|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||18.53||| 76376|EAP|0402|3D RENDERING|Blue Cross PPO Specialty|BCBSTX PPO|18.53||||1,962.20||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Blue Cross HMO Specialty|BCBSTX HMO|27.85||||27.85||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Blue Cross PPO Specialty|BCBSTX PPO|2,949.13||||2,949.13||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.85||||27.85||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2,949.13||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Aetna|AETNA QHP HMO|2,949.13||||||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Aetna|AETNA PPO|27.85||||27.85||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Humana Medicare Advantage|HUMANA MA|27.85||||||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.85||||||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,949.13||||||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Veterans Affairs|VETERANS ADMINISTRATION|27.85||||||| 76377|EAP|0402|IR-3D RENDERING W POST PR|United Medicare Advantage|UHC MEDICARE GOLD MA|27.85||||||| 76377|EAP|0402|IR-3D RENDERING W POST PR|United Medicare Advantage|UHC AARP MCR HMO MA|2,949.13||||||| 76377|EAP|0402|IR-3D RENDERING W POST PR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.85||||2,949.13||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Medicaid|MEDICAID|27.85||||||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.85||||||| 76377|EAP|0402|IR-3D RENDERING W POST PR|Medicare|MEDICARE ACUTE|2,949.13||||27.85||| 76377|EAP|0402|IR-3D RENDERING W POST PR|United Healthcare|UNITED HEALTHCARE|2,949.13||||||| 76380|EAP|0350|IR-CT-LIMITED F/U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||35.23||| 76506|EAP|0402|US ECHO EXAM OF HEAD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.91||| 76506|EAP|0402|US ECHO EXAM OF HEAD|Managed Medicaid|MEDICAID AMERIGROUP|||||995.25||| 76506|EAP|0402|US ECHO EXAM OF HEAD|Managed Medicaid|MEDICAID SUPERIOR|||||9.91||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Tricare|TRICARE EAST REGION|||||908.88||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|United Healthcare|UNITED HEALTHCARE OTHER|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|United Healthcare|UNITED HEALTHCARE|||||908.88||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|PHCS|GROUP AND PENSION|||||908.88||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|NON CONTRACTED|COMMERCIAL OTHER 1|||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|PHCS|HUMANA|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Medicare|UTSW MC KIDNEY PROGRAM|||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Medicare|MEDICARE ACUTE|912.76||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Managed Medicare|HEALTHSPRING MA|9.05||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Managed Medicare|BCBS MEDICARE PPO MA|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Medicaid|SMITH COUNTY JAIL|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Blue Cross PPO Specialty|BCBSTX PPO|9.05||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Blue Cross PPO Specialty|BCBSTX OTHER|||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Blue Cross HMO Specialty|BCBSTX HMO|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Medicaid|MEDICAID|||||908.88||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Aetna|AETNA OTHER|||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Aetna|AETNA PPO|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Aetna Value Network|AETNA VALUE NETWORK|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Multiplan|WEB TPA|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|ChampVA|CHAMPVA CENTER|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Cigna|CIGNA OTHER|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Cigna|CIGNA|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Humana Medicare Advantage|HUMANA MA|9.05||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Managed Medicaid|MEDICAID AMERIGROUP|||||908.88||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|United Healthcare|UNITED HEALTHCARE|||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Managed Medicaid|MEDICAID SUPERIOR|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|United Medicare Advantage|UHC AARP MCR HMO MA|9.05||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|United Medicare Advantage|UHC MEDICARE GOLD MA|9.05||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.05||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Veterans Affairs|VETERANS ADMINISTRATION|9.05||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Access Direct Platinum|HEALTHFIRST TPA|||||9.05||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||912.76||| 76536|EAP|0402|US EXAM OF HEAD AND NECK|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.05||| 76604|EAP|0402|US EXAM CHEST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.92||||||| 76604|EAP|0402|US EXAM CHEST|United Medicare Advantage|UHC AARP MCR HMO MA|1,101.37||||||| 76604|EAP|0402|US EXAM CHEST|United Medicare Advantage|UHC MEDICARE GOLD MA|10.92||||10.92||| 76604|EAP|0402|US EXAM CHEST|Access Direct Platinum|HEALTHFIRST TPA|||||1,101.37||| 76604|EAP|0402|US EXAM CHEST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,101.37||| 76604|EAP|0402|US EXAM CHEST|Managed Medicaid|MEDICAID AMERIGROUP|||||10.92||| 76604|EAP|0402|US EXAM CHEST|Humana Medicare Advantage|HUMANA MA|10.92||||10.92||| 76604|EAP|0402|US EXAM CHEST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.92||||||| 76604|EAP|0402|US EXAM CHEST|Blue Cross HMO Specialty|BCBSTX HMO|||||1,101.37||| 76604|EAP|0402|US EXAM CHEST|Blue Cross PPO Specialty|BCBSTX PPO|||||10.92||| 76604|EAP|0402|US EXAM CHEST|Medicaid|MEDICAID|10.92||||10.92||| 76604|EAP|0402|US EXAM CHEST|Managed Medicare|HEALTHSPRING MA|||||1,101.37||| 76604|EAP|0402|US EXAM CHEST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,101.37||||10.92||| 76604|EAP|0402|US EXAM CHEST|Medicare|MEDICARE ACUTE|1,101.37||||10.92||| 76604|EAP|0402|US EXAM CHEST|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,101.37||||||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Healthcare|UNITED HEALTHCARE ERS|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Healthcare|UNITED HEALTHCARE|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Healthcare|GOLDEN RULE|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Healthcare|GEHA|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Healthcare|UNITED HEALTHCARE|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Tricare|TRICARE FOR LIFE|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Tricare|TRICARE EAST REGION|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|PHCS|MULTIPLAN PHCS OTHER|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|PHCS|GROUP AND PENSION|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|NON CONTRACTED|COMMERCIAL OTHER 1|||||604.14||| 76641|EAP|0402|US BREAST LT|Medicare|MEDICARE ACUTE|604.14||||8.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Medicare|MEDICARE ACUTE|604.14||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Multiplan|WEB TPA|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Medicare|UTSW MC KIDNEY PROGRAM|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Managed Medicare|BCBS MEDICARE PPO MA|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Medicaid|MEDICAID|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Blue Cross PPO Specialty|BCBSTX PPO|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Blue Cross PPO Specialty|BCBSTX OTHER|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Blue Cross HMO Specialty|BCBSTX HMO|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Aetna|BOON CHAPMAN|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Aetna|AETNA OTHER|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Aetna|AETNA PPO|8.14||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Aetna Value Network|AETNA VALUE NETWORK|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Managed Medicare|HEALTHSPRING MA|||||601.57||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.99||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE BIL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.99||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|ChampVA|CHAMPVA CENTER|||||601.57||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Cigna|CIGNA|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|NON CONTRACTED|COMMERCIAL OTHER 2|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Cigna|CIGNA|5.99||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Cigna|CIGNA OTHER|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Humana Medicare Advantage|HUMANA MA|604.14||||604.14||| 76641|EAP|0402|US BREAST LT|Humana Medicare Advantage|HUMANA MA|820.98||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Managed Medicaid|MEDICAID SUPERIOR|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Managed Medicaid|MEDICAID AMERIGROUP|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||601.57||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Medicare Advantage|UHC AARP MCR HMO MA|||||604.14||| 76641|EAP|0402|US BREAST LT|United Medicare Advantage|UHC AARP MCR HMO MA|||||820.98||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Healthcare|UNITED HEALTHCARE OTHER|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|United Healthcare|TML GROUP BENEFITS|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Veterans Affairs|VETERANS ADMINISTRATION|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Access Direct Platinum|HEALTHFIRST TPA|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||604.14||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Access Direct Platinum|HEALTHFIRST TPA TYLER ISD|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.99||| 76641|EAP|0402|BC US BREAST COMPLETE UNI|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Access Direct Platinum|HEALTHFIRST TPA|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Veterans Affairs|VETERANS ADMINISTRATION|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||601.57||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|United Medicare Advantage|UHC AARP MCR HMO MA|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Managed Medicaid|MEDICAID SUPERIOR|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Managed Medicaid|MEDICAID AMERIGROUP|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Humana Medicare Advantage|HUMANA MA|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Cigna|CIGNA|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Cigna|CIGNA|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Aetna Value Network|AETNA VALUE NETWORK|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Aetna|AETNA PPO|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Blue Cross HMO Specialty|BCBSTX HMO|||||601.57||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Blue Cross PPO Specialty|BCBSTX PPO|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||601.57||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Medicaid|MEDICAID|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Managed Medicare|HEALTHSPRING MA|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Managed Medicare|BCBS MEDICARE PPO MA|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Multiplan|WEB TPA|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Medicare|MEDICARE ACUTE|5.99||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|NON CONTRACTED|COMMERCIAL OTHER 2|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|Tricare|TRICARE EAST REGION|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|United Healthcare|UNITED HEALTHCARE|||||604.14||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|United Healthcare|UNITED HEALTHCARE|||||5.99||| 76642|EAP|0402|BC US BREAST LIMITED UNIL|United Healthcare|UNITED HEALTHCARE OTHER|||||604.14||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|United Healthcare|UNITED HEALTHCARE|12.21||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|United Healthcare|TML GROUP BENEFITS|||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|United Healthcare|UNITED HEALTHCARE|1,226.24||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.21||||||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Tricare|TRICARE EAST REGION|||||1,226.24||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Tricare|TRICARE SOUTH PHYSICIAN|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Rusk State Hospital|RUSK STATE HOSP|12.21||||||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|NON CONTRACTED|COMMERCIAL OTHER 1|1,226.24||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|PHCS|GROUP AND PENSION|||||1,226.24||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Medicare|UTSW MC KIDNEY PROGRAM|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Multiplan|NALC|||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Medicare|MEDICARE ACUTE|12.21||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Managed Medicare|WELLCARE CHOICE MA|1,231.47||||||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Managed Medicare|BCBS MEDICARE PPO MA|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,226.24||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Medicaid|MEDICAID|12.21||||1,226.24||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Medicaid|MEDICAID HMO|1,231.47||||1,226.24||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Medicaid|SMITH COUNTY INDIGENT HEALTH|12.21||||||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Medicaid|COUNTY INDIGENT HEALTH OTHER|12.21||||||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|12.21||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,226.24||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Medicaid|SMITH COUNTY JAIL|12.21||||||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,231.47||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Blue Cross HMO Specialty|BCBSTX HMO|1,231.47||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Aetna|BOON CHAPMAN|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Managed Medicare|HEALTHSPRING MA|12.21||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Aetna|AETNA PPO|1,231.47||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Aetna|AETNA OTHER|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,231.47||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|ChampVA|CHAMPVA CENTER|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Medicare|MEDICARE PART B ONLY IP|1,231.47||||||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Cigna|CIGNA OTHER|||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Cigna|CIGNA|||||1,226.24||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Cigna|CIGNA|1,226.24||||1,226.24||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Humana Medicare Advantage|HUMANA MA|12.21||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|1,231.47||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.21||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.21||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Managed Medicaid|MEDICAID SUPERIOR|1,231.47||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|United Healthcare|GEHA|||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|United Healthcare|UNITED HEALTHCARE OTHER|12.21||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|United Medicare Advantage|UHC MEDICARE GOLD MA|12.21||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|United Medicare Advantage|UHC AARP MCR HMO MA|1,231.47||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.21||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Veterans Affairs|VETERANS ADMINISTRATION|1,231.47||||||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Workers Compensation|WORKERS COMPENSATION OTHER|1,231.47||||||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Access Direct Platinum|HEALTHFIRST TPA|12.21||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Access Direct Platinum|HEALTHFIRST TPA UMR|1,226.24||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|12.21||||12.21||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,231.47||| 76700|EAP|0402|US EXAM ABDOM COMPLETE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.21||||12.21||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST TPA|8.08||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.08||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|811.47||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.08||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Workers Compensation|WORKERS COMPENSATION OTHER|||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|United Medicare Advantage|UHC MEDICARE GOLD MA|8.08||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|United Medicare Advantage|UHC AARP WELLMED HMO MA|814.93||||||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|814.93||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Managed Medicaid|MEDICAID SUPERIOR|8.08||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|814.93||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Managed Medicaid|MEDICAID AMERIGROUP|814.93||||8.08||| 76705|EAP|0402|ECHO EXAM OF ABDOMEN|Managed Medicaid|MEDICAID AMERIGROUP|814.93||||11.45||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Humana Medicare Advantage|HUMANA MA|814.93||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|ChampVA|CHAMPVA CENTER|||||811.47||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Cigna|CIGNA|||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Cigna|CIGNA OTHER|814.93||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Cigna|CIGNA|8.08||||811.47||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Aetna|BOON CHAPMAN|8.08||||||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Aetna|AETNA OTHER|8.08||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Aetna|AETNA PPO|11.45||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Aetna|AETNA PPO|814.93||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Aenta Medicare Advantage|AETNA MEDICARE MA|814.93||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Blue Cross HMO Specialty|BCBSTX HMO|811.47||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Blue Cross PPO Specialty|BCBSTX PPO|814.93||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.08||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Blue Cross PPO Specialty|BCBSTX OTHER|8.08||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|814.93||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||814.93||| 76705|EAP|0402|ECHO EXAM OF ABDOMEN|Blue Cross PPO Specialty|BCBSTX PPO|11.45||||1,154.82||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|814.93||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||811.47||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Medicaid|MEDICAID|8.08||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|814.93||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|United Medicare Advantage|UHC AARP MCR HMO MA|814.93||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Medicaid|SMITH COUNTY INDIGENT HEALTH|814.93||||||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Medicaid|MEDICAID HMO|||||811.47||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.08||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.45||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Veterans Affairs|VETERANS ADMINISTRATION|814.93||||8.08||| 76705|EAP|0402|ECHO EXAM OF ABDOMEN|Managed Medicare|BCBS MEDICARE PPO MA|8.08||||11.45||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Managed Medicare|BCBS MEDICARE PPO MA|8.08||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Managed Medicare|HEALTHSPRING MA|8.08||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Medicare|MEDICARE PART B ONLY IP|811.47||||||| 76705|EAP|0402|ECHO EXAM OF ABDOMEN|Medicare|MEDICARE ACUTE|1,154.82||||1,149.91||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Medicare|MEDICARE ACUTE|814.93||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|PHCS|HUMANA|||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|PHCS|GROUP AND PENSION|8.08||||||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|PHCS|HUMANA INSURANCE|||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|NON CONTRACTED|COMMERCIAL OTHER 1|8.08||||8.08||| 76705|EAP|0402|ECHO EXAM OF ABDOMEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.45||||||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|Tricare|TRICARE EAST REGION|811.47||||8.08||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|814.93||||||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|United Healthcare|UNITED HEALTHCARE OTHER|811.47||||814.93||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|United Healthcare|UNITED HEALTHCARE|814.93||||811.47||| 76705|EAP|0402|US ECHO EXAM OF ABDOMEN|United Healthcare|UNITED HEALTHCARE|811.47||||8.08||| 76706|EAP|0402|US EXAM AAA SCREEN|United Healthcare|UNITED HEALTHCARE|||||138.18||| 76706|EAP|0402|US EXAM AAA SCREEN|Tricare|TRICARE FOR LIFE|||||1.37||| 76706|EAP|0402|US EXAM AAA SCREEN|NON CONTRACTED|COMMERCIAL OTHER 1|||||138.18||| 76706|EAP|0402|US EXAM AAA SCREEN|Medicare|MEDICARE ACUTE|138.18||||1.37||| 76706|EAP|0402|US EXAM AAA SCREEN|Managed Medicare|BCBS MEDICARE PPO MA|||||1.37||| 76706|EAP|0402|US EXAM AAA SCREEN|Managed Medicare|HEALTHSPRING MA|||||138.18||| 76706|EAP|0402|US EXAM AAA SCREEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.37||| 76706|EAP|0402|US EXAM AAA SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|||||138.18||| 76706|EAP|0402|US EXAM AAA SCREEN|Cigna|CIGNA|||||138.18||| 76706|EAP|0402|US EXAM AAA SCREEN|Humana Medicare Advantage|HUMANA MA|||||1.37||| 76706|EAP|0402|US EXAM AAA SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|||||138.18||| 76706|EAP|0402|US EXAM AAA SCREEN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.37||| 76706|EAP|0402|US EXAM AAA SCREEN|United Medicare Advantage|UHC AARP MCR HMO MA|138.18||||138.18||| 76706|EAP|0402|US EXAM AAA SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||137.59||| 76706|EAP|0402|US EXAM AAA SCREEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||137.59||| 76770|EAP|0402|RETROPERITONEAL PORT|Humana Medicare Advantage|HUMANA MA|||||426.25||| 76770|EAP|0402|RETROPERITONEAL PORT|Blue Cross PPO Specialty|BCBSTX PPO|||||426.25||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Medicaid|MEDICAID|11.66||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.66||||||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Medicaid|SMITH COUNTY JAIL|11.66||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Medicaid|MOLINA HEALTHCARE OF TEXAS|11.66||||||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.66||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Managed Medicare|HEALTHSPRING MA|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Managed Medicare|OTHER INSTITUTIONS|||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Managed Medicare|BCBS MEDICARE PPO MA|11.76||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Medicare|UTSW MC KIDNEY PROGRAM|||||11.71||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Medicare|MEDICARE ACUTE|11.66||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|NON CONTRACTED|COMMERCIAL OTHER 1|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|PHCS|GROUP AND PENSION|11.76||||||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Tricare|TRICARE EAST REGION|||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.76||||||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|United Healthcare|UNITED HEALTHCARE OTHER|11.66||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|United Healthcare|UNITED HEALTHCARE|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|United Healthcare|UNITED HEALTHCARE|11.66||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|United Healthcare|TML GROUP BENEFITS|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Veterans Affairs|VETERANS ADMINISTRATION|11.76||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|PHCS|HUMANA|11.71||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Access Direct Platinum|HEALTHFIRST TPA UMR|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.66||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.66||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Medicare|MEDICARE PART B ONLY IP|11.66||||||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Access Direct Platinum|HEALTHFIRST TPA|11.66||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|United Medicare Advantage|UHC MEDICARE GOLD MA|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|United Medicare Advantage|UHC AARP MCR HMO MA|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Managed Medicare|WELLCARE CHOICE MA|11.76||||||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Aetna|AETNA PPO|11.76||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Aetna|AETNA OTHER|11.71||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Aenta Medicare Advantage|AETNA MEDICARE MA|11.71||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Aetna Value Network|AETNA VALUE NETWORK|||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.76||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Blue Cross HMO Specialty|BCBSTX HMO|11.71||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Blue Cross PPO Specialty|BCBSTX OTHER|11.66||||11.71||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Blue Cross PPO Specialty|BCBSTX PPO|11.76||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Managed Medicaid|MEDICAID SUPERIOR|11.66||||11.71||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.66||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Managed Medicaid|MEDICAID AMERIGROUP|11.66||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.76||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|ChampVA|CHAMPVA CENTER|||||11.66||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Cigna|CIGNA|||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Cigna|CIGNA|11.76||||11.76||| 76775|EAP|0402|US EXAM ABDO BACK WALL LI|Humana Medicare Advantage|HUMANA MA|11.76||||11.76||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,276.86||||||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Blue Cross PPO Specialty|BCBSTX PPO|1,276.86||||1,276.86||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Blue Cross PPO Specialty|BCBSTX PPO|1,276.86||||12.66||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.66||||||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|United Medicare Advantage|UHC MEDICARE GOLD MA|1,276.86||||1,271.43||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|United Medicare Advantage|UHC AARP MCR HMO MA|1,276.86||||||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.66||||1,276.86||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,276.86||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.66||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Workers Compensation|WORKERS COMPENSATION OTHER|||||12.66||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|United Healthcare|UNITED HEALTHCARE OTHER|12.66||||||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|NON CONTRACTED|COMMERCIAL OTHER 1|1,276.86||||||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Medicare|UTSW MC KIDNEY PROGRAM|||||1,276.86||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Medicare|MEDICARE ACUTE|1,276.86||||1,276.86||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Medicare|MEDICARE PART B ONLY IP|1,276.86||||||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Medicare|MEDICARE ACUTE|12.66||||1,271.43||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Managed Medicare|HEALTHSPRING MA|12.66||||||| 76776|EAP|0402|US EXAM K TRANSPL W/DOPPL|Medicaid|MEDICAID|1,276.86||||||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|United Healthcare|UNITED HEALTHCARE OTHER|21,747.17|65.98|12222.49|34.02|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15,049.94|87.91|12222.49|34.02|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Access Direct Platinum|HEALTHFIRST TPA|19,132.95|87.91|12222.49|34.02|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Aetna|AETNA PPO|25,840.84|12222.49|12222.49|34.02|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Blue Cross HMO Specialty|BCBSTX HMO|27,164.95|34.02|12222.49|34.02|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38,533.36|107.16|12222.49|34.02|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Blue Cross PPO Specialty|BCBSTX PPO|24,685.34|7682.21|12222.49|34.02|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|21,933.05|7168.71|12222.49|34.02|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Managed Medicaid|MEDICAID SUPERIOR|23,998.92|3778.59|12222.49|34.02|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Cigna|CIGNA|20,985.49|67.2|12222.49|34.02|||| 76800|EAP|0402|US EXAM SPINAL CANAL|Managed Medicaid|MEDICAID SUPERIOR|564.41||||||| 76800|EAP|0402|US EXAM SPINAL CANAL|Blue Cross PPO Specialty|BCBSTX PPO|5.62||||||| 76800|EAP|0402|US EXAM SPINAL CANAL|Blue Cross HMO Specialty|BCBSTX HMO|566.82||||||| 76800|EAP|0402|US EXAM SPINAL CANAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.62||||||| 76800|EAP|0402|US EXAM SPINAL CANAL|Medicaid|MEDICAID|||||5.62||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Medicare|MEDICARE ACUTE|||||976.17||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|United Healthcare|UNITED HEALTHCARE OTHER|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|United Healthcare|UNITED HEALTHCARE|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Medicaid|MEDICAID|9.72||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||980.34||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Medicaid|MEDICAID HMO|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Access Direct Platinum|HEALTHFIRST TPA|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|980.34||||980.34||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||980.34||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|NON CONTRACTED|COMMERCIAL OTHER 1|||||980.34||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Aetna|AETNA OTHER|||||976.17||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Blue Cross HMO Specialty|BCBSTX HMO|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||976.17||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Blue Cross PPO Specialty|BCBSTX PPO|9.72||||980.34||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Cigna|CIGNA|||||976.17||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Cigna|CIGNA|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Managed Medicaid|MEDICAID SUPERIOR|980.34||||980.34||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.72||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Managed Medicaid|MEDICAID AMERIGROUP|9.72||||980.34||| 76801|EAP|0402|US OB < 14 WKS SINGLE FET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||980.34||| 76802|EAP|0402|US OB < 14 WKS ADDL FETUS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,429.15||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||15.74||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Medicaid|MEDICAID HMO|||||1,587.50||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Medicaid|MEDICAID|15.74||||1,587.50||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|United Healthcare|UNITED HEALTHCARE|15.74||||1,587.50||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|United Healthcare|UNITED HEALTHCARE|||||15.74||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|NON CONTRACTED|COMMERCIAL OTHER 2|||||15.74||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,580.75||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Medicare|MEDICARE ACUTE|1,587.50||||||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Managed Medicaid|MEDICAID AMERIGROUP|1,587.50||||1,587.50||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,587.50||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Managed Medicaid|MEDICAID SUPERIOR|1,580.75||||15.74||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Blue Cross PPO Specialty|BCBSTX PPO|15.74||||1,580.75||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,587.50||||15.74||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||15.74||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||15.74||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Access Direct Platinum|HEALTHFIRST TPA UMR|15.74||||||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,587.50||| 76805|EAP|0402|US OB >/= 14 WKS SNGL FET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.74||||15.74||| 76810|EAP|0402|US OB >/= 14 WKS ADDL FET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.96||| 76810|EAP|0402|US OB >/= 14 WKS ADDL FET|Managed Medicaid|MEDICAID SUPERIOR|||||6.96||| 76815|EAP|0402|OB US LIMITED FETUS(S)|Cigna|CIGNA OTHER|||||7.99||| 76815|EAP|0402|US OB LIMITED FETUS(S)|Managed Medicaid|MEDICAID AMERIGROUP|799.80||||799.80||| 76815|EAP|0402|US OB LIMITED FETUS(S)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||799.80||| 76815|EAP|0402|US OB LIMITED FETUS(S)|Managed Medicaid|MEDICAID SUPERIOR|7.93||||||| 76815|EAP|0402|OB US LIMITED FETUS(S)|Blue Cross PPO Specialty|BCBSTX PPO|||||7.99||| 76816|EAP|0402|US OB FOLLOW-UP PER FETUS|Managed Medicaid|MEDICAID AMERIGROUP|6.96||||6.96||| 76818|EAP|0320|US FETAL BIOPHYSICAL PROF|Medicare|MEDICARE ACUTE|1,318.21||||||| 76818|EAP|0320|US FETAL BIOPHYSICAL PROF|Medicaid|MEDICAID HMO|||||13.07||| 76818|EAP|0320|US FETAL BIOPHYSICAL PROF|Aetna|AETNA PPO|||||1,318.21||| 76818|EAP|0320|US FETAL BIOPHYSICAL PROF|Blue Cross PPO Specialty|BCBSTX PPO|13.07||||13.07||| 76818|EAP|0320|US FETAL BIOPHYSICAL PROF|Managed Medicaid|MEDICAID SUPERIOR|13.07||||13.07||| 76818|EAP|0320|US FETAL BIOPHYSICAL PROF|Managed Medicaid|MEDICAID AMERIGROUP|1,318.21||||1,318.21||| 76830|EAP|0402|US TRANVAGINAL|Veterans Affairs|VETERANS ADMINISTRATION|1,231.47||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Access Direct Platinum|HEALTHFIRST TPA|||||1,226.24||| 76830|EAP|0402|US TRANVAGINAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.21||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Humana Medicare Advantage|HUMANA MA|1,226.24||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Cigna|CIGNA|12.21||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Cigna|CIGNA OTHER|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Managed Medicaid|MEDICAID SUPERIOR|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Managed Medicaid|MEDICAID AMERIGROUP|1,226.24||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.21||||1,226.24||| 76830|EAP|0402|US TRANVAGINAL|Cigna|CIGNA|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Blue Cross HMO Specialty|BCBSTX HMO|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Blue Cross PPO Specialty|BCBSTX PPO|12.21||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,226.24||| 76830|EAP|0402|US TRANVAGINAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,231.47||| 76830|EAP|0402|US TRANVAGINAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.21||||12.21||| 76830|EAP|0402|US TRANVAGINAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Aetna|AETNA OTHER|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Aetna|AETNA PPO|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Managed Medicare|HEALTHSPRING MA|1,231.47||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Managed Medicare|BCBS MEDICARE PPO MA|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Medicaid|SMITH COUNTY JAIL|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Medicaid|MEDICAID|12.21||||1,226.24||| 76830|EAP|0402|US TRANVAGINAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|Tricare|TRICARE EAST REGION|12.21||||1,231.47||| 76830|EAP|0402|US TRANVAGINAL|United Healthcare|UNITED HEALTHCARE OTHER|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|United Healthcare|UNITED HEALTHCARE|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|United Healthcare|UNITED HEALTHCARE|12.21||||1,226.24||| 76830|EAP|0402|US TRANVAGINAL|United Healthcare|TML GROUP BENEFITS|||||12.21||| 76830|EAP|0402|US TRANVAGINAL|NON CONTRACTED|COMMERCIAL OTHER 1|12.21||||1,231.47||| 76830|EAP|0402|US TRANVAGINAL|Medicare|MEDICARE ACUTE|1,231.47||||12.21||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Medicare|MEDICARE ACUTE|1,077.16||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|PHCS|HUMANA|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|NON CONTRACTED|COMMERCIAL OTHER 1|10.68||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|United Healthcare|UNITED HEALTHCARE|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|United Healthcare|UNITED HEALTHCARE|10.68||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|United Healthcare|TML GROUP BENEFITS|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Medicaid|MEDICAID HMO|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Medicaid|SMITH COUNTY JAIL|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Medicaid|MEDICAID|1,077.16||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.68||||||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Managed Medicare|HEALTHSPRING MA|1,077.16||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Aetna|AETNA OTHER|1,077.16||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Managed Medicare|BCBS MEDICARE PPO MA|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Aetna|AETNA PPO|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,077.16||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|1,077.16||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,072.58||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Tricare|TRICARE EAST REGION|10.68||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Blue Cross HMO Specialty|BCBSTX HMO|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Managed Medicaid|MEDICAID SUPERIOR|||||1,072.58||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.68||||1,072.58||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|1,077.16||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|United Healthcare|UNITED HEALTHCARE OTHER|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Cigna|CIGNA|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Cigna|CIGNA OTHER|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Cigna|CIGNA|1,077.16||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Humana Medicare Advantage|HUMANA MA|10.68||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.68||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|United Medicare Advantage|UHC AARP MCR HMO MA|1,077.16||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|United Medicare Advantage|UHC MEDICARE GOLD MA|1,077.16||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||10.68||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Access Direct Platinum|HEALTHFIRST TPA|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10.68||||1,072.58||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,077.16||| 76856|EAP|0402|US EXAM PELVIC COMPLETE|Veterans Affairs|VETERANS ADMINISTRATION|1,077.16||||10.68||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.70||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Managed Medicaid|MEDICAID AMERIGROUP|9.78||||877.46||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Blue Cross HMO Specialty|BCBSTX HMO|||||689.39||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.78||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.78||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Blue Cross PPO Specialty|BCBSTX PPO|||||8.70||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Blue Cross PPO Specialty|BCBSTX PPO|||||689.39||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Aenta Medicare Advantage|AETNA MEDICARE MA|||||986.39||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Managed Medicare|BCBS MEDICARE PPO MA|||||9.78||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Managed Medicare|HEALTHSPRING MA|9.78||||689.39||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Medicaid|MEDICAID|9.78||||||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Medicare|MEDICARE ACUTE|||||833.70||| 76857|EAP|0402|US EXAM PELVIC LIMITED|Medicare|MEDICARE ACUTE|||||877.46||| 76870|EAP|0402|US EXAM SCROTUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|919.93||||||| 76870|EAP|0402|US EXAM SCROTUM|Tricare|TRICARE FOR LIFE|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|United Healthcare|UNITED HEALTHCARE OTHER|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|United Healthcare|TML GROUP BENEFITS|||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|United Healthcare|UNITED HEALTHCARE|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|PHCS|HUMANA|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|PHCS|MULTIPLAN PHCS|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Medicare|MEDICARE PART B ONLY IP|9.16||||||| 76870|EAP|0402|US EXAM SCROTUM|Medicare|MEDICARE ACUTE|9.16||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Medicaid|MEDICAID HMO|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Medicaid|SMITH COUNTY JAIL|9.16||||919.93||| 76870|EAP|0402|US EXAM SCROTUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Managed Medicare|OTHER INSTITUTIONS|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Managed Medicare|BCBS MEDICARE PPO MA|||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.16||||919.93||| 76870|EAP|0402|US EXAM SCROTUM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Aetna|AETNA PPO|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Aetna|AETNA OTHER|9.16||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Managed Medicare|HEALTHSPRING MA|919.93||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Blue Cross PPO Specialty|BCBSTX PPO|923.86||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Blue Cross PPO Specialty|BCBSTX OTHER|9.16||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Medicaid|MEDICAID|9.16||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Blue Cross HMO Specialty|BCBSTX HMO|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Humana Medicare Advantage|HUMANA MA|919.93||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Cigna|CIGNA OTHER|||||919.93||| 76870|EAP|0402|US EXAM SCROTUM|Cigna|CIGNA|923.86||||||| 76870|EAP|0402|US EXAM SCROTUM|Cigna|CIGNA|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Managed Medicaid|MEDICAID AMERIGROUP|919.93||||919.93||| 76870|EAP|0402|US EXAM SCROTUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|919.93||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|United Healthcare|UNITED HEALTHCARE|||||919.93||| 76870|EAP|0402|US EXAM SCROTUM|Tricare|TRICARE EAST REGION|||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Managed Medicaid|MEDICAID SUPERIOR|9.16||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|United Medicare Advantage|UHC AARP MCR HMO MA|923.86||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|United Medicare Advantage|UHC MEDICARE GOLD MA|923.86||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.16||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Workers Compensation|WORKERS COMPENSATION OTHER|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Veterans Affairs|VETERANS ADMINISTRATION|||||919.93||| 76870|EAP|0402|US EXAM SCROTUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||919.93||| 76870|EAP|0402|US EXAM SCROTUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||923.86||| 76870|EAP|0402|US EXAM SCROTUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.16||||9.16||| 76870|EAP|0402|US EXAM SCROTUM|Access Direct Platinum|HEALTHFIRST TPA|||||919.93||| 76872|EAP|0402|US TRANSRECTAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||12.85||| 76872|EAP|0402|US TRANSRECTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Veterans Affairs|VETERANS ADMINISTRATION|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Cigna|CIGNA|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Cigna|CIGNA|||||1,290.51||| 76872|EAP|0402|US TRANSRECTAL|Humana Medicare Advantage|HUMANA MA|1,296.02||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Blue Cross HMO Specialty|BCBSTX HMO|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Blue Cross PPO Specialty|BCBSTX PPO|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||12.85||| 76872|EAP|0402|US TRANSRECTAL|Aetna|AETNA PPO|||||1,290.51||| 76872|EAP|0402|US TRANSRECTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Access Direct Platinum|HEALTHFIRST TPA|||||12.85||| 76872|EAP|0402|US TRANSRECTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Managed Medicare|HEALTHSPRING MA|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Managed Medicare|BCBS MEDICARE PPO MA|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|Multiplan|WEB TPA|||||12.85||| 76872|EAP|0402|US TRANSRECTAL|Medicare|MEDICARE ACUTE|1,296.02||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|PHCS|HUMANA|||||1,290.51||| 76872|EAP|0402|US TRANSRECTAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|PHCS|HUMANA INSURANCE|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|United Healthcare|UNITED HEALTHCARE OTHER|||||1,290.51||| 76872|EAP|0402|US TRANSRECTAL|United Healthcare|UNITED HEALTHCARE|||||12.85||| 76872|EAP|0402|US TRANSRECTAL|United Healthcare|UNITED HEALTHCARE|||||1,296.02||| 76872|EAP|0402|US TRANSRECTAL|United Healthcare|AARP|||||1,296.02||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Tricare|TRICARE EAST REGION|||||9.16||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|United Healthcare|UNITED HEALTHCARE|||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.16||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Managed Medicare|HEALTHSPRING MA|9.16||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Managed Medicare|BCBS MEDICARE PPO MA|||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.16||||9.16||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Aetna|AETNA PPO|||||9.16||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Blue Cross PPO Specialty|BCBSTX OTHER|||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Medicare|MEDICARE ACUTE|923.86||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|9.16||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Blue Cross HMO Specialty|BCBSTX HMO|||||9.16||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Humana Medicare Advantage|HUMANA MA|923.86||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Cigna|CIGNA|||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.16||||||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.16||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|||||9.16||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Managed Medicaid|MEDICAID SUPERIOR|||||919.93||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Workers Compensation|UT EMPLOYEE INJURY|||||9.16||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Access Direct Platinum|HEALTHFIRST TPA|||||923.86||| 76881|EAP|0402|US XTR NON-VASC COMPLETE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||923.86||| 76882|EAP|0402|US XTR NON-VASC LMTD|Humana Medicare Advantage|HUMANA MA|||||7.83||| 76885|EAP|0402|US EXAM INFANT HIPS DYNAM|Medicaid|MEDICAID|||||517.21||| 76885|EAP|0402|US EXAM INFANT HIPS DYNAM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||519.42||| 76885|EAP|0402|US EXAM INFANT HIPS DYNAM|Blue Cross HMO Specialty|BCBSTX HMO|||||519.42||| 76885|EAP|0402|US EXAM INFANT HIPS DYNAM|Blue Cross PPO Specialty|BCBSTX PPO|||||5.15||| 76885|EAP|0402|US EXAM INFANT HIPS DYNAM|Aetna|AETNA PPO|||||5.15||| 76885|EAP|0402|US EXAM INFANT HIPS DYNAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.15||| 76885|EAP|0402|US EXAM INFANT HIPS DYNAM|Managed Medicaid|MEDICAID SUPERIOR|||||5.15||| 76885|EAP|0402|US EXAM INFANT HIPS DYNAM|Managed Medicaid|MEDICAID AMERIGROUP|||||5.15||| 769|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|79,849.72|12020.24|46203.52|84.15|||| 769|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE|Managed Medicaid|MEDICAID SUPERIOR|104,255.40|7294.92|46203.52|84.15|||| 769|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE|Blue Cross HMO Specialty|BCBSTX HMO|63,805.91|84.15|46203.52|84.15|||| 769|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE|Blue Cross PPO Specialty|BCBSTX PPO|29,914.37|9899.14|46203.52|84.15|||| 769|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE|NON CONTRACTED|COMMERCIAL OTHER 1|46,203.52|46203.52|46203.52|84.15|||| 76930|EAP|0402|US GUIDANCE PERICARDIOCEN|Blue Cross PPO Specialty|BCBSTX PPO|14.20||||||| 76936|EAP|0402|PSEUDO ANEURYSM COMPRESSI|Managed Medicare|HEALTHSPRING MA|77.22||||||| 76937|EAP|0402|IR-US GUIDANCE CVAD|United Medicare Advantage|UHC AARP MCR HMO MA|1,519.93||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.07||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Veterans Affairs|VETERANS ADMINISTRATION|15.07||||15.07||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Workers Compensation|WORKERS COMPENSATION OTHER|||||15.07||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,513.47||||||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,519.93||||1,519.93||| 76937|EAP|0402|ULTRASOUND GUIDE VASCULAR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,407.97||||15.07||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Managed Medicaid|MEDICAID AMERIGROUP|||||1,513.47||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.07||||15.07||| 76937|EAP|0402|ULTRASOUND GUIDE VASCULAR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.96||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Humana Medicare Advantage|HUMANA MA|1,519.93||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Aetna|AETNA PPO|||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Aenta Medicare Advantage|AETNA MEDICARE MA|15.07||||15.07||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,519.93||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Blue Cross HMO Specialty|BCBSTX HMO|15.07||||15.07||| 76937|EAP|0402|ULTRASOUND GUIDE VASCULAR|Blue Cross HMO Specialty|BCBSTX HMO|1,407.97||||15.07||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Blue Cross PPO Specialty|BCBSTX PPO|1,519.93||||1,519.93||| 76937|EAP|0402|ULTRASOUND GUIDE VASCULAR|Humana Medicare Advantage|HUMANA MA|13.96||||1,519.93||| 76937|EAP|0402|ULTRASOUND GUIDE VASCULAR|Blue Cross PPO Specialty|BCBSTX PPO|1,401.99||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,513.47||||||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Blue Cross PPO Specialty|BCBSTX OTHER|||||15.07||| 76937|EAP|0402|ULTRASOUND GUIDE VASCULAR|United Healthcare|UNITED HEALTHCARE|1,407.97||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|United Healthcare|UNITED HEALTHCARE OTHER|1,519.93||||15.07||| 76937|EAP|0402|IR-US GUIDANCE CVAD|United Healthcare|UNITED HEALTHCARE|15.07||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|United Healthcare|UNITED HEALTHCARE|1,513.47||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.07||||||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Access Direct Platinum|HEALTHFIRST TPA|15.07||||||| 76937|EAP|0402|IR-US GUIDANCE CVAD|United Medicare Advantage|UHC MEDICARE GOLD MA|1,519.93||||15.07||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Tricare|TRICARE EAST REGION|||||1,513.47||| 76937|EAP|0402|US GUIDE VASCULAR ACCESS|NON CONTRACTED|COMMERCIAL OTHER 1|9.43||||1,513.47||| 76937|EAP|0402|IR-US GUIDANCE CVAD|NON CONTRACTED|COMMERCIAL OTHER 1|15.07||||1,513.47||| 76937|EAP|0402|ULTRASOUND GUIDE VASCULAR|Medicare|MEDICARE ACUTE|1,407.97||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Medicare|MEDICARE PART B ONLY IP|15.07||||||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Medicare|MEDICARE ACUTE|15.07||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Medicare|UTSW MC KIDNEY PROGRAM|||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Medicaid|MEDICAID|1,513.47||||1,519.93||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Medicaid|SMITH COUNTY JAIL|15.07||||||| 76937|EAP|0402|ULTRASOUND GUIDE VASCULAR|Medicaid|CRIME VICTIMS COMPENSATION|13.96||||||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Managed Medicare|HEALTHSPRING MA|15.07||||1,513.47||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.07||||15.07||| 76937|EAP|0402|IR-US GUIDANCE CVAD|Managed Medicare|BCBS MEDICARE PPO MA|15.07||||||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Managed Medicare|HEALTHSPRING MA|2,052.46||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Managed Medicare|BCBS MEDICARE PPO MA|1,880.03||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Managed Medicare|HEALTHSPRING MA|1,888.06||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|18.72||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Medicaid|COUNTY INDIGENT HEALTH OTHER|1,888.06||||||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Medicaid|MEDICAID HMO|||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Medicaid|SMITH COUNTY JAIL|20.35||||||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Medicaid|MOLINA HEALTHCARE OF TEXAS|1,888.06||||||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Medicaid|SUPERIOR HEALTHPLAN CHIP|18.72||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Multiplan|WEB TPA|||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Medicare|MEDICARE PART B ONLY IP|1,888.06||||||| 76942|EAP|0320|US GUIDANCE NEEDLE PLCMNT|Medicare|MEDICARE ACUTE|||||11.90||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Medicare|MEDICARE ACUTE|1,888.06||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|PHCS|HUMANA INSURANCE|||||2,052.46||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|NON CONTRACTED|COMMERCIAL OTHER 1|1,888.06||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|NON CONTRACTED|COMMERCIAL OTHER 1|1,888.06||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|PHCS|GROUP AND PENSION|||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Rusk State Hospital|RUSK STATE HOSP|1,888.06||||2,052.46||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|PHCS|HUMANA|1,880.03||||2,043.73||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Tricare|TRICARE EAST REGION|1,888.06||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Tricare|TRICARE EAST REGION|1,888.06||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Tricare|TRICARE FOR LIFE|||||18.72||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,880.03||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|United Healthcare|UNITED HEALTHCARE OTHER|1,888.06||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|United Healthcare|UNITED HEALTHCARE OTHER|1,888.06||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|United Healthcare|UNITED HEALTHCARE|18.72||||2,052.46||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|United Healthcare|UNITED HEALTHCARE|1,888.06||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|United Healthcare|UNITED HEALTHCARE|1,888.06||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,880.03||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Blue Cross PPO Specialty|BCBSTX PPO|18.72||||20.35||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Blue Cross PPO Specialty|BCBSTX OTHER|18.72||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Blue Cross PPO Specialty|BCBSTX OTHER|18.72||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,880.03||||2,043.73||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Brinson Benefits|THE HEALTH PLAN SMITH CO|18.72||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Brinson Benefits|THE HEALTH PLAN SMITH CO|18.72||||2,043.73||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Blue Cross HMO Specialty|BCBSTX HMO|18.72||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Blue Cross HMO Specialty|BCBSTX HMO|18.72||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,888.06||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,888.06||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Aetna|BOON CHAPMAN|18.72||||||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Aetna|AETNA PPO|1,880.03||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Aenta Medicare Advantage|AETNA MEDICARE MA|1,880.03||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Aetna|AETNA PPO|1,880.03||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Aetna|AETNA OTHER|||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Aetna|AETNA QHP HMO|1,888.06||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Aenta Medicare Advantage|AETNA MEDICARE MA|1,880.03||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Blue Cross PPO Specialty|BCBSTX PPO|18.72||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Aetna|AETNA OTHER|||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Cigna|CIGNA|||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Cigna|CIGNA|||||20.35||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Cigna|CIGNA|18.72||||20.35||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Cigna|CIGNA OTHER|||||2,052.46||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Cigna|CIGNA|18.72||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Cigna|CIGNA OTHER|||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Humana Medicare Advantage|HUMANA MA|18.72||||1,888.06||| 76942|EAP|0320|US GUIDANCE NEEDLE PLCMNT|Blue Cross PPO Specialty|BCBSTX PPO|||||11.90||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|United Healthcare|UNITED HEALTHCARE|18.72||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Humana Medicare Advantage|HUMANA MA|18.72||||2,052.46||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Managed Medicaid|MEDICAID SUPERIOR|1,880.03||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Managed Medicaid|MEDICAID SUPERIOR|1,880.03||||1,888.06||| 76942|EAP|0320|US GUIDANCE NEEDLE PLCMNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||11.90||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Texas Workforce Commission|DIS DETER SERV (DDS)|1,880.03||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.72||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.72||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.72||||18.72||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Managed Medicaid|MEDICAID AMERIGROUP|1,888.06||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|PHCS|HUMANA|1,880.03||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Managed Medicaid|MEDICAID AMERIGROUP|1,888.06||||20.35||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.72||||2,043.73||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|18.72||||20.35||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Access Direct Platinum|HEALTHFIRST TPA|1,888.06||||20.35||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Medicare|MEDICARE ACUTE|20.35||||20.35||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||20.35||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.72||||2,052.46||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.72||||1,880.03||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Access Direct Platinum|HEALTHFIRST TPA UMR|1,888.06||||1,880.03||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,888.06||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Access Direct Platinum|HEALTHFIRST TPA|1,888.06||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Medicaid|MEDICAID|18.72||||||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|18.72||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,888.06||||2,052.46||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|18.72||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Access Direct Platinum|HEALTHFIRST TPA UMR|1,888.06||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Workers Compensation|WORKERS COMPENSATION OTHER|1,888.06||||18.72||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|Veterans Affairs|VETERANS ADMINISTRATION|1,888.06||||20.35||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|18.72||||||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Workers Compensation|BROOKSHIRES WORKERS COMP|||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Workers Compensation|UT EMPLOYEE INJURY|||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Workers Compensation|WORKERS COMP PHYSICIAN|||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||1,888.06||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|Veterans Affairs|VETERANS ADMINISTRATION|1,888.06||||18.72||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,888.06||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|United Medicare Advantage|UHC MEDICARE GOLD MA|20.35||||2,052.46||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,888.06||||2,052.46||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|United Medicare Advantage|UHC AARP MCR HMO MA|1,888.06||||1,888.06||| 76942|EAP|0402|US ECHO GUIDE FOR BIOPSY|United Medicare Advantage|UHC AARP MCR HMO MA|1,888.06||||2,052.46||| 76942|EAP|0402|ULTRASOUND GUIDED NERVE B|United Medicare Advantage|UHC MEDICARE GOLD MA|1,888.06||||1,888.06||| 76998|EAP|0402|US GUIDANCE INTER-OPERATI|Managed Medicare|HEALTHSPRING MA|||||13.13||| 77|DRG||HYPERTENSIVE ENCEPHALOPATHY W MCC|Humana Medicare Advantage|HUMANA MA|131,936.05|9924.2|9924.2|9924.2|||| 77|DRG||HYPERTENSIVE ENCEPHALOPATHY W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|38,266.88|9924.2|9924.2|9924.2|||| 770|DRG||ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY|Medicaid|MEDICAID|478,752.60|17548.69|17548.69|17548.69|||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.99||||1,057.87||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|United Medicare Advantage|UHC AARP MCR HMO MA|1,057.87||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|United Medicare Advantage|UHC MEDICARE GOLD MA|1,028.44||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.99||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|United Medicare Advantage|UHC AARP MCR HMO MA|1,057.87||||1,057.87||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|United Medicare Advantage|UHC MEDICARE GOLD MA|1,057.87||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Veterans Affairs|VETERANS ADMINISTRATION|9.99||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Workers Compensation|WORKERS COMPENSATION OTHER|||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Veterans Affairs|VETERANS ADMINISTRATION|1,028.44||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Access Direct Platinum|HEALTHFIRST TPA|9.99||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Access Direct Platinum|HEALTHFIRST TPA UMR|9.99||||1,028.44||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.99||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Access Direct Platinum|HEALTHFIRST TPA UMR|9.99||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Access Direct Platinum|HEALTHFIRST TPA|1,057.87||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Aenta Medicare Advantage|AETNA MEDICARE MA|1,057.87||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Aetna|AETNA PPO|1,057.87||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.99||||1,057.87||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,057.87||||1,028.44||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Blue Cross HMO Specialty|BCBSTX HMO|9.99||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Blue Cross HMO Specialty|BCBSTX HMO|9.99||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Blue Cross PPO Specialty|BCBSTX PPO|1,057.87||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,057.87||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Blue Cross PPO Specialty|BCBSTX PPO|1,057.87||||1,057.87||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Managed Medicaid|MEDICAID AMERIGROUP|9.99||||1,028.44||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.99||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,057.87||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.99||||1,057.87||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.99||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Managed Medicaid|MEDICAID SUPERIOR|1,057.87||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Managed Medicaid|MEDICAID AMERIGROUP|9.99||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Humana Medicare Advantage|HUMANA MA|9.99||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Humana Medicare Advantage|HUMANA MA|1,057.87||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Cigna|CIGNA|1,057.87||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Cigna|CIGNA|||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,028.44||||||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|ChampVA|CHAMPVA CENTER|1,057.87||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|PHCS|GROUP AND PENSION|||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|NON CONTRACTED|COMMERCIAL OTHER 1|9.99||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|NON CONTRACTED|COMMERCIAL OTHER 2|1,057.87||||||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|NON CONTRACTED|COMMERCIAL OTHER 1|9.99||||1,028.44||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Aenta Medicare Advantage|AETNA MEDICARE MA|9.99||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Medicare|MEDICARE ACUTE|9.99||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Medicare|MEDICARE PART B ONLY IP|1,057.87||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,028.44||||1,057.87||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Medicare|UTSW MC KIDNEY PROGRAM|||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Medicare|MEDICARE ACUTE|9.99||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Medicare|MEDICARE PART B ONLY IP|9.99||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,057.87||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Tricare|TRICARE EAST REGION|1,057.87||||1,057.87||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Tricare|TRICARE EAST REGION|1,057.87||||1,028.44||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.99||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|United Healthcare|UNITED HEALTHCARE|1,028.44||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|United Healthcare|TML GROUP BENEFITS|9.99||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|United Healthcare|UNITED HEALTHCARE|9.99||||1,057.87||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|United Healthcare|UNITED HEALTHCARE OTHER|1,057.87||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|United Healthcare|UNITED HEALTHCARE|9.99||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|United Healthcare|UNITED HEALTHCARE OTHER|1,057.87||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,057.87||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Medicaid|SMITH COUNTY JAIL|9.99||||||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Medicaid|MEDICAID|1,057.87||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Medicaid|MEDICAID|9.99||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Medicaid|SMITH COUNTY JAIL|9.99||||||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Managed Medicare|HEALTHSPRING MA|9.99||||1,057.87||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.99||||9.99||| 77001|EAP|0320|XR-OR FLUORO GUIDANCE CVA|Managed Medicare|BCBS MEDICARE PPO MA|9.99||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.99||||9.99||| 77001|EAP|0320|IR-FLUORO GUIDANCE CVAD|Managed Medicare|HEALTHSPRING MA|9.99||||1,028.44||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Managed Medicare|HEALTHSPRING MA|13.76||||1,416.55||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|United Healthcare|UNITED HEALTHCARE OTHER|||||13.76||| 77002|EAP|0320|XR-FLUORO ASPIRATION|United Healthcare|UNITED HEALTHCARE OTHER|||||1,457.09||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Tricare|TRICARE EAST REGION|||||13.76||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Medicare|MEDICARE ACUTE|1,457.09||||1,457.09||| 77002|EAP|0320|IR-FLUORO GUIDE NDL PLCMN|Medicare|MEDICARE ACUTE|1,457.09||||1,085.41||| 77002|EAP|0320|FLUORO FOR PERICARDIOCENT|Medicare|MEDICARE ACUTE|1,615.93||||15.26||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Medicare|MEDICARE ACUTE|1,457.09||||13.76||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Humana Medicare Advantage|HUMANA MA|13.76||||13.76||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Humana Medicare Advantage|HUMANA MA|13.76||||13.76||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.76||||13.76||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.76||||13.76||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Managed Medicaid|MEDICAID SUPERIOR|||||13.76||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.76||||13.76||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Managed Medicaid|MEDICAID AMERIGROUP|||||13.76||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Blue Cross PPO Specialty|BCBSTX PPO|1,416.55||||1,457.09||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Blue Cross PPO Specialty|BCBSTX PPO|1,416.55||||13.76||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Blue Cross HMO Specialty|BCBSTX HMO|1,457.09||||1,457.09||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Tricare|TRICARE EAST REGION|||||1,457.09||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,457.09||||1,457.09||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,457.09||||1,457.09||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,457.09||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Aetna|AETNA PPO|||||13.76||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||13.76||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,457.09||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,457.09||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,457.09||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,457.09||| 77002|EAP|0320|XR-FLUORO ASPIRATION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,457.09||| 77002|EAP|0320|IR-FLUORO GUIDE NDL PLCMN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10.25||| 77002|EAP|0320|XR-FLUORO ASPIRATION|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,457.09||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.76||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||13.76||| 77002|EAP|0320|FLUOROSCOPIC GUIDANCE|United Medicare Advantage|UHC AARP MCR HMO MA|1,615.93||||1,416.55||| 77003|EAP|0320|IR-FLUORO GUIDE LOC SPINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|868.32||||||| 77003|EAP|0320|IR-FLUORO GUIDE LOC SPINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|844.16||||||| 77003|EAP|0320|IR-FLUORO GUIDE LOC SPINE|Humana Medicare Advantage|HUMANA MA|8.20||||8.20||| 77003|EAP|0320|IR-FLUORO GUIDE LOC SPINE|Medicare|MEDICARE ACUTE|844.16||||868.32||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Medicaid|SMITH COUNTY JAIL|48.89||||||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Medicaid|MEDICAID|48.89||||5,377.90||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5,866.80||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Managed Medicare|HEALTHSPRING MA|5,866.80||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Managed Medicare|BCBS MEDICARE PPO MA|||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|UTMB|UTMB CORRECTIONAL MANAGED CARE|5,866.80||||||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Tricare|TRICARE EAST REGION|5,866.80||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|United Healthcare|UNITED HEALTHCARE OTHER|5,866.80||||5,377.90||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|United Healthcare|UNITED HEALTHCARE|||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|NON CONTRACTED|COMMERCIAL OTHER 1|5,866.80||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Medicare|MEDICARE ACUTE|48.89||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|48.89||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,866.80||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Managed Medicaid|MEDICAID AMERIGROUP|||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Managed Medicaid|MEDICAID SUPERIOR|||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Cigna|CIGNA OTHER|||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Cigna|CIGNA|5,866.80||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Rusk State Hospital|RUSK STATE HOSP|||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|United Healthcare|UNITED HEALTHCARE|||||5,377.90||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Humana Medicare Advantage|HUMANA MA|48.89||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Blue Cross HMO Specialty|BCBSTX HMO|||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,377.90||||||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Blue Cross PPO Specialty|BCBSTX PPO|5,866.80||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Aenta Medicare Advantage|AETNA MEDICARE MA|48.89||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Aetna|AETNA PPO|5,866.80||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,866.80||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|48.89||||||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Workers Compensation|WORKERS COMPENSATION OTHER|||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Veterans Affairs|VETERANS ADMINISTRATION|5,866.80||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,866.80||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||48.89||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|United Medicare Advantage|UHC MEDICARE GOLD MA|5,866.80||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,377.90||||5,866.80||| 77012|EAP|0350|CT-SCAN FOR NEEDLE BIOPSY|United Medicare Advantage|UHC AARP MCR HMO MA|5,866.80||||5,866.80||| 77013|EAP|0350|CT-GUIDE FOR TISSUE ABLAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,180.40||| 77013|EAP|0350|CT-GUIDE FOR TISSUE ABLAT|Blue Cross PPO Specialty|BCBSTX PPO|||||5,180.40||| 77013|EAP|0350|CT-GUIDE FOR TISSUE ABLAT|Blue Cross HMO Specialty|BCBSTX HMO|||||5,180.40||| 77013|EAP|0350|CT-GUIDE FOR TISSUE ABLAT|Humana Medicare Advantage|HUMANA MA|||||43.17||| 77013|EAP|0350|CT-GUIDE FOR TISSUE ABLAT|Medicare|MEDICARE ACUTE|||||43.17||| 77047|EAP|0610|MRI BREAST BILAT W/O CONT|Medicare|MEDICARE ACUTE|||||7,903.50||| 77047|EAP|0610|MRI BREAST BILAT W/O CONT|Blue Cross PPO Specialty|BCBSTX PPO|||||7,903.50||| 77047|EAP|0610|MRI BREAST BILAT W/O CONT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7,903.50||| 77047|EAP|0610|MRI BREAST BILAT W/O CONT|Aetna|AETNA PPO|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Access Direct Platinum|HEALTHFIRST TPA|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Veterans Affairs|VETERANS ADMINISTRATION|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Managed Medicaid|MEDICAID SUPERIOR|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Managed Medicaid|MEDICAID AMERIGROUP|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Cigna|CIGNA|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Aetna|AETNA OTHER|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Aetna|AETNA PPO|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Blue Cross HMO Specialty|BCBSTX HMO|||||7,544.25||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Blue Cross PPO Specialty|BCBSTX PPO|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Managed Medicare|HEALTHSPRING MA|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Medicaid|MEDICAID|||||7,544.25||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|United Healthcare|UNITED HEALTHCARE|||||7,544.25||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|United Healthcare|GEHA|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|United Healthcare|TML GROUP BENEFITS|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|United Healthcare|UNITED HEALTHCARE OTHER|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Tricare|TRICARE EAST REGION|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|PHCS|GROUP AND PENSION|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|NON CONTRACTED|COMMERCIAL OTHER 1|||||71.85||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|PHCS|HUMANA|||||7,903.50||| 77049|EAP|0610|MRI BREAST W/WO CON BILAT|Medicare|MEDICARE ACUTE|||||7,903.50||| 77053|EAP|0320|BC MAMMARY DUCTOGRAM OR G|Medicare|MEDICARE ACUTE|||||14.02||| 77053|EAP|0320|BC MAMMARY DUCTOGRAM OR G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14.02||| 77053|EAP|0320|BC MAMMARY DUCTOGRAM OR G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,475.87||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|United Medicare Advantage|UHC AARP MCR HMO MA|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Veterans Affairs|VETERANS ADMINISTRATION|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Access Direct Platinum|HEALTHFIRST TPA UMR|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Humana Medicare Advantage|HUMANA MA|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|ChampVA|CHAMPVA CENTER|||||126.44||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Cigna|CIGNA|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Managed Medicaid|MEDICAID SUPERIOR|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Managed Medicaid|MEDICAID AMERIGROUP|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Blue Cross PPO Specialty|BCBSTX PPO|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Blue Cross PPO Specialty|BCBSTX OTHER|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Blue Cross HMO Specialty|BCBSTX HMO|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Aetna|BOON CHAPMAN|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||126.44||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Aetna|AETNA OTHER|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Aenta Medicare Advantage|AETNA MEDICARE MA|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Aetna|AETNA PPO|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Aetna Value Network|AETNA VALUE NETWORK|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Cigna|CIGNA OTHER|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Medicaid|MEDICAID|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Access Direct Platinum|HEALTHFIRST TPA|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Managed Medicare|BCBS MEDICARE PPO MA|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Managed Medicare|HEALTHSPRING MA|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Tricare|TRICARE FOR LIFE|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Tricare|TRICARE EAST REGION|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|United Healthcare|TML GROUP BENEFITS|||||126.44||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|United Healthcare|AARP|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|United Healthcare|GEHA|||||126.44||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|United Healthcare|UNITED HEALTHCARE OTHER|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|United Healthcare|UNITED HEALTHCARE|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|NON CONTRACTED|COMMERCIAL OTHER 1|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|PHCS|HUMANA INSURANCE|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|PHCS|HUMANA|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|PHCS|GROUP AND PENSION|||||129.68||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Multiplan|GILSBAR INC|||||123.19||| 77063|EAP|0403|BC SCR BREAST TOMOSYNTHES|Medicare|MEDICARE ACUTE|||||123.19||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Aetna|AETNA PPO|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Blue Cross PPO Specialty|BCBSTX PPO|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Blue Cross PPO Specialty|BCBSTX PPO|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicaid|MEDICAID SUPERIOR|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicaid|MEDICAID SUPERIOR|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicaid|MEDICAID AMERIGROUP|||||708.18||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||708.18||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicaid|MEDICAID AMERIGROUP|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Cigna|CIGNA|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Cigna|CIGNA OTHER|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|ChampVA|CHAMPVA CENTER|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Cigna|CIGNA|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Humana Medicare Advantage|HUMANA MA|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Access Direct Platinum|HEALTHFIRST TPA|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Blue Cross HMO Specialty|BCBSTX HMO|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Aetna Value Network|AETNA VALUE NETWORK|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Access Direct Platinum|HEALTHFIRST TPA TYLER ISD|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Veterans Affairs|VETERANS ADMINISTRATION|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Medicare Advantage|UHC AARP MCR HMO MA|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Multiplan|WEB TPA|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|NON CONTRACTED|COMMERCIAL OTHER 2|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|PHCS|GROUP AND PENSION|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Tricare|TRICARE EAST REGION|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicare|HEALTHSPRING MA|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Tricare|TRICARE EAST REGION|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicare|BCBS MEDICARE PPO MA|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicare|HEALTHSPRING MA|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Tricare|TRICARE FOR LIFE|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|NON CONTRACTED|COMMERCIAL OTHER 1|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Healthcare|UNITED HEALTHCARE OTHER|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Healthcare|TML GROUP BENEFITS|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Healthcare|UNITED HEALTHCARE|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Healthcare|UNITED HEALTHCARE|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Medicare|UTSW MC KIDNEY PROGRAM|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Medicaid|MEDICAID|||||726.35||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Medicare|MEDICARE ACUTE|6.90||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|United Healthcare|GOLDEN RULE|||||6.90||| 77065|EAP|0401|BC DX MAMMO INCL CAD UNI|Tricare|TRICARE FOR LIFE|||||726.35||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|United Healthcare|UNITED HEALTHCARE|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Blue Cross PPO Specialty|BCBSTX PPO|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Aetna Value Network|AETNA VALUE NETWORK|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|ChampVA|CHAMPVA CENTER|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Cigna|CIGNA OTHER|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Managed Medicaid|MEDICAID AMERIGROUP|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||758.47||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Managed Medicaid|MEDICAID SUPERIOR|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Cigna|CIGNA|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|NON CONTRACTED|COMMERCIAL OTHER 1|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Aetna|AETNA PPO|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Access Direct Platinum|HEALTHFIRST TPA|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Multiplan|WEB TPA|||||758.47||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|United Healthcare|TML GROUP BENEFITS|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Medicare|MEDICARE ACUTE|7.39||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|PHCS|GROUP AND PENSION|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Managed Medicare|BCBS MEDICARE PPO MA|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Veterans Affairs|VETERANS ADMINISTRATION|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|United Healthcare|UNITED HEALTHCARE|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Medicaid|MEDICAID|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|United Healthcare|UNITED HEALTHCARE OTHER|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Tricare|TRICARE FOR LIFE|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Tricare|TRICARE EAST REGION|||||758.47||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|United Medicare Advantage|UHC AARP MCR HMO MA|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|United Healthcare|UNITED HEALTHCARE ERS|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Managed Medicare|HEALTHSPRING MA|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Humana Medicare Advantage|HUMANA MA|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Blue Cross HMO Specialty|BCBSTX HMO|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||777.94||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Medicare|UTSW MC KIDNEY PROGRAM|||||7.39||| 77066|EAP|0401|BC DX MAMMO INCL CAD BI|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||7.39||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Aetna|BOON CHAPMAN|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Blue Cross PPO Specialty|BCBSTX PPO|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Aetna|AETNA OTHER|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|Blue Cross HMO Specialty|BCBSTX HMO|||||522.13||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|Blue Cross PPO Specialty|BCBSTX PPO|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||509.07||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Blue Cross HMO Specialty|BCBSTX HMO|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Aetna|AETNA PPO|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Healthcare|TML GROUP BENEFITS|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Managed Medicare|HEALTHSPRING MA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Aetna Value Network|AETNA VALUE NETWORK|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Medicaid|MEDICAID|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Managed Medicare|HEALTHSPRING MA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|ChampVA|CHAMPVA CENTER|||||509.07||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Managed Medicaid|MEDICAID SUPERIOR|||||509.07||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|United Healthcare|UNITED HEALTHCARE|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Cigna|CIGNA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Managed Medicaid|MEDICAID AMERIGROUP|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||509.07||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Managed Medicare|BCBS MEDICARE PPO MA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Humana Medicare Advantage|HUMANA MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Cigna|CIGNA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Blue Cross PPO Specialty|BCBSTX OTHER|||||522.13||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Blue Cross HMO Specialty|BCBSTX HMO|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|Aetna|AETNA PPO|||||522.13||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Aetna|AETNA PPO|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Access Direct Platinum|HEALTHFIRST TPA TYLER ISD|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Cigna|CIGNA OTHER|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Blue Cross PPO Specialty|BCBSTX PPO|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Humana Medicare Advantage|HUMANA MA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|United Medicare Advantage|UHC AARP MCR HMO MA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Medicare|MEDICARE ACUTE|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Access Direct Platinum|HEALTHFIRST TPA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Healthcare|UNITED HEALTHCARE OTHER|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Multiplan|UNION PACIFIC RAILROAD|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|United Medicare Advantage|UHC AARP MCR HMO MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Healthcare|UNITED HEALTHCARE|||||522.13||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Medicare|UTSW MC KIDNEY PROGRAM|||||509.07||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Multiplan|WEB TPA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|Medicare|MEDICARE ACUTE|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|PHCS|HUMANA INSURANCE|||||509.07||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Tricare|TRICARE EAST REGION|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Tricare|TRICARE FOR LIFE|||||509.07||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Healthcare|AARP|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|NON CONTRACTED|COMMERCIAL OTHER 2|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Multiplan|GILSBAR INC|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Healthcare|GOLDEN RULE|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Healthcare|UNITED HEALTHCARE|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Multiplan|NALC|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Medicare Advantage|UHC AARP MCR HMO MA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|Humana Medicare Advantage|HUMANA MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Healthcare|GEHA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD RT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.96||| 77067|EAP|0403|BC SCR MAMMO INCL CAD LT|Managed Medicare|HEALTHSPRING MA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||522.13||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Medicare|MEDICARE ACUTE|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|PHCS|HUMANA|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|Veterans Affairs|VETERANS ADMINISTRATION|||||4.96||| 77067|EAP|0403|BC SCR MAMMO BI INCL CAD|PHCS|GROUP AND PENSION|||||522.13||| 77071|EAP|0320|X-RAY STRESS VIEW JOINT F|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.67||| 77071|EAP|0320|X-RAY STRESS VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||215.70||| 77071|EAP|0320|X-RAY STRESS VIEW JOINT F|Humana Medicare Advantage|HUMANA MA|||||1.67||| 77071|EAP|0320|X-RAY STRESS VIEW JOINT F|Blue Cross PPO Specialty|BCBSTX PPO|||||1.67||| 77071|EAP|0320|X-RAY STRESS VIEW JOINT F|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.67||| 77071|EAP|0320|X-RAY STRESS VIEW|Tricare|TRICARE EAST REGION|||||215.70||| 77071|EAP|0320|X-RAY STRESS VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||215.70||| 77071|EAP|0320|X-RAY STRESS VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||215.70||| 77071|EAP|0320|X-RAY STRESS VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||215.70||| 77071|EAP|0320|X-RAY STRESS VIEW|Blue Cross HMO Specialty|BCBSTX HMO|||||215.70||| 77071|EAP|0320|X-RAY STRESS VIEW|United Healthcare|UNITED HEALTHCARE OTHER|||||215.70||| 77071|EAP|0320|X-RAY STRESS VIEW|Medicare|MEDICARE ACUTE|||||215.70||| 77072|EAP|0320|XR-BONE AGE STUDY|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Medicaid|MEDICAID HMO|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Blue Cross PPO Specialty|BCBSTX PPO|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Tricare|TRICARE EAST REGION|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Blue Cross HMO Specialty|BCBSTX HMO|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|United Healthcare|UNITED HEALTHCARE|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|United Healthcare|UNITED HEALTHCARE OTHER|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Aetna|BOON CHAPMAN|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Aetna|AETNA PPO|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Managed Medicaid|MEDICAID SUPERIOR|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Medicaid|MEDICAID|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Managed Medicaid|MEDICAID AMERIGROUP|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Cigna|CIGNA|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.36||| 77072|EAP|0320|XR-BONE AGE STUDY|Cigna|CIGNA OTHER|||||6.36||| 77073|EAP|0320|CT-BONE LENGTH STUDIES|United Healthcare|UNITED HEALTHCARE|||||8.24||| 77073|EAP|0320|CT-BONE LENGTH STUDIES|Medicare|MEDICARE ACUTE|||||8.24||| 77074|EAP|0320|XR-METASTIC SURVEY|Managed Medicare|BCBS MEDICARE PPO MA|||||12.09||| 77074|EAP|0320|XR-METASTIC SURVEY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||12.09||| 77074|EAP|0320|XR-METASTIC SURVEY|Humana Medicare Advantage|HUMANA MA|12.09||||12.09||| 77074|EAP|0320|XR-METASTIC SURVEY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.09||||12.09||| 77074|EAP|0320|XR-METASTIC SURVEY|Blue Cross PPO Specialty|BCBSTX PPO|12.09||||||| 77074|EAP|0320|XR-METASTIC SURVEY|Cigna|CIGNA|||||12.09||| 77074|EAP|0320|XR-METASTIC SURVEY|Medicaid|MEDICAID|12.09||||||| 77074|EAP|0320|XR-METASTIC SURVEY|Medicare|MEDICARE ACUTE|12.09||||12.09||| 77074|EAP|0320|XR-METASTIC SURVEY|United Healthcare|UNITED HEALTHCARE OTHER|12.09||||12.09||| 77074|EAP|0320|XR-METASTIC SURVEY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||12.09||| 77074|EAP|0320|XR-METASTIC SURVEY|Managed Medicare|HEALTHSPRING MA|||||12.09||| 77075|EAP|0320|XR-XRAYS BONE SURVEY COMP|Managed Medicaid|MEDICAID SUPERIOR|||||17.68||| 77076|EAP|0320|XR-INFANT BONE SURVEY|Managed Medicaid|MEDICAID AMERIGROUP|||||12.34||| 77076|EAP|0320|XR-INFANT BONE SURVEY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||12.34||| 77076|EAP|0320|XR-INFANT BONE SURVEY|Managed Medicaid|MEDICAID SUPERIOR|||||12.34||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Cigna|CIGNA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Medicare|MEDICARE ACUTE|19.51||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|PHCS|HUMANA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Blue Cross PPO Specialty|BCBSTX PPO|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Aetna|AETNA PPO|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Blue Cross PPO Specialty|BCBSTX OTHER|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Blue Cross HMO Specialty|BCBSTX HMO|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Blue Cross PPO Specialty|BCBSTX PPO|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Humana Medicare Advantage|HUMANA MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|NON CONTRACTED|COMMERCIAL OTHER 1|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|NON CONTRACTED|COMMERCIAL OTHER 1|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|United Healthcare|TML GROUP BENEFITS|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|ChampVA|CHAMPVA CENTER|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Tricare|TRICARE EAST REGION|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|United Healthcare|UNITED HEALTHCARE|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Tricare|TRICARE FOR LIFE|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Tricare|TRICARE EAST REGION|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Managed Medicaid|MEDICAID AMERIGROUP|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Cigna|CIGNA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Managed Medicaid|MEDICAID AMERIGROUP|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|United Healthcare|GOLDEN RULE|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Aetna|AETNA PPO|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Multiplan|NALC|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|United Healthcare|UNITED HEALTHCARE|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Humana Medicare Advantage|HUMANA MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|PHCS|HUMANA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Aetna|BOON CHAPMAN|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Blue Cross HMO Specialty|BCBSTX HMO|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Aenta Medicare Advantage|AETNA MEDICARE MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Managed Medicare|HEALTHSPRING MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Cigna|CIGNA OTHER|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Medicare|MEDICARE ACUTE|19.51||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|United Healthcare|UNITED HEALTHCARE OTHER|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Managed Medicare|BCBS MEDICARE PPO MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Medicaid|MEDICAID HMO|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Managed Medicare|HEALTHSPRING MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Managed Medicare|BCBS MEDICARE PPO MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|United Medicare Advantage|UHC AARP MCR HMO MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|United Healthcare|UNITED HEALTHCARE OTHER|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Access Direct Platinum|HEALTHFIRST TPA UMR|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|United Medicare Advantage|UHC AARP MCR HMO MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Access Direct Platinum|HEALTHFIRST TPA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Access Direct Platinum|HEALTHFIRST TPA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Veterans Affairs|VETERANS ADMINISTRATION|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Workers Compensation|TEXAS MUTUAL INSURANCE|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|United Medicare Advantage|UHC MEDICARE GOLD MA|||||19.51||| 77080|EAP|0320|BC BONE DENSITY SKELETON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||19.51||| 77080|EAP|0320|BC BONE DENSITY STUDY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||19.51||| 77081|EAP|0320|BC BONE DENSITY WRIST NO|Medicare|MEDICARE ACUTE|||||5.47||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|52,690.50|8402.38|10524.27|35.72|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7,663.85|35.72|10524.27|35.72|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Managed Medicaid|MEDICAID SUPERIOR|19,419.05|4082.76|10524.27|35.72|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|NON CONTRACTED|COMMERCIAL OTHER 1|25,931.93|10524.27|10524.27|35.72|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Managed Medicaid|MEDICAID AMERIGROUP|175.79|2669.04|10524.27|35.72|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Blue Cross PPO Specialty|BCBSTX PPO|22,941.50|4474.61|10524.27|35.72|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12,381.45|6716.26|10524.27|35.72|||| 78|DRG||HYPERTENSIVE ENCEPHALOPATHY W CC|Medicare|MEDICARE ACUTE|41,530.12|6562.79|6562.79|6537.75|||| 78|DRG||HYPERTENSIVE ENCEPHALOPATHY W CC|Managed Medicare|BCBS MEDICARE PPO MA|46,555.37|6561.91|6562.79|6537.75|||| 78|DRG||HYPERTENSIVE ENCEPHALOPATHY W CC|Humana Medicare Advantage|HUMANA MA|46,875.32|6537.75|6562.79|6537.75|||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|Managed Medicare|HEALTHSPRING MA|||||1,846.95||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|Medicare|MEDICARE ACUTE|||||17.50||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,943.90||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|Blue Cross HMO Specialty|BCBSTX HMO|||||17.50||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|United Healthcare|UNITED HEALTHCARE OTHER|||||17.50||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|Blue Cross PPO Specialty|BCBSTX PPO|||||1,943.90||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|Humana Medicare Advantage|HUMANA MA|||||17.50||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,943.90||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|United Healthcare|UNITED HEALTHCARE|||||17.50||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|Access Direct Platinum|HEALTHFIRST TPA UMR|||||17.50||| 78014|EAP|0340|NM THYROID IMAGNG W/BLD F|Managed Medicaid|MEDICAID SUPERIOR|||||17.50||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Managed Medicare|HEALTHSPRING MA|||||1,034.16||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,034.16||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Humana Medicare Advantage|HUMANA MA|||||1,034.16||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Blue Cross PPO Specialty|BCBSTX PPO|||||9.31||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Medicare|MEDICARE ACUTE|9.31||||1,034.16||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.31||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Veterans Affairs|VETERANS ADMINISTRATION|9.31||||1,034.16||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Aetna|AETNA OTHER|||||1,034.16||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.31||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Managed Medicare|BCBS MEDICARE PPO MA|||||9.31||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.31||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.31||| 78072|EAP|0340|NM PARATHYRD PLANAR W/SPE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.31||| 78195|EAP|0340|NM LYMPH SYSTEM IMAGING|Humana Medicare Advantage|HUMANA MA|||||25.80||| 78195|EAP|0340|NM LYMPH SYSTEM IMAGING|Blue Cross PPO Specialty|BCBSTX PPO|||||2,865.87||| 78195|EAP|0340|NM LYMPH SYSTEM IMAGING|Medicare|MEDICARE ACUTE|||||25.80||| 78195|EAP|0340|NM LYMPH SYSTEM IMAGING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,865.87||| 78205|EAP|0340||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||39.62||| 78205|EAP|0340||United Medicare Advantage|UHC MEDICARE GOLD MA|||||39.62||| 78205|EAP|0340||Medicare|MEDICARE ACUTE|||||39.62||| 78215|EAP|0340|NM LIVER AND SPLEEN IMAGI|Medicaid|MEDICAID|2,952.51||||||| 78215|EAP|0340|NM LIVER AND SPLEEN IMAGI|United Medicare Advantage|UHC MEDICARE GOLD MA|2,952.51||||||| 78215|EAP|0340|NM LIVER AND SPLEEN IMAGI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,952.51||||2,952.51||| 78215|EAP|0340|NM LIVER AND SPLEEN IMAGI|Managed Medicare|HEALTHSPRING MA|||||2,952.51||| 78215|EAP|0340|NM LIVER AND SPLEEN IMAGI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,952.51||||||| 78215|EAP|0340|NM LIVER AND SPLEEN IMAGI|Humana Medicare Advantage|HUMANA MA|26.58||||||| 78215|EAP|0340|NM LIVER AND SPLEEN IMAGI|Medicare|MEDICARE ACUTE|2,805.26||||2,805.26||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.93||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|United Healthcare|UNITED HEALTHCARE|||||24.93||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Veterans Affairs|VETERANS ADMINISTRATION|2,631.12||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|NON CONTRACTED|COMMERCIAL OTHER 1|24.93||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Blue Cross HMO Specialty|BCBSTX HMO|2,769.23||||2,769.23||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Medicare|MEDICARE ACUTE|2,769.23||||2,769.23||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|United Medicare Advantage|UHC AARP MCR HMO MA|2,769.23||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|24.93||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,769.23||||2,769.23||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|PHCS|GROUP AND PENSION|24.93||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Blue Cross PPO Specialty|BCBSTX OTHER|24.93||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|United Medicare Advantage|UHC MEDICARE GOLD MA|24.93||||2,769.23||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Blue Cross PPO Specialty|BCBSTX PPO|24.93||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Aetna|AETNA OTHER|24.93||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Managed Medicaid|MEDICAID SUPERIOR|24.93||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.93||||24.93||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.93||||2,769.23||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Aenta Medicare Advantage|AETNA MEDICARE MA|2,769.23||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Cigna|CIGNA|||||24.93||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||24.93||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Managed Medicaid|MEDICAID AMERIGROUP|||||2,769.23||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.93||||||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Humana Medicare Advantage|HUMANA MA|2,769.23||||2,769.23||| 78226|EAP|0340|NM HEPATOBILIARY SYSTEM I|Managed Medicare|HEALTHSPRING MA|2,631.12||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,769.23||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Cigna|CIGNA|24.93||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Managed Medicaid|MEDICAID AMERIGROUP|2,769.23||||2,631.12||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Access Direct Platinum|HEALTHFIRST TPA UMR|2,769.23||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Aetna|AETNA OTHER|24.93||||||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.93||||2,631.12||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,769.23||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Blue Cross PPO Specialty|BCBSTX OTHER|24.93||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|24.93||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Blue Cross PPO Specialty|BCBSTX PPO|24.93||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|24.93||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Blue Cross HMO Specialty|BCBSTX HMO|2,631.12||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Aetna|AETNA PPO|||||2,631.12||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Managed Medicaid|MEDICAID SUPERIOR|24.93||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Access Direct Platinum|HEALTHFIRST TPA|||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|United Medicare Advantage|UHC MEDICARE GOLD MA|24.93||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Veterans Affairs|VETERANS ADMINISTRATION|2,769.23||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|United Medicare Advantage|UHC AARP MCR HMO MA|24.93||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Aenta Medicare Advantage|AETNA MEDICARE MA|2,769.23||||||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|24.93||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Humana Medicare Advantage|HUMANA MA|24.93||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Managed Medicare|HEALTHSPRING MA|2,769.23||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|24.93||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Medicaid|MEDICAID HMO|2,769.23||||||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Medicare|MEDICARE ACUTE|2,631.12||||2,631.12||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|United Healthcare|UNITED HEALTHCARE|||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Medicaid|SMITH COUNTY INDIGENT HEALTH|24.93||||||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.93||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|United Healthcare|UNITED HEALTHCARE OTHER|||||24.93||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Tricare|TRICARE EAST REGION|||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|NON CONTRACTED|COMMERCIAL OTHER 1|24.93||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|United Healthcare|UNITED HEALTHCARE|||||2,631.12||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Tricare|TRICARE SOUTH PHYSICIAN|||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Medicaid|MEDICAID|||||2,769.23||| 78227|EAP|0340|NM HEPATOBIL SYST IMAGE W|Managed Medicare|BCBS MEDICARE PPO MA|||||24.93||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Humana Medicare Advantage|HUMANA MA|25.80||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|United Medicare Advantage|UHC MEDICARE GOLD MA|25.80||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|United Healthcare|UNITED HEALTHCARE OTHER|25.80||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Tricare|TRICARE EAST REGION|||||2,722.94||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Managed Medicare|BCBS MEDICARE PPO MA|||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|NON CONTRACTED|COMMERCIAL OTHER 1|25.80||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Cigna|CIGNA|||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Blue Cross HMO Specialty|BCBSTX HMO|||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Workers Compensation|ZURICH COMPANY|2,865.87||||||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|PHCS|HUMANA|||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Aetna|AETNA PPO|||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.80||||||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Managed Medicare|HEALTHSPRING MA|25.80||||2,722.94||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Medicare|MEDICARE ACUTE|25.80||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|United Healthcare|UNITED HEALTHCARE|||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Access Direct Platinum|HEALTHFIRST TPA|||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Aenta Medicare Advantage|AETNA MEDICARE MA|25.80||||||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,865.87||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,722.94||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Blue Cross PPO Specialty|BCBSTX PPO|2,865.87||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Cigna|CIGNA|25.80||||||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Managed Medicaid|MEDICAID SUPERIOR|||||25.80||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|United Healthcare|UNITED HEALTHCARE|||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,865.87||||2,865.87||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,722.94||| 78264|EAP|0340|NM GASTRIC EMPTYING IMAG|Managed Medicaid|MEDICAID AMERIGROUP|2,865.87||||2,722.94||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.29||||3,253.54||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|Blue Cross PPO Specialty|BCBSTX PPO|29.29||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|Humana Medicare Advantage|HUMANA MA|3,091.27||||29.29||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|Aenta Medicare Advantage|AETNA MEDICARE MA|29.29||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|United Medicare Advantage|UHC MEDICARE GOLD MA|29.29||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,091.27||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|Managed Medicare|HEALTHSPRING MA|3,253.54||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|United Healthcare|UNITED HEALTHCARE OTHER|29.29||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|Access Direct Platinum|HEALTHFIRST TPA UMR|29.29||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,253.54||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|Cigna|CIGNA|3,253.54||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|United Medicare Advantage|UHC AARP MCR HMO MA|3,091.27||||||| 78278|EAP|0340|NM ACUTE GI BLOOD LOSS IM|Medicare|MEDICARE ACUTE|3,253.54||||3,253.54||| 78290|EAP|0340|NM MECKELS DIVERT EXAM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|22.24||||||| 78290|EAP|0340|NM MECKELS DIVERT EXAM|Blue Cross PPO Specialty|BCBSTX PPO|||||22.24||| 783|DRG||CESAREAN SECTION W STERILIZATION W MCC|Managed Medicaid|MEDICAID SUPERIOR|36,057.40|5495.15|5495.15|68.04|||| 783|DRG||CESAREAN SECTION W STERILIZATION W MCC|Managed Medicaid|MEDICAID AMERIGROUP|50,630.80|5495.15|5495.15|68.04|||| 783|DRG||CESAREAN SECTION W STERILIZATION W MCC|Blue Cross HMO Specialty|BCBSTX HMO|26,222.80|68.04|5495.15|68.04|||| 783|DRG||CESAREAN SECTION W STERILIZATION W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62,200.50|107.16|5495.15|68.04|||| 78305|EAP|0340|NM BONE IMAGING MULTIPLE|Medicare|MEDICARE ACUTE|||||2,351.43||| 78305|EAP|0340|NM BONE IMAGING MULTIPLE|Managed Medicare|HEALTHSPRING MA|||||22.28||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Medicaid|MEDICAID|23.85||||2,649.26||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,517.13||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|United Medicare Advantage|UHC MEDICARE GOLD MA|2,649.26||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Workers Compensation|WORKERS COMPENSATION OTHER|||||2,517.13||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|United Healthcare|UNITED HEALTHCARE|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Blue Cross PPO Specialty|BCBSTX PPO|2,517.13||||2,649.26||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Aetna|AETNA PPO|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,517.13||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,649.26||||2,517.13||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Cigna|CIGNA|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Humana Medicare Advantage|HUMANA MA|2,649.26||||2,649.26||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Aenta Medicare Advantage|AETNA MEDICARE MA|23.85||||2,649.26||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2,517.13||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,649.26||||2,649.26||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Blue Cross PPO Specialty|BCBSTX OTHER|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Managed Medicare|BCBS MEDICARE PPO MA|||||2,517.13||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Cigna|CIGNA OTHER|||||2,517.13||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2,649.26||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Access Direct Platinum|HEALTHFIRST TPA|||||2,649.26||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|23.85||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Managed Medicare|HEALTHSPRING MA|2,517.13||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Veterans Affairs|VETERANS ADMINISTRATION|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|United Healthcare|UNITED HEALTHCARE OTHER|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,649.26||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Multiplan|WEB TPA|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Access Direct Platinum|HEALTHFIRST TPA UMR|||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Blue Cross HMO Specialty|BCBSTX HMO|||||2,517.13||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|Medicare|MEDICARE ACUTE|2,649.26||||23.85||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|United Medicare Advantage|UHC AARP MCR HMO MA|2,649.26||||2,649.26||| 78306|EAP|0340|NM BONE IMAGING WHOLE BOD|PHCS|HUMANA|||||2,649.26||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Tricare|TRICARE EAST REGION|||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|PHCS|HUMANA|||||25.41||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,681.78||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Managed Medicare|HEALTHSPRING MA|||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|United Healthcare|UNITED HEALTHCARE|||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Blue Cross PPO Specialty|BCBSTX PPO|25.41||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||25.41||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||25.41||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Blue Cross HMO Specialty|BCBSTX HMO|25.41||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Workers Compensation|WORKERS COMPENSATION OTHER|||||2,822.55||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Medicare|MEDICARE ACUTE|||||25.41||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|United Medicare Advantage|UHC AARP MCR HMO MA|25.41||||||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||25.41||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Veterans Affairs|VETERANS ADMINISTRATION|||||25.41||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Cigna|CIGNA|||||25.41||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,681.78||| 78315|EAP|0340|NM BONE IMAGING 3 PHASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||25.41||| 78320|EAP|0340||Cigna|CIGNA|||||31.43||| 78320|EAP|0340||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||31.43||| 78320|EAP|0340||Medicare|MEDICARE ACUTE|||||31.43||| 78320|EAP|0340||Managed Medicare|HEALTHSPRING MA|||||31.43||| 78320|EAP|0340||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||31.43||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Managed Medicaid|MEDICAID AMERIGROUP|45,911.99|5495.15|9053.83|3456.07|||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Medicaid|MEDICAID|23,637.41|3456.07|9053.83|3456.07|||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|24,641.36|9053.83|9053.83|3456.07|||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Managed Medicaid|MEDICAID SUPERIOR|28,198.88|6015.855|9053.83|3456.07|||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Blue Cross PPO Specialty|BCBSTX PPO|36,585.40|7483.26|9053.83|3456.07|||| 78451|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Humana Medicare Advantage|HUMANA MA|42.83||||42.83||| 78451|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicaid|MEDICAID|4,757.56||||||| 78451|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Blue Cross PPO Specialty|BCBSTX PPO|||||4,757.56||| 78451|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Veterans Affairs|VETERANS ADMINISTRATION|4,757.56||||||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Access Direct Platinum|HEALTHFIRST TPA UMR|7,295.74||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7,295.74||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6,931.87||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Veterans Affairs|VETERANS ADMINISTRATION|65.68||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Access Direct Platinum|HEALTHFIRST TPA|65.68||||6,931.87||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|65.68||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7,295.74||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|United Medicare Advantage|UHC AARP MCR HMO MA|7,295.74||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicaid|LAW ENFORCEMENT OTHER|7,295.74||||||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Managed Medicaid|MEDICAID SUPERIOR|7,295.74||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|United Healthcare|GEHA|||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicaid|SMITH COUNTY JAIL|||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicaid|MEDICAID|65.68||||6,931.87||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|65.68||||6,931.87||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Tricare|TRICARE FOR LIFE|7,295.74||||||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|NON CONTRACTED|COMMERCIAL OTHER 1|65.68||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Managed Medicare|BCBS MEDICARE PPO MA|7,295.74||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicare|MEDICARE PART B ONLY IP|65.68||||||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Managed Medicare|OTHER INSTITUTIONS|||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Managed Medicare|HEALTHSPRING MA|65.68||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicare|UTSW MC KIDNEY PROGRAM|||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|United Healthcare|UNITED HEALTHCARE|||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicare|MEDICARE ACUTE|65.68||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|65.68||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|United Healthcare|GOLDEN RULE|||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicaid|COUNTY INDIGENT HEALTH OTHER|7,295.74||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Managed Medicaid|MEDICAID UNITED HEALTHCARE|65.68||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Tricare|TRICARE EAST REGION|65.68||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Managed Medicaid|MEDICAID AMERIGROUP|65.68||||6,931.87||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|65.68||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Humana Medicare Advantage|HUMANA MA|65.68||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Cigna|CIGNA OTHER|||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|United Healthcare|UNITED HEALTHCARE OTHER|||||6,931.87||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Cigna|CIGNA|7,295.74||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|United Healthcare|UNITED HEALTHCARE|7,295.74||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Aenta Medicare Advantage|AETNA MEDICARE MA|65.68||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Aetna|AETNA OTHER|65.68||||||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Aetna|BOON CHAPMAN|||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Aetna|AETNA PPO|65.68||||6,931.87||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,931.87||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|65.68||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Blue Cross PPO Specialty|BCBSTX OTHER|7,295.74||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|65.68||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Blue Cross PPO Specialty|BCBSTX PPO|7,295.74||||65.68||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Blue Cross HMO Specialty|BCBSTX HMO|7,295.74||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7,295.74||| 78452|EAP|0340|NM HT MUSCLE IMAGE SPECT-|United Medicare Advantage|UHC MEDICARE GOLD MA|65.68||||7,295.74||| 78472|EAP|0340|NM GATED HEART PLANAR SIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||38.85||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|39,316.38|93.37|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|36,522.10|35181.25|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Medicaid|MEDICAID|33,971.80|2606.28|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|29,350.89|93.37|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|35,124.44|93.37|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|36,990.30|7661.61|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|United Healthcare|TML GROUP BENEFITS|16,503.63|93.37|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|225.44|7751.54|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|38,568.34|7751.54|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|32,450.95|4143.99|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32,846.36|107.16|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|31,138.16|4143.99|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Cigna|CIGNA|20,264.23|89.25|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|30,345.65|5740.95|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33,646.05|4143.99|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Aetna|AETNA OTHER|33,768.57|78.54|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Cigna|CIGNA|31,182.25|89.25|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|ChampVA|CHAMPVA CENTER|26,533.11|4712.16|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38,310.95|4880.23|35181.25|78.54|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|28,994.20|4226.115|35181.25|78.54|||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Medicaid|MEDICAID|2,601.50||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Blue Cross HMO Specialty|BCBSTX HMO|||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,601.50||||||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,601.50||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,601.50||||||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Humana Medicare Advantage|HUMANA MA|2,601.50||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Managed Medicaid|MEDICAID SUPERIOR|2,601.50||||||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|United Medicare Advantage|UHC MEDICARE GOLD MA|2,601.50||||||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Veterans Affairs|VETERANS ADMINISTRATION|2,601.50||||||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,601.50||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|United Medicare Advantage|UHC AARP WELLMED HMO MA|2,601.50||||||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Blue Cross PPO Specialty|BCBSTX PPO|2,601.50||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Medicare|MEDICARE ACUTE|2,601.50||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Managed Medicaid|MEDICAID AMERIGROUP|2,601.50||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|United Medicare Advantage|UHC AARP MCR HMO MA|2,601.50||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,601.50||||2,601.50||| 78580|EAP|0340|NM LUNG PERFUSION IMAGING|Managed Medicare|HEALTHSPRING MA|2,601.50||||2,601.50||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Managed Medicare|HEALTHSPRING MA|36.23||||3,823.72||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|36.23||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Access Direct Platinum|HEALTHFIRST TPA|36.23||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Veterans Affairs|VETERANS ADMINISTRATION|36.23||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Medicaid|MEDICAID|36.23||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,024.43||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|United Healthcare|UNITED HEALTHCARE OTHER|36.23||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|United Healthcare|UNITED HEALTHCARE|36.23||||4,024.43||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Medicaid|SMITH COUNTY JAIL|||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Medicare|MEDICARE PART B ONLY IP|36.23||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|United Medicare Advantage|UHC MEDICARE GOLD MA|36.23||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|36.23||||3,823.72||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Cigna|CIGNA|4,024.43||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Managed Medicaid|MEDICAID AMERIGROUP|||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Blue Cross PPO Specialty|BCBSTX PPO|36.23||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Aenta Medicare Advantage|AETNA MEDICARE MA|36.23||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36.23||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Aetna|AETNA PPO|||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.23||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.23||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|United Medicare Advantage|UHC AARP MCR HMO MA|4,024.43||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Blue Cross HMO Specialty|BCBSTX HMO|36.23||||||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Humana Medicare Advantage|HUMANA MA|36.23||||36.23||| 78582|EAP|0340|NM LUNG VENTILAT&PERFUS I|Medicare|MEDICARE ACUTE|36.23||||36.23||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|Managed Medicare|HEALTHSPRING MA|||||1,631.77||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,631.77||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,631.77||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|Blue Cross PPO Specialty|BCBSTX PPO|||||1,631.77||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|Humana Medicare Advantage|HUMANA MA|1,631.77||||1,631.77||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,631.77||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,631.77||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,631.77||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|Medicare|MEDICARE ACUTE|||||1,631.77||| 78598|EAP|0340|NM LUNG PERF&VENTILAT DIF|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,631.77||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Blue Cross PPO Specialty|BCBSTX PPO|34,241.05|10557.09|13835.17|85.05|||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26,532.66|13719.92|13835.17|85.05|||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Managed Medicaid|MEDICAID SUPERIOR|42,497.13|6021.97|13835.17|85.05|||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Blue Cross HMO Specialty|BCBSTX HMO|58,773.53|8974.31|13835.17|85.05|||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Medicaid|MEDICAID|169,336.61|13835.17|13835.17|85.05|||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|37,850.13|85.05|13835.17|85.05|||| 78607|EAP|0340||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||39.86||| 78607|EAP|0340||Aenta Medicare Advantage|AETNA MEDICARE MA|||||39.86||| 78607|EAP|0340||Humana Medicare Advantage|HUMANA MA|||||39.86||| 78607|EAP|0340||Tricare|TRICARE EAST REGION|||||39.86||| 78607|EAP|0340||United Healthcare|UNITED HEALTHCARE|||||39.86||| 78607|EAP|0340||Medicare|MEDICARE ACUTE|39.86||||39.86||| 78607|EAP|0340||Managed Medicare|OTHER INSTITUTIONS|||||39.86||| 78608|EAP|0404|NM BRAIN IMAGING PET|United Healthcare|UNITED HEALTHCARE|||||10,304.90||| 78610|EAP|0340|NM BRAIN FLOW IMAGING ONL|Managed Medicaid|MEDICAID SUPERIOR|2,649.26||||||| 78610|EAP|0340|NM BRAIN FLOW IMAGING ONL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23.85||||||| 78610|EAP|0340|NM BRAIN FLOW IMAGING ONL|United Healthcare|UNITED HEALTHCARE|2,649.26||||||| 78610|EAP|0340|NM BRAIN FLOW IMAGING ONL|Humana Medicare Advantage|HUMANA MA|1,722.50||||||| 78610|EAP|0340|NM BRAIN FLOW IMAGING ONL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,649.26||||||| 78630|EAP|0340|NM CEREBROSPINAL FLUID SC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,281.31||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|United Healthcare|UNITED HEALTHCARE|23,953.91|93.37|9055.92|93.37|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|29,491.09|9055.92|9055.92|93.37|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Blue Cross PPO Specialty|BCBSTX PPO|38,942.50|7340.67|9055.92|93.37|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Aetna|AETNA PPO|32,101.55|5596.73|9055.92|93.37|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41,899.77|142.88|9055.92|93.37|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Medicaid|MEDICAID|26,439.76|3456.07|9055.92|93.37|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Managed Medicaid|MEDICAID AMERIGROUP|31,345.09|4929.34|9055.92|93.37|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Managed Medicaid|MEDICAID SUPERIOR|26,863.37|4143.99|9055.92|93.37|||| 78707|EAP|0341|NM K FLOW/FUNCT-IMAGE W/O|Blue Cross PPO Specialty|BCBSTX PPO|||||26.25||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|Managed Medicare|BCBS MEDICARE PPO MA|||||30.35||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|Medicare|MEDICARE ACUTE|3,371.28||||3,371.28||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|United Healthcare|UNITED HEALTHCARE|||||3,371.28||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|United Healthcare|UNITED HEALTHCARE OTHER|||||30.35||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|Managed Medicaid|MEDICAID SUPERIOR|||||3,371.28||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,371.28||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|Aetna|AETNA PPO|||||30.35||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|Humana Medicare Advantage|HUMANA MA|||||30.35||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||30.35||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|Blue Cross PPO Specialty|BCBSTX PPO|||||3,371.28||| 78708|EAP|0340|NM K FLOW/FUNCT-IMAGE W/D|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||30.35||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|39,581.46|20849.22|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28,960.78|8084.78|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|30,096.05|8046.44|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|31,642.88|5198.84|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|28,579.41|5657.295|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|31,620.55|6115.75|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|24,986.06|8084.78|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Cigna|CIGNA|27,831.91|89.25|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|28,106.60|4143.99|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Medicare|MEDICARE ACUTE|27,188.89|6259.92|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX OTHER|23,122.91|6115.75|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Tricare|TRICARE EAST REGION|29,157.44|4290.76|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|28,585.99|8065.61|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|29,392.18|11552.7|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|28,698.05|93.37|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|29,963.25|93.37|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|34,831.67|93.37|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|30,400.18|4143.99|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39,517.50|5495.15|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Cigna|CIGNA|29,267.50|89.25|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Aetna|AETNA PPO|34,215.11|77|20849.22|71.44|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29,113.55|71.44|20849.22|71.44|||| 78801|EAP|0340|LOCALIZE TUMOR MULTIPLE A|Medicare|MEDICARE ACUTE|||||6.38||| 78802|EAP|0340|NM TUMOR IMAGING WHOLE BO|Blue Cross HMO Specialty|BCBSTX HMO|||||26.96||| 78803|EAP|0340|NM BONE IMAGING (3D)|Managed Medicare|HEALTHSPRING MA|||||3,491.25||| 78803|EAP|0340|NM BONE IMAGING (3D)|Medicare|MEDICARE ACUTE|||||3,491.25||| 78803|EAP|0340|NM BRAIN IMAGING (3D)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4,437.65||| 78803|EAP|0340|NM PYP IMAGING FOR ATTR|Medicaid|SMITH COUNTY INDIGENT HEALTH|16.30||||||| 78803|EAP|0340|NM BONE IMAGING (3D)|United Healthcare|UNITED HEALTHCARE OTHER|||||3,491.25||| 78803|EAP|0340|NM LIVER IMAGING (3D)|Rusk State Hospital|RUSK STATE HOSP|||||4,400.99||| 78803|EAP|0340|NM PYP IMAGING FOR ATTR|Medicare|MEDICARE ACUTE|||||1,810.61||| 78803|EAP|0340|NM LIVER IMAGING (3D)|Veterans Affairs|VETERANS ADMINISTRATION|||||4,400.99||| 78803|EAP|0340|NM BRAIN IMAGING (3D)|Medicare|MEDICARE ACUTE|||||4,427.65||| 78803|EAP|0340|NM BONE IMAGING (3D)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,491.25||| 78803|EAP|0340|NM LIVER IMAGING (3D)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,400.99||| 78803|EAP|0340|NM BRAIN IMAGING (3D)|Humana Medicare Advantage|HUMANA MA|||||4,437.65||| 78803|EAP|0340|NM LIVER IMAGING (3D)|United Medicare Advantage|UHC AARP MCR HMO MA|||||4,400.99||| 78803|EAP|0340|NM BONE IMAGING (3D)|Workers Compensation|WORKERS COMPENSATION OTHER|||||31.43||| 78803|EAP|0340|NM BONE IMAGING (3D)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,491.25||| 78803|EAP|0340|NM PYP IMAGING FOR ATTR|Cigna|CIGNA OTHER|1,810.61||||||| 78803|EAP|0340|NM LIVER IMAGING (3D)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4,400.99||| 78803|EAP|0340|NM PYP IMAGING FOR ATTR|Humana Medicare Advantage|HUMANA MA|||||1,810.61||| 78803|EAP|0340|NM LIVER IMAGING (3D)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,400.99||||39.62||| 78803|EAP|0340|NM BRAIN IMAGING (3D)|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4,437.65||| 78803|EAP|0340|NM BONE IMAGING (3D)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,491.25||| 78803|EAP|0340|NM BRAIN IMAGING (3D)|Blue Cross PPO Specialty|BCBSTX PPO|||||4,427.65||| 78803|EAP|0340|NM LIVER IMAGING (3D)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4,400.99||| 78803|EAP|0340|NM LIVER IMAGING (3D)|Medicare|MEDICARE ACUTE|||||4,400.99||| 78806|EAP|0340|NM ABSCESS IMAGING WHOLE|Medicare|MEDICARE ACUTE|||||25.80||| 78806|EAP|0340|NM ABSCESS IMAGING WHOLE|Blue Cross PPO Specialty|BCBSTX PPO|||||25.80||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|United Healthcare|UNITED HEALTHCARE|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|United Healthcare|TML GROUP BENEFITS|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|United Healthcare|GEHA|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Tricare|TRICARE EAST REGION|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Medicaid|MEDICAID|98.81||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Managed Medicare|HEALTHSPRING MA|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Managed Medicare|BCBS MEDICARE PPO MA|98.81||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|United Healthcare|UNITED HEALTHCARE OTHER|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Medicaid|SMITH COUNTY JAIL|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|United Healthcare|UNITED HEALTHCARE|||||10,375.05||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|PHCS|HUMANA|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Managed Medicare|OTHER INSTITUTIONS|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Medicare|MEDICARE ACUTE|10,869.10||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Access Direct Platinum|HEALTHFIRST TPA UMR|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|NON CONTRACTED|COMMERCIAL OTHER 1|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Rusk State Hospital|RUSK STATE HOSP|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Veterans Affairs|VETERANS ADMINISTRATION|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|PHCS|GROUP AND PENSION|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10,375.05||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|United Medicare Advantage|UHC AARP MCR HMO MA|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Managed Medicaid|MEDICAID SUPERIOR|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Multiplan|WEB TPA|||||98.81||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|98.81||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Cigna|CIGNA OTHER|||||10,375.05||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Managed Medicaid|MEDICAID AMERIGROUP|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Cigna|CIGNA|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Aenta Medicare Advantage|AETNA MEDICARE MA|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Aetna|AETNA PPO|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Aetna Value Network|AETNA VALUE NETWORK|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Humana Medicare Advantage|HUMANA MA|10,869.10||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Blue Cross PPO Specialty|BCBSTX PPO|||||10,869.10||| 78815|EAP|0404|NM PET IMAGE W/CT-SKULL-T|Blue Cross HMO Specialty|BCBSTX HMO|||||10,869.10||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|Blue Cross PPO Specialty|BCBSTX PPO|||||10,869.10||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|Blue Cross HMO Specialty|BCBSTX HMO|||||10,869.10||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||98.81||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||10,375.05||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|United Medicare Advantage|UHC AARP MCR HMO MA|||||10,869.10||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|Medicare|MEDICARE ACUTE|||||10,869.10||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|United Healthcare|UNITED HEALTHCARE OTHER|||||98.81||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|Managed Medicare|HEALTHSPRING MA|||||10,375.05||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10,869.10||| 78816|EAP|0404|NM PET IMAGE W/CT-FULL BO|Humana Medicare Advantage|HUMANA MA|||||10,375.05||| 78831|EAP|0340|RP LOCLZJ TUM SPECT 2 ARE|Humana Medicare Advantage|HUMANA MA|||||3,438.27||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|United Healthcare|UNITED HEALTHCARE OTHER|11,767.03|13.52|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Medicaid|MEDICAID|11,652.76|12.37|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Multiplan|WEB TPA|10,117.02|7486.59|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|NON CONTRACTED|COMMERCIAL OTHER 1|11,968.50|11968.5|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Blue Cross PPO Specialty|BCBSTX PPO|7,529.13|11.59|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Access Direct Platinum|HEALTHFIRST TPA UMR|5,220.50|5220.5|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12,231.81|13677.19|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14,627.33|10.72|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Blue Cross HMO Specialty|BCBSTX HMO|10,920.75|9.85|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Access Direct Platinum|HEALTHFIRST TPA|20,805.75|13365.76|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Managed Medicaid|MEDICAID AMERIGROUP|6,560.75|6354.43|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5,263.75|13365.76|13677.19|9.85|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Managed Medicaid|MEDICAID SUPERIOR|12,986.52|1966.83|13677.19|9.85|||| 79|DRG||HYPERTENSIVE ENCEPHALOPATHY W/O CC/MCC|Medicare|MEDICARE ACUTE|45,695.87|5350.63|5350.63|5350.63|||| 790|DRG||EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE|Blue Cross PPO Specialty|BCBSTX PPO|17,205.85|1738.5|1738.5|1738.5|||| 79005|EAP|0340|NM NUCLEAR RX ORAL ADMIN|Blue Cross PPO Specialty|BCBSTX PPO|||||11.13||| 79005|EAP|0340|NM NUCLEAR RX ORAL ADMIN|Blue Cross HMO Specialty|BCBSTX HMO|||||11.13||| 791|DRG||PREMATURITY W MAJOR PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|103.48|1109.55|28430.47|1109.55|||| 791|DRG||PREMATURITY W MAJOR PROBLEMS|Managed Medicaid|MEDICAID AMERIGROUP|11,648.75|8614.13|28430.47|1109.55|||| 791|DRG||PREMATURITY W MAJOR PROBLEMS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6,091.60|28430.47|28430.47|1109.55|||| 791|DRG||PREMATURITY W MAJOR PROBLEMS|Blue Cross PPO Specialty|BCBSTX PPO|162.51|6374.5|28430.47|1109.55|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|United Healthcare|UNITED HEALTHCARE OTHER|9,686.75|27.04|17905.46|19.7|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Blue Cross HMO Specialty|BCBSTX HMO|10,469.50|2462.5|17905.46|19.7|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,114.68|21.44|17905.46|19.7|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9,971.75|19.7|17905.46|19.7|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Blue Cross PPO Specialty|BCBSTX PPO|5,632.75|23.18|17905.46|19.7|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,884.10|17905.46|17905.46|19.7|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9,387.05|17905.46|17905.46|19.7|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5,652.50|17656.58|17905.46|19.7|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Access Direct Platinum|HEALTHFIRST TPA UMR|8,711.50|17656.58|17905.46|19.7|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|5,599.88|662.26|17905.46|19.7|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|71,986.72|28728.15|29152.03|20.42|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Blue Cross PPO Specialty|BCBSTX PPO|15,548.67|34.77|29152.03|20.42|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Managed Medicaid|MEDICAID AMERIGROUP|11,706.50|1109.55|29152.03|20.42|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11,236.25|20.42|29152.03|20.42|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Blue Cross HMO Specialty|BCBSTX HMO|12,896.68|2462.5|29152.03|20.42|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|14,016.75|1109.55|29152.03|20.42|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Aetna|AETNA PPO|6,137.50|36|29152.03|20.42|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17,213.88|29152.03|29152.03|20.42|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Medicaid|MEDICAID|6,746.75|697.83|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross HMO Specialty|BCBSTX HMO|8,418.96|19.7|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Aetna Value Network|AETNA VALUE NETWORK|8,167.75|15.3|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|7,091.30|885.905|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|United Healthcare|UNITED HEALTHCARE OTHER|6,003.90|27.04|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,782.76|10.72|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,152.35|23.18|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|United Healthcare|UNITED HEALTHCARE|7,180.10|13.52|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross PPO Specialty|BCBSTX OTHER|9,806.15|23.18|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross PPO Specialty|BCBSTX PPO|6,916.25|23.18|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Aetna|AETNA PPO|9,874.25|36.72|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Cigna|CIGNA|4,403.63|31.5|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Cigna|CIGNA|7,004.13|31.5|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|PHCS|HUMANA INSURANCE|7,455.25|7455.25|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Tricare|TRICARE EAST REGION|3,417.35|1056.64|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Managed Medicaid|MEDICAID AMERIGROUP|7,455.25|1109.55|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|PHCS|GROUP AND PENSION|10,432.25|10432.25|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Access Direct Platinum|HEALTHFIRST TPA UMR|9,624.17|11542.49|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4,904.55|11467.545|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10,158.25|11542.49|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Access Direct Platinum|HEALTHFIRST TPA|63.35|11328.56|11542.49|10.72|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|NON CONTRACTED|COMMERCIAL OTHER 1|5,511.75|36|11542.49|10.72|||| 79445|EAP|0330|IR-NUCLEAR RX INTRA-ARTER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.20||| 79445|EAP|0330|IR-NUCLEAR RX INTRA-ARTER|Medicare|MEDICARE ACUTE|||||915.30||| 795|DRG||NORMAL NEWBORN|United Healthcare|UNITED HEALTHCARE|7,016.75|1243.5|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|United Healthcare|UNITED HEALTHCARE|6,916.55|8.29|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|United Healthcare|TML GROUP BENEFITS|3,417.35|8.29|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Medicaid|MEDICAID|5,084.25|416.52|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Medicaid|SUPERIOR HEALTHPLAN CHIP|3,320.75|416.52|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Medicaid|MEDICAID HMO|4,236.55|416.52|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|United Healthcare|UNITED HEALTHCARE OTHER|4,535.18|16.58|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|PHCS|GROUP AND PENSION|12,200.25|3184.1|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|NON CONTRACTED|COMMERCIAL OTHER 1|3,369.05|3320.75|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Medicaid|MOLINA HEALTHCARE OF TEXAS|5,152.35|416.52|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4,850.50|3180.76|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Tricare|TRICARE EAST REGION|6,220.05|720.91|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Access Direct Platinum|HEALTHFIRST TPA UMR|4,598.35|3190.87|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Cigna|CIGNA|7,455.25|21|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Managed Medicaid|MEDICAID AMERIGROUP|5,104.05|662.26|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Access Direct Platinum|HEALTHFIRST TPA|5,174.85|3200.98|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Managed Medicaid|MEDICAID SUPERIOR|5,351.35|662.26|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3,417.35|3200.98|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Cigna|CIGNA|5,055.75|4136.25|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Cigna|CIGNA OTHER|3,417.35|21|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,152.35|3200.98|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Blue Cross PPO Specialty|BCBSTX OTHER|5,238.75|1252.08|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Blue Cross PPO Specialty|BCBSTX PPO|69.38|1252.08|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Blue Cross HMO Specialty|BCBSTX HMO|77.55|1064.36|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,152.35|1252.08|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|ChampVA|CHAMPVA CENTER|9,874.25|801.01|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Aetna|AETNA PPO|5,152.35|18.36|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Aetna Value Network|AETNA VALUE NETWORK|5,055.75|30.6|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,603.50|35.72|4136.25|8.29|||| 795|DRG||NORMAL NEWBORN|Aetna|AETNA OTHER|5,152.35|36.72|4136.25|8.29|||| 798|DRG||VAGINAL DELIVERY W STERILIZATION/D&C W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|24,970.83|5750.45|6277.225|5750.45|||| 798|DRG||VAGINAL DELIVERY W STERILIZATION/D&C W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32,406.68|6277.225|6277.225|5750.45|||| 799|DRG||SPLENECTOMY W MCC|Blue Cross PPO Specialty|BCBSTX PPO|182,428.19|31923.86|31923.86|28412.83|||| 799|DRG||SPLENECTOMY W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|174,111.50|28412.83|31923.86|28412.83|||| 800|DRG||SPLENECTOMY W CC|Blue Cross PPO Specialty|BCBSTX PPO|141,734.62|17835.97|17835.97|16878.1|||| 800|DRG||SPLENECTOMY W CC|Medicare|MEDICARE ACUTE|55,587.43|16878.1|17835.97|16878.1|||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Multiplan|WEB TPA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|NON CONTRACTED|COMMERCIAL OTHER 1|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Texas Workforce Commission|DIS DETER SERV (DDS)|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|PHCS|HUMANA INSURANCE|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Tricare|TRICARE FOR LIFE|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Healthcare|UNITED HEALTHCARE ERS|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Healthcare|UNITED HEALTHCARE|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Healthcare|GEHA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|PHCS|MULTIPLAN PHCS|||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicare|BCBS MEDICARE PPO MA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Aetna|AETNA OTHER|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicare|MA PART B ONLY IP|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|LAW ENFORCEMENT OTHER|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Workers Compensation|WORKERS COMPENSATION OTHER|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicare|MEDICARE PART B ONLY IP|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicare|MEDICARE ACUTE|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Medicare Advantage|UHC AARP MCR HMO MA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Workers Compensation|TEXAS MUTUAL INSURANCE|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Veterans Affairs|VETERANS ADMINISTRATION|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Workers Compensation|BROOKSHIRES WORKERS COMP|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Access Direct Platinum|HEALTHFIRST TPA UMR|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Workers Compensation|UT EMPLOYEE INJURY|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Workers Compensation|ZURICH COMPANY|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Access Direct Platinum|HEALTHFIRST TPA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Workers Compensation|TRAVELERS INSURANCE COMPANY|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Access Direct Platinum|ANDREWS CENTER|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicaid|MEDICAID AMERIGROUP|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicare|UTSW MC KIDNEY PROGRAM|||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicaid|MEDICAID SUPERIOR|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicare|OTHER INSTITUTIONS|||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Cigna|CIGNA OTHER|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Aenta Medicare Advantage|AETNA MEDICARE MA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Humana Medicare Advantage|HUMANA MA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|MEDICAID HMO|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|MEDICAID BCBSTX|||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Aetna|AETNA PPO|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Aetna|BOON CHAPMAN|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|CRIME VICTIMS COMPENSATION|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Aetna|AETNA QHP HMO|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Cigna|CIGNA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicare|HEALTHSPRING MA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Aetna|BH AETNA|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicare|WELLCARE CHOICE MA|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Aetna Value Network|AETNA VALUE NETWORK|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Healthcare|UNITED HEALTHCARE OTHER|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Healthcare|AARP|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Blue Cross PPO Specialty|BCBSTX OTHER|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|SMITH COUNTY JAIL|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Medicaid|MEDICAID|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|PHCS|HUMANA|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Blue Cross PPO Specialty|BCBSTX PPO|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Optum Behavioral Health|BH OPTUM UHC|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Healthcare|TML GROUP BENEFITS|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Rusk State Hospital|RUSK STATE HOSP|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Tricare|TRICARE EAST REGION|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|United Healthcare|GOLDEN RULE|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|PHCS|GROUP AND PENSION|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|ChampVA|CHAMPVA CENTER|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Multiplan|PACIFICARE|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||337.25||| 80048|EAP|0300|BASIC METABOLIC PROFILE|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.09||||||| 80048|EAP|0300|BASIC METABOLIC PROFILE|Blue Cross HMO Specialty|BCBSTX HMO|2.09||||2.09||| 80048|EAP|0300|BASIC METABOLIC PROFILE|NON CONTRACTED|COMMERCIAL OTHER 2|2.09||||2.09||| 80051|EAP|0300|ELECTROLYTES PANEL|ChampVA|CHAMPVA CENTER|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Aetna|AETNA OTHER|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|2.48||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Aetna|AETNA PPO|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Aetna|BOON CHAPMAN|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Aetna|AETNA QHP HMO|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Humana Medicare Advantage|HUMANA MA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Humana Medicare Advantage|HUMANA MA|2.48||||2.48||| 80051|EAP|0300|ELECTROLYTES PANEL|Cigna|CIGNA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicaid|MEDICAID AMERIGROUP|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicaid|MEDICAID SUPERIOR|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Access Direct Platinum|HEALTHFIRST TPA UMR|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Access Direct Platinum|HEALTHFIRST TPA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Workers Compensation|WORKERS COMPENSATION OTHER|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Workers Compensation|TEXAS MUTUAL INSURANCE|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Workers Compensation|UT EMPLOYEE INJURY|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Veterans Affairs|VETERANS ADMINISTRATION|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|United Medicare Advantage|UHC AARP MCR HMO MA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|2.48||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Cigna|CIGNA OTHER|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicare|MEDICARE ACUTE|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicare|MEDICARE PART B ONLY IP|2.48||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicare|MEDICARE PART B ONLY IP|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicare|MEDICARE ACUTE|2.48||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.48||||2.48||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicare|BCBS MEDICARE PPO MA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid|BH TEXAS CHILDRENS MEDICAID|2.48||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid|CRIME VICTIMS COMPENSATION|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid|MEDICAID|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicare|WELLCARE CHOICE MA|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid|SMITH COUNTY JAIL|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicare|HEALTHSPRING MA|2.48||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Blue Cross HMO Specialty|BCBSTX HMO|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Blue Cross HMO Specialty|BCBSTX HMO|2.48||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid|MEDICAID HMO|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicare|OTHER INSTITUTIONS|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Managed Medicare|HEALTHSPRING MA|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Medicaid|LAW ENFORCEMENT OTHER|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|United Healthcare|TML GROUP BENEFITS|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|United Healthcare|UNITED HEALTHCARE|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|PHCS|GROUP AND PENSION|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Rusk State Hospital|RUSK STATE HOSP|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Multiplan|WEB TPA|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Tricare|TRICARE EAST REGION|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|PHCS|HUMANA|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Texas Workforce Commission|DIS DETER SERV (DDS)|||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|NON CONTRACTED|COMMERCIAL OTHER 2|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|United Healthcare|UNITED HEALTHCARE OTHER|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|United Healthcare|UNITED HEALTHCARE OTHER|2.48||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|United Healthcare|UNITED HEALTHCARE|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Blue Cross PPO Specialty|BCBSTX OTHER|3.00||||||| 80051|EAP|0300|ELECTROLYTES PANEL|Blue Cross PPO Specialty|BCBSTX PPO|3.00||||3.00||| 80051|EAP|0300|ELECTROLYTES PANEL|Blue Cross PPO Specialty|BCBSTX PPO|2.48||||3.00||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Tricare|TRICARE FOR LIFE|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Multiplan|NALC|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Multiplan|MUTUAL OF OMAHA|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|NON CONTRACTED|COMMERCIAL OTHER 1|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|NON CONTRACTED|COMMUNITY HEALTH CENTER|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|NON CONTRACTED|COMMERCIAL OTHER 2|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Tricare|TRICARE EAST REGION|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|PHCS|HUMANA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Rusk State Hospital|RUSK STATE HOSP|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Multiplan|WEB TPA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|PHCS|GROUP AND PENSION|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|PHCS|HUMANA INSURANCE|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|PHCS|HUMANA INSURANCE|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Optum Behavioral Health|BH OPTUM UHC|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Multiplan|TRUSTMARK|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Healthcare|UNITED HEALTHCARE|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Healthcare|GOLDEN RULE|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Healthcare|GEHA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Healthcare|UNITED HEALTHCARE ERS|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Healthcare|UNITED HEALTHCARE OTHER|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicare|BCBS MEDICARE PPO MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicare|OTHER INSTITUTIONS|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicare|JACKSONVILLE ACCESS|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicare|WELLCARE CHOICE MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|LAW ENFORCEMENT OTHER|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|MEDICAID BCBSTX|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|SUPERIOR HEALTHPLAN CHIP|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|BH TEXAS CHILDRENS MEDICAID|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|MEDICAID HMO|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicare|UTSW MC KIDNEY PROGRAM|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicare|MEDICARE ACUTE|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|CRIME VICTIMS COMPENSATION|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Medicare Advantage|UHC AARP MCR HMO MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Medicare Advantage|UHC MEDICARE GOLD MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicare|MA PART B ONLY IP|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicare|MEDICARE PART B ONLY IP|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|MEDICAID|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|TEXAS MUTUAL INSURANCE|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Medicaid|SMITH COUNTY JAIL|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicare|ETMC REHABILITATION HOSPITAL|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicare|HEALTHSPRING MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Veterans Affairs|VETERANS ADMINISTRATION|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|ZURICH COMPANY|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Healthcare|AARP|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|WORKERS COMPENSATION OTHER|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|UT EMPLOYEE INJURY|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|TRAVELERS INSURANCE COMPANY|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|GALLAGHER BASSETT|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Access Direct Platinum|ANDREWS CENTER|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Access Direct Platinum|HEALTHFIRST TPA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicaid|MEDICAID SUPERIOR|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|United Healthcare|TML GROUP BENEFITS|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Access Direct Platinum|HEALTHFIRST TPA UMR|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Tricare|TRICARE SOUTH PHYSICIAN|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Managed Medicaid|MEDICAID AMERIGROUP|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Cigna|CIGNA OTHER|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Cigna|CIGNA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Texas Workforce Commission|DIS DETER SERV (DDS)|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Cigna Behavioral Health|BH CIGNA|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Magellan Behavioral Health|BH MAGELLAN|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|WORKERS COMP PHYSICIAN|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Humana Medicare Advantage|HUMANA MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Aetna|AETNA OTHER|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|NON CONTRACTED|COMMERCIAL OTHER 4|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Aenta Medicare Advantage|AETNA MEDICARE MA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Aetna|BH AETNA|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Aetna|BOON CHAPMAN|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Workers Compensation|BROOKSHIRES WORKERS COMP|3.07||||||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Aetna|AETNA PPO|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Aetna|AETNA QHP HMO|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Aetna Value Network|AETNA VALUE NETWORK|||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|ChampVA|CHAMPVA CENTER|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Blue Cross HMO Specialty|BCBSTX HMO|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Blue Cross PPO Specialty|BCBSTX PPO|3.07||||3.07||| 80053|EAP|0300|COMPREHENSIVE METABOLIC P|Blue Cross PPO Specialty|BCBSTX OTHER|3.07||||3.07||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicare|HEALTHSPRING MA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicare|JACKSONVILLE ACCESS|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Blue Cross HMO Specialty|BCBSTX HMO|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|ChampVA|CHAMPVA CENTER|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Aetna|AETNA QHP HMO|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Aetna|BH AETNA|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Aetna|AETNA OTHER|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Magellan Behavioral Health|BH MAGELLAN|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Cigna|CIGNA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Cigna Behavioral Health|BH CIGNA|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicaid|MEDICAID AMERIGROUP|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Access Direct Platinum|ANDREWS CENTER|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Access Direct Platinum|HEALTHFIRST TPA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Workers Compensation|TEXAS MUTUAL INSURANCE|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|United Medicare Advantage|UHC AARP MCR HMO MA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Veterans Affairs|VETERANS ADMINISTRATION|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Cigna|CIGNA|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicare|MEDICARE PART B ONLY IP|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Workers Compensation|WORKERS COMPENSATION OTHER|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Access Direct Platinum|HEALTHFIRST TPA UMR|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Cigna|CIGNA OTHER|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicare|UTSW MC KIDNEY PROGRAM|||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicare|MEDICARE ACUTE|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|LAW ENFORCEMENT OTHER|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Humana Medicare Advantage|HUMANA MA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|MEDICAID|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicaid|MEDICAID SUPERIOR|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|CRIME VICTIMS COMPENSATION|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|BH TEXAS CHILDRENS MEDICAID|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|SMITH COUNTY JAIL|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|MEDICAID HMO|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Blue Cross PPO Specialty|BCBSTX PPO|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Aetna|AETNA PPO|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Blue Cross PPO Specialty|BCBSTX OTHER|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicare|BCBS MEDICARE PPO MA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|United Healthcare|TML GROUP BENEFITS|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|United Healthcare|GOLDEN RULE|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|United Healthcare|UNITED HEALTHCARE|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|United Healthcare|UNITED HEALTHCARE OTHER|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Tricare|TRICARE EAST REGION|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Texas Workforce Commission|DIS DETER SERV (DDS)|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|PHCS|HUMANA|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Tricare|TRICARE FOR LIFE|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|NON CONTRACTED|COMMERCIAL OTHER 1|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Multiplan|WEB TPA|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|NON CONTRACTED|COMMUNITY HEALTH CENTER|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|PHCS|GROUP AND PENSION|1.98||||1.98||| 80061|EAP|0300|CARDIAC RISK PROFILE|Optum Behavioral Health|BH OPTUM UHC|1.98||||||| 80061|EAP|0300|CARDIAC RISK PROFILE|PHCS|HUMANA INSURANCE|1.98||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Tricare|TRICARE EAST REGION|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|PHCS|GROUP AND PENSION|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|PHCS|HUMANA INSURANCE|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Healthcare|GEHA|||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Healthcare|UNITED HEALTHCARE|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Healthcare|UNITED HEALTHCARE|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|MA PART B ONLY IP|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|BCBS MEDICARE PPO MA|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|HEALTHSPRING MA|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|PHCS|HUMANA|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|LAW ENFORCEMENT OTHER|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|CRIME VICTIMS COMPENSATION|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Texas Workforce Commission|DIS DETER SERV (DDS)|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|MEDICAID HMO|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicare|UTSW MC KIDNEY PROGRAM|||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicare|MEDICARE ACUTE|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicare|MEDICARE PART B ONLY IP|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|UHC AARP MCR HMO MA|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Workers Compensation|WORKERS COMPENSATION OTHER|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Workers Compensation|UT EMPLOYEE INJURY|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Workers Compensation|BROOKSHIRES WORKERS COMP|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Workers Compensation|ZURICH COMPANY|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Veterans Affairs|VETERANS ADMINISTRATION|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA UMR|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|MEDICAID|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Multiplan|WEB TPA|||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|SMITH COUNTY JAIL|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Rusk State Hospital|RUSK STATE HOSP|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|OTHER INSTITUTIONS|||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Healthcare|TML GROUP BENEFITS|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Healthcare|UNITED HEALTHCARE OTHER|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|WELLCARE CHOICE MA|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID AMERIGROUP|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID SUPERIOR|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Cigna|CIGNA OTHER|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Cigna|CIGNA|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Humana Medicare Advantage|HUMANA MA|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Aetna|AETNA OTHER|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Aetna|AETNA QHP HMO|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross PPO Specialty|BCBSTX OTHER|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross HMO Specialty|BCBSTX HMO|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross PPO Specialty|BCBSTX PPO|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|ChampVA|CHAMPVA CENTER|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Aetna|BOON CHAPMAN|3.07||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|3.07||||3.07||| 80069|EAP|0300|RENAL FUNCTION PANEL|Aetna|AETNA PPO|3.07||||3.07||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Blue Cross HMO Specialty|BCBSTX HMO|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|ChampVA|CHAMPVA CENTER|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Aetna|AETNA QHP HMO|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Aenta Medicare Advantage|AETNA MEDICARE MA|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Humana Medicare Advantage|HUMANA MA|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Cigna|CIGNA OTHER|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Managed Medicaid|MEDICAID SUPERIOR|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Access Direct Platinum|HEALTHFIRST TPA UMR|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Access Direct Platinum|ANDREWS CENTER|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Veterans Affairs|VETERANS ADMINISTRATION|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|United Medicare Advantage|UHC MEDICARE GOLD MA|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|United Medicare Advantage|UHC AARP MCR HMO MA|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Medicare|MEDICARE PART B ONLY IP|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Aetna|AETNA PPO|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Aetna|BH AETNA|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Medicare|MEDICARE ACUTE|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Medicaid|SMITH COUNTY INDIGENT HEALTH|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Medicaid|COUNTY INDIGENT HEALTH OTHER|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Medicaid|MEDICAID|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Managed Medicare|WELLCARE CHOICE MA|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Managed Medicare|HEALTHSPRING MA|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|United Healthcare|UNITED HEALTHCARE|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Blue Cross PPO Specialty|BCBSTX OTHER|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|United Healthcare|UNITED HEALTHCARE|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|United Healthcare|TML GROUP BENEFITS|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Tricare|TRICARE EAST REGION|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Rusk State Hospital|RUSK STATE HOSP|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|NON CONTRACTED|COMMERCIAL OTHER 1|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|PHCS|HUMANA|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|PHCS|GROUP AND PENSION|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|United Healthcare|UNITED HEALTHCARE OTHER|18.53||||18.53||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.53||||||| 80074|EAP|0300|HEPATITIS PANEL COMPLETE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|18.53||||18.53||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Tricare|TRICARE EAST REGION|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Rusk State Hospital|RUSK STATE HOSP|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Healthcare|UNITED HEALTHCARE OTHER|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Healthcare|UNITED HEALTHCARE|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Healthcare|TML GROUP BENEFITS|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Healthcare|UNITED HEALTHCARE|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicare|JACKSONVILLE ACCESS|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicare|WELLCARE CHOICE MA|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicare|MA PART B ONLY IP|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicare|HEALTHSPRING MA|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|SMITH COUNTY JAIL|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|MEDICAID HMO|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|MEDICAID|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|LAW ENFORCEMENT OTHER|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicare|UTSW MC KIDNEY PROGRAM|||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicare|MEDICARE ACUTE|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicare|MEDICARE PART B ONLY IP|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|UHC AARP MCR HMO MA|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Veterans Affairs|VETERANS ADMINISTRATION|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|BH TEXAS CHILDRENS MEDICAID|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicare|BCBS MEDICARE PPO MA|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA UMR|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Access Direct Platinum|ANDREWS CENTER|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID AMERIGROUP|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID SUPERIOR|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Healthcare|GEHA|||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Optum Behavioral Health|BH OPTUM UHC|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Cigna|CIGNA|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Cigna|CIGNA|||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Humana Medicare Advantage|HUMANA MA|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Aetna|AETNA QHP HMO|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Aetna|BH AETNA|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Aetna Value Network|AETNA VALUE NETWORK|||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross PPO Specialty|BCBSTX PPO|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.89||||2.89||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross PPO Specialty|BCBSTX OTHER|2.89||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross HMO Specialty|BCBSTX HMO|2.89||||2.89||| 801|DRG||SPLENECTOMY W/O CC/MCC|Medicare|MEDICARE ACUTE|122,262.90|11825.58|11825.58|11825.58|||| 80150|EAP|0300|AMIKACIN|Aenta Medicare Advantage|AETNA MEDICARE MA|4.71||||||| 80150|EAP|0300|AMIKACIN|Medicare|MEDICARE ACUTE|4.71||||||| 80156|EAP|0300|CARBAMAZEPINE|United Healthcare|UNITED HEALTHCARE OTHER|||||4.55||| 80156|EAP|0300|CARBAMAZEPINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|523.25||||||| 80156|EAP|0300|CARBAMAZEPINE|Optum Behavioral Health|BH OPTUM UHC|||||4.55||| 80156|EAP|0300|CARBAMAZEPINE|PHCS|HUMANA|523.25||||||| 80156|EAP|0300|CARBAMAZEPINE|Multiplan|WEB TPA|4.55||||4.55||| 80156|EAP|0300|CARBAMAZEPINE|Medicare|MEDICARE ACUTE|4.55||||4.55||| 80156|EAP|0300|CARBAMAZEPINE|Medicare|MEDICARE PART B ONLY IP|489.13||||||| 80156|EAP|0300|CARBAMAZEPINE|Access Direct Platinum|ANDREWS CENTER|4.55||||||| 80156|EAP|0300|CARBAMAZEPINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.55||||||| 80156|EAP|0300|CARBAMAZEPINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|523.25||||||| 80156|EAP|0300|CARBAMAZEPINE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.55||| 80156|EAP|0300|CARBAMAZEPINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||4.55||| 80156|EAP|0300|CARBAMAZEPINE|Humana Medicare Advantage|HUMANA MA|523.25||||523.25||| 80156|EAP|0300|CARBAMAZEPINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.55||||4.55||| 80156|EAP|0300|CARBAMAZEPINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.55||||523.25||| 80156|EAP|0300|CARBAMAZEPINE|Managed Medicaid|MEDICAID AMERIGROUP|4.55||||||| 80156|EAP|0300|CARBAMAZEPINE|Managed Medicaid|MEDICAID SUPERIOR|||||4.55||| 80156|EAP|0300|CARBAMAZEPINE|Blue Cross PPO Specialty|BCBSTX PPO|4.55||||4.55||| 80156|EAP|0300|CARBAMAZEPINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||523.25||| 80158|EAP|0300|CYCLOSPORIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.21||| 80158|EAP|0300|CYCLOSPORIN|Veterans Affairs|VETERANS ADMINISTRATION|714.15||||||| 80158|EAP|0300|CYCLOSPORIN|Medicare|MEDICARE ACUTE|714.15||||||| 80162|EAP|0300|DIGOXIN|United Healthcare|UNITED HEALTHCARE OTHER|477.25||||||| 80162|EAP|0300|DIGOXIN|NON CONTRACTED|COMMERCIAL OTHER 1|477.25||||||| 80162|EAP|0300|DIGOXIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|477.25||||||| 80162|EAP|0300|DIGOXIN|United Healthcare|UNITED HEALTHCARE|477.25||||||| 80162|EAP|0300|DIGOXIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.15||||||| 80162|EAP|0300|DIGOXIN|Managed Medicare|HEALTHSPRING MA|446.13||||4.15||| 80162|EAP|0300|DIGOXIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.15||||||| 80162|EAP|0300|DIGOXIN|Medicaid|MEDICAID|477.25||||||| 80162|EAP|0300|DIGOXIN|Medicare|MEDICARE PART B ONLY IP|4.15||||||| 80162|EAP|0300|DIGOXIN|Aenta Medicare Advantage|AETNA MEDICARE MA|446.13||||4.15||| 80162|EAP|0300|DIGOXIN|Blue Cross PPO Specialty|BCBSTX PPO|477.25||||||| 80162|EAP|0300|DIGOXIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|477.25||||||| 80162|EAP|0300|DIGOXIN|United Healthcare|TML GROUP BENEFITS|477.25||||||| 80162|EAP|0300|DIGOXIN|PHCS|HUMANA|477.25||||||| 80162|EAP|0300|DIGOXIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|477.25||||477.25||| 80162|EAP|0300|DIGOXIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|477.25||||4.15||| 80162|EAP|0300|DIGOXIN|Humana Medicare Advantage|HUMANA MA|477.25||||||| 80162|EAP|0300|DIGOXIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|477.25||||||| 80162|EAP|0300|DIGOXIN|Medicare|MEDICARE ACUTE|477.25||||446.13||| 80162|EAP|0300|DIGOXIN|Veterans Affairs|VETERANS ADMINISTRATION|477.25||||||| 80162|EAP|0300|DIGOXIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|477.25||||477.25||| 80162|EAP|0300|DIGOXIN|United Medicare Advantage|UHC MEDICARE GOLD MA|4.15||||||| 80162|EAP|0300|DIGOXIN|United Medicare Advantage|UHC AARP MCR HMO MA|446.13||||477.25||| 80162|EAP|0300|DIGOXIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|477.25||||||| 80162|EAP|0300|DIGOXIN|Blue Cross HMO Specialty|BCBSTX HMO|4.15||||||| 80164|EAP|0300|VALPROIC ACID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|487.60||||487.60||| 80164|EAP|0300|VALPROIC ACID|United Medicare Advantage|UHC AARP MCR HMO MA|487.60||||487.60||| 80164|EAP|0300|VALPROIC ACID|United Medicare Advantage|UHC MEDICARE GOLD MA|4.24||||455.80||| 80164|EAP|0300|VALPROIC ACID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.24||||||| 80164|EAP|0300|VALPROIC ACID|Access Direct Platinum|ANDREWS CENTER|4.24||||||| 80164|EAP|0300|VALPROIC ACID|Humana Medicare Advantage|HUMANA MA|4.24||||455.80||| 80164|EAP|0300|VALPROIC ACID|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|4.24||||||| 80164|EAP|0300|VALPROIC ACID|Managed Medicaid|MEDICAID SUPERIOR|4.24||||487.60||| 80164|EAP|0300|VALPROIC ACID|Managed Medicaid|MEDICAID AMERIGROUP|4.24||||487.60||| 80164|EAP|0300|VALPROIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|487.60||||4.24||| 80164|EAP|0300|VALPROIC ACID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|487.60||||4.24||| 80164|EAP|0300|VALPROIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|487.60||||4.24||| 80164|EAP|0300|VALPROIC ACID|Blue Cross HMO Specialty|BCBSTX HMO|487.60||||||| 80164|EAP|0300|VALPROIC ACID|Magellan Behavioral Health|BH MAGELLAN|455.80||||||| 80164|EAP|0300|VALPROIC ACID|Veterans Affairs|VETERANS ADMINISTRATION|4.24||||||| 80164|EAP|0300|VALPROIC ACID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.24||||487.60||| 80164|EAP|0300|VALPROIC ACID|Aenta Medicare Advantage|AETNA MEDICARE MA|||||487.60||| 80164|EAP|0300|VALPROIC ACID|Aetna|BH AETNA|4.24||||||| 80164|EAP|0300|VALPROIC ACID|Medicare|MEDICARE PART B ONLY IP|4.24||||||| 80164|EAP|0300|VALPROIC ACID|Medicare|MEDICARE ACUTE|4.24||||487.60||| 80164|EAP|0300|VALPROIC ACID|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.24||||4.24||| 80164|EAP|0300|VALPROIC ACID|Medicaid|MEDICAID HMO|||||487.60||| 80164|EAP|0300|VALPROIC ACID|United Healthcare|UNITED HEALTHCARE|487.60||||||| 80164|EAP|0300|VALPROIC ACID|Rusk State Hospital|RUSK STATE HOSP|487.60||||487.60||| 80164|EAP|0300|VALPROIC ACID|Tricare|TRICARE EAST REGION|4.24||||4.24||| 80164|EAP|0300|VALPROIC ACID|Managed Medicare|HEALTHSPRING MA|455.80||||487.60||| 80164|EAP|0300|VALPROIC ACID|UTMB|UTMB CORRECTIONAL MANAGED CARE|487.60||||||| 80164|EAP|0300|VALPROIC ACID|Managed Medicare|JACKSONVILLE ACCESS|4.24||||||| 80164|EAP|0300|VALPROIC ACID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4.24||| 80164|EAP|0300|VALPROIC ACID|Medicaid|MEDICAID|4.24||||||| 80169|EAP|0300|DS QUANT EVEROLIMUS|Medicare|MEDICARE ACUTE|1,254.30||||1,045.25||| 80169|EAP|0300|DS QUANT EVEROLIMUS|Medicare|UTSW MC KIDNEY PROGRAM|||||1,254.30||| 80169|EAP|0300|DS QUANT EVEROLIMUS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,045.25||||||| 80169|EAP|0300|DS QUANT EVEROLIMUS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,045.25||| 80170|EAP|0300|GENTAMYCIN PEAK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.13||||||| 80170|EAP|0300|GENTAMYCIN PEAK|United Medicare Advantage|UHC AARP MCR HMO MA|589.95||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.13||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.13||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Managed Medicaid|MEDICAID AMERIGROUP|589.95||||||| 80170|EAP|0300|GENTAMICIN RANDOM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.13||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Humana Medicare Advantage|HUMANA MA|589.95||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Blue Cross PPO Specialty|BCBSTX PPO|5.13||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Blue Cross HMO Specialty|BCBSTX HMO|589.95||||||| 80170|EAP|0300|GENTAMYCIN PEAK|NON CONTRACTED|COMMERCIAL OTHER 1|5.13||||||| 80170|EAP|0300|GENTAMYCIN PEAK|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.13||||||| 80170|EAP|0300|GENTAMICIN RANDOM|Medicare|MEDICARE ACUTE|589.95||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.13||||||| 80170|EAP|0300|GENTAMICIN RANDOM|Managed Medicare|HEALTHSPRING MA|589.95||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Medicare|MEDICARE ACUTE|589.95||||||| 80175|EAP|0300|DS QUAN LAMOTRIGINE|Medicare|MEDICARE ACUTE|488.40||||||| 80175|EAP|0300|DS QUAN LAMOTRIGINE|United Healthcare|UNITED HEALTHCARE|4.07||||||| 80175|EAP|0300|DS QUAN LAMOTRIGINE|Aenta Medicare Advantage|AETNA MEDICARE MA|4.07||||||| 80175|EAP|0300|DS QUAN LAMOTRIGINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|488.40||||4.07||| 80175|EAP|0300|DS QUAN LAMOTRIGINE|Blue Cross PPO Specialty|BCBSTX PPO|488.40||||4.07||| 80175|EAP|0300|DS QUAN LAMOTRIGINE|Humana Medicare Advantage|HUMANA MA|447.70||||||| 80175|EAP|0300|DS QUAN LAMOTRIGINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.07||| 80175|EAP|0300|DS QUAN LAMOTRIGINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||488.40||| 80175|EAP|0300|DS QUAN LAMOTRIGINE|Managed Medicaid|MEDICAID AMERIGROUP|4.07||||4.07||| 80176|EAP|0300|LIDOCAINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|527.85||||||| 80176|EAP|0300|LIDOCAINE|Blue Cross PPO Specialty|BCBSTX PPO|527.85||||||| 80176|EAP|0300|LIDOCAINE|Medicare|MEDICARE ACUTE|527.85||||||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Managed Medicare|OTHER INSTITUTIONS|||||545.75||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||654.90||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|United Medicare Advantage|UHC MEDICARE GOLD MA|545.75||||||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|654.90||||545.75||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||654.90||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Blue Cross HMO Specialty|BCBSTX HMO|654.90||||||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||600.33||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Humana Medicare Advantage|HUMANA MA|545.75||||||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Managed Medicaid|MEDICAID SUPERIOR|545.75||||600.33||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|654.90||||||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Medicare|MEDICARE PART B ONLY IP|545.75||||||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|654.90||||654.90||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|Medicare|MEDICARE ACUTE|654.90||||600.33||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|United Healthcare|UNITED HEALTHCARE|||||545.75||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|UTMB|UTMB CORRECTIONAL MANAGED CARE|545.75||||||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|United Medicare Advantage|UHC AARP MCR HMO MA|654.90||||||| 80177|EAP|0300|KEPPRA LEVATIRACETAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|545.75||||654.90||| 80178|EAP|0300|LITHIUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|238.05||||||| 80178|EAP|0300|LITHIUM|Aetna|BH AETNA|2.07||||||| 80178|EAP|0300|LITHIUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|238.05||||238.05||| 80178|EAP|0300|LITHIUM|Magellan Behavioral Health|BH MAGELLAN|2.07||||||| 80178|EAP|0300|LITHIUM|Blue Cross PPO Specialty|BCBSTX PPO|238.05||||2.07||| 80178|EAP|0300|LITHIUM|Aetna|AETNA PPO|||||2.07||| 80178|EAP|0300|LITHIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|238.05||||||| 80178|EAP|0300|LITHIUM|Workers Compensation|UT EMPLOYEE INJURY|238.05||||||| 80178|EAP|0300|LITHIUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.07||||238.05||| 80178|EAP|0300|LITHIUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|238.05||||||| 80178|EAP|0300|LITHIUM|Medicaid|MEDICAID|2.07||||||| 80178|EAP|0300|LITHIUM|Medicaid|SMITH COUNTY JAIL|||||2.07||| 80178|EAP|0300|LITHIUM|Medicare|MEDICARE ACUTE|2.07||||238.05||| 80178|EAP|0300|LITHIUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.07||||2.07||| 80178|EAP|0300|LITHIUM|Managed Medicare|HEALTHSPRING MA|2.07||||||| 80178|EAP|0300|LITHIUM|Managed Medicare|BCBS MEDICARE PPO MA|2.07||||||| 80178|EAP|0300|LITHIUM|Rusk State Hospital|RUSK STATE HOSP|2.07||||||| 80178|EAP|0300|LITHIUM|Optum Behavioral Health|BH OPTUM UHC|2.07||||||| 80178|EAP|0300|LITHIUM|Multiplan|WEB TPA|2.07||||||| 80178|EAP|0300|LITHIUM|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.07||||||| 80178|EAP|0300|LITHIUM|NON CONTRACTED|COMMERCIAL OTHER 1|222.53||||238.05||| 80178|EAP|0300|LITHIUM|United Healthcare|UNITED HEALTHCARE|||||2.07||| 80178|EAP|0300|LITHIUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|238.05||||238.05||| 80183|EAP|0300|TRILEPTAL|Medicaid|MEDICAID HMO|||||490.25||| 80183|EAP|0300|TRILEPTAL|Blue Cross PPO Specialty|BCBSTX PPO|||||490.25||| 80183|EAP|0300|TRILEPTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||490.25||| 80184|EAP|0300|PHENOBARBITAL|Managed Medicaid|MEDICAID AMERIGROUP|||||3.58||| 80184|EAP|0300|PHENOBARBITAL|Blue Cross PPO Specialty|BCBSTX PPO|||||3.58||| 80184|EAP|0300|PHENOBARBITAL|Medicare|MEDICARE ACUTE|411.70||||||| 80184|EAP|0300|PHENOBARBITAL|Medicare|MEDICARE ACUTE|1.54||||||| 80184|EAP|0300|PHENOBARBITAL|United Healthcare|UNITED HEALTHCARE OTHER|||||411.70||| 80184|EAP|0300|PHENOBARBITAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|411.70||||||| 80184|EAP|0300|PHENOBARBITAL|Managed Medicaid|MEDICAID SUPERIOR|||||411.70||| 80184|EAP|0300|PHENOBARBITAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||411.70||| 80184|EAP|0300|PHENOBARBITAL|Humana Medicare Advantage|HUMANA MA|3.58||||||| 80184|EAP|0300|PHENOBARBITAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|411.70||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Managed Medicare|HEALTHSPRING MA|4.15||||477.25||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Managed Medicare|BCBS MEDICARE PPO MA|4.15||||477.25||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.15||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Managed Medicare|MA PART B ONLY IP|4.15||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||4.15||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Medicaid|MEDICAID|4.15||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Medicare|MEDICARE ACUTE|477.25||||4.15||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Medicare|MEDICARE PART B ONLY IP|477.25||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.15||||4.15||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|United Healthcare|UNITED HEALTHCARE OTHER|477.25||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|United Medicare Advantage|UHC AARP MCR HMO MA|477.25||||477.25||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|477.25||||477.25||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|477.25||||477.25||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|477.25||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|477.25||||446.13||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Veterans Affairs|VETERANS ADMINISTRATION|477.25||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.15||||477.25||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|477.25||||477.25||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|477.25||||4.15||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Managed Medicaid|MEDICAID SUPERIOR|4.15||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Cigna|CIGNA|4.15||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|477.25||||||| 80185|EAP|0300|PHENYTOIN DILANTIN TOTAL|Humana Medicare Advantage|HUMANA MA|477.25||||477.25||| 80186|EAP|0300|PHENYTOIN DILANTIN FREE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|495.65||||||| 80186|EAP|0300|PHENYTOIN DILANTIN FREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.31||||||| 80186|EAP|0300|PHENYTOIN DILANTIN FREE|Medicare|MEDICARE ACUTE|4.31||||||| 80186|EAP|0300|PHENYTOIN DILANTIN FREE|Medicaid|MEDICAID|4.31||||||| 80188|EAP|0300|PRIMIDONE|Medicare|MEDICARE ACUTE|5.19||||||| 80195|EAP|0300|RAPAMYCIN|Medicare|MEDICARE ACUTE|545.75||||||| 80197|EAP|0300|TACROLIMUS|United Medicare Advantage|UHC MEDICARE GOLD MA|546.75||||546.75||| 80197|EAP|0300|TACROLIMUS|United Medicare Advantage|UHC AARP MCR HMO MA|628.76||||628.76||| 80197|EAP|0300|TACROLIMUS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|546.75||||587.76||| 80197|EAP|0300|TACROLIMUS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||546.75||| 80197|EAP|0300|TACROLIMUS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||546.75||| 80197|EAP|0300|TACROLIMUS|Blue Cross PPO Specialty|BCBSTX PPO|628.76||||546.75||| 80197|EAP|0300|TACROLIMUS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|546.75||||||| 80197|EAP|0300|TACROLIMUS|Humana Medicare Advantage|HUMANA MA|546.75||||||| 80197|EAP|0300|TACROLIMUS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|587.76||||||| 80197|EAP|0300|TACROLIMUS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|628.76||||628.76||| 80197|EAP|0300|TACROLIMUS|NON CONTRACTED|COMMERCIAL OTHER 1|628.76||||||| 80197|EAP|0300|TACROLIMUS|United Healthcare|UNITED HEALTHCARE|||||546.75||| 80197|EAP|0300|TACROLIMUS|Medicaid|MEDICAID|628.76||||||| 80197|EAP|0300|TACROLIMUS|Medicare|MEDICARE PART B ONLY IP|546.75||||||| 80197|EAP|0300|TACROLIMUS|Medicare|MEDICARE ACUTE|546.75||||546.75||| 80197|EAP|0300|TACROLIMUS|Medicaid|SMITH COUNTY JAIL|546.75||||||| 80197|EAP|0300|TACROLIMUS|Medicare|UTSW MC KIDNEY PROGRAM|||||628.76||| 80197|EAP|0300|TACROLIMUS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||546.75||| 80197|EAP|0300|TACROLIMUS|Managed Medicare|HEALTHSPRING MA|546.75||||||| 80197|EAP|0300|TACROLIMUS|Managed Medicare|BCBS MEDICARE PPO MA|||||546.75||| 80197|EAP|0300|TACROLIMUS|United Healthcare|UNITED HEALTHCARE OTHER|546.75||||546.75||| 80198|EAP|0300|THEOPHYLLINE|Medicaid|MEDICAID|4.42||||||| 80198|EAP|0300|THEOPHYLLINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|508.30||||||| 80198|EAP|0300|THEOPHYLLINE|Humana Medicare Advantage|HUMANA MA|4.42||||||| 80198|EAP|0300|THEOPHYLLINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|508.30||||||| 80198|EAP|0300|THEOPHYLLINE|Blue Cross HMO Specialty|BCBSTX HMO|4.42||||||| 80198|EAP|0300|THEOPHYLLINE|Medicare|MEDICARE ACUTE|4.42||||||| 80198|EAP|0300|THEOPHYLLINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|508.30||||||| 802|DRG||OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W MCC|Medicare|MEDICARE ACUTE|101,025.85|11032.05|11032.05|11032.05|||| 80200|EAP|0300|TOBRAMYCIN RANDOM|United Medicare Advantage|UHC MEDICARE GOLD MA|5.04||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Veterans Affairs|VETERANS ADMINISTRATION|5.04||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.04||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Aetna|AETNA PPO|5.04||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Aenta Medicare Advantage|AETNA MEDICARE MA|579.60||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|579.60||||||| 80200|EAP|0300|TOBRAMYCIN PEAK|Blue Cross PPO Specialty|BCBSTX PPO|579.60||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Blue Cross PPO Specialty|BCBSTX PPO|541.80||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|579.60||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Humana Medicare Advantage|HUMANA MA|579.60||||||| 80200|EAP|0300|TOBRAMYCIN PEAK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|579.60||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|541.80||||||| 80200|EAP|0300|TOBRAMYCIN PEAK|UTMB|UTMB CORRECTIONAL MANAGED CARE|579.60||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|NON CONTRACTED|COMMERCIAL OTHER 1|579.60||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Managed Medicare|HEALTHSPRING MA|5.04||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.04||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Medicare|MEDICARE PART B ONLY IP|5.04||||||| 80200|EAP|0300|TOBRAMYCIN PEAK|Medicare|MEDICARE ACUTE|5.04||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Medicare|MEDICARE ACUTE|579.60||||||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Managed Medicare|BCBS MEDICARE PPO MA|5.04||||5.04||| 80200|EAP|0300|TOBRAMYCIN RANDOM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.04||||||| 80201|EAP|0300|TOPAMAX TOPIRAMATE|Medicare|MEDICARE ACUTE|474.75||||474.75||| 80201|EAP|0300|TOPAMAX TOPIRAMATE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||474.75||| 80201|EAP|0300|TOPAMAX TOPIRAMATE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||474.75||| 80202|EAP|0300|VANCOMYCIN PEAK|United Medicare Advantage|UHC MEDICARE GOLD MA|455.80||||487.60||| 80202|EAP|0300|VANCOMYCIN PEAK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|487.60||||4.24||| 80202|EAP|0300|VANCOMYCIN PEAK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Workers Compensation|BROOKSHIRES WORKERS COMP|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Access Direct Platinum|HEALTHFIRST TPA|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Workers Compensation|WORKERS COMPENSATION OTHER|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Veterans Affairs|VETERANS ADMINISTRATION|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Brinson Benefits|THE HEALTH PLAN SMITH CO|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Blue Cross PPO Specialty|BCBSTX PPO|4.24||||4.24||| 80202|EAP|0300|VANCOMYCIN PEAK|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Blue Cross PPO Specialty|BCBSTX OTHER|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Aetna|AETNA OTHER|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Aetna|AETNA QHP HMO|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Cigna|CIGNA|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Cigna|CIGNA OTHER|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicaid|MEDICAID SUPERIOR|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicaid|MEDICAID AMERIGROUP|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Tricare|TRICARE EAST REGION|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|PHCS|GROUP AND PENSION|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Rusk State Hospital|RUSK STATE HOSP|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|PHCS|HUMANA INSURANCE|455.80||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|487.60||||4.24||| 80202|EAP|0300|VANCOMYCIN PEAK|NON CONTRACTED|COMMERCIAL OTHER 1|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|United Healthcare|UNITED HEALTHCARE OTHER|4.24||||487.60||| 80202|EAP|0300|VANCOMYCIN PEAK|ChampVA|CHAMPVA CENTER|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|United Medicare Advantage|UHC AARP MCR HMO MA|487.60||||4.24||| 80202|EAP|0300|VANCOMYCIN PEAK|Blue Cross HMO Specialty|BCBSTX HMO|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|United Healthcare|TML GROUP BENEFITS|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Aetna|AETNA PPO|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|United Healthcare|UNITED HEALTHCARE|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|United Healthcare|UNITED HEALTHCARE|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Aenta Medicare Advantage|AETNA MEDICARE MA|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|UTMB|UTMB CORRECTIONAL MANAGED CARE|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Access Direct Platinum|HEALTHFIRST TPA UMR|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicare|BCBS MEDICARE PPO MA|4.24||||4.24||| 80202|EAP|0300|VANCOMYCIN PEAK|Humana Medicare Advantage|HUMANA MA|487.60||||4.24||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicare|HEALTHSPRING MA|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicare|ETMC AFFILIATE HOSPITALS|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicaid|MEDICAID HMO|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicaid|SMITH COUNTY INDIGENT HEALTH|455.80||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicaid|CRIME VICTIMS COMPENSATION|487.60||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicare|MEDICARE PART B ONLY IP|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicare|MEDICARE ACUTE|487.60||||487.60||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicaid|SMITH COUNTY JAIL|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicaid|MEDICAID|4.24||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Medicaid|SUPERIOR HEALTHPLAN CHIP|487.60||||||| 80203|EAP|0300|DS QUANT ZONISAMIDE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|488.40||||||| 80203|EAP|0300|DS QUANT ZONISAMIDE|Managed Medicaid|MEDICAID AMERIGROUP|||||4.07||| 80235|EAP|0300|METHASUXOMIDE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||325.20||| 80285|EAP|0300|VORCONAZOLE|Medicare|MEDICARE ACUTE|530.50||||||| 80285|EAP|0300|VORCONAZOLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|530.50||||||| 80285|EAP|0300|VORCONAZOLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|530.50||||||| 80285|EAP|0300|VORCONAZOLE|United Medicare Advantage|UHC MEDICARE GOLD MA|530.50||||||| 80299|EAP|0300|AMIODARONE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||545.75||| 80299|EAP|0300|METHOTREXATE|Blue Cross PPO Specialty|BCBSTX PPO|545.75||||||| 80299|EAP|0300|METHOTREXATE|Blue Cross HMO Specialty|BCBSTX HMO|545.75||||||| 80299|EAP|0300|AMIODARONE|Humana Medicare Advantage|HUMANA MA|545.75||||||| 80299|EAP|0300|METHOTREXATE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|545.75||||||| 80299|EAP|0300|METHOTREXATE|NON CONTRACTED|COMMERCIAL OTHER 1|545.75||||||| 80299|EAP|0300|METHOTREXATE|Managed Medicare|WELLCARE CHOICE MA|545.75||||||| 80299|EAP|0300|METHOTREXATE|Medicare|MEDICARE ACUTE|545.75||||||| 80299|EAP|0300||Medicare|MEDICARE ACUTE|530.50||||||| 803|DRG||OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|60,829.64|7159.14|7159.14|7159.14|||| 80307|EAP|0301||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.15||| 80307|EAP|0301||Medicaid|MOLINA HEALTHCARE OF TEXAS|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|MEDICAID BCBSTX|||||2.58||| 80307|EAP|0301||Medicaid|MEDICAID|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.43||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|SMITH COUNTY JAIL|171.60||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Medicaid|MEDICAID HMO|171.60||||171.60||| 80307|EAP|0300|SALICYLATES|Medicaid|MEDICAID HMO|171.60||||171.60||| 80307|EAP|0300|SALICYLATES|Medicaid|MEDICAID|1.43||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|MEDICAID|2.58||||1.43||| 80307|EAP|0300|ACETAMINOPHEN|Medicaid|SMITH COUNTY JAIL|4.43||||1.43||| 80307|EAP|0300|ACETAMINOPHEN|Medicaid|MEDICAID|1.43||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|MEDICAID HMO|4.43||||2.58||| 80307|EAP|0301||Medicaid|BH TEXAS CHILDRENS MEDICAID|2.15||||2.58||| 80307|EAP|0301||Medicaid|SMITH COUNTY INDIGENT HEALTH|2.15||||2.15||| 80307|EAP|0301||Medicaid|SMITH COUNTY JAIL|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|MEDICAID|430.50||||2.58||| 80307|EAP|0301||Medicaid|MEDICAID BCBSTX|||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.58||||||| 80307|EAP|0301||Medicaid|CRIME VICTIMS COMPENSATION|2.15||||||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.43||||2.58||| 80307|EAP|0301||Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.15||||2.15||| 80307|EAP|0300|ALCOHOL BLOOD|Medicare|MEDICARE ACUTE|430.50||||430.50||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicare|MEDICARE ACUTE|4.43||||2.58||| 80307|EAP|0300|SALICYLATES|Medicare|MEDICARE PART B ONLY IP|1.43||||||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicare|MEDICARE PART B ONLY IP|2.58||||||| 80307|EAP|0300|DRUG SCREEN|Medicare|MEDICARE ACUTE|548.75||||548.75||| 80307|EAP|0300|ACETAMINOPHEN|Medicare|MEDICARE PART B ONLY IP|1.43||||||| 80307|EAP|0300|ACETAMINOPHEN|Medicare|MEDICARE ACUTE|171.60||||157.30||| 80307|EAP|0300|ACETAMINOPHEN|Managed Medicare|HEALTHSPRING MA|1.43||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.43||||171.60||| 80307|EAP|0301||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.15||||2.15||| 80307|EAP|0301||Managed Medicare|HEALTHSPRING MA|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.43||||2.58||| 80307|EAP|0300|SALICYLATES|Managed Medicare|HEALTHSPRING MA|1.43||||1.43||| 80307|EAP|0301||Managed Medicare|OTHER INSTITUTIONS|||||2.15||| 80307|EAP|0301||Managed Medicare|WELLCARE CHOICE MA|||||2.15||| 80307|EAP|0300|SALICYLATES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.43||||171.60||| 80307|EAP|0300|SALICYLATES|UTMB|UTMB CORRECTIONAL MANAGED CARE|157.30||||171.60||| 80307|EAP|0300|SALICYLATES|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.58||||171.60||| 80307|EAP|0300|SALICYLATES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.58||||171.60||| 80307|EAP|0300|ACETAMINOPHEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|157.30||||171.60||| 80307|EAP|0301||Tricare|TRICARE FOR LIFE|||||2.15||| 80307|EAP|0301||Tricare|TRICARE EAST REGION|2.15||||2.15||| 80307|EAP|0300|ALCOHOL BLOOD|United Healthcare|UNITED HEALTHCARE|2.58||||430.50||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Healthcare|GOLDEN RULE|||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Healthcare|UNITED HEALTHCARE|2.58||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|United Healthcare|UNITED HEALTHCARE OTHER|1.43||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Healthcare|TML GROUP BENEFITS|4.43||||2.58||| 80307|EAP|0300|SALICYLATES|United Healthcare|UNITED HEALTHCARE|157.30||||171.60||| 80307|EAP|0300|SALICYLATES|United Healthcare|UNITED HEALTHCARE|171.60||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Healthcare|TML GROUP BENEFITS|2.58||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Healthcare|UNITED HEALTHCARE OTHER|2.58||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|United Healthcare|UNITED HEALTHCARE|171.60||||171.60||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Healthcare|UNITED HEALTHCARE|171.60||||2.58||| 80307|EAP|0301||United Healthcare|UNITED HEALTHCARE|2.15||||2.15||| 80307|EAP|0301||Managed Medicare|MA PART B ONLY IP|2.15||||||| 80307|EAP|0301||NON CONTRACTED|COMMERCIAL OTHER 1|2.15||||2.15||| 80307|EAP|0300|ETHYL GLUCURONIDE|Optum Behavioral Health|BH OPTUM UHC|2.58||||3.15||| 80307|EAP|0300|ACETAMINOPHEN|Tricare|TRICARE FOR LIFE|2.58||||1.43||| 80307|EAP|0301||Texas Workforce Commission|DIS DETER SERV (DDS)|||||2.15||| 80307|EAP|0301||Optum Behavioral Health|BH OPTUM UHC|2.15||||2.15||| 80307|EAP|0301||NON CONTRACTED|COMMERCIAL OTHER 4|||||2.15||| 80307|EAP|0301||PHCS|HUMANA|236.50||||2.15||| 80307|EAP|0300|SALICYLATES|Tricare|TRICARE FOR LIFE|2.58||||1.43||| 80307|EAP|0301||United Healthcare|UNITED HEALTHCARE OTHER|2.15||||2.15||| 80307|EAP|0300|SALICYLATES|Tricare|TRICARE EAST REGION|157.30||||171.60||| 80307|EAP|0300|ALCOHOL BLOOD|PHCS|HUMANA|2.58||||430.50||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Tricare|TRICARE EAST REGION|2.58||||2.58||| 80307|EAP|0301||Multiplan|WEB TPA|2.15||||||| 80307|EAP|0300|SALICYLATES|NON CONTRACTED|COMMERCIAL OTHER 1|171.60||||1.43||| 80307|EAP|0301||Medicare|MEDICARE ACUTE|2.15||||2.15||| 80307|EAP|0300|SALICYLATES|United Healthcare|UNITED HEALTHCARE OTHER|171.60||||1.43||| 80307|EAP|0300|ACETAMINOPHEN|NON CONTRACTED|COMMERCIAL OTHER 1|1.43||||157.30||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|NON CONTRACTED|COMMERCIAL OTHER 1|430.50||||2.58||| 80307|EAP|0301||Workers Compensation|UT EMPLOYEE INJURY|||||2.15||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|NON CONTRACTED|COMMERCIAL OTHER 1|4.43||||1.43||| 80307|EAP|0301||Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||2.15||| 80307|EAP|0301||Veterans Affairs|VETERANS ADMINISTRATION|2.15||||2.15||| 80307|EAP|0300|SALICYLATES|Workers Compensation|WORKERS COMPENSATION OTHER|2.58||||1.43||| 80307|EAP|0300|ACETAMINOPHEN|Workers Compensation|WORKERS COMPENSATION OTHER|2.58||||1.43||| 80307|EAP|0300|SALICYLATES|Veterans Affairs|VETERANS ADMINISTRATION|171.60||||171.60||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Veterans Affairs|VETERANS ADMINISTRATION|4.43||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Veterans Affairs|VETERANS ADMINISTRATION|171.60||||171.60||| 80307|EAP|0300|SALICYLATES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.43||||171.60||| 80307|EAP|0301||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.15||||2.15||| 80307|EAP|0301||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.15||||2.15||| 80307|EAP|0301||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|236.50||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Workers Compensation|UT EMPLOYEE INJURY|||||2.58||| 80307|EAP|0301||Access Direct Platinum|HEALTHFIRST TPA|||||2.15||| 80307|EAP|0301||Access Direct Platinum|ANDREWS CENTER|2.15||||||| 80307|EAP|0300|ACETAMINOPHEN|Access Direct Platinum|HEALTHFIRST TPA UMR|1.43||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|NON CONTRACTED|COMMERCIAL OTHER 1|2.58||||1.43||| 80307|EAP|0300|ACETAMINOPHEN|Access Direct Platinum|HEALTHFIRST TPA|2.58||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Access Direct Platinum|HEALTHFIRST TPA UMR|2.58||||2.58||| 80307|EAP|0301||Medicare|MEDICARE PART B ONLY IP|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.43||||2.58||| 80307|EAP|0300|SALICYLATES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.58||||171.60||| 80307|EAP|0300|SALICYLATES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.43||||1.43||| 80307|EAP|0300|SALICYLATES|Access Direct Platinum|HEALTHFIRST TPA UMR|1.43||||1.43||| 80307|EAP|0300|ETHYL GLUCURONIDE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.58||||3.15||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.43||||4.43||| 80307|EAP|0300|ACETAMINOPHEN|United Medicare Advantage|UHC AARP MCR HMO MA|171.60||||171.60||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Medicare Advantage|UHC AARP MCR HMO MA|2.58||||171.60||| 80307|EAP|0300|ACETAMINOPHEN|United Medicare Advantage|UHC MEDICARE GOLD MA|1.43||||1.43||| 80307|EAP|0300|SALICYLATES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.43||||171.60||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.43||||2.58||| 80307|EAP|0300|SALICYLATES|United Medicare Advantage|UHC MEDICARE GOLD MA|157.30||||1.43||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.58||||4.43||| 80307|EAP|0301||Workers Compensation|TRAVELERS INSURANCE COMPANY|2.15||||||| 80307|EAP|0300|ACETAMINOPHEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.43||||1.43||| 80307|EAP|0301||United Medicare Advantage|UHC AARP MCR HMO MA|2.58||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.43||||171.60||| 80307|EAP|0300|SALICYLATES|Access Direct Platinum|HEALTHFIRST TPA|2.58||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.58||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Medicare Advantage|UHC AARP MCR HMO MA|430.50||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.58||| 80307|EAP|0300|SALICYLATES|NON CONTRACTED|COMMERCIAL OTHER 1|548.75||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Access Direct Platinum|HEALTHFIRST TPA|2.58||||2.58||| 80307|EAP|0301||Access Direct Platinum|HEALTHFIRST TPA UMR|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|548.75||||548.75||| 80307|EAP|0300|ACETAMINOPHEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.43||||171.60||| 80307|EAP|0301||Workers Compensation|WORKERS COMPENSATION OTHER|2.15||||2.15||| 80307|EAP|0300|SALICYLATES|Veterans Affairs|VETERANS ADMINISTRATION|2.58||||171.60||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Workers Compensation|WORKERS COMPENSATION OTHER|2.58||||2.58||| 80307|EAP|0301||United Medicare Advantage|UHC MEDICARE GOLD MA|2.15||||2.15||| 80307|EAP|0301||United Medicare Advantage|UHC AARP WELLMED HMO MA|2.58||||||| 80307|EAP|0300|SALICYLATES|United Medicare Advantage|UHC AARP MCR HMO MA|171.60||||171.60||| 80307|EAP|0300|SALICYLATES|United Medicare Advantage|UHC AARP MCR HMO MA|548.75||||171.60||| 80307|EAP|0300|ALCOHOL BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|430.50||||430.50||| 80307|EAP|0300|ALCOHOL BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|1.43||||430.50||| 80307|EAP|0301||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Aenta Medicare Advantage|AETNA MEDICARE MA|2.58||||4.43||| 80307|EAP|0301||Aetna|BH AETNA|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Aetna|BH AETNA|||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Medicare Advantage|UHC MEDICARE GOLD MA|4.43||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Aetna|AETNA PPO|171.60||||1.43||| 80307|EAP|0301||Aenta Medicare Advantage|AETNA MEDICARE MA|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Aetna|AETNA PPO|2.58||||2.58||| 80307|EAP|0300|SALICYLATES|Aetna|AETNA PPO|171.60||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.43||||2.58||| 80307|EAP|0300|DRUG SCREEN|Aenta Medicare Advantage|AETNA MEDICARE MA|4.43||||548.75||| 80307|EAP|0300|ACETAMINOPHEN|Aetna|AETNA OTHER|2.58||||171.60||| 80307|EAP|0301||Aetna|AETNA OTHER|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.58||||171.60||| 80307|EAP|0300|ETHYL GLUCURONIDE|Aetna|BH AETNA|||||3.15||| 80307|EAP|0300|SALICYLATES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|548.75||||171.60||| 80307|EAP|0301||PHCS|HUMANA INSURANCE|||||2.15||| 80307|EAP|0300|SALICYLATES|Aetna|AETNA OTHER|2.58||||1.43||| 80307|EAP|0300|SALICYLATES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.43||||171.60||| 80307|EAP|0300|ACETAMINOPHEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.43||||171.60||| 80307|EAP|0300|ETHYL GLUCURONIDE|Medicare|MEDICARE ACUTE|2.58||||3.15||| 80307|EAP|0301||NON CONTRACTED|COMMUNITY HEALTH CENTER|2.15||||||| 80307|EAP|0300|ACETAMINOPHEN|Tricare|TRICARE EAST REGION|157.30||||171.60||| 80307|EAP|0301||NON CONTRACTED|COMMERCIAL OTHER 2|2.58||||2.58||| 80307|EAP|0300|DRUG SCREEN|PHCS|HUMANA|2.58||||548.75||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.43||||171.60||| 80307|EAP|0301||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|430.50||||2.58||| 80307|EAP|0300|DRUG SCREEN|Blue Cross HMO Specialty|BCBSTX HMO|2.58||||548.75||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Blue Cross HMO Specialty|BCBSTX HMO|1.43||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Blue Cross HMO Specialty|BCBSTX HMO|1.43||||1.43||| 80307|EAP|0300|SALICYLATES|Blue Cross HMO Specialty|BCBSTX HMO|1.43||||1.43||| 80307|EAP|0301||Blue Cross HMO Specialty|BCBSTX HMO|2.15||||2.15||| 80307|EAP|0301||Blue Cross PPO Specialty|BCBSTX PPO|2.15||||2.15||| 80307|EAP|0300|ETHYL GLUCURONIDE|Blue Cross PPO Specialty|BCBSTX PPO|171.60||||3.15||| 80307|EAP|0301||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.58||| 80307|EAP|0300|SALICYLATES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|171.60||||||| 80307|EAP|0300|ACETAMINOPHEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|171.60||||||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.58||||||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.58||||||| 80307|EAP|0300|DRUG SCREEN|United Healthcare|UNITED HEALTHCARE|157.30||||548.75||| 80307|EAP|0301||Managed Medicare|BCBS MEDICARE PPO MA|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|United Healthcare|UNITED HEALTHCARE|157.30||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Blue Cross PPO Specialty|BCBSTX PPO|171.60||||171.60||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Medicaid|MEDICAID|4.43||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Managed Medicare|HEALTHSPRING MA|2.58||||2.58||| 80307|EAP|0301||United Healthcare|TML GROUP BENEFITS|||||2.15||| 80307|EAP|0301||Aetna|AETNA PPO|2.15||||2.15||| 80307|EAP|0300|ALCOHOL BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|430.50||||430.50||| 80307|EAP|0301||Blue Cross PPO Specialty|BCBSTX OTHER|236.50||||2.15||| 80307|EAP|0301||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.43||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Blue Cross PPO Specialty|BCBSTX PPO|2.58||||2.58||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Blue Cross PPO Specialty|BCBSTX PPO|4.43||||4.43||| 80307|EAP|0300|SALICYLATES|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.43||| 80307|EAP|0300|ACETAMINOPHEN|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.43||| 80307|EAP|0301||Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.15||||2.15||| 80307|EAP|0301||Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.15||||2.15||| 80307|EAP|0301||UTMB|UTMB CORRECTIONAL MANAGED CARE|2.15||||2.15||| 80307|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID AMERIGROUP|1.43||||1.43||| 80307|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|157.30||||171.60||| 80307|EAP|0300|ACETAMINOPHEN|Managed Medicaid|MEDICAID SUPERIOR|1.43||||1.43||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Managed Medicare|HEALTHSPRING MA|4.43||||4.43||| 80307|EAP|0301||Managed Medicaid|MEDICAID AMERIGROUP|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Managed Medicaid|MEDICAID AMERIGROUP|548.75||||4.43||| 80307|EAP|0300|ACETAMINOPHEN|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.12||||2.58||| 80307|EAP|0301||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.15||||2.15||| 80307|EAP|0300|ACETAMINOPHEN|Managed Medicaid|MEDICAID AMERIGROUP|1.43||||1.43||| 80307|EAP|0301||Managed Medicaid|MEDICAID SUPERIOR|2.15||||2.15||| 80307|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|548.75||||157.30||| 80307|EAP|0300|SALICYLATES|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||1.43||| 80307|EAP|0300|SALICYLATES|Medicare|MEDICARE ACUTE|1.43||||1.43||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Managed Medicaid|MEDICAID SUPERIOR|548.75||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.43||||171.60||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.43||||157.30||| 80307|EAP|0300|DRUG SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|548.75||||548.75||| 80307|EAP|0300|PAIN MANAGEMENT DRUG SCRE|Managed Medicaid|MEDICAID SUPERIOR|4.43||||67.20||| 80307|EAP|0300|ALCOHOL BLOOD|Medicare|UTSW MC KIDNEY PROGRAM|||||430.50||| 80307|EAP|0300|SALICYLATES|Medicaid|SMITH COUNTY JAIL|171.60||||1.43||| 80307|EAP|0300|DRUG SCREEN|Medicare|UTSW MC KIDNEY PROGRAM|||||548.75||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|430.50||||4.43||| 80307|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID SUPERIOR|2.58||||1.43||| 80307|EAP|0301||Medicaid|MEDICAID HMO|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Medicaid|CRIME VICTIMS COMPENSATION|2.58||||||| 80307|EAP|0300|SALICYLATES|Blue Cross PPO Specialty|BCBSTX PPO|171.60||||171.60||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Managed Medicaid|MEDICAID AMERIGROUP|2.58||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|171.60||||157.30||| 80307|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|171.60||||157.30||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.58||||171.60||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.58||||157.30||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|430.50||||2.58||| 80307|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|548.75||||171.60||| 80307|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID SUPERIOR|171.60||||1.43||| 80307|EAP|0301||Cigna Behavioral Health|BH CIGNA|2.58||||2.15||| 80307|EAP|0300|SALICYLATES|Medicaid|MEDICAID|548.75||||1.43||| 80307|EAP|0301||Cigna|CIGNA|2.58||||2.15||| 80307|EAP|0301||ChampVA|CHAMPVA CENTER|2.15||||||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.43||||171.60||| 80307|EAP|0301||Cigna|CIGNA|2.15||||2.15||| 80307|EAP|0300|SALICYLATES|Cigna|CIGNA OTHER|2.58||||157.30||| 80307|EAP|0300|SALICYLATES|Cigna|CIGNA|1.43||||||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Cigna|CIGNA OTHER|2.58||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Cigna|CIGNA|4.43||||2.58||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Cigna|CIGNA|2.58||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Cigna|CIGNA OTHER|2.58||||157.30||| 80307|EAP|0301||Cigna|CIGNA OTHER|2.15||||2.15||| 80307|EAP|0301||Medicaid|COUNTY INDIGENT HEALTH OTHER|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Magellan Behavioral Health|BH MAGELLAN|||||4.43||| 80307|EAP|0300|SALICYLATES|Humana Medicare Advantage|HUMANA MA|171.60||||1.43||| 80307|EAP|0300|DRUG SCREEN PRESCRIPTION|Humana Medicare Advantage|HUMANA MA|171.60||||4.43||| 80307|EAP|0300|ETHYL GLUCURONIDE|Cigna Behavioral Health|BH CIGNA|||||3.15||| 80307|EAP|0300|ACETAMINOPHEN|Humana Medicare Advantage|HUMANA MA|171.60||||157.30||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Magellan Behavioral Health|BH MAGELLAN|||||2.58||| 80307|EAP|0300|ACETAMINOPHEN|Cigna|CIGNA|1.43||||||| 80307|EAP|0301||Magellan Behavioral Health|BH MAGELLAN|2.15||||2.15||| 80307|EAP|0301||Humana Medicare Advantage|HUMANA MA|2.15||||2.15||| 80307|EAP|0300|DRUG SCREEN RAPID STAT|Humana Medicare Advantage|HUMANA MA|171.60||||2.58||| 80307|EAP|0300|DRUG SCREEN|Humana Medicare Advantage|HUMANA MA|2.58||||548.75||| 80307|EAP|0300|ALCOHOL BLOOD|Humana Medicare Advantage|HUMANA MA|4.43||||430.50||| 80320|EAP|0300|METHANOL|Humana Medicare Advantage|HUMANA MA|768.90||||||| 80320|EAP|0300|METHANOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|768.90||||||| 80320|EAP|0300|METHANOL|Blue Cross PPO Specialty|BCBSTX PPO|640.75||||||| 80320|EAP|0300|METHANOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|768.90||||||| 80320|EAP|0300|METHANOL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|640.75||||||| 80320|EAP|0300|METHANOL|Medicare|MEDICARE ACUTE|640.75||||||| 80323|EAP|0300|NICOTINE QUALITATIVE|United Healthcare|UNITED HEALTHCARE OTHER|||||1.32||| 80323|EAP|0300|NICOTINE QUALITATIVE|Managed Medicare|HEALTHSPRING MA|||||1.32||| 80323|EAP|0300|NICOTINE ASSAY|Medicare|UTSW MC KIDNEY PROGRAM|||||909.50||| 80323|EAP|0300|NICOTINE QUALITATIVE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.32||| 80323|EAP|0300|NICOTINE QUALITATIVE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.32||| 80323|EAP|0300|NICOTINE ASSAY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||909.50||| 80323|EAP|0300|NICOTINE QUALITATIVE|Medicare|MEDICARE ACUTE|909.50||||1.32||| 80323|EAP|0300|NICOTINE QUALITATIVE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.32||| 80323|EAP|0300|NICOTINE ASSAY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||909.50||| 80323|EAP|0300|NICOTINE QUALITATIVE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.32||| 80323|EAP|0300|NICOTINE ASSAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||909.50||| 80323|EAP|0300|NICOTINE QUALITATIVE|Aetna|AETNA PPO|||||1.32||| 80323|EAP|0300|NICOTINE QUALITATIVE|Blue Cross HMO Specialty|BCBSTX HMO|||||1.32||| 80323|EAP|0300|NICOTINE QUALITATIVE|Blue Cross PPO Specialty|BCBSTX PPO|1.32||||1.32||| 80323|EAP|0300|NICOTINE ASSAY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||909.50||| 80323|EAP|0300|NICOTINE QUALITATIVE|Managed Medicaid|MEDICAID AMERIGROUP|||||1.32||| 80323|EAP|0300|NICOTINE QUALITATIVE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.32||| 80323|EAP|0300|NICOTINE QUALITATIVE|Humana Medicare Advantage|HUMANA MA|1.32||||1.32||| 80324|EAP|0300|AMPHETAMINE QUANT URINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.13||||||| 80324|EAP|0300|AMPHETAMINE QUANT URINE|Medicare|MEDICARE ACUTE|375.60||||||| 80324|EAP|0300|AMPHETAMINE QUANT URINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.13||||||| 80324|EAP|0300|AMPHETAMINE QUANT URINE|Humana Medicare Advantage|HUMANA MA|375.60||||3.13||| 80339|EAP|0300||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.71||| 80339|EAP|0300||United Healthcare|UNITED HEALTHCARE OTHER|||||2.71||| 80345|EAP|0300|BARBITURATE QUANT URINE|Humana Medicare Advantage|HUMANA MA|277.20||||||| 80345|EAP|0300|BARBITURATE QUANT URINE|Medicare|MEDICARE ACUTE|277.20||||||| 80345|EAP|0300|BARBITURATE QUANT URINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.31||||||| 80345|EAP|0300|BARBITURATE QUANT URINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.31||||||| 80346|EAP|0300|BENZODIAZEPINE QUANT URIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.73||||||| 80346|EAP|0300|BENZODIAZEPINE QUANT URIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.73||||||| 80346|EAP|0300|BENZODIAZEPINE QUANT URIN|Medicaid|MEDICAID HMO|3.73||||||| 80346|EAP|0300|BENZODIAZEPINE QUANT URIN|Medicare|MEDICARE ACUTE|447.60||||||| 80346|EAP|0300|BENZODIAZEPINE QUANT URIN|Blue Cross PPO Specialty|BCBSTX PPO|3.73||||||| 80346|EAP|0300|BENZODIAZEPINE QUANT URIN|Humana Medicare Advantage|HUMANA MA|447.60||||||| 80348|EAP|0300|BUPHRENORPHINE QUATN URIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.40||| 80348|EAP|0300|BUPHRENORPHINE QUATN URIN|Medicare|MEDICARE ACUTE|||||1.40||| 80348|EAP|0300|BUPHRENORPHINE QUATN URIN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.40||| 80349|EAP|0300|THC METABOLITE QUANT URIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.26||||||| 80349|EAP|0300|THC METABOLITE QUANT URIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.26||||||| 80349|EAP|0300|THC METABOLITE QUANT URIN|Medicare|MEDICARE ACUTE|151.20||||||| 80349|EAP|0300|THC METABOLITE QUANT URIN|Humana Medicare Advantage|HUMANA MA|151.20||||||| 80353|EAP|0300|COCAINE METABOLITE QUANT|Humana Medicare Advantage|HUMANA MA|3.66||||||| 80353|EAP|0300|COCAINE METABOLITE QUANT|Medicare|MEDICARE ACUTE|3.66||||||| 80353|EAP|0300|COCAINE METABOLITE QUANT|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.05||||||| 80353|EAP|0300|COCAINE METABOLITE QUANT|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.05||||||| 80364|EAP|0300|OPIATE QUANT URINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.92||||||| 80364|EAP|0300|OPIATE QUANT URINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.92||||||| 80364|EAP|0300|OPIATE QUANT URINE|Medicare|MEDICARE ACUTE|4.70||||||| 80364|EAP|0300|OPIATE QUANT URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|3.92||||||| 80364|EAP|0300|OPIATE QUANT URINE|Blue Cross PPO Specialty|BCBSTX PPO|3.92||||||| 80364|EAP|0300|OPIATE QUANT URINE|Humana Medicare Advantage|HUMANA MA|4.70||||||| 80375|EAP|0300|METFORMIN LEVEL|Blue Cross PPO Specialty|BCBSTX PPO|446.20||||||| 804|DRG||OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W/O CC/MCC|Medicare|MEDICARE ACUTE|69,085.05|59.15|8932.67|59.15|||| 804|DRG||OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|50,171.75|8766.04|8932.67|59.15|||| 804|DRG||OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|170,453.30|8932.67|8932.67|59.15|||| 805|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|18,453.29|18453.29|18453.29|52.76|||| 805|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22,531.67|9022.46|18453.29|52.76|||| 805|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21,881.35|8900.46|18453.29|52.76|||| 805|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC|Cigna|CIGNA|21,713.55|67.2|18453.29|52.76|||| 805|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC|Managed Medicaid|MEDICAID SUPERIOR|21,189.25|3124.3|18453.29|52.76|||| 805|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC|Blue Cross HMO Specialty|BCBSTX HMO|18,103.50|52.76|18453.29|52.76|||| 805|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC|Blue Cross PPO Specialty|BCBSTX PPO|227.17|6947.53|18453.29|52.76|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Medicaid|MEDICAID HMO|19,291.62|1964.97|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Medicare|MEDICARE ACUTE|24,307.50|5174.69|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|PHCS|GROUP AND PENSION|21,126.27|12056.4|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|United Healthcare|UNITED HEALTHCARE|24,507.75|65.98|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|NON CONTRACTED|COMMERCIAL OTHER 1|18,781.00|13796.695|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|United Healthcare|UNITED HEALTHCARE OTHER|18,184.30|65.98|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Blue Cross PPO Specialty|BCBSTX OTHER|26,829.75|4083.11|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Blue Cross PPO Specialty|BCBSTX PPO|23,358.12|4803.25|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21,874.30|71.44|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Blue Cross HMO Specialty|BCBSTX HMO|247.85|4083.11|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Managed Medicaid|MEDICAID AMERIGROUP|24,666.80|3124.3|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Managed Medicaid|MEDICAID SUPERIOR|20,143.74|3124.3|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Cigna|CIGNA|23,360.47|67.2|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21,561.15|6698.83|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Access Direct Platinum|HEALTHFIRST TPA|24,453.30|4703.75|13796.695|65.98|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|21,873.53|6711.38|13796.695|65.98|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|23,558.93|6047.68|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA|21,043.62|6136.92|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|16,112.50|4712.27|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Cigna|CIGNA|15,025.38|67.2|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Cigna|CIGNA OTHER|24,498.35|67.2|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21,362.75|65.98|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|20,119.50|2615.12|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Aetna|AETNA PPO|22,255.94|50|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Aetna Value Network|AETNA VALUE NETWORK|17,751.17|42.5|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21,837.30|71.44|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|18,302.35|3544.01|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|24,620.60|3856.535|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Brinson Benefits|THE HEALTH PLAN SMITH CO|13,783.75|4722.56|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|19,274.70|2615.12|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Cigna|CIGNA|21,384.85|67.2|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|21,274.98|4169.06|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX OTHER|20,496.54|3544.01|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|20,599.63|65.98|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|21,161.59|65.98|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|20,862.40|6136.92|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|United Healthcare|TML GROUP BENEFITS|20,856.85|65.98|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|17,768.59|65.98|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Tricare|TRICARE EAST REGION|22,654.46|2386.05|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|PHCS|HUMANA INSURANCE|21,541.75|10655.6|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Medicaid|MEDICAID|22,624.37|1644.73|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|23,346.57|1690.61|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Medicaid|MEDICAID HMO|18,032.75|1644.73|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|PHCS|GROUP AND PENSION|22,973.75|10655.6|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Tricare|TRICARE FOR LIFE|16,485.60|2272.44|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|19,277.59|10655.6|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|20,939.03|6136.92|10655.6|42.5|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20,511.38|6136.92|10655.6|42.5|||| 808|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC|Medicare|MEDICARE ACUTE|76,956.74|13091.77|17062.32|12941.63|||| 808|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|168,114.77|12941.63|17062.32|12941.63|||| 808|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|88,282.35|12941.63|17062.32|12941.63|||| 808|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC|Managed Medicare|HEALTHSPRING MA|54,181.61|12969.79|17062.32|12941.63|||| 808|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|104,428.81|16613.82|17062.32|12941.63|||| 808|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|135,811.60|17062.32|17062.32|12941.63|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Veterans Affairs|VETERANS ADMINISTRATION|83,470.34|8094.22|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Blue Cross PPO Specialty|BCBSTX PPO|58,629.85|9804.76|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35,719.15|142.88|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Blue Cross HMO Specialty|BCBSTX HMO|68,696.96|6952.37|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Managed Medicaid|MEDICAID AMERIGROUP|49,559.93|7591.77|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55,628.37|7591.77|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Humana Medicare Advantage|HUMANA MA|56,263.99|7960.14|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Managed Medicare|HEALTHSPRING MA|93,917.30|7956.03|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|64,836.75|7956.03|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|NON CONTRACTED|COMMERCIAL OTHER 1|101,976.64|66411.145|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|United Medicare Advantage|UHC AARP MCR HMO MA|51,063.35|7956.03|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|67,254.53|8026.845|66411.145|142.88|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Medicare|MEDICARE ACUTE|45,810.65|7955.15|66411.145|142.88|||| 81|DRG||NONTRAUMATIC STUPOR & COMA W/O MCC|Medicare|MEDICARE ACUTE|46,545.15|6107.89|6207.1|6107.89|||| 81|DRG||NONTRAUMATIC STUPOR & COMA W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|77,717.95|6207.1|6207.1|6107.89|||| 810|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|41,265.39|6522.57|6522.57|5321.78|||| 810|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX OTHER|18,358.75|5321.78|6522.57|5321.78|||| 810|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W/O CC/MCC|Medicare|MEDICARE ACUTE|26,373.50|6522.57|6522.57|5321.78|||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Tricare|TRICARE EAST REGION|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|PHCS|HUMANA INSURANCE|||||2.05||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|PHCS|HUMANA|||||2.05||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|PHCS|GROUP AND PENSION|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|PHCS|HUMANA INSURANCE|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Multiplan|WEB TPA|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|NON CONTRACTED|COMMERCIAL OTHER 1|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|United Healthcare|GEHA|||||145.21||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|United Healthcare|UNITED HEALTHCARE|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|United Healthcare|AARP|||||2.05||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||2.05||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|United Healthcare|TML GROUP BENEFITS|||||2.05||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Managed Medicare|BCBS MEDICARE PPO MA|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.05||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Medicaid|MEDICAID|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.05||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Veterans Affairs|VETERANS ADMINISTRATION|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Medicare|MEDICARE ACUTE|145.21||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Access Direct Platinum|HEALTHFIRST TPA UMR|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Access Direct Platinum|HEALTHFIRST TPA|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Managed Medicare|HEALTHSPRING MA|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|United Healthcare|UNITED HEALTHCARE OTHER|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|United Medicare Advantage|UHC AARP MCR HMO MA|85.42||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Aetna|BOON CHAPMAN|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Aetna|AETNA PPO|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Aetna|AETNA QHP HMO|||||145.21||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Aetna|AETNA OTHER|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Aetna Value Network|AETNA VALUE NETWORK|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Tricare|TRICARE FOR LIFE|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Blue Cross PPO Specialty|BCBSTX PPO|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Blue Cross PPO Specialty|BCBSTX OTHER|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|ChampVA|CHAMPVA CENTER|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Blue Cross HMO Specialty|BCBSTX HMO|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Cigna|CIGNA OTHER|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Cigna|CIGNA|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Humana Medicare Advantage|HUMANA MA|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Managed Medicaid|MEDICAID SUPERIOR|||||2.05||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Managed Medicaid|MEDICAID AMERIGROUP|||||85.42||| 81000|EAP|0300|URINALYSIS NONAUTO W/SCOP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||85.42||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Humana Medicare Advantage|HUMANA MA|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Cigna|CIGNA|116.15||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Cigna Behavioral Health|BH CIGNA|1.01||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Cigna|CIGNA OTHER|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Blue Cross HMO Specialty|BCBSTX HMO|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Blue Cross PPO Specialty|BCBSTX OTHER|1.01||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|116.15||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Blue Cross PPO Specialty|BCBSTX PPO|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|ChampVA|CHAMPVA CENTER|1.01||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Aetna Value Network|AETNA VALUE NETWORK|||||108.58||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Aetna|AETNA PPO|116.15||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Aetna|AETNA OTHER|108.58||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Aetna|AETNA QHP HMO|1.01||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Aetna|BOON CHAPMAN|108.58||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Aenta Medicare Advantage|AETNA MEDICARE MA|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Medicare Advantage|UHC AARP WELLMED HMO MA|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Medicare Advantage|UHC AARP MCR HMO MA|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Medicare Advantage|UHC MEDICARE GOLD MA|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Access Direct Platinum|ANDREWS CENTER|1.01||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Access Direct Platinum|HEALTHFIRST TPA UMR|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Access Direct Platinum|HEALTHFIRST TPA|1.01||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Workers Compensation|TRAVELERS INSURANCE COMPANY|1.01||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Workers Compensation|TEXAS MUTUAL INSURANCE|1.01||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Workers Compensation|ZURICH COMPANY|||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Workers Compensation|UT EMPLOYEE INJURY|||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Workers Compensation|GALLAGHER BASSETT|||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Veterans Affairs|VETERANS ADMINISTRATION|116.15||||108.58||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Workers Compensation|WORKERS COMPENSATION OTHER|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicare|MEDICARE ACUTE|116.15||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicare|MEDICARE PART B ONLY IP|108.58||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicare|UTSW MC KIDNEY PROGRAM|||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.01||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|BH TEXAS CHILDRENS MEDICAID|116.15||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.01||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|MEDICAID HMO|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|COUNTY INDIGENT HEALTH OTHER|108.58||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|MEDICAID|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|SMITH COUNTY JAIL|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|MEDICAID BCBSTX|||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Aetna|BH AETNA|1.01||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Medicaid|CRIME VICTIMS COMPENSATION|1.01||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicare|OTHER INSTITUTIONS|116.15||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicare|WELLCARE CHOICE MA|116.15||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicare|BCBS MEDICARE PPO MA|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.01||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicare|HEALTHSPRING MA|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|UTMB|UTMB CORRECTIONAL MANAGED CARE|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Healthcare|UNITED HEALTHCARE|1.01||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Healthcare|TML GROUP BENEFITS|116.15||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Healthcare|GOLDEN RULE|116.15||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Healthcare|GEHA|||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Healthcare|UNITED HEALTHCARE OTHER|1.01||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicaid|MEDICAID SUPERIOR|116.15||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|United Healthcare|UNITED HEALTHCARE|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|NON CONTRACTED|COMMERCIAL OTHER 2|116.15||||108.58||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Managed Medicaid|MEDICAID AMERIGROUP|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Multiplan|NALC|||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Multiplan|WEB TPA|1.01||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|NON CONTRACTED|COMMERCIAL OTHER 1|1.01||||108.58||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Tricare|TRICARE EAST REGION|116.15||||108.58||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|PHCS|GROUP AND PENSION|108.58||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Tricare|TRICARE FOR LIFE|||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Rusk State Hospital|RUSK STATE HOSP|116.15||||116.15||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|PHCS|HUMANA INSURANCE|108.58||||1.01||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|Optum Behavioral Health|BH OPTUM UHC|116.15||||||| 81001|EAP|0300|URINALYSIS AUTO W/MICROSC|PHCS|HUMANA|116.15||||1.01||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Tricare|TRICARE EAST REGION|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Tricare|TRICARE FOR LIFE|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|PHCS|HUMANA INSURANCE|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|PHCS|GROUP AND PENSION|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|PHCS|HUMANA INSURANCE|||||26.61||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|PHCS|HUMANA|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Multiplan|PACIFICARE|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Multiplan|NALC|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|NON CONTRACTED|COMMERCIAL OTHER 2|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||26.61||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Healthcare|TML GROUP BENEFITS|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Healthcare|AARP|||||24.75||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Healthcare|UNITED HEALTHCARE|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Healthcare|UNITED HEALTHCARE OTHER|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Healthcare|UNITED HEALTHCARE ERS|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Healthcare|GEHA|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Managed Medicare|OTHER INSTITUTIONS|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|24.75||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Managed Medicare|HEALTHSPRING MA|24.75||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Managed Medicare|UNIVERSAL HEALTHCARE MA|||||24.75||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Managed Medicare|BCBS MEDICARE PPO MA|28.46||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Medicaid|MEDICAID HMO|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Medicare|MEDICARE ACUTE|26.61||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Medicaid|MEDICAID|24.75||||24.75||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Medicare|MEDICARE PART B ONLY IP|||||24.75||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Medicare|UTSW MC KIDNEY PROGRAM|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Veterans Affairs|VETERANS ADMINISTRATION|||||26.61||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Access Direct Platinum|HEALTHFIRST TPA|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||24.75||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Medicare Advantage|UHC AARP MCR HMO MA|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|United Healthcare|GOLDEN RULE|||||24.75||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|NON CONTRACTED|COMMERCIAL OTHER 1|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Aetna|AETNA OTHER|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Aetna|BOON CHAPMAN|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Aetna|AETNA QHP HMO|||||24.75||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Aetna|AETNA PPO|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Aetna Value Network|AETNA VALUE NETWORK|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Blue Cross PPO Specialty|BCBSTX PPO|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Rusk State Hospital|RUSK STATE HOSP|||||26.61||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|ChampVA|CHAMPVA CENTER|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Blue Cross PPO Specialty|BCBSTX OTHER|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Blue Cross HMO Specialty|BCBSTX HMO|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Cigna|CIGNA OTHER|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Cigna|CIGNA|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Humana Medicare Advantage|HUMANA MA|28.46||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Managed Medicaid|MEDICAID AMERIGROUP|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Managed Medicaid|MEDICAID SUPERIOR|||||28.46||| 81002|EAP|0300|CLINITEST FOR GALACTOSEMI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||28.46||| 81003|EAP|0300|DIPSTICK URINE|Managed Medicaid|MEDICAID SUPERIOR|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.41||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicaid|MEDICAID AMERIGROUP|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|101.20||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Managed Medicaid|MEDICAID AMERIGROUP|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicaid|MEDICAID SUPERIOR|101.20||||0.88||| 81003|EAP|0300|ACETONE URINE|Managed Medicaid|MEDICAID SUPERIOR|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.41||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Humana Medicare Advantage|HUMANA MA|162.15||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Humana Medicare Advantage|HUMANA MA|94.60||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Magellan Behavioral Health|BH MAGELLAN|0.88||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Cigna|CIGNA|94.60||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Cigna|CIGNA|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Cigna|CIGNA OTHER|101.20||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Cigna|CIGNA|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Blue Cross HMO Specialty|BCBSTX HMO|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Blue Cross HMO Specialty|BCBSTX HMO|162.15||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Blue Cross HMO Specialty|BCBSTX HMO|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|ChampVA|CHAMPVA CENTER|0.88||||94.60||| 81003|EAP|0300|DIPSTICK URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Blue Cross PPO Specialty|BCBSTX OTHER|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Blue Cross PPO Specialty|BCBSTX PPO|101.20||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Blue Cross PPO Specialty|BCBSTX PPO|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Blue Cross PPO Specialty|BCBSTX PPO|1.41||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|151.58||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|101.20||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Aetna|AETNA OTHER|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Aetna|BOON CHAPMAN|94.60||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Aetna|AETNA QHP HMO|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Aetna|BH AETNA|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|Aetna|AETNA PPO|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Aetna|AETNA PPO|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Aetna|AETNA OTHER|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Aenta Medicare Advantage|AETNA MEDICARE MA|94.60||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|United Medicare Advantage|UHC AARP MCR HMO MA|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|United Medicare Advantage|UHC AARP WELLMED HMO MA|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.88||||0.88||| 81003|EAP|0300|DIPSTICK URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|101.20||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Access Direct Platinum|HEALTHFIRST TPA|94.60||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Access Direct Platinum|HEALTHFIRST TPA UMR|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Access Direct Platinum|HEALTHFIRST TPA|0.88||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Access Direct Platinum|ANDREWS CENTER|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|BROOKSHIRES WORKERS COMP|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|GALLAGHER BASSETT|||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|94.60||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|UT EMPLOYEE INJURY|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|TEXAS MUTUAL INSURANCE|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|WORKERS COMP PHYSICIAN|||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Veterans Affairs|VETERANS ADMINISTRATION|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Veterans Affairs|VETERANS ADMINISTRATION|0.88||||101.20||| 81003|EAP|0300|PH URINE OR BODY FLUID|Veterans Affairs|VETERANS ADMINISTRATION|162.15||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|ZURICH COMPANY|101.20||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|94.60||||94.60||| 81003|EAP|0300|URINALYSIS ROUTINE|Workers Compensation|WORKERS COMPENSATION OTHER|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|94.60||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicare|UTSW MC KIDNEY PROGRAM|||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicare|MEDICARE ACUTE|1.41||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicare|MEDICARE ACUTE|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.88||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Medicare|MEDICARE ACUTE|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicare|MEDICARE PART B ONLY IP|0.88||||0.88||| 81003|EAP|0300|SPECIFIC GRAVITY|Medicare|MEDICARE ACUTE|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.88||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|SMITH COUNTY JAIL|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|MEDICAID|1.41||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|MEDICAID HMO|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|MEDICAID|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|LAW ENFORCEMENT OTHER|||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|United Medicare Advantage|UHC MEDICARE GOLD MA|162.15||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Medicaid|MEDICAID|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|CRIME VICTIMS COMPENSATION|94.60||||||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|BH TEXAS CHILDRENS MEDICAID|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|SUPERIOR HEALTHPLAN CHIP|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|94.60||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Medicaid|MEDICAID BCBSTX|||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Medicaid|MEDICAID HMO|0.88||||94.60||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicare|MA PART B ONLY IP|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicare|BCBS MEDICARE PPO MA|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicare|ETMC REHABILITATION HOSPITAL|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicare|WELLCARE CHOICE MA|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|Aetna Value Network|AETNA VALUE NETWORK|||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicare|OTHER INSTITUTIONS|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Managed Medicare|BCBS MEDICARE PPO MA|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Blue Cross PPO Specialty|BCBSTX OTHER|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicare|HEALTHSPRING MA|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicare|JACKSONVILLE ACCESS|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|Brinson Benefits|THE HEALTH PLAN SMITH CO|94.60||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|United Healthcare|UNITED HEALTHCARE OTHER|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|United Healthcare|UNITED HEALTHCARE OTHER|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|United Healthcare|UNITED HEALTHCARE|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|United Healthcare|UNITED HEALTHCARE|101.20||||94.60||| 81003|EAP|0300|URINALYSIS ROUTINE|United Healthcare|UNITED HEALTHCARE ERS|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|Cigna Behavioral Health|BH CIGNA|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|United Healthcare|GOLDEN RULE|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|United Healthcare|UNITED HEALTHCARE|1.41||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|United Healthcare|TML GROUP BENEFITS|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|United Healthcare|AARP|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Cigna|CIGNA OTHER|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|United Healthcare|GEHA|94.60||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Humana Medicare Advantage|HUMANA MA|101.20||||101.20||| 81003|EAP|0300|DIPSTICK URINE|United Healthcare|UNITED HEALTHCARE|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|NON CONTRACTED|COMMERCIAL OTHER 1|1.41||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Multiplan|WEB TPA|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Multiplan|MUTUAL OF OMAHA|||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|NON CONTRACTED|COMMERCIAL OTHER 1|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|NON CONTRACTED|COMMERCIAL OTHER 4|||||101.20||| 81003|EAP|0300|DIPSTICK URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.88||||0.88||| 81003|EAP|0300|DIPSTICK URINE|NON CONTRACTED|COMMERCIAL OTHER 1|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|NON CONTRACTED|COMMERCIAL OTHER 2|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Multiplan|NALC|0.88||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|PHCS|HUMANA|101.20||||0.88||| 81003|EAP|0300|DIPSTICK URINE|Tricare|TRICARE EAST REGION|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Tricare|TRICARE FOR LIFE|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Optum Behavioral Health|BH OPTUM UHC|0.88||||||| 81003|EAP|0300|URINALYSIS ROUTINE|PHCS|MULTIPLAN PHCS|||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Rusk State Hospital|RUSK STATE HOSP|101.20||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|PHCS|GROUP AND PENSION|94.60||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|PHCS|HUMANA INSURANCE|0.88||||0.88||| 81003|EAP|0300|URINALYSIS ROUTINE|Tricare|TRICARE EAST REGION|101.20||||101.20||| 81003|EAP|0300|URINALYSIS ROUTINE|Tricare|TRICARE SOUTH PHYSICIAN|||||101.20||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|PHCS|GROUP AND PENSION|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Rusk State Hospital|RUSK STATE HOSP|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|PHCS|HUMANA|1.29||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|NON CONTRACTED|COMMERCIAL OTHER 1|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|United Healthcare|UNITED HEALTHCARE OTHER|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|United Healthcare|UNITED HEALTHCARE|1.29||||1.20||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|United Healthcare|UNITED HEALTHCARE|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Managed Medicare|HEALTHSPRING MA|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Managed Medicare|BCBS MEDICARE PPO MA|1.20||||1.20||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Medicaid|SMITH COUNTY JAIL|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Medicaid|MEDICAID|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Medicare|MEDICARE PART B ONLY IP|1.29||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Medicare|MEDICARE ACUTE|1.38||||1.20||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Workers Compensation|WORKERS COMPENSATION OTHER|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Veterans Affairs|VETERANS ADMINISTRATION|1.29||||1.20||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Access Direct Platinum|HEALTHFIRST TPA UMR|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Access Direct Platinum|HEALTHFIRST TPA|1.29||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Managed Medicare|WELLCARE CHOICE MA|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.20||||1.20||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|United Medicare Advantage|UHC AARP MCR HMO MA|1.38||||1.38||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.38||||1.29||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.38||||1.20||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Aetna|AETNA PPO|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Aetna|AETNA OTHER|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.38||||1.29||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Blue Cross PPO Specialty|BCBSTX OTHER|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Blue Cross PPO Specialty|BCBSTX PPO|1.38||||1.29||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Blue Cross HMO Specialty|BCBSTX HMO|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Cigna|CIGNA|1.38||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Humana Medicare Advantage|HUMANA MA|1.20||||1.29||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Managed Medicaid|MEDICAID AMERIGROUP|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.20||||1.20||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Managed Medicaid|MEDICAID SUPERIOR|1.20||||||| 81015|EAP|0300|EOSINOPHIL COUNT URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.38||||1.29||| 81025|EAP|0300|UCG PREGNANCY TEST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Managed Medicaid|MEDICAID SUPERIOR|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.49||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.52||||2.52||| 81025|EAP|0300|UCG PREGNANCY TEST|Humana Medicare Advantage|HUMANA MA|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Magellan Behavioral Health|BH MAGELLAN|2.49||||267.68||| 81025|EAP|0300|UCG PREGNANCY TEST|Cigna|CIGNA OTHER|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Cigna|CIGNA|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Cigna|CIGNA|267.68||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Cigna Behavioral Health|BH CIGNA|2.49||||||| 81025|EAP|0300|UCG PREGNANCY TEST|ChampVA|CHAMPVA CENTER|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Blue Cross PPO Specialty|BCBSTX PPO|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Blue Cross PPO Specialty|BCBSTX OTHER|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Aetna Value Network|AETNA VALUE NETWORK|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Aetna|BH AETNA|2.49||||||| 81025|EAP|0300|UCG PREGNANCY TEST|Aetna|AETNA PPO|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Aenta Medicare Advantage|AETNA MEDICARE MA|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Aetna|AETNA OTHER|2.49||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|United Medicare Advantage|UHC MEDICARE GOLD MA|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|286.35||||267.68||| 81025|EAP|0300|UCG PREGNANCY TEST|United Medicare Advantage|UHC AARP MCR HMO MA|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Access Direct Platinum|ANDREWS CENTER|2.49||||||| 81025|EAP|0300|UCG PREGNANCY TEST|Access Direct Platinum|HEALTHFIRST TPA UMR|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Access Direct Platinum|HEALTHFIRST TPA|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Workers Compensation|BROOKSHIRES WORKERS COMP|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Workers Compensation|ZURICH COMPANY|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Workers Compensation|UT EMPLOYEE INJURY|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Workers Compensation|GALLAGHER BASSETT|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Workers Compensation|WORKERS COMP PHYSICIAN|||||267.68||| 81025|EAP|0300|UCG PREGNANCY TEST|Veterans Affairs|VETERANS ADMINISTRATION|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Workers Compensation|WORKERS COMPENSATION OTHER|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicare|MEDICARE ACUTE|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicare|MEDICARE PART B ONLY IP|2.49||||||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|MEDICAID BCBSTX|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|SUPERIOR HEALTHPLAN CHIP|286.35||||267.68||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|MEDICAID HMO|2.49||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|LAW ENFORCEMENT OTHER|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|BH TEXAS CHILDRENS MEDICAID|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|MEDICAID|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|CRIME VICTIMS COMPENSATION|286.35||||||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|SMITH COUNTY JAIL|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Managed Medicare|HEALTHSPRING MA|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Managed Medicare|BCBS MEDICARE PPO MA|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Aetna|AETNA QHP HMO|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Brinson Benefits|THE HEALTH PLAN SMITH CO|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|267.68||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|United Healthcare|UNITED HEALTHCARE ERS|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Blue Cross HMO Specialty|BCBSTX HMO|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|United Healthcare|UNITED HEALTHCARE|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|United Healthcare|GOLDEN RULE|286.35||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|United Healthcare|UNITED HEALTHCARE OTHER|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|United Healthcare|TML GROUP BENEFITS|286.35||||267.68||| 81025|EAP|0300|UCG PREGNANCY TEST|United Healthcare|GEHA|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|NON CONTRACTED|COMMERCIAL OTHER 1|2.49||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Multiplan|TRUSTMARK|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Multiplan|WEB TPA|2.49||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Managed Medicaid|MEDICAID AMERIGROUP|2.49||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Multiplan|NALC|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.49||||||| 81025|EAP|0300|UCG PREGNANCY TEST|NON CONTRACTED|COMMERCIAL OTHER 4|||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|NON CONTRACTED|COMMERCIAL OTHER 2|||||267.68||| 81025|EAP|0300|UCG PREGNANCY TEST|PHCS|HUMANA INSURANCE|||||267.68||| 81025|EAP|0300|UCG PREGNANCY TEST|Optum Behavioral Health|BH OPTUM UHC|267.68||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|PHCS|GROUP AND PENSION|2.49||||286.35||| 81025|EAP|0300|UCG PREGNANCY TEST|Rusk State Hospital|RUSK STATE HOSP|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Tricare|TRICARE FOR LIFE|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Tricare|TRICARE EAST REGION|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|PHCS|HUMANA|||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Texas Workforce Commission|DIS DETER SERV (DDS)|286.35||||2.49||| 81025|EAP|0300|UCG PREGNANCY TEST|Tricare|TRICARE SOUTH PHYSICIAN|||||286.35||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|198,928.55|8791.24|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|55,597.64|8791.24|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|United Medicare Advantage|UHC AARP WELLMED HMO MA|150,619.47|8791.24|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|United Healthcare|UNITED HEALTHCARE OTHER|54,268.91|15863.79|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Medicare|MEDICARE ACUTE|45,059.97|8637.76|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Workers Compensation|ZURICH COMPANY|23,194.48|12571.47|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|82,016.17|8610.48|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44,823.40|107.16|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|185,578.33|7826.83|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|96,070.65|9207.24|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|64,236.44|8791.24|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|131,093.62|11661.22|15863.79|107.16|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Managed Medicare|HEALTHSPRING MA|69,384.99|7404.6|15863.79|107.16|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Managed Medicare|HEALTHSPRING MA|55,205.50|6110.46|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|65,035.86|6061.77|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|40,789.36|5658.88|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Cigna|CIGNA OTHER|33,218.25|8959.5|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Cigna|CIGNA|43,641.76|8959.5|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Humana Medicare Advantage|HUMANA MA|25,231.93|6160.03|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|26,562.90|5996.93|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Brinson Benefits|THE HEALTH PLAN SMITH CO|28,156.95|11088.05|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30,577.58|85.9|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|28,202.43|6165.295|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|29,705.41|8434.66|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|27,641.43|6160.03|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Medicaid|SMITH COUNTY JAIL|35,655.35|2494.94|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|66,705.18|7113.21|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|47,495.21|6160.03|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Medicare|MEDICARE PART B ONLY IP|148.96|537.93|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|PHCS|HUMANA|59,511.21|14801.9|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|19,986.65|10305.61|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|28,437.11|6047.46|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38,557.91|6115.085|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|33,066.41|6165.295|14801.9|85.9|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|38,352.31|6104.62|14801.9|85.9|||| 81219|EAP|0310|CALR MUTATION ANALYSIS (M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.40||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|United Healthcare|UNITED HEALTHCARE OTHER|411.75||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Tricare|TRICARE EAST REGION|411.75||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Medicaid|MEDICAID|411.75||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Medicare|MEDICARE ACUTE|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Medicare|UTSW MC KIDNEY PROGRAM|||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Managed Medicare|HEALTHSPRING MA|411.75||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Managed Medicare|ETMC AFFILIATE HOSPITALS|411.75||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Access Direct Platinum|HEALTHFIRST TPA|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|United Medicare Advantage|UHC AARP MCR HMO MA|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|411.75||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|United Medicare Advantage|UHC MEDICARE GOLD MA|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Aetna|AETNA PPO|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|United Healthcare|UNITED HEALTHCARE|||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Aenta Medicare Advantage|AETNA MEDICARE MA|411.75||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Blue Cross PPO Specialty|BCBSTX OTHER|411.75||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Blue Cross PPO Specialty|BCBSTX PPO|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Blue Cross HMO Specialty|BCBSTX HMO|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Humana Medicare Advantage|HUMANA MA|411.75||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||411.75||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Managed Medicaid|MEDICAID SUPERIOR|411.75||||||| 81240|EAP|0300|PROTHROMBIN G20210A MUTAT|Managed Medicaid|MEDICAID AMERIGROUP|411.75||||411.75||| 81241|EAP|0300|FACTOR V LEIDEN|Managed Medicaid|MEDICAID AMERIGROUP|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Managed Medicaid|MEDICAID SUPERIOR|15.91||||||| 81241|EAP|0300|FACTOR V LEIDEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Blue Cross HMO Specialty|BCBSTX HMO|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Blue Cross PPO Specialty|BCBSTX OTHER|15.91||||||| 81241|EAP|0300|FACTOR V LEIDEN|Blue Cross PPO Specialty|BCBSTX PPO|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Aetna|AETNA PPO|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Aenta Medicare Advantage|AETNA MEDICARE MA|15.91||||||| 81241|EAP|0300|FACTOR V LEIDEN|United Medicare Advantage|UHC MEDICARE GOLD MA|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|United Medicare Advantage|UHC AARP MCR HMO MA|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.91||||||| 81241|EAP|0300|FACTOR V LEIDEN|Humana Medicare Advantage|HUMANA MA|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Access Direct Platinum|HEALTHFIRST TPA|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Managed Medicare|ETMC AFFILIATE HOSPITALS|15.91||||||| 81241|EAP|0300|FACTOR V LEIDEN|Managed Medicare|HEALTHSPRING MA|15.91||||||| 81241|EAP|0300|FACTOR V LEIDEN|Medicare|MEDICARE ACUTE|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Medicare|UTSW MC KIDNEY PROGRAM|||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Medicaid|MEDICAID|15.91||||||| 81241|EAP|0300|FACTOR V LEIDEN|NON CONTRACTED|COMMERCIAL OTHER 1|||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|Tricare|TRICARE EAST REGION|15.91||||||| 81241|EAP|0300|FACTOR V LEIDEN|United Healthcare|UNITED HEALTHCARE|15.91||||15.91||| 81241|EAP|0300|FACTOR V LEIDEN|United Healthcare|UNITED HEALTHCARE|15.91||||||| 81241|EAP|0300|FACTOR V LEIDEN|United Healthcare|UNITED HEALTHCARE OTHER|15.91||||||| 81256|EAP|0300|HEMOCHROMATOSIS(HFE) PCR|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.80||| 81256|EAP|0300|HEMOCHROMATOSIS(HFE) PCR|Medicaid|MEDICAID|4.80||||||| 81256|EAP|0300|HEMOCHROMATOSIS(HFE) PCR|Medicare|MEDICARE ACUTE|4.80||||4.80||| 81256|EAP|0300|HEMOCHROMATOSIS(HFE) PCR|Workers Compensation|WORKERS COMPENSATION OTHER|4.80||||||| 81256|EAP|0300|HEMOCHROMATOSIS(HFE) PCR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.80||||||| 81256|EAP|0300|HEMOCHROMATOSIS(HFE) PCR|United Medicare Advantage|UHC AARP MCR HMO MA|4.80||||||| 81256|EAP|0300|HEMOCHROMATOSIS(HFE) PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.80||||||| 81256|EAP|0300|HEMOCHROMATOSIS(HFE) PCR|Humana Medicare Advantage|HUMANA MA|4.80||||||| 81256|EAP|0300|HEMOCHROMATOSIS(HFE) PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.80||||||| 81257|EAP|0300|HBA1/HBA2 ANALYSIS FOR CO|Blue Cross PPO Specialty|BCBSTX PPO|7.59||||||| 81270|EAP|0310|MUTATION ANALYSIS|Managed Medicare|HEALTHSPRING MA|0.80||||||| 81270|EAP|0310|MUTATION ANALYSIS|PHCS|HUMANA INSURANCE|||||0.80||| 81270|EAP|0310|MUTATION ANALYSIS|Medicare|MEDICARE ACUTE|0.80||||||| 81270|EAP|0300|JAK 2 MUTATION|United Medicare Advantage|UHC MEDICARE GOLD MA|11.09||||||| 81270|EAP|0310|MUTATION ANALYSIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.80||| 81270|EAP|0310|MUTATION ANALYSIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.80||| 81272|EAP|0310|KIT GENE TARGETED SEQ ANA|Medicare|MEDICARE ACUTE|1.45||||||| 81287|EAP|0300|GENE PROMOTER METHYLATION|United Medicare Advantage|UHC AARP MCR HMO MA|6.40||||||| 81287|EAP|0300|GENE PROMOTER METHYLATION|Medicare|MEDICARE ACUTE|6.40||||||| 81291|EAP|0300|MTHFR|United Healthcare|UNITED HEALTHCARE|715.75||||715.75||| 81291|EAP|0300|MTHFR|Tricare|TRICARE EAST REGION|715.75||||||| 81291|EAP|0300|MTHFR|Managed Medicare|ETMC AFFILIATE HOSPITALS|715.75||||||| 81291|EAP|0300|MTHFR|Medicare|MEDICARE ACUTE|715.75||||715.75||| 81291|EAP|0300|MTHFR|Aetna|AETNA PPO|||||715.75||| 81291|EAP|0300|MTHFR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|715.75||||715.75||| 81291|EAP|0300|MTHFR|Blue Cross HMO Specialty|BCBSTX HMO|||||715.75||| 81291|EAP|0300|MTHFR|Blue Cross PPO Specialty|BCBSTX OTHER|715.75||||||| 81291|EAP|0300|MTHFR|Blue Cross PPO Specialty|BCBSTX PPO|715.75||||715.75||| 81291|EAP|0300|MTHFR|Humana Medicare Advantage|HUMANA MA|715.75||||||| 81291|EAP|0300|MTHFR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|715.75||||||| 81291|EAP|0300|MTHFR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||715.75||| 81291|EAP|0300|MTHFR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|715.75||||715.75||| 81291|EAP|0300|MTHFR|United Medicare Advantage|UHC AARP MCR HMO MA|715.75||||||| 81291|EAP|0300|MTHFR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||715.75||| 81291|EAP|0300|MTHFR|United Medicare Advantage|UHC MEDICARE GOLD MA|715.75||||||| 813|DRG||COAGULATION DISORDERS|Managed Medicare|HEALTHSPRING MA|136.43|9954.32|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|Humana Medicare Advantage|HUMANA MA|49,043.76|10071.58|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18,668.65|6673.25|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26,017.45|7956.53|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|52,556.89|10942.08|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|Blue Cross PPO Specialty|BCBSTX PPO|17,181.25|10942.08|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|128,440.33|196.46|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|Medicare|MEDICARE ACUTE|86,712.81|10072.515|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|United Healthcare|UNITED HEALTHCARE OTHER|49,978.66|18762.43|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|United Medicare Advantage|UHC AARP MCR HMO MA|120,520.38|10163.43|18762.43|196.46|||| 813|DRG||COAGULATION DISORDERS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|44,024.96|10163.43|18762.43|196.46|||| 81301|EAP|0301|MICROSATELLITE INSTABILIT|Medicare|MEDICARE ACUTE|16.08||||16.08||| 81301|EAP|0301|MICROSATELLITE INSTABILIT|Humana Medicare Advantage|HUMANA MA|16.08||||||| 81301|EAP|0301|MICROSATELLITE INSTABILIT|Cigna|CIGNA|||||16.08||| 81305|EAP|0300|MYD88 GENE P.LEU265PRO VR|Medicare|MEDICARE ACUTE|2.90||||||| 81306|EAP|0300|NUDT15 GENE ANALYSIS COMM|Humana Medicare Advantage|HUMANA MA|562.50||||||| 81306|EAP|0300|NUDT15 GENE ANALYSIS COMM|Medicaid|COUNTY INDIGENT HEALTH OTHER|562.50||||||| 81335|EAP|0300|TPMT GENE ANALYSIS COMMON|Medicaid|COUNTY INDIGENT HEALTH OTHER|562.50||||||| 81335|EAP|0300|TPMT GENE ANALYSIS COMMON|Humana Medicare Advantage|HUMANA MA|562.50||||||| 81373|EAP|0300|CLASS 1 HLA ABC TYPE|Blue Cross PPO Specialty|BCBSTX PPO|349.80||||||| 81373|EAP|0300|CLASS 1 HLA ABC TYPE|Managed Medicare|HEALTHSPRING MA|349.80||||||| 81373|EAP|0300|CLASS 1 HLA ABC TYPE|Medicare|MEDICARE ACUTE|||||349.80||| 814|DRG||RETICULOENDOTHELIAL & IMMUNITY DISORDERS W MCC|Medicare|MEDICARE ACUTE|59,055.75|10853.71|10853.71|10853.71|||| 81403|EAP|0300|MOLECULAR TESTING CARTER|Managed Medicaid|MEDICAID AMERIGROUP|2.82||||||| 81403|EAP|0300|MOLECULAR TESTING CARTER|Humana Medicare Advantage|HUMANA MA|2.82||||||| 81403|EAP|0300|MOLECULAR TESTING CARTER|Blue Cross PPO Specialty|BCBSTX PPO|||||2.82||| 81403|EAP|0300|MOLECULAR TESTING CARTER|Managed Medicare|HEALTHSPRING MA|||||2.82||| 81450|EAP|0300|MYELOID DISORDERS PROFILE|United Healthcare|UNITED HEALTHCARE OTHER|52.00||||||| 81450|EAP|0300|NEO TYPE AML PROGNOSTIC|United Healthcare|UNITED HEALTHCARE OTHER|32.00||||||| 81450|EAP|0300|NEO TYPE AML PROGNOSTIC|Medicaid|MEDICAID|32.00||||||| 81450|EAP|0300|MYELOID DISORDERS PROFILE|Medicare|MEDICARE ACUTE|52.00||||||| 81450|EAP|0300|NEO TYPE AML PROGNOSTIC|Medicare|MEDICARE ACUTE|32.00||||||| 81450|EAP|0300|NEO TYPE AML PROGNOSTIC|Managed Medicare|HEALTHSPRING MA|32.00||||||| 81450|EAP|0300|MYELOID DISORDERS PROFILE|Veterans Affairs|VETERANS ADMINISTRATION|||||52.00||| 81450|EAP|0300|NEO TYPE AML PROGNOSTIC|Humana Medicare Advantage|HUMANA MA|52.00||||32.00||| 81450|EAP|0300|NEO TYPE AML PROGNOSTIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|32.00||||32.00||| 81450|EAP|0300|MYELOID DISORDERS PROFILE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|52.00||||52.00||| 81450|EAP|0300|NEO TYPE AML PROGNOSTIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32.00||||||| 81479|EAP|0310|UNLISTED MOLECULAR PATH 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|189.20||||||| 81479|EAP|0310|IDH1/IDH2 MUTATION ANALYS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.30||| 81479|EAP|0310|MPN EXTENDED REFLEX PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||34.23||| 81479|EAP|0300|FLT3 MUTATION (ITD & TKD)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.00||| 81479|EAP|0300|CLL PROGNOSTIC PROFILE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.00||||||| 81479|EAP|0310|UNLISTED MOLECULAR PATH 2|United Medicare Advantage|UHC AARP MCR HMO MA|189.20||||||| 81479|EAP|0300|CLL PROGNOSTIC PROFILE|Medicare|MEDICARE ACUTE|10.00||||||| 81479|EAP|0310|IDH1/IDH2 MUTATION ANALYS|Medicare|MEDICARE ACUTE|5.30||||||| 815|DRG||RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC|Medicare|MEDICARE ACUTE|69,487.25|6841.53|6841.53|1985.18|||| 815|DRG||RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC|Medicare|MEDICARE PART B ONLY IP|25,944.47|1985.18|6841.53|1985.18|||| 816|DRG||RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|29,510.75|4621.22|4621.22|4621.22|||| 817|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W MCC|Access Direct Platinum|HEALTHFIRST TPA|58,600.05|19417.1|19417.1|19417.1|||| 818|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W CC|NON CONTRACTED|COMMERCIAL OTHER 1|24,443.79|16437.13|16437.13|3056.3|||| 818|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W CC|Medicaid|SUPERIOR HEALTHPLAN CHIP|23,014.51|3056.3|16437.13|3056.3|||| 819|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W/O CC/MCC|Medicaid|MEDICAID|50,009.78|3056.3|3056.3|3056.3|||| 82|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC|Humana Medicare Advantage|HUMANA MA|151,579.72|13771.145|30685.26|10337.65|||| 82|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC|Managed Medicaid|MEDICAID SUPERIOR|94,078.67|30685.26|30685.26|10337.65|||| 82|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|72,252.25|13640.35|30685.26|10337.65|||| 82|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC|Veterans Affairs|VETERANS ADMINISTRATION|161,745.63|13639.47|30685.26|10337.65|||| 82|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|239,022.20|13735.5|30685.26|10337.65|||| 82|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC|Medicare|MEDICARE ACUTE|88,356.73|13773.545|30685.26|10337.65|||| 82|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC|Medicaid|MEDICAID|136,090.91|10337.65|30685.26|10337.65|||| 820|DRG||LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC|Medicare|MEDICARE ACUTE|137,326.78|32982.54|67662.86|32982.54|||| 820|DRG||LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC|United Healthcare|UNITED HEALTHCARE OTHER|219,363.64|67662.86|67662.86|32982.54|||| 820|DRG||LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|83,358.88|36962.72|67662.86|32982.54|||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Veterans Affairs|VETERANS ADMINISTRATION|||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Access Direct Platinum|HEALTHFIRST TPA UMR|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|United Medicare Advantage|UHC MEDICARE GOLD MA|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Managed Medicaid|MEDICAID AMERIGROUP|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Managed Medicaid|MEDICAID SUPERIOR|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Humana Medicare Advantage|HUMANA MA|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Cigna|CIGNA|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Cigna|CIGNA OTHER|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Aetna|AETNA PPO|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|United Medicare Advantage|UHC AARP MCR HMO MA|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Blue Cross PPO Specialty|BCBSTX PPO|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Blue Cross HMO Specialty|BCBSTX HMO|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|NON CONTRACTED|COMMERCIAL OTHER 1|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|United Healthcare|UNITED HEALTHCARE|||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|United Healthcare|UNITED HEALTHCARE OTHER|||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Managed Medicare|HEALTHSPRING MA|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Medicaid|MEDICAID|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Medicaid|SMITH COUNTY JAIL|2.38||||||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Medicare|MEDICARE ACUTE|2.38||||2.38||| 82010|EAP|0300|B-HYDROXYBUTYRATE (BHB)|Medicare|MEDICARE PART B ONLY IP|2.38||||||| 82017|EAP|0300|ACYLCARNITINES QUANT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.22||||||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Medicare|MEDICARE ACUTE|13.82||||13.82||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Medicaid|MEDICAID|13.82||||||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Blue Cross HMO Specialty|BCBSTX HMO|||||13.82||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Blue Cross PPO Specialty|BCBSTX PPO|13.82||||||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.82||||||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Humana Medicare Advantage|HUMANA MA|13.82||||||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.82||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.82||||||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.82||||||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|United Medicare Advantage|UHC MEDICARE GOLD MA|13.82||||13.82||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|United Medicare Advantage|UHC AARP MCR HMO MA|13.82||||||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.82||||||| 82024|EAP|0300|ADRENOCORTICOTROPIC HORMO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.82||||||| 82040|EAP|0300|ALBUMIN SERUM|Veterans Affairs|VETERANS ADMINISTRATION|1.00||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|United Medicare Advantage|UHC AARP MCR HMO MA|||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|Managed Medicaid|MEDICAID AMERIGROUP|||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|Managed Medicaid|MEDICAID SUPERIOR|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|Cigna|CIGNA|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|Humana Medicare Advantage|HUMANA MA|1.00||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|1.00||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.00||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|Blue Cross PPO Specialty|BCBSTX PPO|1.00||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|Blue Cross HMO Specialty|BCBSTX HMO|1.00||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|United Healthcare|UNITED HEALTHCARE|||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|United Healthcare|TML GROUP BENEFITS|||||1.00||| 82040|EAP|0300|ALBUMIN SERUM|Tricare|TRICARE FOR LIFE|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|PHCS|HUMANA|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|Managed Medicare|HEALTHSPRING MA|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|Managed Medicare|BCBS MEDICARE PPO MA|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|Medicaid|MEDICAID|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|Medicaid|SMITH COUNTY JAIL|1.00||||||| 82040|EAP|0300|ALBUMIN SERUM|Medicare|MEDICARE ACUTE|1.00||||1.00||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Medicare|MEDICARE ACUTE|1.04||||1.04||| 82042|EAP|0300|ALBUMIN SERUM|Medicare|MEDICARE ACUTE|1.00||||1.00||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Medicaid|SMITH COUNTY JAIL|1.04||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Medicaid|MEDICAID|1.04||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Medicaid|MEDICAID|1.00||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Managed Medicare|HEALTHSPRING MA|1.04||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.04||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|NON CONTRACTED|COMMERCIAL OTHER 1|1.04||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|PHCS|HUMANA|1.04||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|United Healthcare|UNITED HEALTHCARE|1.04||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|United Healthcare|TML GROUP BENEFITS|||||1.04||| 82042|EAP|0300|ALBUMIN SERUM|United Healthcare|UNITED HEALTHCARE OTHER|1.00||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Blue Cross HMO Specialty|BCBSTX HMO|1.04||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Blue Cross PPO Specialty|BCBSTX PPO|1.00||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Blue Cross PPO Specialty|BCBSTX PPO|1.04||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.04||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.04||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.00||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Humana Medicare Advantage|HUMANA MA|1.04||||1.04||| 82042|EAP|0300|ALBUMIN SERUM|Humana Medicare Advantage|HUMANA MA|1.00||||1.00||| 82042|EAP|0300|ALBUMIN SERUM|Cigna|CIGNA|1.00||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Tricare|TRICARE FOR LIFE|1.04||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Cigna|CIGNA OTHER|1.04||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.04||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Managed Medicare|HEALTHSPRING MA|1.00||||1.04||| 82042|EAP|0300|ALBUMIN SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.00||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Managed Medicaid|MEDICAID AMERIGROUP|1.04||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.04||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.00||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Managed Medicaid|MEDICAID SUPERIOR|1.04||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.04||||1.00||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|United Medicare Advantage|UHC AARP MCR HMO MA|1.04||||||| 82042|EAP|0300|ALBUMIN SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.00||||1.00||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.00||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.04||||1.04||| 82042|EAP|0300|ALBUMIN SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.00||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.04||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.04||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.04||||||| 82042|EAP|0300|ALBUMIN SERUM|Workers Compensation|WORKERS COMPENSATION OTHER|1.00||||||| 82042|EAP|0300|ALBUMIN, OTHER SOURCE|Veterans Affairs|VETERANS ADMINISTRATION|1.04||||||| 82042|EAP|0300|ALBUMIN SERUM|Veterans Affairs|VETERANS ADMINISTRATION|1.00||||||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|Veterans Affairs|VETERANS ADMINISTRATION|1.12||||1.12||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.12||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.12||||1.12||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.12||||||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.12||||||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.12||||||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|Blue Cross HMO Specialty|BCBSTX HMO|||||1.12||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|United Healthcare|UNITED HEALTHCARE OTHER|||||1.12||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|United Healthcare|UNITED HEALTHCARE|||||1.12||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.12||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|Medicare|UTSW MC KIDNEY PROGRAM|||||1.12||| 82043|EAP|0300|MICROALBUMIN 24HR URINE|Medicare|MEDICARE ACUTE|1.12||||1.12||| 82085|EAP|0300|ALDOLASE|Medicare|MEDICARE ACUTE|||||386.50||| 82085|EAP|0300|ALDOLASE|United Healthcare|UNITED HEALTHCARE|386.50||||||| 82085|EAP|0300|ALDOLASE|United Healthcare|UNITED HEALTHCARE OTHER|386.50||||||| 82085|EAP|0300|ALDOLASE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||386.50||| 82085|EAP|0300|ALDOLASE|Blue Cross PPO Specialty|BCBSTX PPO|386.50||||||| 82085|EAP|0300|ALDOLASE|Cigna|CIGNA|386.50||||||| 82085|EAP|0300|ALDOLASE|Humana Medicare Advantage|HUMANA MA|386.50||||||| 82085|EAP|0300|ALDOLASE|United Medicare Advantage|UHC MEDICARE GOLD MA|386.50||||||| 82085|EAP|0300|ALDOLASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|386.50||||||| 82088|EAP|0300|ALDOSTERONE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.74||||||| 82088|EAP|0300|ALDOSTERONE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.74||||||| 82088|EAP|0300|ALDOSTERONE|Access Direct Platinum|HEALTHFIRST TPA UMR|7.74||||||| 82088|EAP|0300|ALDOSTERONE|United Medicare Advantage|UHC AARP MCR HMO MA|7.74||||||| 82088|EAP|0300|ALDOSTERONE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.74||||||| 82088|EAP|0300|ALDOSTERONE|Humana Medicare Advantage|HUMANA MA|7.74||||||| 82088|EAP|0300|ALDOSTERONE|Cigna|CIGNA|7.74||||||| 82088|EAP|0300|ALDOSTERONE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.74||| 82088|EAP|0300|ALDOSTERONE|Aetna|AETNA OTHER|7.74||||||| 82088|EAP|0300|ALDOSTERONE|Blue Cross HMO Specialty|BCBSTX HMO|7.74||||||| 82088|EAP|0300|ALDOSTERONE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.74||||||| 82088|EAP|0300|ALDOSTERONE|Blue Cross PPO Specialty|BCBSTX PPO|7.74||||||| 82088|EAP|0300|ALDOSTERONE|United Healthcare|UNITED HEALTHCARE OTHER|||||7.74||| 82088|EAP|0300|ALDOSTERONE|Medicaid|MEDICAID|7.74||||||| 82088|EAP|0300|ALDOSTERONE|Medicare|MEDICARE ACUTE|7.74||||||| 821|DRG||LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC|Medicare|MEDICARE ACUTE|159,852.25|13789.2|16257.3|250.04|||| 821|DRG||LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC|Blue Cross PPO Specialty|BCBSTX PPO|58,352.56|16257.3|16257.3|250.04|||| 821|DRG||LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|292,056.73|250.04|16257.3|250.04|||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|United Medicare Advantage|UHC MEDICARE GOLD MA|2.92||||2.92||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN TOTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|525.25||||525.25||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN TOTAL|Veterans Affairs|VETERANS ADMINISTRATION|525.25||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Veterans Affairs|VETERANS ADMINISTRATION|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN TOTAL|Humana Medicare Advantage|HUMANA MA|525.25||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|United Medicare Advantage|UHC AARP MCR HMO MA|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Humana Medicare Advantage|HUMANA MA|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|525.25||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.92||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Blue Cross PPO Specialty|BCBSTX PPO|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|NON CONTRACTED|COMMERCIAL OTHER 1|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Managed Medicare|HEALTHSPRING MA|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Medicaid|MEDICAID|2.92||||||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN TOTAL|Medicare|MEDICARE ACUTE|525.25||||2.92||| 82103|EAP|0300|ALPHA-1-ANTITRYPSIN|Medicare|MEDICARE ACUTE|2.92||||2.92||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Medicare|MEDICARE ACUTE|3.72||||3.72||| 82105|EAP|0300|ALPHA FETOPROTEIN PROFILE|Medicaid|MEDICAID|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Medicaid|MEDICAID|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.72||||3.72||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Managed Medicare|HEALTHSPRING MA|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|United Healthcare|UNITED HEALTHCARE OTHER|3.72||||3.72||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|United Healthcare|UNITED HEALTHCARE|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Tricare|TRICARE EAST REGION|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Blue Cross HMO Specialty|BCBSTX HMO|||||3.72||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|||||3.72||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Blue Cross PPO Specialty|BCBSTX PPO|3.72||||3.72||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Aetna|AETNA PPO|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Aenta Medicare Advantage|AETNA MEDICARE MA|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.72||||3.72||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.72||||3.72||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Managed Medicaid|MEDICAID SUPERIOR|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Managed Medicaid|MEDICAID AMERIGROUP|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Cigna|CIGNA OTHER|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Cigna|CIGNA|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Humana Medicare Advantage|HUMANA MA|3.72||||3.72||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|Workers Compensation|WORKERS COMPENSATION OTHER|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|3.72||||||| 82105|EAP|0300|ALPHA FETOPROTEIN SERUM|United Medicare Advantage|UHC AARP MCR HMO MA|3.72||||||| 82135|EAP|0300|AMINOLEVULINIC ACID|Medicare|MEDICARE ACUTE|||||6.56||| 82139|EAP|0300|AMINO ACIDS 6 OR MORE QUA|Humana Medicare Advantage|HUMANA MA|397.50||||||| 82140|EAP|0300|AMMONIA|NON CONTRACTED|COMMERCIAL OTHER 1|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Rusk State Hospital|RUSK STATE HOSP|2.94||||||| 82140|EAP|0300|AMMONIA|Optum Behavioral Health|BH OPTUM UHC|2.94||||||| 82140|EAP|0300|AMMONIA|Tricare|TRICARE EAST REGION|2.94||||||| 82140|EAP|0300|AMMONIA|United Healthcare|UNITED HEALTHCARE|2.94||||||| 82140|EAP|0300|AMMONIA|United Healthcare|UNITED HEALTHCARE OTHER|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Managed Medicare|MA PART B ONLY IP|2.94||||||| 82140|EAP|0300|AMMONIA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Managed Medicare|BCBS MEDICARE PPO MA|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.94||||||| 82140|EAP|0300|AMMONIA|Managed Medicare|HEALTHSPRING MA|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.94||||||| 82140|EAP|0300|AMMONIA|Medicaid|CRIME VICTIMS COMPENSATION|2.94||||||| 82140|EAP|0300|AMMONIA|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.94||||||| 82140|EAP|0300|AMMONIA|Medicaid|MEDICAID|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Medicaid|SMITH COUNTY JAIL|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Medicare|MEDICARE ACUTE|2.94||||2.94||| 82140|EAP|0300|AMMONIA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.94||||2.94||| 82140|EAP|0300|AMMONIA|United Medicare Advantage|UHC AARP MCR HMO MA|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Medicare|MEDICARE PART B ONLY IP|2.94||||||| 82140|EAP|0300|AMMONIA|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.94||||||| 82140|EAP|0300|AMMONIA|United Medicare Advantage|UHC MEDICARE GOLD MA|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Access Direct Platinum|HEALTHFIRST TPA|2.94||||||| 82140|EAP|0300|AMMONIA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Access Direct Platinum|HEALTHFIRST TPA UMR|2.94||||||| 82140|EAP|0300|AMMONIA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.94||||||| 82140|EAP|0300|AMMONIA|Workers Compensation|TEXAS MUTUAL INSURANCE|2.94||||||| 82140|EAP|0300|AMMONIA|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.94||||||| 82140|EAP|0300|AMMONIA|Veterans Affairs|VETERANS ADMINISTRATION|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Aetna|AETNA PPO|2.94||||||| 82140|EAP|0300|AMMONIA|Aetna|AETNA QHP HMO|2.94||||||| 82140|EAP|0300|AMMONIA|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Aetna|BH AETNA|2.94||||||| 82140|EAP|0300|AMMONIA|Aenta Medicare Advantage|AETNA MEDICARE MA|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Aetna|AETNA OTHER|2.94||||||| 82140|EAP|0300|AMMONIA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.94||||||| 82140|EAP|0300|AMMONIA|PHCS|HUMANA|2.94||||||| 82140|EAP|0300|AMMONIA|Blue Cross PPO Specialty|BCBSTX OTHER|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Blue Cross PPO Specialty|BCBSTX PPO|2.94||||2.94||| 82140|EAP|0300|AMMONIA|ChampVA|CHAMPVA CENTER|2.94||||||| 82140|EAP|0300|AMMONIA|Blue Cross HMO Specialty|BCBSTX HMO|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Managed Medicaid|MEDICAID AMERIGROUP|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Managed Medicaid|MEDICAID SUPERIOR|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Cigna|CIGNA|2.94||||||| 82140|EAP|0300|AMMONIA|Cigna|CIGNA|2.94||||2.94||| 82140|EAP|0300|AMMONIA|Cigna|CIGNA OTHER|2.94||||||| 82140|EAP|0300|AMMONIA|Humana Medicare Advantage|HUMANA MA|2.94||||2.94||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Humana Medicare Advantage|HUMANA MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Humana Medicare Advantage|HUMANA MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Cigna|CIGNA|1.31||||||| 82150|EAP|0300|AMYLASE|Cigna|CIGNA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Managed Medicaid|MEDICAID SUPERIOR|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Managed Medicaid|MEDICAID AMERIGROUP|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Managed Medicaid|MEDICAID SUPERIOR|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Blue Cross HMO Specialty|BCBSTX HMO|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Blue Cross PPO Specialty|BCBSTX PPO|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Blue Cross PPO Specialty|BCBSTX OTHER|1.31||||||| 82150|EAP|0300|AMYLASE|Aetna|AETNA PPO|1.31||||||| 82150|EAP|0300|AMYLASE|Aetna|AETNA OTHER|1.31||||||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Aetna|AETNA OTHER|1.31||||||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Aetna|AETNA QHP HMO|1.31||||||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Aetna Value Network|AETNA VALUE NETWORK|||||1.31||| 82150|EAP|0300|AMYLASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|1.31||||||| 82150|EAP|0300|AMYLASE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|1.31||||||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Veterans Affairs|VETERANS ADMINISTRATION|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Access Direct Platinum|HEALTHFIRST TPA UMR|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Access Direct Platinum|HEALTHFIRST TPA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||1.31||| 82150|EAP|0300|AMYLASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.31||||1.31||| 82150|EAP|0300|AMYLASE|United Medicare Advantage|UHC AARP MCR HMO MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Veterans Affairs|VETERANS ADMINISTRATION|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Workers Compensation|UT EMPLOYEE INJURY|1.31||||||| 82150|EAP|0300|AMYLASE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|United Medicare Advantage|UHC AARP MCR HMO MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Medicare|MEDICARE ACUTE|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.31||||||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Medicare|MEDICARE PART B ONLY IP|1.31||||||| 82150|EAP|0300|AMYLASE|Blue Cross PPO Specialty|BCBSTX PPO|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Medicare|MEDICARE ACUTE|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Medicaid|MEDICAID BCBSTX|||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Medicaid|MEDICAID|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.31||| 82150|EAP|0300|AMYLASE|Blue Cross HMO Specialty|BCBSTX HMO|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.31||||||| 82150|EAP|0300|AMYLASE|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.31||||||| 82150|EAP|0300|AMYLASE|Medicaid|MEDICAID|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Medicaid|MEDICAID HMO|||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|Managed Medicare|HEALTHSPRING MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Managed Medicare|HEALTHSPRING MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Managed Medicare|BCBS MEDICARE PPO MA|1.31||||1.31||| 82150|EAP|0300|AMYLASE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.31||||||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.31||||||| 82150|EAP|0300|AMYLASE|United Healthcare|UNITED HEALTHCARE|1.31||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|United Healthcare|UNITED HEALTHCARE|1.31||||1.31||| 82150|EAP|0300|AMYLASE|United Healthcare|UNITED HEALTHCARE OTHER|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Tricare|TRICARE EAST REGION|1.31||||1.31||| 82150|EAP|0300|AMYLASE|Tricare|TRICARE FOR LIFE|||||1.31||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|PHCS|HUMANA|1.31||||||| 82150|EAP|0300|AMYLASE|NON CONTRACTED|COMMERCIAL OTHER 1|1.31||||1.31||| 82150|EAP|0300|AMYLASE|NON CONTRACTED|COMMERCIAL OTHER 2|1.31||||||| 82150|EAP|0300|AMYLASE, OTHER SOURCE|NON CONTRACTED|COMMERCIAL OTHER 1|1.31||||1.31||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|NON CONTRACTED|COMMERCIAL OTHER 1|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|PHCS|HUMANA|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|United Healthcare|UNITED HEALTHCARE|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|United Healthcare|UNITED HEALTHCARE OTHER|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Managed Medicare|HEALTHSPRING MA|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Medicaid|MEDICAID|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Medicare|MEDICARE PART B ONLY IP|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Medicare|MEDICARE ACUTE|581.50||||581.50||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|United Medicare Advantage|UHC MEDICARE GOLD MA|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|UTMB|UTMB CORRECTIONAL MANAGED CARE|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|United Medicare Advantage|UHC AARP MCR HMO MA|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Veterans Affairs|VETERANS ADMINISTRATION|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Tricare|TRICARE FOR LIFE|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Aenta Medicare Advantage|AETNA MEDICARE MA|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Blue Cross PPO Specialty|BCBSTX PPO|581.50||||581.50||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|ChampVA|CHAMPVA CENTER|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Blue Cross HMO Specialty|BCBSTX HMO|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Managed Medicaid|MEDICAID AMERIGROUP|||||581.50||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Cigna|CIGNA|581.50||||||| 82164|EAP|0300|ANGIOTENSIN CONVERT ENZY|Humana Medicare Advantage|HUMANA MA|581.50||||||| 82175|EAP|0300|ARSENIC URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|3.82||||||| 82175|EAP|0300|ARSENIC URINE|Managed Medicare|HOSPICE OF EAST TEXAS|3.82||||||| 82180|EAP|0300|ASCORBIC ACID VITAMIN C|Tricare|TRICARE EAST REGION|||||3.94||| 82180|EAP|0300|ASCORBIC ACID VITAMIN C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.94||| 82180|EAP|0300|ASCORBIC ACID VITAMIN C|Blue Cross PPO Specialty|BCBSTX PPO|3.94||||||| 822|DRG||LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|64,704.07|8214.54|8214.54|8214.54|||| 82232|EAP|0300|BETA-2 MICROGLOBULIN|Medicare|MEDICARE ACUTE|644.50||||||| 82232|EAP|0300|BETA-2 MICROGLOBULIN|Medicaid|MEDICAID|644.50||||||| 82232|EAP|0300|BETA-2 MICROGLOBULIN|Managed Medicare|HEALTHSPRING MA|644.50||||||| 82232|EAP|0300|BETA-2 MICROGLOBULIN|NON CONTRACTED|COMMERCIAL OTHER 1|644.50||||||| 82232|EAP|0300|BETA-2 MICROGLOBULIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|644.50||||||| 82232|EAP|0300|BETA-2 MICROGLOBULIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|644.50||||||| 82232|EAP|0300|BETA-2 MICROGLOBULIN|Humana Medicare Advantage|HUMANA MA|644.50||||||| 82239|EAP|0300|BILE ACIDS TOTAL|Managed Medicaid|MEDICAID SUPERIOR|||||682.50||| 82247|EAP|0300|BILIRUBIN TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|United Healthcare|TML GROUP BENEFITS|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|United Healthcare|UNITED HEALTHCARE|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|United Healthcare|UNITED HEALTHCARE OTHER|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Tricare|TRICARE EAST REGION|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|PHCS|HUMANA INSURANCE|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|1.01||||1.01||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicare|HEALTHSPRING MA|1.01||||1.01||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|MEDICAID HMO|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|MEDICAID|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicare|MEDICARE ACUTE|1.01||||1.01||| 82247|EAP|0300|BILIRUBIN TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.01||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicare|MEDICARE PART B ONLY IP|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA UMR|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.01||||1.01||| 82247|EAP|0300|BILIRUBIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.01||||1.01||| 82247|EAP|0300|BILIRUBIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|PHCS|GROUP AND PENSION|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Aetna Value Network|AETNA VALUE NETWORK|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Aetna|AETNA OTHER|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Aetna|AETNA PPO|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|ChampVA|CHAMPVA CENTER|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross PPO Specialty|BCBSTX OTHER|1.01||||1.01||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|1.01||||1.01||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Cigna|CIGNA|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Cigna|CIGNA OTHER|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Humana Medicare Advantage|HUMANA MA|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.01||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicaid|MEDICAID AMERIGROUP|1.01||||1.01||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicaid|MEDICAID SUPERIOR|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID AMERIGROUP|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID SUPERIOR|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Managed Medicaid|MEDICAID SUPERIOR|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Humana Medicare Advantage|HUMANA MA|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Cigna|CIGNA|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Cigna|CIGNA OTHER|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross PPO Specialty|BCBSTX PPO|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT|ChampVA|CHAMPVA CENTER|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Aetna|AETNA PPO|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Aetna|AETNA OTHER|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Aetna Value Network|AETNA VALUE NETWORK|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Veterans Affairs|VETERANS ADMINISTRATION|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Blue Cross PPO Specialty|BCBSTX PPO|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT|Access Direct Platinum|HEALTHFIRST TPA UMR|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Access Direct Platinum|HEALTHFIRST TPA|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross HMO Specialty|BCBSTX HMO|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Humana Medicare Advantage|HUMANA MA|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Medicare|MEDICARE PART B ONLY IP|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Medicare|MEDICARE ACUTE|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicare|MEDICARE ACUTE|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Medicaid|MEDICAID|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|MEDICAID HMO|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|MEDICAID|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|Managed Medicare|HEALTHSPRING MA|1.01||||1.01||| 82248|EAP|0300|BILIRUBIN DIRECT|NON CONTRACTED|COMMERCIAL OTHER 2|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|NON CONTRACTED|COMMERCIAL OTHER 1|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Tricare|TRICARE EAST REGION|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|PHCS|HUMANA INSURANCE|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|PHCS|GROUP AND PENSION|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|United Healthcare|UNITED HEALTHCARE|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|United Healthcare|TML GROUP BENEFITS|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT SERUM|United Healthcare|UNITED HEALTHCARE|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|United Healthcare|UNITED HEALTHCARE OTHER|1.01||||||| 82248|EAP|0300|BILIRUBIN DIRECT|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.01||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|United Healthcare|GOLDEN RULE|||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|United Healthcare|GEHA|||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|United Healthcare|UNITED HEALTHCARE OTHER|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|PHCS|HUMANA INSURANCE|||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Tricare|TRICARE EAST REGION|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Rusk State Hospital|RUSK STATE HOSP|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|PHCS|HUMANA|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Multiplan|NALC|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|NON CONTRACTED|COMMERCIAL OTHER 1|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Managed Medicare|HEALTHSPRING MA|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Medicaid|MEDICAID|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Medicare|MEDICARE ACUTE|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Medicare|UTSW MC KIDNEY PROGRAM|||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|United Medicare Advantage|UHC AARP MCR HMO MA|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Medicare|MEDICARE PART B ONLY IP|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Medicaid|SMITH COUNTY JAIL|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Access Direct Platinum|HEALTHFIRST TPA|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Managed Medicare|BCBS MEDICARE PPO MA|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Access Direct Platinum|HEALTHFIRST TPA UMR|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Workers Compensation|WORKERS COMPENSATION OTHER|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Veterans Affairs|VETERANS ADMINISTRATION|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Workers Compensation|ZURICH COMPANY|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Aetna|BH AETNA|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Aetna|AETNA OTHER|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|United Healthcare|UNITED HEALTHCARE|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Aetna|AETNA PPO|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Blue Cross PPO Specialty|BCBSTX OTHER|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Blue Cross PPO Specialty|BCBSTX PPO|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Blue Cross HMO Specialty|BCBSTX HMO|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Cigna|CIGNA|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Cigna|CIGNA OTHER|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Humana Medicare Advantage|HUMANA MA|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Managed Medicaid|MEDICAID AMERIGROUP|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Managed Medicaid|MEDICAID SUPERIOR|0.66||||||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.66||||0.66||| 82270|EAP|0300|OCCULT BLOOD FECES QUAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.66||||0.66||| 823|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W MCC|Humana Medicare Advantage|HUMANA MA|365,299.91|24476.72|36201.46|24468.32|||| 823|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W MCC|Medicare|MEDICARE ACUTE|135,918.40|24468.32|36201.46|24468.32|||| 823|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W MCC|Medicaid|MEDICAID|400,518.98|26444.42|36201.46|24468.32|||| 823|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W MCC|Tricare|TRICARE EAST REGION|246,840.57|36201.46|36201.46|24468.32|||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|United Healthcare|TML GROUP BENEFITS|||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|United Healthcare|UNITED HEALTHCARE|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|United Healthcare|UNITED HEALTHCARE OTHER|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|NON CONTRACTED|COMMERCIAL OTHER 1|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Tricare|TRICARE EAST REGION|||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Optum Behavioral Health|BH OPTUM UHC|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|PHCS|HUMANA|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Managed Medicare|WELLCARE CHOICE MA|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Managed Medicare|BCBS MEDICARE PPO MA|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Managed Medicare|HEALTHSPRING MA|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Medicaid|SMITH COUNTY INDIGENT HEALTH|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Medicaid|COUNTY INDIGENT HEALTH OTHER|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Medicaid|MEDICAID|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Medicare|MEDICARE ACUTE|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Medicare|MEDICARE PART B ONLY IP|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Veterans Affairs|VETERANS ADMINISTRATION|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Access Direct Platinum|HEALTHFIRST TPA|||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Medicaid|MOLINA HEALTHCARE OF TEXAS|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Access Direct Platinum|HEALTHFIRST TPA UMR|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|United Medicare Advantage|UHC AARP WELLMED HMO MA|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|United Medicare Advantage|UHC MEDICARE GOLD MA|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|United Medicare Advantage|UHC AARP MCR HMO MA|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Blue Cross HMO Specialty|BCBSTX HMO|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|PHCS|GROUP AND PENSION|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Blue Cross PPO Specialty|BCBSTX OTHER|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Blue Cross PPO Specialty|BCBSTX PPO|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Multiplan|WEB TPA|||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|ChampVA|CHAMPVA CENTER|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|United Healthcare|GEHA|||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Aetna|AETNA OTHER|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Aetna|BH AETNA|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Aetna|AETNA PPO|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Aenta Medicare Advantage|AETNA MEDICARE MA|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Managed Medicaid|MEDICAID SUPERIOR|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Managed Medicaid|MEDICAID AMERIGROUP|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Magellan Behavioral Health|BH MAGELLAN|1,082.50||||||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Humana Medicare Advantage|HUMANA MA|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Cigna|CIGNA|1,082.50||||1,082.50||| 82306|EAP|0300|VITAMIN D 25 HYDROXYT|Cigna|CIGNA|||||1,082.50||| 82308|EAP|0300|CALCITONIN|Medicaid|CRIME VICTIMS COMPENSATION|10.67||||||| 82308|EAP|0300|CALCITONIN|NON CONTRACTED|COMMERCIAL OTHER 1|10.67||||||| 82310|EAP|0300|CALCIUM TOTAL|Cigna|CIGNA|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Aetna|AETNA PPO|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Aetna|AETNA OTHER|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Access Direct Platinum|HEALTHFIRST TPA UMR|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|United Medicare Advantage|UHC AARP MCR HMO MA|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Veterans Affairs|VETERANS ADMINISTRATION|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|United Healthcare|AARP|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|United Healthcare|UNITED HEALTHCARE|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|United Healthcare|UNITED HEALTHCARE OTHER|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|PHCS|HUMANA|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Humana Medicare Advantage|HUMANA MA|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|PHCS|GROUP AND PENSION|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Managed Medicare|HEALTHSPRING MA|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Managed Medicare|WELLCARE CHOICE MA|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Managed Medicare|BCBS MEDICARE PPO MA|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Medicare|MEDICARE PART B ONLY IP|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Medicare|MEDICARE ACUTE|1.04||||1.04||| 82310|EAP|0300|CALCIUM TOTAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Medicaid|MEDICAID|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Medicaid|SMITH COUNTY JAIL|1.04||||||| 82310|EAP|0300|CALCIUM TOTAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.04||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Medicaid|MEDICAID|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Medicare|MEDICARE ACUTE|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Managed Medicare|HEALTHSPRING MA|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|NON CONTRACTED|COMMERCIAL OTHER 1|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|United Healthcare|UNITED HEALTHCARE|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|United Healthcare|UNITED HEALTHCARE OTHER|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Veterans Affairs|VETERANS ADMINISTRATION|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.76||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.76||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.76||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Blue Cross HMO Specialty|BCBSTX HMO|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Blue Cross PPO Specialty|BCBSTX PPO|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Aenta Medicare Advantage|AETNA MEDICARE MA|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.76||||2.76||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.76||||||| 82330|EAP|0300|CALCIUM IONIZED (FREE)|Humana Medicare Advantage|HUMANA MA|2.76||||||| 82340|EAP|0300|CALCIUM URINE QUANT TIMED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.22||||||| 82340|EAP|0300|CALCIUM URINE QUANT TIMED|United Medicare Advantage|UHC AARP MCR HMO MA|1.22||||||| 82340|EAP|0300|CALCIUM QUANT URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.22||| 82340|EAP|0300|CALCIUM URINE QUANT TIMED|Medicare|MEDICARE ACUTE|1.22||||||| 82340|EAP|0300|CALCIUM QUANT URINE|Medicare|MEDICARE ACUTE|1.22||||||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|Managed Medicare|HEALTHSPRING MA|188.25||||188.25||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|Managed Medicare|BCBS MEDICARE PPO MA|||||188.25||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||188.25||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|Medicare|MEDICARE PART B ONLY IP|188.25||||||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|Medicare|MEDICARE ACUTE|188.25||||188.25||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|United Medicare Advantage|UHC AARP MCR HMO MA|188.25||||1.81||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|United Medicare Advantage|UHC MEDICARE GOLD MA|188.25||||188.25||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|188.25||||188.25||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|Aenta Medicare Advantage|AETNA MEDICARE MA|||||188.25||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|Humana Medicare Advantage|HUMANA MA|188.25||||188.25||| 82370|EAP|0300|ASSAY CALCULUS; X-RAY DIF|Managed Medicaid|MEDICAID AMERIGROUP|||||188.25||| 82373|EAP|0300|CARBOHYDRATE DEFICIENT TR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.30||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|United Healthcare|UNITED HEALTHCARE|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|United Healthcare|UNITED HEALTHCARE OTHER|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Tricare|TRICARE EAST REGION|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|NON CONTRACTED|COMMERCIAL OTHER 1|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Medicaid|MEDICAID|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG CEA|Medicare|MEDICARE ACUTE|755.50||||755.50||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Medicare|MEDICARE ACUTE|4.21||||4.21||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Managed Medicare|HEALTHSPRING MA|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG CEA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.21||||755.50||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Workers Compensation|WORKERS COMPENSATION OTHER|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Access Direct Platinum|HEALTHFIRST TPA|||||4.21||| 82378|EAP|0300|CARCINOEMBRYONIC AG|United Medicare Advantage|UHC MEDICARE GOLD MA|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.21||||4.21||| 82378|EAP|0300|CARCINOEMBRYONIC AG|United Medicare Advantage|UHC AARP MCR HMO MA|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|ChampVA|CHAMPVA CENTER|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|United Healthcare|UNITED HEALTHCARE|4.21||||4.21||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Blue Cross PPO Specialty|BCBSTX PPO|4.21||||4.21||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.21||||4.21||| 82378|EAP|0300|CARCINOEMBRYONIC AG CEA|Aetna|AETNA PPO|4.21||||755.50||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Aenta Medicare Advantage|AETNA MEDICARE MA|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Aetna|AETNA OTHER|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG CEA|Aetna|AETNA OTHER|755.50||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Cigna|CIGNA|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Humana Medicare Advantage|HUMANA MA|4.21||||4.21||| 82378|EAP|0300|CARCINOEMBRYONIC AG CEA|Humana Medicare Advantage|HUMANA MA|4.21||||755.50||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Managed Medicaid|MEDICAID AMERIGROUP|4.21||||||| 82378|EAP|0300|CARCINOEMBRYONIC AG CEA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.21||||755.50||| 82378|EAP|0300|CARCINOEMBRYONIC AG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.21||||||| 82379|EAP|0300|CARNITINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|397.50||||||| 82384|EAP|0300|CATECHOLAMINES URINE|Medicare|MEDICARE ACUTE|252.75||||||| 82384|EAP|0300|CATECHOLAMINES PLASMA|Humana Medicare Advantage|HUMANA MA|||||998.75||| 82384|EAP|0300|CATECHOLAMINES PLASMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|998.75||||||| 82384|EAP|0300|CATECHOLAMINES URINE|Blue Cross PPO Specialty|BCBSTX PPO|252.75||||||| 82390|EAP|0300|CERULOPLASMIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.17||||||| 82390|EAP|0300|CERULOPLASMIN|United Medicare Advantage|UHC AARP MCR HMO MA|2.17||||||| 82390|EAP|0300|CERULOPLASMIN|Blue Cross PPO Specialty|BCBSTX PPO|2.17||||||| 82390|EAP|0300|CERULOPLASMIN|United Medicare Advantage|UHC MEDICARE GOLD MA|2.17||||2.17||| 82390|EAP|0300|CERULOPLASMIN|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.17||| 82390|EAP|0300|CERULOPLASMIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.17||||||| 82390|EAP|0300|CERULOPLASMIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.17||||||| 82390|EAP|0300|CERULOPLASMIN|Humana Medicare Advantage|HUMANA MA|2.17||||||| 82390|EAP|0300|CERULOPLASMIN|NON CONTRACTED|COMMERCIAL OTHER 1|2.17||||||| 82390|EAP|0300|CERULOPLASMIN|United Healthcare|UNITED HEALTHCARE|2.17||||||| 82390|EAP|0300|CERULOPLASMIN|Managed Medicare|HEALTHSPRING MA|2.17||||2.17||| 82390|EAP|0300|CERULOPLASMIN|Medicaid|MEDICAID|2.17||||||| 82390|EAP|0300|CERULOPLASMIN|Medicare|MEDICARE ACUTE|2.17||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|Medicare|MEDICARE ACUTE|5.63||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|Medicaid|SMITH COUNTY JAIL|5.63||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|Managed Medicare|BCBS MEDICARE PPO MA|5.63||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|Cigna|CIGNA|5.63||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|Humana Medicare Advantage|HUMANA MA|5.63||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|Aenta Medicare Advantage|AETNA MEDICARE MA|5.63||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.63||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|Blue Cross PPO Specialty|BCBSTX PPO|5.63||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|Veterans Affairs|VETERANS ADMINISTRATION|5.63||||||| 82397|EAP|0300|PTH-RELATED PROTEIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.63||||||| 824|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W CC|Medicare|MEDICARE ACUTE|115,100.81|14042.56|14042.56|14042.56|||| 82435|EAP|0300|CHLORIDE|United Medicare Advantage|UHC AARP MCR HMO MA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.93||| 82435|EAP|0300|CHLORIDE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Access Direct Platinum|HEALTHFIRST TPA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.93||| 82435|EAP|0300|CHLORIDE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Veterans Affairs|VETERANS ADMINISTRATION|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Workers Compensation|BROOKSHIRES WORKERS COMP|0.93||||||| 82435|EAP|0300|CHLORIDE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||0.93||| 82435|EAP|0300|CHLORIDE|Workers Compensation|UT EMPLOYEE INJURY|||||0.93||| 82435|EAP|0300|CHLORIDE|Blue Cross HMO Specialty|BCBSTX HMO|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Blue Cross PPO Specialty|BCBSTX PPO|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.93||| 82435|EAP|0300|CHLORIDE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Aetna|AETNA PPO|||||0.93||| 82435|EAP|0300|CHLORIDE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Managed Medicaid|MEDICAID SUPERIOR|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Managed Medicaid|MEDICAID AMERIGROUP|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Humana Medicare Advantage|HUMANA MA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Aetna|AETNA OTHER|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.93||| 82435|EAP|0300|CHLORIDE|Cigna|CIGNA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Cigna|CIGNA|||||0.93||| 82435|EAP|0300|CHLORIDE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.93||||||| 82435|EAP|0300|CHLORIDE|United Healthcare|TML GROUP BENEFITS|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Workers Compensation|WORKERS COMPENSATION OTHER|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|United Healthcare|UNITED HEALTHCARE OTHER|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|United Healthcare|UNITED HEALTHCARE|||||0.93||| 82435|EAP|0300|CHLORIDE|Rusk State Hospital|RUSK STATE HOSP|||||0.93||| 82435|EAP|0300|CHLORIDE|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.93||| 82435|EAP|0300|CHLORIDE|Tricare|TRICARE EAST REGION|||||0.93||| 82435|EAP|0300|CHLORIDE|PHCS|GROUP AND PENSION|||||0.93||| 82435|EAP|0300|CHLORIDE|NON CONTRACTED|COMMERCIAL OTHER 1|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Managed Medicare|BCBS MEDICARE PPO MA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.93||| 82435|EAP|0300|CHLORIDE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.93||| 82435|EAP|0300|CHLORIDE|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.93||| 82435|EAP|0300|CHLORIDE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Managed Medicare|HEALTHSPRING MA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Medicaid|MEDICAID HMO|||||0.93||| 82435|EAP|0300|CHLORIDE|Medicaid|MEDICAID|0.93||||0.93||| 82435|EAP|0300|CHLORIDE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.93||||||| 82435|EAP|0300|CHLORIDE|Medicaid|CRIME VICTIMS COMPENSATION|0.93||||||| 82435|EAP|0300|CHLORIDE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.93||| 82435|EAP|0300|CHLORIDE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.93||| 82435|EAP|0300|CHLORIDE|Medicaid|LAW ENFORCEMENT OTHER|||||0.93||| 82435|EAP|0300|CHLORIDE|Medicare|MEDICARE PART B ONLY IP|0.93||||||| 82435|EAP|0300|CHLORIDE|Medicare|MEDICARE ACUTE|0.93||||0.93||| 82436|EAP|0300|CHLORIDE URINE|Medicare|MEDICARE ACUTE|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Medicaid|MEDICAID|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Managed Medicare|HEALTHSPRING MA|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Managed Medicare|BCBS MEDICARE PPO MA|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|NON CONTRACTED|COMMERCIAL OTHER 1|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|PHCS|HUMANA|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Tricare|TRICARE EAST REGION|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|United Healthcare|UNITED HEALTHCARE|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|United Healthcare|UNITED HEALTHCARE OTHER|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Cigna|CIGNA|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Humana Medicare Advantage|HUMANA MA|0.93||||0.93||| 82436|EAP|0300|CHLORIDE URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Managed Medicaid|MEDICAID AMERIGROUP|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Aetna|AETNA OTHER|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Aetna|AETNA PPO|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Medicaid|SMITH COUNTY JAIL|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Blue Cross PPO Specialty|BCBSTX OTHER|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Blue Cross PPO Specialty|BCBSTX PPO|0.93||||0.93||| 82436|EAP|0300|CHLORIDE URINE|Blue Cross HMO Specialty|BCBSTX HMO|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Veterans Affairs|VETERANS ADMINISTRATION|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Access Direct Platinum|HEALTHFIRST TPA|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|United Medicare Advantage|UHC AARP MCR HMO MA|0.93||||||| 82436|EAP|0300|CHLORIDE URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.93||||0.93||| 82436|EAP|0300|CHLORIDE URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.93||||0.93||| 82438|EAP|0300|CHLORIDE STOOL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.95||||||| 82438|EAP|0300|CHLORIDE STOOL|Blue Cross PPO Specialty|BCBSTX PPO|1.95||||||| 82438|EAP|0300|CHLORIDE STOOL|Humana Medicare Advantage|HUMANA MA|1.95||||||| 82438|EAP|0300|CHLORIDE STOOL|Medicaid|MEDICAID|1.95||||||| 82438|EAP|0300|CHLORIDE STOOL|Medicare|MEDICARE ACUTE|1.95||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|United Healthcare|UNITED HEALTHCARE|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Managed Medicare|HEALTHSPRING MA|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|Medicare|MEDICARE PART B ONLY IP|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Medicare|MEDICARE ACUTE|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|Medicaid|MEDICAID|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Humana Medicare Advantage|HUMANA MA|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|Managed Medicare|BCBS MEDICARE PPO MA|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|PHCS|HUMANA|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Aetna|AETNA OTHER|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Aetna|AETNA QHP HMO|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|United Medicare Advantage|UHC AARP MCR HMO MA|0.88||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|Veterans Affairs|VETERANS ADMINISTRATION|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Access Direct Platinum|HEALTHFIRST TPA|0.88||||||| 82465|EAP|0300|CHOLESTEROL TOTAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.88||| 82465|EAP|0300|CHOLESTEROL TOTAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.88||| 82492|EAP|0300|ACETYLAIDEHYDE|Blue Cross PPO Specialty|BCBSTX PPO|3.52||||||| 825|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|159,213.49|14335.38|14335.38|7844.15|||| 825|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|72,243.73|8870.81|14335.38|7844.15|||| 825|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|64,991.10|7844.15|14335.38|7844.15|||| 82507|EAP|0300|CITRATE URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,108.50||| 82523|EAP|0300|C TELOPEPTIDE|Medicare|MEDICARE ACUTE|||||7.45||| 82523|EAP|0300|C TELOPEPTIDE|Humana Medicare Advantage|HUMANA MA|||||7.45||| 82523|EAP|0300|N-TELOPEPTIDE CROSS LINK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.45||| 82525|EAP|0300|COPPER SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|494.50||||494.50||| 82525|EAP|0300|COPPER SERUM|Blue Cross PPO Specialty|BCBSTX PPO|494.50||||||| 82525|EAP|0300|COPPER SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|||||494.50||| 82525|EAP|0300|COPPER SERUM|Aetna|AETNA PPO|||||494.50||| 82525|EAP|0300|COPPER URINE 24 HR|Aenta Medicare Advantage|AETNA MEDICARE MA|494.50||||||| 82525|EAP|0300|COPPER SERUM|Aetna|AETNA QHP HMO|494.50||||||| 82525|EAP|0300|COPPER SERUM|Aenta Medicare Advantage|AETNA MEDICARE MA|494.50||||||| 82525|EAP|0300|COPPER SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||494.50||| 82525|EAP|0300|COPPER SERUM|United Medicare Advantage|UHC AARP MCR HMO MA|494.50||||||| 82525|EAP|0300|COPPER SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|494.50||||||| 82525|EAP|0300|COPPER SERUM|Humana Medicare Advantage|HUMANA MA|494.50||||||| 82525|EAP|0300|COPPER SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|494.50||||||| 82525|EAP|0300|COPPER SERUM|Tricare|TRICARE EAST REGION|||||494.50||| 82525|EAP|0300|COPPER SERUM|United Healthcare|UNITED HEALTHCARE|494.50||||||| 82525|EAP|0300|COPPER URINE 24 HR|United Healthcare|UNITED HEALTHCARE|494.50||||||| 82525|EAP|0300|COPPER SERUM|Managed Medicare|HEALTHSPRING MA|494.50||||494.50||| 82525|EAP|0300|COPPER URINE 24 HR|Managed Medicare|HEALTHSPRING MA|494.50||||494.50||| 82525|EAP|0300|COPPER SERUM|Medicaid|MEDICAID|494.50||||||| 82525|EAP|0300|COPPER SERUM|Medicare|MEDICARE ACUTE|494.50||||494.50||| 82533|EAP|0300|CORTISOL RANDOM|Medicare|MEDICARE PART B ONLY IP|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Medicare|MEDICARE ACUTE|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Medicaid|MEDICAID|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Managed Medicare|BCBS MEDICARE PPO MA|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Managed Medicare|HEALTHSPRING MA|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|United Healthcare|UNITED HEALTHCARE OTHER|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|United Healthcare|UNITED HEALTHCARE|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|United Healthcare|UNITED HEALTHCARE|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Tricare|TRICARE EAST REGION|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|NON CONTRACTED|COMMERCIAL OTHER 1|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Cigna|CIGNA|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Cigna|CIGNA OTHER|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Humana Medicare Advantage|HUMANA MA|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Managed Medicaid|MEDICAID SUPERIOR|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Managed Medicaid|MEDICAID AMERIGROUP|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Aetna|AETNA PPO|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Aenta Medicare Advantage|AETNA MEDICARE MA|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Blue Cross HMO Specialty|BCBSTX HMO|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|ChampVA|CHAMPVA CENTER|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Blue Cross PPO Specialty|BCBSTX PPO|649.75||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Blue Cross PPO Specialty|BCBSTX PPO|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Medicare|MEDICARE ACUTE|649.75||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Workers Compensation|TEXAS MUTUAL INSURANCE|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Veterans Affairs|VETERANS ADMINISTRATION|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Access Direct Platinum|HEALTHFIRST TPA UMR|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|Access Direct Platinum|HEALTHFIRST TPA|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.62||||3.62||| 82533|EAP|0300|CORTISOL RANDOM|United Medicare Advantage|UHC AARP MCR HMO MA|3.62||||||| 82533|EAP|0300|CORTISOL RANDOM|United Medicare Advantage|UHC MEDICARE GOLD MA|3.62||||3.62||| 82550|EAP|0300|CREATINE KINASE CK|United Medicare Advantage|UHC MEDICARE GOLD MA|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Access Direct Platinum|HEALTHFIRST TPA|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Access Direct Platinum|HEALTHFIRST TPA UMR|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Workers Compensation|TEXAS MUTUAL INSURANCE|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Workers Compensation|WORKERS COMPENSATION OTHER|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Workers Compensation|UT EMPLOYEE INJURY|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Workers Compensation|BROOKSHIRES WORKERS COMP|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Veterans Affairs|VETERANS ADMINISTRATION|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Blue Cross PPO Specialty|BCBSTX OTHER|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Blue Cross PPO Specialty|BCBSTX PPO|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Blue Cross HMO Specialty|BCBSTX HMO|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Aetna|AETNA PPO|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Aetna|AETNA QHP HMO|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Aenta Medicare Advantage|AETNA MEDICARE MA|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Managed Medicaid|MEDICAID AMERIGROUP|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Managed Medicaid|MEDICAID SUPERIOR|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Humana Medicare Advantage|HUMANA MA|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Magellan Behavioral Health|BH MAGELLAN|||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Cigna|CIGNA|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Aetna|AETNA OTHER|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Cigna|CIGNA|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Cigna|CIGNA OTHER|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|ChampVA|CHAMPVA CENTER|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|NON CONTRACTED|COMMUNITY HEALTH CENTER|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|NON CONTRACTED|COMMERCIAL OTHER 1|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|NON CONTRACTED|COMMERCIAL OTHER 2|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Tricare|TRICARE FOR LIFE|||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Rusk State Hospital|RUSK STATE HOSP|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|PHCS|GROUP AND PENSION|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Tricare|TRICARE EAST REGION|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|PHCS|HUMANA|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|United Healthcare|UNITED HEALTHCARE|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|United Healthcare|UNITED HEALTHCARE OTHER|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|United Healthcare|GOLDEN RULE|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|United Healthcare|TML GROUP BENEFITS|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Managed Medicare|BCBS MEDICARE PPO MA|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|United Medicare Advantage|UHC AARP MCR HMO MA|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Managed Medicare|HEALTHSPRING MA|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid|MEDICAID HMO|||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid|MEDICAID|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid|SMITH COUNTY JAIL|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid|CRIME VICTIMS COMPENSATION|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid|MEDICAID BCBSTX|||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Medicare|MEDICARE PART B ONLY IP|1.31||||||| 82550|EAP|0300|CREATINE KINASE CK|Medicare|MEDICARE ACUTE|1.31||||1.31||| 82550|EAP|0300|CREATINE KINASE CK|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.31||||1.31||| 82552|EAP|0300|ASSAY OF CREATINE KINASE|Medicare|MEDICARE ACUTE|1.59||||||| 82552|EAP|0300|ASSAY OF CREATINE KINASE|Medicaid|CRIME VICTIMS COMPENSATION|1.59||||||| 82552|EAP|0300|ASSAY OF CREATINE KINASE|Managed Medicare|HEALTHSPRING MA|1.59||||||| 82552|EAP|0300|ASSAY OF CREATINE KINASE|Tricare|TRICARE EAST REGION|1.59||||||| 82552|EAP|0300|ASSAY OF CREATINE KINASE|Cigna|CIGNA|1.59||||||| 82552|EAP|0300|ASSAY OF CREATINE KINASE|Humana Medicare Advantage|HUMANA MA|1.59||||||| 82552|EAP|0300|ASSAY OF CREATINE KINASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.59||||||| 82552|EAP|0300|ASSAY OF CREATINE KINASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.59||||1.59||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Workers Compensation|WORKERS COMPENSATION OTHER|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Access Direct Platinum|HEALTHFIRST TPA|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|United Medicare Advantage|UHC AARP MCR HMO MA|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Blue Cross HMO Specialty|BCBSTX HMO|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Blue Cross PPO Specialty|BCBSTX PPO|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|ChampVA|CHAMPVA CENTER|||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Aenta Medicare Advantage|AETNA MEDICARE MA|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Aetna|AETNA OTHER|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Managed Medicaid|MEDICAID AMERIGROUP|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Managed Medicaid|MEDICAID SUPERIOR|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Aetna|AETNA PPO|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Humana Medicare Advantage|HUMANA MA|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Cigna|CIGNA OTHER|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Cigna|CIGNA|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Cigna|CIGNA|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Blue Cross PPO Specialty|BCBSTX OTHER|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|United Healthcare|UNITED HEALTHCARE|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|United Healthcare|UNITED HEALTHCARE OTHER|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|NON CONTRACTED|COMMERCIAL OTHER 1|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|United Medicare Advantage|UHC MEDICARE GOLD MA|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|NON CONTRACTED|COMMERCIAL OTHER 2|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Tricare|TRICARE EAST REGION|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Rusk State Hospital|RUSK STATE HOSP|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Tricare|TRICARE FOR LIFE|||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|PHCS|HUMANA|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Managed Medicare|HEALTHSPRING MA|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Managed Medicare|BCBS MEDICARE PPO MA|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Veterans Affairs|VETERANS ADMINISTRATION|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Medicaid|SMITH COUNTY JAIL|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Medicaid|MEDICAID HMO|||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Medicaid|MEDICAID|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Medicaid|CRIME VICTIMS COMPENSATION|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.24||||||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Medicare|MEDICARE ACUTE|1.24||||1.24||| 82553|EAP|0300|CREATINE KINASE MB FRACTI|Medicare|MEDICARE PART B ONLY IP|1.24||||||| 82565|EAP|0300|CREATININE BLOOD|Medicare|UTSW MC KIDNEY PROGRAM|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicare|MEDICARE ACUTE|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicaid|MEDICAID|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicaid|SMITH COUNTY JAIL|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicaid|MEDICAID HMO|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicaid|LAW ENFORCEMENT OTHER|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicaid|CRIME VICTIMS COMPENSATION|1.03||||||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicare|BCBS MEDICARE PPO MA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicare|HEALTHSPRING MA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.03||||||| 82565|EAP|0300|CREATININE BLOOD|Tricare|TRICARE EAST REGION|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Rusk State Hospital|RUSK STATE HOSP|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|PHCS|HUMANA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Tricare|TRICARE FOR LIFE|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|PHCS|GROUP AND PENSION|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|NON CONTRACTED|COMMERCIAL OTHER 2|1.03||||||| 82565|EAP|0300|CREATININE BLOOD|Multiplan|WEB TPA|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|NON CONTRACTED|COMMERCIAL OTHER 1|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|United Healthcare|GOLDEN RULE|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|United Healthcare|UNITED HEALTHCARE|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|United Healthcare|UNITED HEALTHCARE OTHER|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|United Healthcare|TML GROUP BENEFITS|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Cigna|CIGNA|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Cigna|CIGNA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Cigna|CIGNA OTHER|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Magellan Behavioral Health|BH MAGELLAN|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Humana Medicare Advantage|HUMANA MA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicaid|MEDICAID SUPERIOR|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicaid|MEDICAID AMERIGROUP|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Aetna Value Network|AETNA VALUE NETWORK|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|PHCS|HUMANA INSURANCE|1.03||||||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Aetna|AETNA PPO|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Aetna|AETNA QHP HMO|1.03||||||| 82565|EAP|0300|CREATININE BLOOD|Managed Medicare|OTHER INSTITUTIONS|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Aetna|AETNA OTHER|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|ChampVA|CHAMPVA CENTER|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Blue Cross PPO Specialty|BCBSTX OTHER|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Medicare|MEDICARE PART B ONLY IP|1.03||||||| 82565|EAP|0300|CREATININE BLOOD|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|United Medicare Advantage|UHC AARP MCR HMO MA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Access Direct Platinum|HEALTHFIRST TPA|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Access Direct Platinum|HEALTHFIRST TPA UMR|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Workers Compensation|UT EMPLOYEE INJURY|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Workers Compensation|BROOKSHIRES WORKERS COMP|1.03||||||| 82565|EAP|0300|CREATININE BLOOD|Workers Compensation|WORKERS COMPENSATION OTHER|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Workers Compensation|TEXAS MUTUAL INSURANCE|1.03||||1.03||| 82565|EAP|0300|CREATININE BLOOD|Veterans Affairs|VETERANS ADMINISTRATION|1.03||||1.03||| 82570|EAP|0300|CREATININE OTHER SOURCE|Workers Compensation|TEXAS MUTUAL INSURANCE|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Workers Compensation|WORKERS COMPENSATION OTHER|0.45||||||| 82570|EAP|0300|CREATININE URINE 24 HR|Veterans Affairs|VETERANS ADMINISTRATION|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Veterans Affairs|VETERANS ADMINISTRATION|0.45||||0.45||| 82570|EAP|0300|CREATININE URINE 24 HR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Access Direct Platinum|HEALTHFIRST TPA|0.45||||||| 82570|EAP|0300|CREATININE URINE 24 HR|United Medicare Advantage|UHC MEDICARE GOLD MA|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Blue Cross HMO Specialty|BCBSTX HMO|0.45||||0.45||| 82570|EAP|0300|CREATININE URINE 24 HR|Blue Cross HMO Specialty|BCBSTX HMO|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Blue Cross PPO Specialty|BCBSTX OTHER|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Aetna|AETNA OTHER|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Aetna|AETNA PPO|0.45||||||| 82570|EAP|0300|CREATININE URINE 24 HR|Aenta Medicare Advantage|AETNA MEDICARE MA|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.45||||0.45||| 82570|EAP|0300|CREATININE URINE 24 HR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Managed Medicaid|MEDICAID AMERIGROUP|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Managed Medicaid|MEDICAID SUPERIOR|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.45||||0.45||| 82570|EAP|0300|CREATININE URINE 24 HR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Humana Medicare Advantage|HUMANA MA|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Cigna|CIGNA|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Cigna|CIGNA OTHER|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|United Healthcare|UNITED HEALTHCARE OTHER|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|United Healthcare|TML GROUP BENEFITS|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|United Healthcare|UNITED HEALTHCARE|0.45||||0.45||| 82570|EAP|0300|CREATININE URINE 24 HR|United Healthcare|UNITED HEALTHCARE OTHER|0.45||||0.45||| 82570|EAP|0300|CREATININE URINE 24 HR|United Healthcare|UNITED HEALTHCARE|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|United Healthcare|GOLDEN RULE|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Blue Cross PPO Specialty|BCBSTX PPO|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|United Medicare Advantage|UHC AARP MCR HMO MA|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|NON CONTRACTED|COMMERCIAL OTHER 1|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Tricare|TRICARE EAST REGION|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|PHCS|GROUP AND PENSION|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Rusk State Hospital|RUSK STATE HOSP|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|PHCS|HUMANA|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Managed Medicare|HEALTHSPRING MA|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Managed Medicare|WELLCARE CHOICE MA|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Managed Medicare|BCBS MEDICARE PPO MA|0.45||||0.45||| 82570|EAP|0300|CREATININE URINE 24 HR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.45||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Medicaid|MEDICAID|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Medicaid|SMITH COUNTY JAIL|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Medicaid|CRIME VICTIMS COMPENSATION|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Medicare|MEDICARE ACUTE|0.45||||0.45||| 82570|EAP|0300|CREATININE URINE 24 HR|Medicare|MEDICARE ACUTE|0.45||||0.45||| 82570|EAP|0300|CREATININE URINE 24 HR|Medicare|UTSW MC KIDNEY PROGRAM|||||0.45||| 82570|EAP|0300|CREATININE OTHER SOURCE|Medicare|MEDICARE PART B ONLY IP|0.45||||||| 82570|EAP|0300|CREATININE OTHER SOURCE|Medicare|UTSW MC KIDNEY PROGRAM|||||0.45||| 82575|EAP|0300|CREATININE CLEARANCE|Medicare|MEDICARE ACUTE|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|Medicaid|MEDICAID|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|Managed Medicare|HEALTHSPRING MA|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|United Healthcare|UNITED HEALTHCARE|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|United Healthcare|UNITED HEALTHCARE OTHER|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|Blue Cross PPO Specialty|BCBSTX PPO|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|Access Direct Platinum|HEALTHFIRST TPA|1.90||||||| 82575|EAP|0300|CREATININE CLEARANCE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.90||| 82575|EAP|0300|CREATININE CLEARANCE|Veterans Affairs|VETERANS ADMINISTRATION|1.90||||||| 82595|EAP|0300|CRYOGLOBULIN QUAL|United Medicare Advantage|UHC MEDICARE GOLD MA|1.30||||||| 82595|EAP|0300|CRYOGLOBULIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|93.25||||||| 82595|EAP|0300|CRYOGLOBULIN QUAL|Aenta Medicare Advantage|AETNA MEDICARE MA|1.30||||||| 82595|EAP|0300|CRYOGLOBULIN QUAL|Blue Cross PPO Specialty|BCBSTX PPO|1.30||||93.25||| 82595|EAP|0300|CRYOGLOBULIN|Blue Cross PPO Specialty|BCBSTX PPO|93.25||||93.25||| 82595|EAP|0300|CRYOGLOBULIN|Humana Medicare Advantage|HUMANA MA|93.25||||||| 82595|EAP|0300|CRYOGLOBULIN QUAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.30||||||| 82595|EAP|0300|CRYOGLOBULIN QUAL|NON CONTRACTED|COMMERCIAL OTHER 1|1.30||||||| 82595|EAP|0300|CRYOGLOBULIN QUAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.30||||||| 82595|EAP|0300|CRYOGLOBULIN|United Healthcare|UNITED HEALTHCARE|93.25||||||| 82595|EAP|0300|CRYOGLOBULIN QUAL|Managed Medicare|HEALTHSPRING MA|1.30||||||| 82595|EAP|0300|CRYOGLOBULIN|Medicaid|MEDICAID|93.25||||||| 82595|EAP|0300|CRYOGLOBULIN|Medicare|MEDICARE ACUTE|1.30||||93.25||| 82595|EAP|0300|CRYOGLOBULIN QUAL|Medicare|MEDICARE ACUTE|1.30||||1.30||| 826|DRG||MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W MCC|Medicare|MEDICARE ACUTE|347,984.54|29510.61|29510.61|29510.61|||| 82607|EAP|0300|VITAMIN B12|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Managed Medicaid|MEDICAID SUPERIOR|3.34||||||| 82607|EAP|0300|VITAMIN B12|Cigna|CIGNA|3.34||||||| 82607|EAP|0300|VITAMIN B12|Magellan Behavioral Health|BH MAGELLAN|3.34||||||| 82607|EAP|0300|VITAMIN B12|Humana Medicare Advantage|HUMANA MA|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Blue Cross HMO Specialty|BCBSTX HMO|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|ChampVA|CHAMPVA CENTER|3.34||||||| 82607|EAP|0300|VITAMIN B12|Blue Cross PPO Specialty|BCBSTX PPO|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Blue Cross PPO Specialty|BCBSTX OTHER|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Aetna|AETNA QHP HMO|3.34||||||| 82607|EAP|0300|VITAMIN B12|Aetna|AETNA OTHER|3.34||||||| 82607|EAP|0300|VITAMIN B12|Aetna|BH AETNA|3.34||||||| 82607|EAP|0300|VITAMIN B12|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Workers Compensation|WORKERS COMPENSATION OTHER|3.34||||||| 82607|EAP|0300|VITAMIN B12|Workers Compensation|ZURICH COMPANY|3.34||||||| 82607|EAP|0300|VITAMIN B12|Access Direct Platinum|HEALTHFIRST TPA|3.34||||||| 82607|EAP|0300|VITAMIN B12|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Access Direct Platinum|HEALTHFIRST TPA UMR|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|United Medicare Advantage|UHC MEDICARE GOLD MA|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|United Medicare Advantage|UHC AARP MCR HMO MA|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Veterans Affairs|VETERANS ADMINISTRATION|3.34||||||| 82607|EAP|0300|VITAMIN B12|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.34||||||| 82607|EAP|0300|VITAMIN B12|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|United Healthcare|GEHA|||||3.34||| 82607|EAP|0300|VITAMIN B12|United Healthcare|UNITED HEALTHCARE|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Aetna|AETNA PPO|3.34||||||| 82607|EAP|0300|VITAMIN B12|United Healthcare|UNITED HEALTHCARE|3.34||||||| 82607|EAP|0300|VITAMIN B12|United Healthcare|AARP|3.34||||||| 82607|EAP|0300|VITAMIN B12|United Healthcare|TML GROUP BENEFITS|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|United Healthcare|GOLDEN RULE|3.34||||||| 82607|EAP|0300|VITAMIN B12|Aenta Medicare Advantage|AETNA MEDICARE MA|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|United Healthcare|UNITED HEALTHCARE OTHER|3.34||||||| 82607|EAP|0300|VITAMIN B12|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.34||||||| 82607|EAP|0300|VITAMIN B12|PHCS|HUMANA|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Tricare|TRICARE EAST REGION|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Tricare|TRICARE FOR LIFE|3.34||||||| 82607|EAP|0300|VITAMIN B12|Multiplan|WEB TPA|3.34||||||| 82607|EAP|0300|VITAMIN B12|Multiplan|NALC|3.34||||||| 82607|EAP|0300|VITAMIN B12|NON CONTRACTED|COMMERCIAL OTHER 1|3.34||||||| 82607|EAP|0300|VITAMIN B12|Cigna|CIGNA|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Managed Medicaid|MEDICAID AMERIGROUP|3.34||||||| 82607|EAP|0300|VITAMIN B12|Managed Medicare|BCBS MEDICARE PPO MA|3.34||||||| 82607|EAP|0300|VITAMIN B12|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Managed Medicare|MA PART B ONLY IP|3.34||||||| 82607|EAP|0300|VITAMIN B12|Managed Medicare|WELLCARE CHOICE MA|3.34||||||| 82607|EAP|0300|VITAMIN B12|Managed Medicare|HEALTHSPRING MA|3.34||||3.34||| 82607|EAP|0300|VITAMIN B12|Medicaid|SMITH COUNTY JAIL|3.34||||||| 82607|EAP|0300|VITAMIN B12|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.34||||||| 82607|EAP|0300|VITAMIN B12|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.34||||||| 82607|EAP|0300|VITAMIN B12|Medicaid|MEDICAID HMO|||||3.34||| 82607|EAP|0300|VITAMIN B12|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.34||||||| 82607|EAP|0300|VITAMIN B12|Medicaid|MEDICAID|3.34||||||| 82607|EAP|0300|VITAMIN B12|Medicare|MEDICARE PART B ONLY IP|3.34||||||| 82607|EAP|0300|VITAMIN B12|Medicare|MEDICARE ACUTE|3.34||||3.34||| 82627|EAP|0300|DEHYDROEPIANDROSTERONE SU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||885.75||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Tricare|TRICARE EAST REGION|||||1,381.75||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|United Healthcare|UNITED HEALTHCARE|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Aenta Medicare Advantage|AETNA MEDICARE MA|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Blue Cross PPO Specialty|BCBSTX PPO|1,381.75||||1,381.75||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,381.75||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Medicare|MEDICARE ACUTE|1,381.75||||1,381.75||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Blue Cross HMO Specialty|BCBSTX HMO|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Humana Medicare Advantage|HUMANA MA|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Managed Medicaid|MEDICAID AMERIGROUP|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|United Medicare Advantage|UHC AARP MCR HMO MA|1,381.75||||1,381.75||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|United Medicare Advantage|UHC MEDICARE GOLD MA|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Veterans Affairs|VETERANS ADMINISTRATION|1,381.75||||||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,381.75||| 82652|EAP|0300|DIHYDROXY VITAMIN D 1 25|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,381.75||||||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|Veterans Affairs|VETERANS ADMINISTRATION|749.25||||||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||749.25||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|749.25||||749.25||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||749.25||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|Humana Medicare Advantage|HUMANA MA|749.25||||749.25||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|Blue Cross HMO Specialty|BCBSTX HMO|749.25||||||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|Blue Cross PPO Specialty|BCBSTX PPO|749.25||||||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|NON CONTRACTED|COMMERCIAL OTHER 1|||||749.25||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|749.25||||||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|Managed Medicare|HEALTHSPRING MA|749.25||||||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|Medicaid|MEDICAID|749.25||||||| 82668|EAP|0300|ERYTHROPOIETIN ASSAY|Medicare|MEDICARE ACUTE|749.25||||749.25||| 82670|EAP|0300|ESTRADIOL|Medicare|MEDICARE ACUTE|||||6.20||| 82670|EAP|0300|ESTRADIOL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.20||| 82670|EAP|0300|ESTRADIOL|Managed Medicare|HEALTHSPRING MA|||||6.20||| 82670|EAP|0300|ESTRADIOL|Managed Medicare|BCBS MEDICARE PPO MA|||||6.20||| 82670|EAP|0300|ESTRADIOL|United Healthcare|UNITED HEALTHCARE|||||6.20||| 82670|EAP|0300|ESTRADIOL|United Healthcare|UNITED HEALTHCARE OTHER|||||6.20||| 82670|EAP|0300|ESTRADIOL|PHCS|HUMANA|||||6.20||| 82670|EAP|0300|ESTRADIOL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.20||| 82670|EAP|0300|ESTRADIOL|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.20||| 82670|EAP|0300|ESTRADIOL|Aetna|ZZZZZ AETNA|||||6.20||| 82670|EAP|0300|ESTRADIOL|Aetna|AETNA OTHER|||||6.20||| 82670|EAP|0300|ESTRADIOL|Aetna|AETNA PPO|||||6.20||| 82670|EAP|0300|ESTRADIOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.20||| 82670|EAP|0300|ESTRADIOL|Blue Cross PPO Specialty|BCBSTX OTHER|||||6.20||| 82670|EAP|0300|ESTRADIOL|Blue Cross PPO Specialty|BCBSTX PPO|||||6.20||| 82670|EAP|0300|ESTRADIOL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.20||| 82670|EAP|0300|ESTRADIOL|Blue Cross HMO Specialty|BCBSTX HMO|||||6.20||| 82670|EAP|0300|ESTRADIOL|Cigna|CIGNA|||||6.20||| 82670|EAP|0300|ESTRADIOL|Humana Medicare Advantage|HUMANA MA|||||6.20||| 82670|EAP|0300|ESTRADIOL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.20||| 82670|EAP|0300|ESTRADIOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.20||| 82670|EAP|0300|ESTRADIOL|United Medicare Advantage|UHC AARP MCR HMO MA|||||6.20||| 82670|EAP|0300|ESTRADIOL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.20||| 82670|EAP|0300|ESTRADIOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.20||| 82670|EAP|0300|ESTRADIOL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.20||| 82670|EAP|0300|ESTRADIOL|Access Direct Platinum|HEALTHFIRST TPA|||||6.20||| 82670|EAP|0300|ESTRADIOL|Veterans Affairs|VETERANS ADMINISTRATION|||||6.20||| 82693|EAP|0300|ETHYLENE GLYCOL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|533.25||||||| 82693|EAP|0300|ETHYLENE GLYCOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|533.25||||||| 82693|EAP|0300|ETHYLENE GLYCOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|533.25||||||| 82693|EAP|0300|ETHYLENE GLYCOL|Humana Medicare Advantage|HUMANA MA|533.25||||||| 82693|EAP|0300|ETHYLENE GLYCOL|Blue Cross PPO Specialty|BCBSTX PPO|533.25||||||| 82693|EAP|0300|ETHYLENE GLYCOL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|533.25||||||| 82693|EAP|0300|ETHYLENE GLYCOL|Medicare|MEDICARE ACUTE|533.25||||||| 827|DRG||MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W CC|Medicare|MEDICARE ACUTE|87,776.90|13993.28|31342.54|13993.28|||| 827|DRG||MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W CC|Blue Cross PPO Specialty|BCBSTX PPO|200,765.98|31342.54|31342.54|13993.28|||| 82705|EAP|0300|FECAL FAT QUAL|United Medicare Advantage|UHC MEDICARE GOLD MA|202.75||||||| 82705|EAP|0300|FECAL FAT QUAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|202.75||||||| 82705|EAP|0300|FECAL FAT QUAL|Managed Medicare|HEALTHSPRING MA|202.75||||||| 82705|EAP|0300|FECAL FAT QUAL|Medicare|MEDICARE ACUTE|202.75||||||| 82710|EAP|0300|FECAL FAT QUANT TIMED|Humana Medicare Advantage|HUMANA MA|669.50||||||| 82728|EAP|0300|FERRITIN|Medicaid|SMITH COUNTY JAIL|3.02||||||| 82728|EAP|0300|FERRITIN|Medicare|MEDICARE PART B ONLY IP|3.02||||||| 82728|EAP|0300|FERRITIN|Medicare|MEDICARE ACUTE|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.02||||||| 82728|EAP|0300|FERRITIN|Managed Medicare|BCBS MEDICARE PPO MA|3.02||||||| 82728|EAP|0300|FERRITIN|Managed Medicare|JACKSONVILLE ACCESS|3.02||||||| 82728|EAP|0300|FERRITIN|Workers Compensation|WORKERS COMPENSATION OTHER|3.02||||||| 82728|EAP|0300|FERRITIN|Workers Compensation|ZURICH COMPANY|3.02||||||| 82728|EAP|0300|FERRITIN|Workers Compensation|UT EMPLOYEE INJURY|3.02||||||| 82728|EAP|0300|FERRITIN|Workers Compensation|TEXAS MUTUAL INSURANCE|3.02||||||| 82728|EAP|0300|FERRITIN|Veterans Affairs|VETERANS ADMINISTRATION|3.02||||||| 82728|EAP|0300|FERRITIN|Access Direct Platinum|HEALTHFIRST TPA|3.02||||||| 82728|EAP|0300|FERRITIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.02||||||| 82728|EAP|0300|FERRITIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.02||||3.02||| 82728|EAP|0300|FERRITIN|United Medicare Advantage|UHC MEDICARE GOLD MA|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Access Direct Platinum|HEALTHFIRST TPA UMR|3.02||||3.02||| 82728|EAP|0300|FERRITIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.02||||3.02||| 82728|EAP|0300|FERRITIN|United Medicare Advantage|UHC AARP MCR HMO MA|3.02||||3.02||| 82728|EAP|0300|FERRITIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.02||||||| 82728|EAP|0300|FERRITIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Aetna|BH AETNA|3.02||||||| 82728|EAP|0300|FERRITIN|Aetna|AETNA PPO|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Managed Medicare|HEALTHSPRING MA|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Aetna|AETNA OTHER|3.02||||||| 82728|EAP|0300|FERRITIN|Aenta Medicare Advantage|AETNA MEDICARE MA|3.02||||3.02||| 82728|EAP|0300|FERRITIN|ChampVA|CHAMPVA CENTER|3.02||||||| 82728|EAP|0300|FERRITIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||3.02||| 82728|EAP|0300|FERRITIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Blue Cross PPO Specialty|BCBSTX PPO|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Managed Medicare|OTHER INSTITUTIONS|||||3.02||| 82728|EAP|0300|FERRITIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.02||||||| 82728|EAP|0300|FERRITIN|Blue Cross PPO Specialty|BCBSTX OTHER|3.02||||||| 82728|EAP|0300|FERRITIN|Blue Cross HMO Specialty|BCBSTX HMO|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Managed Medicaid|MEDICAID AMERIGROUP|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|3.02||||||| 82728|EAP|0300|FERRITIN|Managed Medicaid|MEDICAID SUPERIOR|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Cigna|CIGNA OTHER|3.02||||||| 82728|EAP|0300|FERRITIN|Cigna Behavioral Health|BH CIGNA|3.02||||||| 82728|EAP|0300|FERRITIN|Cigna|CIGNA|3.02||||||| 82728|EAP|0300|FERRITIN|Humana Medicare Advantage|HUMANA MA|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Multiplan|NALC|3.02||||||| 82728|EAP|0300|FERRITIN|United Healthcare|UNITED HEALTHCARE|3.02||||||| 82728|EAP|0300|FERRITIN|Rusk State Hospital|RUSK STATE HOSP|3.02||||3.02||| 82728|EAP|0300|FERRITIN|United Healthcare|UNITED HEALTHCARE OTHER|3.02||||||| 82728|EAP|0300|FERRITIN|United Healthcare|UNITED HEALTHCARE|3.02||||3.02||| 82728|EAP|0300|FERRITIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.02||||3.02||| 82728|EAP|0300|FERRITIN|PHCS|HUMANA|3.02||||||| 82728|EAP|0300|FERRITIN|PHCS|GROUP AND PENSION|3.02||||||| 82728|EAP|0300|FERRITIN|United Healthcare|TML GROUP BENEFITS|3.02||||||| 82728|EAP|0300|FERRITIN|Texas Workforce Commission|DIS DETER SERV (DDS)|||||3.02||| 82728|EAP|0300|FERRITIN|NON CONTRACTED|COMMERCIAL OTHER 1|3.02||||||| 82728|EAP|0300|FERRITIN|Multiplan|WEB TPA|3.02||||||| 82728|EAP|0300|FERRITIN|Medicaid|MEDICAID|3.02||||||| 82728|EAP|0300|FERRITIN|Tricare|TRICARE EAST REGION|3.02||||3.02||| 82728|EAP|0300|FERRITIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.02||||||| 82731|EAP|0300|FETAL FIBRONECTIN|Cigna|CIGNA|||||12.99||| 82731|EAP|0300|FETAL FIBRONECTIN|Managed Medicaid|MEDICAID SUPERIOR|||||12.99||| 82731|EAP|0300|FETAL FIBRONECTIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||12.99||| 82731|EAP|0300|FETAL FIBRONECTIN|United Healthcare|UNITED HEALTHCARE|||||12.99||| 82731|EAP|0300|FETAL FIBRONECTIN|Medicaid|MEDICAID|||||12.99||| 82731|EAP|0300|FETAL FIBRONECTIN|Medicare|MEDICARE ACUTE|12.99||||12.99||| 82746|EAP|0300|FOLATE|Aenta Medicare Advantage|AETNA MEDICARE MA|3.26||||3.26||| 82746|EAP|0300|FOLATE|Blue Cross PPO Specialty|BCBSTX PPO|3.26||||||| 82746|EAP|0300|FOLATE|ChampVA|CHAMPVA CENTER|3.26||||||| 82746|EAP|0300|FOLATE|United Healthcare|UNITED HEALTHCARE|3.26||||||| 82746|EAP|0300|FOLATE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.26||||||| 82746|EAP|0300|FOLATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.26||||3.26||| 82746|EAP|0300|FOLATE|Tricare|TRICARE EAST REGION|3.26||||||| 82746|EAP|0300|FOLATE|United Healthcare|UNITED HEALTHCARE OTHER|3.26||||||| 82746|EAP|0300|FOLATE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.26||||3.26||| 82746|EAP|0300|FOLATE|Medicaid|SMITH COUNTY JAIL|3.26||||||| 82746|EAP|0300|FOLATE|Medicaid|MEDICAID HMO|||||3.26||| 82746|EAP|0300|FOLATE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.26||||3.26||| 82746|EAP|0300|FOLATE|United Healthcare|GOLDEN RULE|3.26||||||| 82746|EAP|0300|FOLATE|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.26||||||| 82746|EAP|0300|FOLATE|United Healthcare|AARP|3.26||||||| 82746|EAP|0300|FOLATE|Humana Medicare Advantage|HUMANA MA|3.26||||3.26||| 82746|EAP|0300|FOLATE|United Medicare Advantage|UHC MEDICARE GOLD MA|3.26||||3.26||| 82746|EAP|0300|FOLATE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.26||| 82746|EAP|0300|FOLATE|Veterans Affairs|VETERANS ADMINISTRATION|3.26||||||| 82746|EAP|0300|FOLATE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.26||||3.26||| 82746|EAP|0300|FOLATE|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.26||||||| 82746|EAP|0300|FOLATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.26||||3.26||| 82746|EAP|0300|FOLATE|Blue Cross PPO Specialty|BCBSTX OTHER|3.26||||3.26||| 82746|EAP|0300|FOLATE|Medicare|MEDICARE ACUTE|3.26||||3.26||| 82746|EAP|0300|FOLATE|Workers Compensation|WORKERS COMPENSATION OTHER|3.26||||||| 82746|EAP|0300|FOLATE|Managed Medicaid|MEDICAID SUPERIOR|3.26||||||| 82746|EAP|0300|FOLATE|United Medicare Advantage|UHC AARP MCR HMO MA|3.26||||3.26||| 82746|EAP|0300|FOLATE|Medicaid|MEDICAID|3.26||||||| 82746|EAP|0300|FOLATE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.26||||||| 82746|EAP|0300|FOLATE|Blue Cross HMO Specialty|BCBSTX HMO|3.26||||||| 82746|EAP|0300|FOLATE|Managed Medicare|HEALTHSPRING MA|3.26||||||| 82746|EAP|0300|FOLATE|Managed Medicare|BCBS MEDICARE PPO MA|3.26||||||| 82746|EAP|0300|FOLATE|Managed Medicaid|MEDICAID AMERIGROUP|3.26||||||| 82747|EAP|0300|RBC FOLATE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.84||||||| 82747|EAP|0300|RBC FOLATE|United Healthcare|GEHA|||||3.84||| 82747|EAP|0300|RBC FOLATE|Managed Medicare|HEALTHSPRING MA|3.84||||||| 82747|EAP|0300|RBC FOLATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.84||||||| 82747|EAP|0300|RBC FOLATE|Managed Medicare|WELLCARE CHOICE MA|3.84||||||| 82747|EAP|0300|RBC FOLATE|Managed Medicare|BCBS MEDICARE PPO MA|3.84||||||| 82747|EAP|0300|RBC FOLATE|United Healthcare|UNITED HEALTHCARE|3.84||||||| 82747|EAP|0300|RBC FOLATE|United Healthcare|UNITED HEALTHCARE OTHER|3.84||||||| 82747|EAP|0300|RBC FOLATE|Managed Medicaid|MEDICAID SUPERIOR|3.84||||||| 82747|EAP|0300|RBC FOLATE|Tricare|TRICARE EAST REGION|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|Humana Medicare Advantage|HUMANA MA|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|Medicare|MEDICARE PART B ONLY IP|3.84||||||| 82747|EAP|0300|RBC FOLATE|Blue Cross PPO Specialty|BCBSTX OTHER|3.84||||||| 82747|EAP|0300|RBC FOLATE|Managed Medicaid|MEDICAID AMERIGROUP|3.84||||||| 82747|EAP|0300|RBC FOLATE|Blue Cross PPO Specialty|BCBSTX PPO|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|Access Direct Platinum|HEALTHFIRST TPA UMR|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|United Medicare Advantage|UHC MEDICARE GOLD MA|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|Medicaid|SMITH COUNTY JAIL|3.84||||||| 82747|EAP|0300|RBC FOLATE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.84||||||| 82747|EAP|0300|RBC FOLATE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.84||||||| 82747|EAP|0300|RBC FOLATE|Veterans Affairs|VETERANS ADMINISTRATION|3.84||||||| 82747|EAP|0300|RBC FOLATE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.84||||||| 82747|EAP|0300|RBC FOLATE|Cigna|CIGNA|3.84||||||| 82747|EAP|0300|RBC FOLATE|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.84||||||| 82747|EAP|0300|RBC FOLATE|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.84||||||| 82747|EAP|0300|RBC FOLATE|ChampVA|CHAMPVA CENTER|3.84||||||| 82747|EAP|0300|RBC FOLATE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.84||||||| 82747|EAP|0300|RBC FOLATE|Medicare|MEDICARE ACUTE|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|United Medicare Advantage|UHC AARP MCR HMO MA|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|Aenta Medicare Advantage|AETNA MEDICARE MA|3.84||||3.84||| 82747|EAP|0300|RBC FOLATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.84||||||| 82747|EAP|0300|RBC FOLATE|Medicaid|MEDICAID|3.84||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Blue Cross HMO Specialty|BCBSTX HMO|1.88||||370.75||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.88||||370.75||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Blue Cross PPO Specialty|BCBSTX PPO|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Aenta Medicare Advantage|AETNA MEDICARE MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|NON CONTRACTED|COMMERCIAL OTHER 1|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Managed Medicaid|MEDICAID SUPERIOR|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Blue Cross HMO Specialty|BCBSTX HMO|1.88||||370.75||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Blue Cross PPO Specialty|BCBSTX PPO|370.75||||370.75||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Managed Medicaid|MEDICAID AMERIGROUP|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Blue Cross PPO Specialty|BCBSTX PPO|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Managed Medicaid|MEDICAID SUPERIOR|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Aetna|AETNA PPO|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.88||||370.75||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Blue Cross PPO Specialty|BCBSTX PPO|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.88||||370.75||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Managed Medicaid|MEDICAID AMERIGROUP|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Cigna|CIGNA OTHER|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Humana Medicare Advantage|HUMANA MA|1.88||||370.75||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Humana Medicare Advantage|HUMANA MA|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|PHCS|HUMANA|370.75||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Cigna|CIGNA OTHER|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|NON CONTRACTED|COMMERCIAL OTHER 1|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Tricare|TRICARE EAST REGION|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Tricare|TRICARE EAST REGION|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Cigna|CIGNA OTHER|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Managed Medicaid|MEDICAID SUPERIOR|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Humana Medicare Advantage|HUMANA MA|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|United Healthcare|TML GROUP BENEFITS|||||370.75||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Tricare|TRICARE FOR LIFE|370.75||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|United Healthcare|UNITED HEALTHCARE|||||1.88||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Humana Medicare Advantage|HUMANA MA|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|United Healthcare|UNITED HEALTHCARE OTHER|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Medicaid|SMITH COUNTY JAIL|370.75||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Veterans Affairs|VETERANS ADMINISTRATION|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Tricare|TRICARE EAST REGION|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|United Medicare Advantage|UHC MEDICARE GOLD MA|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Veterans Affairs|VETERANS ADMINISTRATION|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|NON CONTRACTED|COMMERCIAL OTHER 1|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Medicare|MEDICARE ACUTE|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|United Medicare Advantage|UHC AARP MCR HMO MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN PANEL|Medicare|MEDICARE ACUTE|370.75||||370.75||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Medicare|MEDICARE ACUTE|370.75||||370.75||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|United Medicare Advantage|UHC MEDICARE GOLD MA|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Veterans Affairs|VETERANS ADMINISTRATION|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Medicaid|MEDICAID|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|370.75||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|United Healthcare|UNITED HEALTHCARE OTHER|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|United Medicare Advantage|UHC AARP MCR HMO MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|United Healthcare|UNITED HEALTHCARE|||||370.75||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|United Healthcare|UNITED HEALTHCARE OTHER|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Veterans Affairs|VETERANS ADMINISTRATION|370.75||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|United Healthcare|UNITED HEALTHCARE|||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Managed Medicare|HEALTHSPRING MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Medicare|MEDICARE ACUTE|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||370.75||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Managed Medicare|HEALTHSPRING MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|United Medicare Advantage|UHC AARP MCR HMO MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Managed Medicare|HEALTHSPRING MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Medicaid|MEDICAID|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.88||||||| 82784|EAP|0300|IMMUNOGLOBUL M QUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|United Medicare Advantage|UHC MEDICARE GOLD MA|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|Medicaid|MEDICAID|1.88||||||| 82784|EAP|0300|IMMUNOGLOBULIN A IGA|Medicare|MEDICARE ACUTE|1.88||||1.88||| 82784|EAP|0300|IMMUNOGLOBUL G QUANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.88||||||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Cigna|CIGNA OTHER|3.65||||||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Veterans Affairs|VETERANS ADMINISTRATION|3.65||||||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.65||||||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Medicare|MEDICARE ACUTE|3.65||||||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.65||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|United Medicare Advantage|UHC MEDICARE GOLD MA|3.65||||3.65||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Humana Medicare Advantage|HUMANA MA|3.65||||||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Blue Cross PPO Specialty|BCBSTX PPO|3.65||||||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.65||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Medicaid|MEDICAID|3.65||||||| 82785|EAP|0300|IMMUNOGLOBULIN IGE|Aetna|AETNA PPO|3.65||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Cigna|CIGNA OTHER|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Medicaid|MEDICAID|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Medicare|MEDICARE ACUTE|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|United Medicare Advantage|UHC MEDICARE GOLD MA|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Blue Cross PPO Specialty|BCBSTX PPO|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|United Medicare Advantage|UHC AARP MCR HMO MA|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Humana Medicare Advantage|HUMANA MA|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Managed Medicare|HEALTHSPRING MA|1.67||||||| 82787|EAP|0300|IMMUNOGLOBUL IGG SUBCLASS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.67||||||| 82787|EAP|0300|IGG4 LEVEL|Managed Medicaid|MEDICAID AMERIGROUP|||||0.63||| 828|DRG||MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|134,827.89|10344.67|10344.67|10344.67|||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|Aetna|AETNA PPO|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|Access Direct Platinum|HEALTHFIRST TPA UMR|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|Managed Medicaid|MEDICAID AMERIGROUP|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|Managed Medicaid|MEDICAID AMERIGROUP|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|United Healthcare|UNITED HEALTHCARE|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|Managed Medicaid|MEDICAID SUPERIOR|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|Blue Cross HMO Specialty|BCBSTX HMO|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|Blue Cross HMO Specialty|BCBSTX HMO|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|Blue Cross PPO Specialty|BCBSTX PPO|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|United Medicare Advantage|UHC MEDICARE GOLD MA|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|Access Direct Platinum|HEALTHFIRST TPA|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|Managed Medicaid|MEDICAID SUPERIOR|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|United Medicare Advantage|UHC MEDICARE GOLD MA|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|United Healthcare|UNITED HEALTHCARE|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD ART|Aetna|AETNA PPO|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|Medicaid|MEDICAID|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|Blue Cross PPO Specialty|BCBSTX PPO|4.72||||||| 82803|EAP|0300|ABG CORD BLOOD VENOUS|Access Direct Platinum|HEALTHFIRST TPA UMR|4.72||||||| 82805|EAP|0300|ABG ANALYSIS|Medicare|MEDICARE PART B ONLY IP|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|United Healthcare|TML GROUP BENEFITS|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Medicaid|MOLINA HEALTHCARE OF TEXAS|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Medicaid|CRIME VICTIMS COMPENSATION|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|United Healthcare|UNITED HEALTHCARE|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Medicaid|COUNTY INDIGENT HEALTH OTHER|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Tricare|TRICARE EAST REGION|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|United Healthcare|UNITED HEALTHCARE OTHER|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Medicaid|MEDICAID HMO|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Access Direct Platinum|HEALTHFIRST TPA UMR|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|United Medicare Advantage|UHC MEDICARE GOLD MA|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Aetna|AETNA PPO|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Blue Cross PPO Specialty|BCBSTX OTHER|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Blue Cross HMO Specialty|BCBSTX HMO|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Aenta Medicare Advantage|AETNA MEDICARE MA|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Medicaid|MEDICAID|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Workers Compensation|WORKERS COMPENSATION OTHER|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Humana Medicare Advantage|HUMANA MA|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|NON CONTRACTED|COMMERCIAL OTHER 1|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|United Healthcare|UNITED HEALTHCARE|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Cigna|CIGNA|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Managed Medicaid|MEDICAID SUPERIOR|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Aetna|AETNA OTHER|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Cigna|CIGNA|||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Managed Medicaid|MEDICAID AMERIGROUP|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Medicare|MEDICARE ACUTE|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Veterans Affairs|VETERANS ADMINISTRATION|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Blue Cross PPO Specialty|BCBSTX PPO|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.93||||||| 82805|EAP|0300|ABG ANALYSIS|Managed Medicare|HEALTHSPRING MA|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.93||||6.93||| 82805|EAP|0300|ABG ANALYSIS|Managed Medicare|BCBS MEDICARE PPO MA|6.93||||6.93||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Aenta Medicare Advantage|AETNA MEDICARE MA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicaid|MEDICAID SUPERIOR|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicaid|MEDICAID AMERIGROUP|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Aetna|AETNA QHP HMO|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Cigna|CIGNA OTHER|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Workers Compensation|TEXAS MUTUAL INSURANCE|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Aetna|AETNA PPO|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Blue Cross PPO Specialty|BCBSTX OTHER|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Blue Cross PPO Specialty|BCBSTX PPO|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Access Direct Platinum|HEALTHFIRST TPA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Access Direct Platinum|HEALTHFIRST TPA UMR|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Cigna|CIGNA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Tricare|TRICARE EAST REGION|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Workers Compensation|WORKERS COMPENSATION OTHER|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||2.44||| 82820|EAP|0301|P50 OXYGEN DISSOCIATION|Medicare|MEDICARE ACUTE|||||353.26||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|United Healthcare|TML GROUP BENEFITS|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|PHCS|HUMANA|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|United Healthcare|UNITED HEALTHCARE|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|United Healthcare|UNITED HEALTHCARE OTHER|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicare|BCBS MEDICARE PPO MA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Humana Medicare Advantage|HUMANA MA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Veterans Affairs|VETERANS ADMINISTRATION|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicaid|MEDICAID HMO|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicare|MEDICARE PART B ONLY IP|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicaid|MEDICAID|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicaid|CRIME VICTIMS COMPENSATION|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Blue Cross HMO Specialty|BCBSTX HMO|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicaid|LAW ENFORCEMENT OTHER|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Aetna|AETNA OTHER|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|United Healthcare|UNITED HEALTHCARE|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicare|MEDICARE ACUTE|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|ChampVA|CHAMPVA CENTER|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Workers Compensation|UT EMPLOYEE INJURY|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Aetna|BOON CHAPMAN|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicare|OTHER INSTITUTIONS|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|United Medicare Advantage|UHC AARP MCR HMO MA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicare|HEALTHSPRING MA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Rusk State Hospital|RUSK STATE HOSP|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|NON CONTRACTED|COMMERCIAL OTHER 1|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Medicaid|SMITH COUNTY JAIL|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|PHCS|GROUP AND PENSION|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|United Medicare Advantage|UHC MEDICARE GOLD MA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|NON CONTRACTED|COMMERCIAL OTHER 2|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.44||||2.44||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Multiplan|WEB TPA|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Managed Medicare|WELLCARE CHOICE MA|2.44||||||| 82820|EAP|0300|CO-OXIMETRY ANALYSIS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.44||||2.44||| 829|DRG||MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS W OTHER PROCEDURE W CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|104,420.95|40012.28|40012.28|9569.08|||| 829|DRG||MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS W OTHER PROCEDURE W CC/MCC|Medicaid|MEDICAID|89,247.28|9569.08|40012.28|9569.08|||| 829|DRG||MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS W OTHER PROCEDURE W CC/MCC|Medicare|MEDICARE ACUTE|123,090.88|18874.55|40012.28|9569.08|||| 82941|EAP|0300|GASTRIN|Humana Medicare Advantage|HUMANA MA|3.91||||||| 82941|EAP|0300|GASTRIN|United Medicare Advantage|UHC AARP MCR HMO MA|3.91||||||| 82941|EAP|0300|GASTRIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.91||||||| 82941|EAP|0300|GASTRIN|Aenta Medicare Advantage|AETNA MEDICARE MA|3.91||||||| 82941|EAP|0300|GASTRIN|Managed Medicare|HEALTHSPRING MA|3.91||||||| 82941|EAP|0300|GASTRIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.91||||||| 82941|EAP|0300|GASTRIN|Aetna|AETNA OTHER|3.91||||||| 82941|EAP|0300|GASTRIN|Blue Cross PPO Specialty|BCBSTX PPO|3.91||||||| 82943|EAP|0300|ASSAY OF GLUCAGON|Managed Medicare|HEALTHSPRING MA|||||0.92||| 82945|EAP|0300|GLUCOSE URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Access Direct Platinum|HEALTHFIRST TPA|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|United Medicare Advantage|UHC MEDICARE GOLD MA|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|United Healthcare|UNITED HEALTHCARE|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|United Medicare Advantage|UHC AARP MCR HMO MA|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Aenta Medicare Advantage|AETNA MEDICARE MA|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Humana Medicare Advantage|HUMANA MA|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Aetna|AETNA OTHER|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Cigna|CIGNA OTHER|||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|United Healthcare|UNITED HEALTHCARE OTHER|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|ChampVA|CHAMPVA CENTER|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|NON CONTRACTED|COMMERCIAL OTHER 1|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Cigna|CIGNA|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Aetna|AETNA QHP HMO|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Managed Medicaid|MEDICAID SUPERIOR|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Blue Cross PPO Specialty|BCBSTX PPO|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Medicaid|MEDICAID|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Aetna|AETNA PPO|||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Tricare|TRICARE FOR LIFE|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|PHCS|HUMANA|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Veterans Affairs|VETERANS ADMINISTRATION|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|United Healthcare|TML GROUP BENEFITS|||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Managed Medicaid|MEDICAID AMERIGROUP|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Blue Cross HMO Specialty|BCBSTX HMO|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Medicare|MEDICARE PART B ONLY IP|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Managed Medicare|HEALTHSPRING MA|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Medicaid|SMITH COUNTY JAIL|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.79||||0.79||| 82945|EAP|0300|GLUCOSE BODY FLUID|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Managed Medicare|BCBS MEDICARE PPO MA|0.79||||||| 82945|EAP|0300|GLUCOSE BODY FLUID|Medicare|MEDICARE ACUTE|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicare|BCBS MEDICARE PPO MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicare|MEDICARE PART B ONLY IP|0.79||||||| 82947|EAP|0300|GLUCOSE BLOOD|Workers Compensation|UT EMPLOYEE INJURY|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Managed Medicare|HEALTHSPRING MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Managed Medicare|JACKSONVILLE ACCESS|0.79||||||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicare|OTHER INSTITUTIONS|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicare|UTSW MC KIDNEY PROGRAM|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicare|MEDICARE ACUTE|0.79||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicaid|MEDICAID|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicare|HEALTHSPRING MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.79||| 82947|EAP|0300|GLUCOSE 1 HOUR|United Healthcare|UNITED HEALTHCARE OTHER|0.79||||0.96||| 82947|EAP|0300|GLUCOSE BLOOD|United Healthcare|UNITED HEALTHCARE OTHER|0.79||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.79||||||| 82947|EAP|0300|GLUCOSE, BLOOD|Medicaid|MEDICAID|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|NON CONTRACTED|COMMERCIAL OTHER 1|0.79||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Medicare|MEDICARE ACUTE|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|PHCS|GROUP AND PENSION|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|PHCS|HUMANA INSURANCE|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.79||||||| 82947|EAP|0300|GLUCOSE, BLOOD|NON CONTRACTED|COMMERCIAL OTHER 1|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.79||||||| 82947|EAP|0300|GLUCOSE BLOOD|Medicaid|CRIME VICTIMS COMPENSATION|0.79||||||| 82947|EAP|0300|GLUCOSE BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|0.79||||0.79||| 82947|EAP|0300|GLUCOSE 1 HOUR|Aetna|AETNA PPO|||||0.96||| 82947|EAP|0300|GLUCOSE BLOOD|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Aetna|AETNA PPO|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Multiplan|WEB TPA|||||0.79||| 82947|EAP|0300|GLUCOSE 1 HOUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.79||||0.96||| 82947|EAP|0300|GLUCOSE BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.79||||0.79||| 82947|EAP|0300|GLUCOSE 1 HOUR|Blue Cross PPO Specialty|BCBSTX PPO|0.79||||0.96||| 82947|EAP|0300|GLUCOSE BLOOD|Aetna|BOON CHAPMAN|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Humana Medicare Advantage|HUMANA MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Aetna|AETNA OTHER|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Humana Medicare Advantage|HUMANA MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.79||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Cigna|CIGNA|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Cigna Behavioral Health|BH CIGNA|0.79||||||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicaid|MEDICAID AMERIGROUP|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Cigna|CIGNA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|PHCS|HUMANA|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Rusk State Hospital|RUSK STATE HOSP|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Cigna|CIGNA OTHER|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Tricare|TRICARE EAST REGION|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Aetna Value Network|AETNA VALUE NETWORK|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Magellan Behavioral Health|BH MAGELLAN|0.79||||||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|United Healthcare|TML GROUP BENEFITS|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|United Healthcare|UNITED HEALTHCARE|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicaid|LAW ENFORCEMENT OTHER|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|United Medicare Advantage|UHC AARP MCR HMO MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Medicaid|MEDICAID HMO|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|United Medicare Advantage|UHC AARP MCR HMO MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Access Direct Platinum|HEALTHFIRST TPA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Managed Medicaid|MEDICAID SUPERIOR|0.79||||0.79||| 82947|EAP|0300|GLUCOSE 1 HOUR|United Healthcare|UNITED HEALTHCARE|0.79||||0.96||| 82947|EAP|0300|GLUCOSE, BLOOD|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.79||||||| 82947|EAP|0300|GLUCOSE BLOOD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Tricare|TRICARE SOUTH PHYSICIAN|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE 1 HOUR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.96||| 82947|EAP|0300|GLUCOSE BLOOD|Access Direct Platinum|HEALTHFIRST TPA UMR|0.79||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Managed Medicaid|MEDICAID AMERIGROUP|0.79||||0.79||| 82947|EAP|0300|GLUCOSE 1 HOUR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.79||||0.96||| 82947|EAP|0300|GLUCOSE, BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Workers Compensation|WORKERS COMPENSATION OTHER|0.79||||0.79||| 82947|EAP|0300|GLUCOSE 1 HOUR|Access Direct Platinum|HEALTHFIRST TPA UMR|0.79||||0.96||| 82947|EAP|0300|GLUCOSE BLOOD|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||0.79||| 82947|EAP|0300|GLUCOSE, BLOOD|Access Direct Platinum|ANDREWS CENTER|0.79||||||| 82947|EAP|0300|GLUCOSE BLOOD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Workers Compensation|TEXAS MUTUAL INSURANCE|||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.79||| 82947|EAP|0300|GLUCOSE 1 HOUR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.96||| 82947|EAP|0300|GLUCOSE BLOOD|Workers Compensation|BROOKSHIRES WORKERS COMP|0.79||||||| 82947|EAP|0300|GLUCOSE BLOOD|Access Direct Platinum|HEALTHFIRST TPA|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.79||||0.79||| 82947|EAP|0300|GLUCOSE BLOOD|Veterans Affairs|VETERANS ADMINISTRATION|0.79||||0.79||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Managed Medicaid|MEDICAID SUPERIOR|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Humana Medicare Advantage|HUMANA MA|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Workers Compensation|UT EMPLOYEE INJURY|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Medicare|MEDICARE ACUTE|1.77||||1.77||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Blue Cross HMO Specialty|BCBSTX HMO|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Tricare|TRICARE EAST REGION|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|NON CONTRACTED|COMMERCIAL OTHER 1|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Medicare|UTSW MC KIDNEY PROGRAM|||||1.77||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Managed Medicare|HEALTHSPRING MA|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Medicaid|MEDICAID|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Blue Cross PPO Specialty|BCBSTX PPO|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Rusk State Hospital|RUSK STATE HOSP|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.77||||||| 82960|EAP|0300|GLUCOSE-6-PHOSPHATE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.77||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Workers Compensation|UT EMPLOYEE INJURY|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Workers Compensation|WORKERS COMPENSATION OTHER|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Access Direct Platinum|HEALTHFIRST TPA UMR|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Veterans Affairs|VETERANS ADMINISTRATION|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Workers Compensation|BROOKSHIRES WORKERS COMP|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Workers Compensation|TEXAS MUTUAL INSURANCE|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Access Direct Platinum|HEALTHFIRST TPA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Access Direct Platinum|ANDREWS CENTER|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Medicare Advantage|UHC AARP MCR HMO MA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|HEALTHSPRING MA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Healthcare|GOLDEN RULE|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|WELLCARE CHOICE MA|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|OTHER INSTITUTIONS|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|MA PART B ONLY IP|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Healthcare|UNITED HEALTHCARE ERS|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid|CRIME VICTIMS COMPENSATION|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|BCBS MEDICARE PPO MA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|HOSPICE OF EAST TEXAS|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid|LAW ENFORCEMENT OTHER|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|PHCS|HUMANA INSURANCE|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Blue Cross PPO Specialty|BCBSTX PPO|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid|MEDICAID HMO|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Tricare|TRICARE EAST REGION|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Multiplan|WEB TPA|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Rusk State Hospital|RUSK STATE HOSP|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|PHCS|GROUP AND PENSION|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Optum Behavioral Health|BH OPTUM UHC|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|PHCS|HUMANA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|NON CONTRACTED|COMMERCIAL OTHER 1|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Blue Cross PPO Specialty|BCBSTX OTHER|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|NON CONTRACTED|COMMERCIAL OTHER 2|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Healthcare|UNITED HEALTHCARE OTHER|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Healthcare|UNITED HEALTHCARE|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Tricare|TRICARE FOR LIFE|||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Healthcare|GEHA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|ChampVA|CHAMPVA CENTER|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Blue Cross HMO Specialty|BCBSTX HMO|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Healthcare|TML GROUP BENEFITS|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Aenta Medicare Advantage|AETNA MEDICARE MA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Aetna|AETNA OTHER|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Aetna|BH AETNA|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid|SMITH COUNTY JAIL|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicaid|MEDICAID|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicare|MEDICARE PART B ONLY IP|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Aetna|AETNA PPO|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Texas Workforce Commission|DIS DETER SERV (DDS)|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Aetna Value Network|AETNA VALUE NETWORK|||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Cigna|CIGNA OTHER|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Medicare|MEDICARE ACUTE|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Aetna|AETNA QHP HMO|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Magellan Behavioral Health|BH MAGELLAN|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Cigna Behavioral Health|BH CIGNA|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicaid|MEDICAID SUPERIOR|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Managed Medicaid|MEDICAID AMERIGROUP|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Cigna|CIGNA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Aetna|BOON CHAPMAN|0.57||||||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|Humana Medicare Advantage|HUMANA MA|0.57||||0.57||| 82962|EAP|0300|GLUCOSE TEST WITH ACCU-CH|United Medicare Advantage|UHC MEDICARE GOLD MA|0.57||||0.57||| 82977|EAP|0300|GAMMA GT|Veterans Affairs|VETERANS ADMINISTRATION|0.55||||||| 82977|EAP|0300|GAMMA GT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.55||||||| 82977|EAP|0300|GAMMA GT|United Medicare Advantage|UHC AARP MCR HMO MA|0.55||||||| 82977|EAP|0300|GAMMA GT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.55||||||| 82977|EAP|0300|GAMMA GT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.55||||0.55||| 82977|EAP|0300|GAMMA GT|Managed Medicaid|MEDICAID SUPERIOR|0.55||||||| 82977|EAP|0300|GAMMA GT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.55||||||| 82977|EAP|0300|GAMMA GT|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.55||||||| 82977|EAP|0300|GAMMA GT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.55||||||| 82977|EAP|0300|GAMMA GT|United Healthcare|UNITED HEALTHCARE OTHER|0.55||||||| 82977|EAP|0300|GAMMA GT|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.55||||||| 82977|EAP|0300|GAMMA GT|Medicaid|MEDICAID|0.55||||||| 82977|EAP|0300|GAMMA GT|NON CONTRACTED|COMMERCIAL OTHER 1|0.55||||||| 82977|EAP|0300|GAMMA GT|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.55||||||| 82977|EAP|0300|GAMMA GT|Medicare|MEDICARE ACUTE|0.55||||0.55||| 82977|EAP|0300|GAMMA GT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.55||||0.55||| 82977|EAP|0300|GAMMA GT|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.55||||||| 82977|EAP|0300|GAMMA GT|NON CONTRACTED|COMMERCIAL OTHER 2|0.55||||||| 82977|EAP|0300|GAMMA GT|Blue Cross PPO Specialty|BCBSTX PPO|0.55||||||| 82977|EAP|0300|GAMMA GT|United Healthcare|UNITED HEALTHCARE|0.55||||||| 82977|EAP|0300|GAMMA GT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.55||||||| 82977|EAP|0300|GAMMA GT|Humana Medicare Advantage|HUMANA MA|0.55||||0.55||| 82977|EAP|0300|GAMMA GT|Medicaid|SMITH COUNTY JAIL|0.55||||||| 83|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|74,192.46|8625.38|17548.82|1016.01|||| 83|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W CC|Medicare|MEDICARE PART B ONLY IP|59,890.32|1016.01|17548.82|1016.01|||| 83|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W CC|United Medicare Advantage|UHC AARP MCR HMO MA|50,316.70|8231.89|17548.82|1016.01|||| 83|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|222,743.50|8453.77|17548.82|1016.01|||| 83|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W CC|Managed Medicare|HEALTHSPRING MA|41,937.21|8558.27|17548.82|1016.01|||| 83|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W CC|Humana Medicare Advantage|HUMANA MA|54,771.12|8625.38|17548.82|1016.01|||| 83|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|138,873.67|17548.82|17548.82|1016.01|||| 83|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W CC|Medicare|MEDICARE ACUTE|104,753.48|8550.79|17548.82|1016.01|||| 83|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W CC|Blue Cross PPO Specialty|BCBSTX PPO|98,955.49|8793.05|17548.82|1016.01|||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.12||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Humana Medicare Advantage|HUMANA MA|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Aetna|AETNA OTHER|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.12||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Blue Cross HMO Specialty|BCBSTX HMO|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|United Healthcare|UNITED HEALTHCARE|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Managed Medicare|BCBS MEDICARE PPO MA|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|United Healthcare|UNITED HEALTHCARE OTHER|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Medicare|MEDICARE ACUTE|4.12||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Aetna|AETNA PPO|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Blue Cross PPO Specialty|BCBSTX PPO|4.12||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|PHCS|HUMANA|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|Blue Cross PPO Specialty|BCBSTX OTHER|||||4.12||| 83001|EAP|0300|FOLICLE STIMULATING HORMO|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.12||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Medicare|MEDICARE ACUTE|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Managed Medicare|BCBS MEDICARE PPO MA|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|PHCS|HUMANA|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|United Healthcare|UNITED HEALTHCARE OTHER|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|United Healthcare|UNITED HEALTHCARE|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Blue Cross HMO Specialty|BCBSTX HMO|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Blue Cross PPO Specialty|BCBSTX PPO|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.11||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Aetna|AETNA OTHER|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Access Direct Platinum|HEALTHFIRST TPA|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Humana Medicare Advantage|HUMANA MA|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Aetna|AETNA PPO|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.11||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Blue Cross PPO Specialty|BCBSTX OTHER|||||4.11||| 83002|EAP|0300|LUTEINIZING HORMONE LH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.11||| 83003|EAP|0300|HUMAN GROWTH HORMONE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.70||||||| 83003|EAP|0300|HUMAN GROWTH HORMONE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.70||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|United Healthcare|UNITED HEALTHCARE OTHER|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|NON CONTRACTED|COMMERCIAL OTHER 1|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Managed Medicare|BCBS MEDICARE PPO MA|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Humana Medicare Advantage|HUMANA MA|2.54||||2.54||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Blue Cross PPO Specialty|BCBSTX PPO|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Aenta Medicare Advantage|AETNA MEDICARE MA|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Aetna|AETNA PPO|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Blue Cross HMO Specialty|BCBSTX HMO|2.54||||2.54||| 83010|EAP|0300|HAPTOGLOBIN QUAN|ChampVA|CHAMPVA CENTER|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|United Medicare Advantage|UHC MEDICARE GOLD MA|2.54||||2.54||| 83010|EAP|0300|HAPTOGLOBIN QUAN|United Medicare Advantage|UHC AARP MCR HMO MA|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Cigna|CIGNA|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Medicaid|MEDICAID|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Managed Medicare|HEALTHSPRING MA|2.54||||2.54||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Access Direct Platinum|HEALTHFIRST TPA UMR|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Workers Compensation|ZURICH COMPANY|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Managed Medicare|WELLCARE CHOICE MA|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Veterans Affairs|VETERANS ADMINISTRATION|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Medicare|MEDICARE ACUTE|2.54||||2.54||| 83010|EAP|0300|HAPTOGLOBIN QUAN|United Healthcare|UNITED HEALTHCARE|2.54||||||| 83010|EAP|0300|HAPTOGLOBIN QUAN|Workers Compensation|WORKERS COMPENSATION OTHER|2.54||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Medicare|MEDICARE ACUTE|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.13||| 83020|EAP|0300|HGB ELECTROPHORESIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Blue Cross PPO Specialty|BCBSTX OTHER|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Aetna|AETNA PPO|||||5.13||| 83020|EAP|0300|HGB ELECTROPHORESIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Aenta Medicare Advantage|AETNA MEDICARE MA|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Blue Cross PPO Specialty|BCBSTX PPO|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Managed Medicaid|MEDICAID AMERIGROUP|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Medicaid|MEDICAID|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|Managed Medicare|HEALTHSPRING MA|5.13||||||| 83020|EAP|0300|HGB ELECTROPHORESIS|United Healthcare|UNITED HEALTHCARE|||||5.13||| 83020|EAP|0300|HGB ELECTROPHORESIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.13||||||| 83036|EAP|0300|HEMOGLOBIN A1C|PHCS|HUMANA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|NON CONTRACTED|COMMERCIAL OTHER 1|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Rusk State Hospital|RUSK STATE HOSP|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Tricare|TRICARE EAST REGION|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|PHCS|GROUP AND PENSION|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Texas Workforce Commission|DIS DETER SERV (DDS)|||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|UTMB|UTMB CORRECTIONAL MANAGED CARE|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Tricare|TRICARE FOR LIFE|||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|NON CONTRACTED|COMMERCIAL OTHER 2|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|United Healthcare|GEHA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|PHCS|HUMANA INSURANCE|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|United Healthcare|UNITED HEALTHCARE|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicare|OTHER INSTITUTIONS|||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicare|HEALTHSPRING MA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicaid|SUPERIOR HEALTHPLAN CHIP|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicaid|SMITH COUNTY JAIL|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicare|BCBS MEDICARE PPO MA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicaid|MEDICAID|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicaid|COUNTY INDIGENT HEALTH OTHER|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicaid|LAW ENFORCEMENT OTHER|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicaid|SMITH COUNTY INDIGENT HEALTH|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicare|MEDICARE ACUTE|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Cigna|CIGNA OTHER|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicare|UTSW MC KIDNEY PROGRAM|||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Cigna|CIGNA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Magellan Behavioral Health|BH MAGELLAN|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Humana Medicare Advantage|HUMANA MA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicare|ETMC AFFILIATE HOSPITALS|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Optum Behavioral Health|BH OPTUM UHC|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Blue Cross HMO Specialty|BCBSTX HMO|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Brinson Benefits|THE HEALTH PLAN SMITH CO|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Aetna|AETNA OTHER|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicaid|MEDICAID SUPERIOR|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Aetna Value Network|AETNA VALUE NETWORK|||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Access Direct Platinum|ANDREWS CENTER|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Workers Compensation|UT EMPLOYEE INJURY|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|United Medicare Advantage|UHC AARP MCR HMO MA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicare|JACKSONVILLE ACCESS|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|United Healthcare|UNITED HEALTHCARE OTHER|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Veterans Affairs|VETERANS ADMINISTRATION|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|United Healthcare|TML GROUP BENEFITS|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|United Medicare Advantage|UHC AARP WELLMED HMO MA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Workers Compensation|TEXAS MUTUAL INSURANCE|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Aetna|BH AETNA|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Aenta Medicare Advantage|AETNA MEDICARE MA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Workers Compensation|WORKERS COMPENSATION OTHER|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Aetna|AETNA PPO|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Aetna|AETNA QHP HMO|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Cigna Behavioral Health|BH CIGNA|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|ChampVA|CHAMPVA CENTER|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Access Direct Platinum|HEALTHFIRST TPA|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Access Direct Platinum|HEALTHFIRST TPA UMR|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Blue Cross PPO Specialty|BCBSTX OTHER|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Medicare|MEDICARE PART B ONLY IP|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Blue Cross PPO Specialty|BCBSTX PPO|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|138.12||||||| 83036|EAP|0300|HEMOGLOBIN A1C|Managed Medicaid|MEDICAID AMERIGROUP|138.12||||138.12||| 83036|EAP|0300|HEMOGLOBIN A1C|United Medicare Advantage|UHC MEDICARE GOLD MA|138.12||||138.12||| 83051|EAP|0300|HEMOGLOBIN PLASMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|291.25||||||| 83088|EAP|0300|ASSAY OF HISTAMINE|Blue Cross PPO Specialty|BCBSTX PPO|2.03||||||| 83090|EAP|0300|HOMOCYSTEINE|United Healthcare|UNITED HEALTHCARE|6.72||||||| 83090|EAP|0300|HOMOCYSTEINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.72||||||| 83090|EAP|0300|HOMOCYSTEINE|Humana Medicare Advantage|HUMANA MA|6.72||||||| 83090|EAP|0300|HOMOCYSTEINE|United Medicare Advantage|UHC MEDICARE GOLD MA|6.72||||||| 83090|EAP|0300|HOMOCYSTEINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.72||||||| 83090|EAP|0300|HOMOCYSTEINE|Blue Cross PPO Specialty|BCBSTX OTHER|6.72||||||| 83090|EAP|0300|HOMOCYSTEINE|United Medicare Advantage|UHC AARP MCR HMO MA|||||6.72||| 83090|EAP|0300|HOMOCYSTEINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.72||| 83090|EAP|0300|HOMOCYSTEINE|Blue Cross HMO Specialty|BCBSTX HMO|||||6.72||| 83090|EAP|0300|HOMOCYSTEINE|Managed Medicaid|MEDICAID AMERIGROUP|||||6.72||| 83090|EAP|0300|HOMOCYSTEINE|Blue Cross PPO Specialty|BCBSTX PPO|6.72||||6.72||| 83090|EAP|0300|HOMOCYSTEINE|Medicare|MEDICARE ACUTE|6.72||||6.72||| 83090|EAP|0300|HOMOCYSTEINE|Medicare|UTSW MC KIDNEY PROGRAM|||||6.72||| 831|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W MCC|Managed Medicaid|MEDICAID AMERIGROUP|55,829.02|5929.15|9285.99|107.16|||| 831|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W MCC|Managed Medicaid|MEDICAID SUPERIOR|15,513.21|3238.78|9285.99|107.16|||| 831|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26,147.71|107.16|9285.99|107.16|||| 831|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|61,578.48|9285.99|9285.99|107.16|||| 831|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W MCC|Medicaid|MEDICAID|70,280.92|7071.63|9285.99|107.16|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Medicare|MEDICARE ACUTE|41,849.50|5290.45|19540.22|51.82|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|9,766.60|51.82|19540.22|51.82|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Managed Medicaid|MEDICAID AMERIGROUP|21,410.30|3238.78|19540.22|51.82|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Managed Medicaid|MEDICAID SUPERIOR|20,020.33|3238.78|19540.22|51.82|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Blue Cross PPO Specialty|BCBSTX PPO|53,725.08|4677.63|19540.22|51.82|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,025.35|107.16|19540.22|51.82|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Access Direct Platinum|HEALTHFIRST TPA UMR|51,795.53|19540.22|19540.22|51.82|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11,982.50|71.44|4262.83|59.08|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|21,503.78|3261.24|4262.83|59.08|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|11,403.38|2844.085|4262.83|59.08|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Medicare|MEDICARE ACUTE|13,320.50|4262.83|4262.83|59.08|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12,226.40|59.08|4262.83|59.08|||| 834|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC|Humana Medicare Advantage|HUMANA MA|376,107.73|33345.84|60228.97|33343.71|||| 834|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|300,681.82|38009.47|60228.97|33343.71|||| 834|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC|Veterans Affairs|VETERANS ADMINISTRATION|351,642.98|33691.335|60228.97|33343.71|||| 834|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC|Medicare|MEDICARE ACUTE|297,657.19|33343.71|60228.97|33343.71|||| 834|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC|Medicaid|MEDICAID|370,124.23|35669.62|60228.97|33343.71|||| 834|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|180,016.46|33917.71|60228.97|33343.71|||| 834|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC|Cigna|CIGNA|2,045.05|60228.97|60228.97|33343.71|||| 834|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|185,275.80|37397.96|60228.97|33343.71|||| 83497|EAP|0300|HYDROXYINDOLACETIC ACID 5|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.85||| 83497|EAP|0300|HYDROXYINDOLACETIC ACID 5|Medicare|MEDICARE ACUTE|1.85||||1.85||| 835|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC|Medicare|MEDICARE PART B ONLY IP|9,881.48|464.9|18063.59|464.9|||| 835|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC|Medicare|MEDICARE ACUTE|24,195.75|12645.6|18063.59|464.9|||| 835|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|149,522.35|18063.59|18063.59|464.9|||| 835|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|128,071.48|535.8|18063.59|464.9|||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|538.75||||443.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|United Medicare Advantage|UHC MEDICARE GOLD MA|443.25||||443.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|United Medicare Advantage|UHC AARP MCR HMO MA|443.25||||||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|United Medicare Advantage|UHC MEDICARE GOLD MA|98.63||||443.25||| 83516|EAP|0300|AB ACHR BLOCKING|Veterans Affairs|VETERANS ADMINISTRATION|538.75||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Veterans Affairs|VETERANS ADMINISTRATION|98.63||||||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Access Direct Platinum|HEALTHFIRST TPA UMR|98.63||||443.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|443.25||||||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|443.25||||530.25||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|98.63||||530.25||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|98.63||||443.25||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|United Medicare Advantage|UHC AARP MCR HMO MA|98.63||||||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|443.25||||443.25||| 83516|EAP|0300|TISSUE TRANSGLUT IGA AB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|459.75||||||| 83516|EAP|0300|AB ACHR BLOCKING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|538.75||||||| 83516|EAP|0300|AB ACHR MODULATING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|538.75||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|98.63||||||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Humana Medicare Advantage|HUMANA MA|443.25||||||| 83516|EAP|0300|AB GAD-65|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.41||||||| 83516|EAP|0300|TISSUE TRANSGLUT IGA AB|Humana Medicare Advantage|HUMANA MA|459.75||||||| 83516|EAP|0300|AB NEUROMYLITIS OPTICA|Blue Cross PPO Specialty|BCBSTX PPO|530.25||||530.25||| 83516|EAP|0300|AB ACHR MODULATING|Blue Cross PPO Specialty|BCBSTX PPO|538.75||||530.25||| 83516|EAP|0300|AB NEUROMYLITIS OPTICA|Blue Cross PPO Specialty|BCBSTX PPO|538.75||||530.25||| 83516|EAP|0300|AB ACHR MODULATING|Aenta Medicare Advantage|AETNA MEDICARE MA|538.75||||||| 83516|EAP|0300|AB NEUROMYLITIS OPTICA|Blue Cross HMO Specialty|BCBSTX HMO|||||530.25||| 83516|EAP|0300|TISSUE TRANSGLUT IGA AB|Blue Cross PPO Specialty|BCBSTX PPO|459.75||||530.25||| 83516|EAP|0300|GANGLIOSIDE GM1 AB|Aenta Medicare Advantage|AETNA MEDICARE MA|4.13||||||| 83516|EAP|0300|AB ACHR BLOCKING|Aenta Medicare Advantage|AETNA MEDICARE MA|538.75||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Aetna|AETNA PPO|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Aenta Medicare Advantage|AETNA MEDICARE MA|98.63||||||| 83516|EAP|0300|AB PARIETAL CELL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|480.50||||443.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|538.75||||443.25||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98.63||||443.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|443.25||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Blue Cross PPO Specialty|BCBSTX PPO|98.63||||530.25||| 83516|EAP|0300|AB ACHR MODULATING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|538.75||||443.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|443.25||||443.25||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|NON CONTRACTED|COMMERCIAL OTHER 1|98.63||||||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Blue Cross PPO Specialty|BCBSTX PPO|443.25||||530.25||| 83516|EAP|0300|AB NEUROMYLITIS OPTICA|PHCS|HUMANA|530.25||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|PHCS|HUMANA|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Humana Medicare Advantage|HUMANA MA|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Managed Medicare|BCBS MEDICARE PPO MA|98.63||||||| 83516|EAP|0300|GANGLIOSIDE GM1 AB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.13||||||| 83516|EAP|0300|AB NEUROMYLITIS OPTICA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.41||||530.25||| 83516|EAP|0300|AB ACHR BLOCKING|United Healthcare|UNITED HEALTHCARE|98.63||||538.75||| 83516|EAP|0300|AB NEUROMYLITIS OPTICA|United Healthcare|UNITED HEALTHCARE|98.63||||530.25||| 83516|EAP|0300|AB PARIETAL CELL|UTMB|UTMB CORRECTIONAL MANAGED CARE|480.50||||||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|443.25||||||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|United Healthcare|UNITED HEALTHCARE OTHER|443.25||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|98.63||||||| 83516|EAP|0300|AB ACHR MODULATING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|538.75||||443.25||| 83516|EAP|0300|AB ACHR MODULATING|United Healthcare|UNITED HEALTHCARE|98.63||||538.75||| 83516|EAP|0300|TISSUE TRANSGLUT IGA AB|Medicare|MEDICARE ACUTE|459.75||||443.25||| 83516|EAP|0300|AB ACHR MODULATING|Medicare|MEDICARE ACUTE|538.75||||538.75||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Medicaid|MEDICAID|443.25||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|UTMB|UTMB CORRECTIONAL MANAGED CARE|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Medicaid|MEDICAID|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|United Healthcare|UNITED HEALTHCARE|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|United Healthcare|UNITED HEALTHCARE OTHER|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Medicaid|COUNTY INDIGENT HEALTH OTHER|98.63||||||| 83516|EAP|0300|AB ACHR MODULATING|Veterans Affairs|VETERANS ADMINISTRATION|538.75||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Managed Medicare|HEALTHSPRING MA|98.63||||||| 83516|EAP|0300|GLIADIN ANTIBODIES IGG/IG|Medicare|MEDICARE ACUTE|12.10||||443.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Medicare|MEDICARE ACUTE|443.25||||443.25||| 83516|EAP|0300|AB NEUROMYLITIS OPTICA|Medicare|MEDICARE ACUTE|98.63||||530.25||| 83516|EAP|0300|AB ACHR BLOCKING|Medicare|MEDICARE ACUTE|538.75||||538.75||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Managed Medicare|WELLCARE CHOICE MA|98.63||||||| 83516|EAP|0300|AB GLOMERULAR BASEMENT IG|Medicare|UTSW MC KIDNEY PROGRAM|||||98.63||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Medicare|MEDICARE ACUTE|480.50||||443.25||| 83519|EAP|0300|AB ACHR BINDING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.57||||||| 83519|EAP|0300|VOLTAGE-GATED CALCIUM CHA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|174.07||||||| 83519|EAP|0300|IMMUNOASSAY QUANT RADIOIM|Managed Medicare|HEALTHSPRING MA|483.75||||||| 83519|EAP|0300|AB ACHR BINDING|Medicare|MEDICARE ACUTE|14.57||||14.57||| 83519|EAP|0300|INSULIN GROWTH FACTOR II|UTMB|UTMB CORRECTIONAL MANAGED CARE|518.75||||||| 83519|EAP|0300|IMMUNOASSAY QUANT RADIOIM|Medicare|MEDICARE ACUTE|483.75||||14.57||| 83519|EAP|0300|AB MUSK|Medicare|MEDICARE ACUTE|5,424.75||||14.57||| 83519|EAP|0300|AB ACHR BINDING|Aenta Medicare Advantage|AETNA MEDICARE MA|14.57||||||| 83519|EAP|0300|AB MUSK|Aenta Medicare Advantage|AETNA MEDICARE MA|5,424.75||||||| 83519|EAP|0300|AB MUSK|Blue Cross PPO Specialty|BCBSTX PPO|5,424.75||||||| 83519|EAP|0300|IMMUNOASSAY QUANT RADIOIM|ChampVA|CHAMPVA CENTER|483.75||||||| 83519|EAP|0300|AB MUSK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,424.75||||||| 83519|EAP|0300|AB ACHR BINDING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14.57||||||| 83519|EAP|0300|AB ACHR BINDING|Veterans Affairs|VETERANS ADMINISTRATION|14.57||||||| 83519|EAP|0300|IMMUNOASSAY QUANT RADIOIM|United Medicare Advantage|UHC MEDICARE GOLD MA|483.75||||||| 83519|EAP|0300|AB MUSK|UTMB|UTMB CORRECTIONAL MANAGED CARE|5,424.75||||||| 83519|EAP|0300|AB MUSK|Veterans Affairs|VETERANS ADMINISTRATION|5,424.75||||||| 83519|EAP|0300|VOLTAGE-GATED CALCIUM CHA|Medicare|MEDICARE ACUTE|174.07||||14.57||| 83519|EAP|0300|AB ACHR BINDING|United Healthcare|UNITED HEALTHCARE|||||14.57||| 83519|EAP|0300|AB ACHR BINDING|Blue Cross PPO Specialty|BCBSTX PPO|14.57||||||| 83519|EAP|0300|AB ACHR BINDING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.57||||||| 83520|EAP|0300|SERUM TYPTASE|Veterans Affairs|VETERANS ADMINISTRATION|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Workers Compensation|UT EMPLOYEE INJURY|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Managed Medicaid|MEDICAID SUPERIOR|215.40||||215.40||| 83520|EAP|0300|SERUM TYPTASE|Workers Compensation|TEXAS MUTUAL INSURANCE|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|497.50||||||| 83520|EAP|0300|SERUM TYPTASE|United Medicare Advantage|UHC AARP WELLMED HMO MA|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Blue Cross PPO Specialty|BCBSTX PPO|215.40||||215.40||| 83520|EAP|0300|SERUM TYPTASE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||215.40||| 83520|EAP|0300|SERUM TYPTASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Cigna|CIGNA|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|United Medicare Advantage|UHC MEDICARE GOLD MA|497.50||||||| 83520|EAP|0300|SERUM TYPTASE|Cigna|CIGNA OTHER|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Humana Medicare Advantage|HUMANA MA|215.40||||497.50||| 83520|EAP|0300|SERUM TYPTASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Blue Cross HMO Specialty|BCBSTX HMO|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|United Medicare Advantage|UHC AARP MCR HMO MA|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Blue Cross HMO Specialty|BCBSTX HMO|497.50||||||| 83520|EAP|0300|AB THYROTROPIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.27||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Veterans Affairs|VETERANS ADMINISTRATION|497.50||||||| 83520|EAP|0300|PROTEIN 14-3-3 CSF|Blue Cross PPO Specialty|BCBSTX PPO|497.50||||5.16||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Blue Cross PPO Specialty|BCBSTX OTHER|497.50||||||| 83520|EAP|0300|SERUM TYPTASE|Blue Cross PPO Specialty|BCBSTX OTHER|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Humana Medicare Advantage|HUMANA MA|497.50||||497.50||| 83520|EAP|0300|SERUM TYPTASE|Workers Compensation|WORKERS COMPENSATION OTHER|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Blue Cross PPO Specialty|BCBSTX PPO|7.27||||497.50||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|497.50||||||| 83520|EAP|0300|SERUM TYPTASE|Aetna|AETNA OTHER|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|United Medicare Advantage|UHC MEDICARE GOLD MA|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|497.50||||||| 83520|EAP|0300|SERUM TYPTASE|Aetna|AETNA PPO|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Aenta Medicare Advantage|AETNA MEDICARE MA|497.50||||||| 83520|EAP|0300|SERUM TYPTASE|NON CONTRACTED|COMMERCIAL OTHER 1|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|United Healthcare|TML GROUP BENEFITS|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Aetna|AETNA QHP HMO|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|United Healthcare|UNITED HEALTHCARE|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|UTMB|UTMB CORRECTIONAL MANAGED CARE|497.50||||||| 83520|EAP|0300|SERUM TYPTASE|Medicare|MEDICARE ACUTE|215.40||||215.40||| 83520|EAP|0300|SERUM TYPTASE|Managed Medicare|BCBS MEDICARE PPO MA|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Medicare|MEDICARE ACUTE|5.16||||215.40||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Medicare|MEDICARE ACUTE|497.50||||497.50||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Managed Medicare|HEALTHSPRING MA|215.40||||497.50||| 83520|EAP|0300|SERUM TYPTASE|Medicaid|MEDICAID|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|Tricare|TRICARE FOR LIFE|497.50||||||| 83520|EAP|0300|SERUM TYPTASE|Rusk State Hospital|RUSK STATE HOSP|215.40||||||| 83520|EAP|0300|PROTEIN 14-3-3 CSF|Managed Medicare|HEALTHSPRING MA|215.40||||5.16||| 83520|EAP|0300|SERUM TYPTASE|United Healthcare|UNITED HEALTHCARE OTHER|215.40||||||| 83520|EAP|0300|PARANEOPLASTIC STRIATION|United Medicare Advantage|UHC AARP MCR HMO MA|497.50||||||| 83520|EAP|0300|SERUM TYPTASE|Aenta Medicare Advantage|AETNA MEDICARE MA|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|UTMB|UTMB CORRECTIONAL MANAGED CARE|215.40||||||| 83520|EAP|0300|SERUM TYPTASE|PHCS|HUMANA|215.40||||||| 83525|EAP|0300|INSULIN TOTAL|Managed Medicare|HEALTHSPRING MA|455.25||||||| 83525|EAP|0300|INSULIN TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|455.25||||||| 83525|EAP|0300|INSULIN TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|455.25||||||| 83525|EAP|0300|INSULIN TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|||||455.25||| 83525|EAP|0300|INSULIN TOTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|455.25||||||| 83525|EAP|0300|INSULIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||455.25||| 83525|EAP|0300|INSULIN TOTAL|Medicare|MEDICARE ACUTE|455.25||||||| 83525|EAP|0300|INSULIN TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|455.25||||455.25||| 83525|EAP|0300|INSULIN TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|455.25||||||| 83525|EAP|0300|INSULIN TOTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|455.25||||455.25||| 83525|EAP|0300|INSULIN TOTAL|Cigna|CIGNA|455.25||||||| 83525|EAP|0300|INSULIN TOTAL|Humana Medicare Advantage|HUMANA MA|455.25||||455.25||| 83525|EAP|0300|INSULIN TOTAL|Veterans Affairs|VETERANS ADMINISTRATION|455.25||||||| 83540|EAP|0300|SERUM IRON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Managed Medicaid|MEDICAID SUPERIOR|1.31||||1.31||| 83540|EAP|0300|ASSAY OF IRON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.53||||0.53||| 83540|EAP|0300|SERUM IRON|Blue Cross HMO Specialty|BCBSTX HMO|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Blue Cross PPO Specialty|BCBSTX OTHER|1.31||||1.31||| 83540|EAP|0300|IRON LIVER TISSUE|Blue Cross PPO Specialty|BCBSTX PPO|1.31||||2.58||| 83540|EAP|0300|ASSAY OF IRON|Aenta Medicare Advantage|AETNA MEDICARE MA|0.53||||0.53||| 83540|EAP|0300|SERUM IRON|Blue Cross PPO Specialty|BCBSTX PPO|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.53||||1.31||| 83540|EAP|0300|SERUM IRON|Aetna|BH AETNA|1.31||||||| 83540|EAP|0300|SERUM IRON|Aetna|AETNA PPO|1.31||||||| 83540|EAP|0300|SERUM IRON|Multiplan|NALC|1.31||||||| 83540|EAP|0300|IRON LIVER TISSUE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.53||||2.58||| 83540|EAP|0300|SERUM IRON|Multiplan|WEB TPA|1.31||||||| 83540|EAP|0300|SERUM IRON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.53||||1.31||| 83540|EAP|0300|SERUM IRON|Blue Cross HMO Specialty|BCBSTX HMO|0.53||||1.31||| 83540|EAP|0300|SERUM IRON|NON CONTRACTED|COMMERCIAL OTHER 1|1.31||||||| 83540|EAP|0300|SERUM IRON|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.31||||||| 83540|EAP|0300|SERUM IRON|United Healthcare|TML GROUP BENEFITS|1.31||||||| 83540|EAP|0300|SERUM IRON|United Healthcare|UNITED HEALTHCARE|1.31||||||| 83540|EAP|0300|SERUM IRON|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.31||||||| 83540|EAP|0300|ASSAY OF IRON|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.53||||||| 83540|EAP|0300|SERUM IRON|PHCS|HUMANA|1.31||||||| 83540|EAP|0300|IRON LIVER TISSUE|Managed Medicare|HEALTHSPRING MA|0.53||||2.58||| 83540|EAP|0300|ASSAY OF IRON|United Healthcare|UNITED HEALTHCARE OTHER|0.53||||||| 83540|EAP|0300|SERUM IRON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.31||||||| 83540|EAP|0300|ASSAY OF IRON|NON CONTRACTED|COMMERCIAL OTHER 1|0.53||||||| 83540|EAP|0300|SERUM IRON|Managed Medicaid|MEDICAID AMERIGROUP|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|United Healthcare|UNITED HEALTHCARE|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|United Healthcare|UNITED HEALTHCARE OTHER|1.31||||||| 83540|EAP|0300|SERUM IRON|Medicaid|SMITH COUNTY JAIL|1.31||||||| 83540|EAP|0300|SERUM IRON|Aenta Medicare Advantage|AETNA MEDICARE MA|1.31||||1.31||| 83540|EAP|0300|ASSAY OF IRON|Blue Cross PPO Specialty|BCBSTX PPO|0.53||||0.53||| 83540|EAP|0300|SERUM IRON|Managed Medicare|BCBS MEDICARE PPO MA|1.31||||||| 83540|EAP|0300|ASSAY OF IRON|Medicaid|MEDICAID HMO|||||0.53||| 83540|EAP|0300|SERUM IRON|Managed Medicare|HEALTHSPRING MA|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Managed Medicare|OTHER INSTITUTIONS|||||1.31||| 83540|EAP|0300|SERUM IRON|Tricare|TRICARE EAST REGION|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Tricare|TRICARE EAST REGION|0.53||||1.31||| 83540|EAP|0300|ASSAY OF IRON|Medicaid|MEDICAID|0.53||||||| 83540|EAP|0300|SERUM IRON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|PHCS|GROUP AND PENSION|1.31||||||| 83540|EAP|0300|SERUM IRON|Rusk State Hospital|RUSK STATE HOSP|||||1.31||| 83540|EAP|0300|ASSAY OF IRON|Medicaid|SMITH COUNTY JAIL|0.53||||||| 83540|EAP|0300|SERUM IRON|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.31||||||| 83540|EAP|0300|SERUM IRON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Managed Medicare|JACKSONVILLE ACCESS|1.31||||||| 83540|EAP|0300|ASSAY OF IRON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.53||||||| 83540|EAP|0300|SERUM IRON|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.31||||1.31||| 83540|EAP|0300|ASSAY OF IRON|Medicare|MEDICARE ACUTE|0.53||||0.53||| 83540|EAP|0300|SERUM IRON|Medicare|MEDICARE ACUTE|1.31||||1.31||| 83540|EAP|0300|ASSAY OF IRON|Managed Medicare|BCBS MEDICARE PPO MA|0.53||||||| 83540|EAP|0300|SERUM IRON|Medicare|MEDICARE PART B ONLY IP|1.31||||||| 83540|EAP|0300|ASSAY OF IRON|Medicare|MEDICARE PART B ONLY IP|0.53||||||| 83540|EAP|0300|SERUM IRON|Medicaid|MEDICAID|1.31||||||| 83540|EAP|0300|ASSAY OF IRON|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.53||||||| 83540|EAP|0300|ASSAY OF IRON|Access Direct Platinum|HEALTHFIRST TPA UMR|1.31||||0.53||| 83540|EAP|0300|ASSAY OF IRON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.31||||0.53||| 83540|EAP|0300|SERUM IRON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.53||||1.31||| 83540|EAP|0300|SERUM IRON|Veterans Affairs|VETERANS ADMINISTRATION|0.53||||1.31||| 83540|EAP|0300|SERUM IRON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Workers Compensation|WORKERS COMPENSATION OTHER|1.31||||||| 83540|EAP|0300|SERUM IRON|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.31||||||| 83540|EAP|0300|SERUM IRON|Access Direct Platinum|ANDREWS CENTER|1.31||||||| 83540|EAP|0300|SERUM IRON|Workers Compensation|ZURICH COMPANY|1.31||||||| 83540|EAP|0300|SERUM IRON|United Medicare Advantage|UHC MEDICARE GOLD MA|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.31||||||| 83540|EAP|0300|SERUM IRON|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.31||||||| 83540|EAP|0300|SERUM IRON|United Medicare Advantage|UHC AARP MCR HMO MA|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Veterans Affairs|VETERANS ADMINISTRATION|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.31||||1.31||| 83540|EAP|0300|ASSAY OF IRON|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.53||||||| 83540|EAP|0300|SERUM IRON|United Medicare Advantage|UHC AARP MCR HMO MA|0.53||||1.31||| 83540|EAP|0300|ASSAY OF IRON|United Medicare Advantage|UHC MEDICARE GOLD MA|0.53||||0.53||| 83540|EAP|0300|SERUM IRON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.53||||1.31||| 83540|EAP|0300|SERUM IRON|Access Direct Platinum|HEALTHFIRST TPA|1.31||||||| 83540|EAP|0300|SERUM IRON|Cigna|CIGNA|1.31||||||| 83540|EAP|0300|SERUM IRON|Cigna|CIGNA OTHER|1.31||||||| 83540|EAP|0300|SERUM IRON|Cigna|CIGNA|1.31||||1.31||| 83540|EAP|0300|SERUM IRON|Cigna|CIGNA|0.53||||1.31||| 83540|EAP|0300|SERUM IRON|Cigna Behavioral Health|BH CIGNA|1.31||||||| 83540|EAP|0300|SERUM IRON|Humana Medicare Advantage|HUMANA MA|1.31||||1.31||| 83540|EAP|0300|ASSAY OF IRON|Humana Medicare Advantage|HUMANA MA|0.53||||0.53||| 83540|EAP|0300|SERUM IRON|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.31||||||| 83540|EAP|0300|ASSAY OF IRON|Managed Medicaid|MEDICAID SUPERIOR|0.53||||0.53||| 83540|EAP|0300|SERUM IRON|Managed Medicaid|MEDICAID AMERIGROUP|0.53||||1.31||| 83550|EAP|0300|IRON BINDING CAPACITY|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Medicare|MEDICARE ACUTE|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Medicaid|MEDICAID HMO|||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Medicaid|SMITH COUNTY JAIL|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Medicaid|MEDICAID|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicare|OTHER INSTITUTIONS|||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicare|JACKSONVILLE ACCESS|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicare|BCBS MEDICARE PPO MA|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicare|HEALTHSPRING MA|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|United Healthcare|UNITED HEALTHCARE|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|United Healthcare|UNITED HEALTHCARE OTHER|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Rusk State Hospital|RUSK STATE HOSP|||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Tricare|TRICARE EAST REGION|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|PHCS|GROUP AND PENSION|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Multiplan|NALC|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Multiplan|WEB TPA|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|NON CONTRACTED|COMMERCIAL OTHER 1|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Aetna|BH AETNA|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|United Healthcare|UNITED HEALTHCARE|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Aenta Medicare Advantage|AETNA MEDICARE MA|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Aetna|AETNA PPO|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Blue Cross PPO Specialty|BCBSTX OTHER|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|PHCS|HUMANA|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|United Healthcare|TML GROUP BENEFITS|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Blue Cross PPO Specialty|BCBSTX PPO|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Blue Cross HMO Specialty|BCBSTX HMO|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Humana Medicare Advantage|HUMANA MA|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Cigna|CIGNA|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Cigna|CIGNA OTHER|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Cigna Behavioral Health|BH CIGNA|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|United Medicare Advantage|UHC MEDICARE GOLD MA|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|United Medicare Advantage|UHC AARP MCR HMO MA|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Workers Compensation|WORKERS COMPENSATION OTHER|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Veterans Affairs|VETERANS ADMINISTRATION|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Medicare|MEDICARE PART B ONLY IP|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Workers Compensation|ZURICH COMPANY|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicaid|MEDICAID AMERIGROUP|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Access Direct Platinum|HEALTHFIRST TPA|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Access Direct Platinum|ANDREWS CENTER|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Managed Medicaid|MEDICAID SUPERIOR|1.77||||1.77||| 83550|EAP|0300|IRON BINDING CAPACITY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.77||||||| 83550|EAP|0300|IRON BINDING CAPACITY|Access Direct Platinum|HEALTHFIRST TPA UMR|1.77||||1.77||| 836|DRG||ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28,719.80|18063.59|18063.59|18063.59|||| 83605|EAP|0300|LACTIC ACID|United Healthcare|TML GROUP BENEFITS|2.15||||||| 83605|EAP|0300|LACTIC ACID|PHCS|HUMANA INSURANCE|2.15||||||| 83605|EAP|0300|LACTIC ACID|NON CONTRACTED|COMMERCIAL OTHER 2|2.15||||||| 83605|EAP|0300|LACTIC ACID|Multiplan|WEB TPA|2.15||||||| 83605|EAP|0300|LACTIC ACID|Tricare|TRICARE FOR LIFE|||||2.15||| 83605|EAP|0300|LACTIC ACID|PHCS|GROUP AND PENSION|||||2.15||| 83605|EAP|0300|LACTIC ACID|Tricare|TRICARE EAST REGION|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|PHCS|HUMANA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|United Healthcare|UNITED HEALTHCARE|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|United Healthcare|GEHA|2.15||||||| 83605|EAP|0300|LACTIC ACID|United Healthcare|UNITED HEALTHCARE OTHER|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Managed Medicare|HEALTHSPRING MA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Managed Medicare|OTHER INSTITUTIONS|||||2.15||| 83605|EAP|0300|LACTIC ACID|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.15||||||| 83605|EAP|0300|LACTIC ACID|Managed Medicare|WELLCARE CHOICE MA|2.15||||||| 83605|EAP|0300|LACTIC ACID|Medicaid|SMITH COUNTY JAIL|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Medicaid|MEDICAID HMO|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Medicaid|LAW ENFORCEMENT OTHER|2.15||||||| 83605|EAP|0300|LACTIC ACID|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Medicaid|MEDICAID|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.15||||||| 83605|EAP|0300|LACTIC ACID|Medicaid|MEDICAID BCBSTX|||||2.15||| 83605|EAP|0300|LACTIC ACID|Medicare|MEDICARE ACUTE|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.15||||||| 83605|EAP|0300|LACTIC ACID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Managed Medicare|BCBS MEDICARE PPO MA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Medicare|MEDICARE PART B ONLY IP|2.15||||||| 83605|EAP|0300|LACTIC ACID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Access Direct Platinum|HEALTHFIRST TPA UMR|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Access Direct Platinum|HEALTHFIRST TPA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Workers Compensation|BROOKSHIRES WORKERS COMP|2.15||||||| 83605|EAP|0300|LACTIC ACID|Workers Compensation|ZURICH COMPANY|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Veterans Affairs|VETERANS ADMINISTRATION|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Workers Compensation|UT EMPLOYEE INJURY|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|United Medicare Advantage|UHC AARP MCR HMO MA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Blue Cross HMO Specialty|BCBSTX HMO|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Aetna|AETNA QHP HMO|2.15||||||| 83605|EAP|0300|LACTIC ACID|Aenta Medicare Advantage|AETNA MEDICARE MA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Aetna|AETNA PPO|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Aetna|AETNA OTHER|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.15||||||| 83605|EAP|0300|LACTIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.15||||||| 83605|EAP|0300|LACTIC ACID|Managed Medicaid|MEDICAID SUPERIOR|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|ChampVA|CHAMPVA CENTER|2.15||||||| 83605|EAP|0300|LACTIC ACID|Managed Medicaid|MEDICAID AMERIGROUP|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Cigna|CIGNA|2.15||||||| 83605|EAP|0300|LACTIC ACID|Rusk State Hospital|RUSK STATE HOSP|2.15||||||| 83605|EAP|0300|LACTIC ACID|Cigna|CIGNA OTHER|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|NON CONTRACTED|COMMERCIAL OTHER 1|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Blue Cross PPO Specialty|BCBSTX OTHER|2.15||||||| 83605|EAP|0300|LACTIC ACID|Cigna|CIGNA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Humana Medicare Advantage|HUMANA MA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|United Medicare Advantage|UHC MEDICARE GOLD MA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.15||||||| 83605|EAP|0300|LACTIC ACID|Aetna|BOON CHAPMAN|2.15||||||| 83605|EAP|0300|LACTIC ACID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.15||||2.15||| 83605|EAP|0300|LACTIC ACID|Workers Compensation|TRAVELERS INSURANCE COMPANY|2.15||||||| 83605|EAP|0300|LACTIC ACID|Workers Compensation|TEXAS MUTUAL INSURANCE|2.15||||||| 83605|EAP|0300|LACTIC ACID|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|2.15||||||| 83605|EAP|0300|LACTIC ACID|Medicaid|CRIME VICTIMS COMPENSATION|2.15||||||| 83605|EAP|0300|LACTIC ACID|Workers Compensation|WORKERS COMPENSATION OTHER|2.15||||2.15||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Humana Medicare Advantage|HUMANA MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Humana Medicare Advantage|HUMANA MA|835.50||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Humana Medicare Advantage|HUMANA MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Cigna|CIGNA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Cigna|CIGNA OTHER|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID AMERIGROUP|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID SUPERIOR|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Aetna|AETNA PPO|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Aetna|AETNA QHP HMO|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Aetna|AETNA OTHER|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Aenta Medicare Advantage|AETNA MEDICARE MA|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross PPO Specialty|BCBSTX OTHER|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross PPO Specialty|BCBSTX PPO|835.50||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Aenta Medicare Advantage|AETNA MEDICARE MA|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Blue Cross HMO Specialty|BCBSTX HMO|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross HMO Specialty|BCBSTX HMO|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|UHC MEDICARE GOLD MA|835.50||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|UHC MEDICARE GOLD MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|UHC AARP MCR HMO MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|United Medicare Advantage|UHC MEDICARE GOLD MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|United Medicare Advantage|UHC AARP MCR HMO MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Veterans Affairs|VETERANS ADMINISTRATION|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Workers Compensation|UT EMPLOYEE INJURY|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Veterans Affairs|VETERANS ADMINISTRATION|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Workers Compensation|ZURICH COMPANY|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Workers Compensation|WORKERS COMPENSATION OTHER|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Workers Compensation|TEXAS MUTUAL INSURANCE|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Access Direct Platinum|HEALTHFIRST TPA|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross PPO Specialty|BCBSTX PPO|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|ChampVA|CHAMPVA CENTER|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Access Direct Platinum|HEALTHFIRST TPA|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicare|MEDICARE ACUTE|835.50||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Blue Cross PPO Specialty|BCBSTX PPO|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicare|MEDICARE PART B ONLY IP|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Medicare|MEDICARE ACUTE|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicare|UTSW MC KIDNEY PROGRAM|||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Medicare|MEDICARE PART B ONLY IP|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicare|MEDICARE ACUTE|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Aetna|AETNA OTHER|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|MEDICAID|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|MEDICAID HMO|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Medicaid|MEDICAID|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|MEDICAID|835.50||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|SMITH COUNTY JAIL|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Managed Medicare|HEALTHSPRING MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicare|BCBS MEDICARE PPO MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicare|WELLCARE CHOICE MA|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicare|HEALTHSPRING MA|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Healthcare|UNITED HEALTHCARE|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|PHCS|HUMANA|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|NON CONTRACTED|COMMERCIAL OTHER 1|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|NON CONTRACTED|COMMERCIAL OTHER 1|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Tricare|TRICARE EAST REGION|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Healthcare|TML GROUP BENEFITS|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Rusk State Hospital|RUSK STATE HOSP|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Healthcare|UNITED HEALTHCARE OTHER|1.22||||1.22||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|United Healthcare|UNITED HEALTHCARE|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE BOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.22||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.22||||||| 83625|EAP|0300|ASSAY OF LDH ENZYMES|Medicare|MEDICARE ACUTE|5.10||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Blue Cross HMO Specialty|BCBSTX HMO|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Humana Medicare Advantage|HUMANA MA|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.48||||6.48||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Managed Medicare|HEALTHSPRING MA|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Medicare|MEDICARE ACUTE|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|NON CONTRACTED|COMMERCIAL OTHER 1|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.48||||6.48||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Blue Cross PPO Specialty|BCBSTX PPO|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|United Medicare Advantage|UHC AARP MCR HMO MA|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.48||||||| 83630|EAP|0300|LACTOFERRIN, FECAL QUALIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.48||||||| 83655|EAP|0300|LEAD BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|113.28||||||| 83655|EAP|0300|LEAD BLOOD|Managed Medicaid|MEDICAID SUPERIOR|||||113.28||| 83690|EAP|0300|LIPASE|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.39||||1.39||| 83690|EAP|0300|LIPASE|Medicaid|MEDICAID HMO|1.39||||1.39||| 83690|EAP|0300|LIPASE|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.39||||1.39||| 83690|EAP|0300|LIPASE|Medicaid|LAW ENFORCEMENT OTHER|||||1.39||| 83690|EAP|0300|LIPASE|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.39||||1.39||| 83690|EAP|0300|LIPASE|Medicaid|MEDICAID BCBSTX|||||1.39||| 83690|EAP|0300|LIPASE|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.39||||1.39||| 83690|EAP|0300|LIPASE|Medicaid|CRIME VICTIMS COMPENSATION|1.39||||||| 83690|EAP|0300|LIPASE|Medicare|MEDICARE PART B ONLY IP|1.39||||||| 83690|EAP|0300|LIPASE|Medicare|MEDICARE ACUTE|1.39||||1.39||| 83690|EAP|0300|LIPASE|Managed Medicare|MA PART B ONLY IP|1.39||||||| 83690|EAP|0300|LIPASE|Managed Medicare|HEALTHSPRING MA|1.39||||1.39||| 83690|EAP|0300|LIPASE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.39||||1.39||| 83690|EAP|0300|LIPASE|Managed Medicare|ETMC REHABILITATION HOSPITAL|1.39||||1.39||| 83690|EAP|0300|LIPASE|Managed Medicare|WELLCARE CHOICE MA|||||1.39||| 83690|EAP|0300|LIPASE|United Healthcare|GOLDEN RULE|||||1.39||| 83690|EAP|0300|LIPASE|United Healthcare|GEHA|1.39||||1.39||| 83690|EAP|0300|LIPASE|United Healthcare|UNITED HEALTHCARE|1.39||||1.39||| 83690|EAP|0300|LIPASE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.39||||1.39||| 83690|EAP|0300|LIPASE|Managed Medicare|BCBS MEDICARE PPO MA|1.39||||1.39||| 83690|EAP|0300|LIPASE|Tricare|TRICARE EAST REGION|1.39||||1.39||| 83690|EAP|0300|LIPASE|Tricare|TRICARE FOR LIFE|||||1.39||| 83690|EAP|0300|LIPASE|Rusk State Hospital|RUSK STATE HOSP|1.39||||||| 83690|EAP|0300|LIPASE|PHCS|HUMANA INSURANCE|||||1.39||| 83690|EAP|0300|LIPASE|Optum Behavioral Health|BH OPTUM UHC|1.39||||||| 83690|EAP|0300|LIPASE|Multiplan|NALC|1.39||||||| 83690|EAP|0300|LIPASE|Multiplan|WEB TPA|||||1.39||| 83690|EAP|0300|LIPASE|NON CONTRACTED|COMMERCIAL OTHER 2|1.39||||||| 83690|EAP|0300|LIPASE|Multiplan|TRUSTMARK|1.39||||||| 83690|EAP|0300|LIPASE|NON CONTRACTED|COMMERCIAL OTHER 1|1.39||||1.39||| 83690|EAP|0300|LIPASE|Workers Compensation|WORKERS COMPENSATION OTHER|1.39||||1.39||| 83690|EAP|0300|LIPASE|NON CONTRACTED|COMMERCIAL OTHER 4|||||1.39||| 83690|EAP|0300|LIPASE|Workers Compensation|UT EMPLOYEE INJURY|1.39||||1.39||| 83690|EAP|0300|LIPASE|PHCS|GROUP AND PENSION|1.39||||1.39||| 83690|EAP|0300|LIPASE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.39||||||| 83690|EAP|0300|LIPASE|Workers Compensation|TRAVELERS INSURANCE COMPANY|1.39||||||| 83690|EAP|0300|LIPASE|Workers Compensation|ZURICH COMPANY|1.39||||1.39||| 83690|EAP|0300|LIPASE|PHCS|HUMANA|1.39||||1.39||| 83690|EAP|0300|LIPASE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|1.39||||1.39||| 83690|EAP|0300|LIPASE|Veterans Affairs|VETERANS ADMINISTRATION|1.39||||1.39||| 83690|EAP|0300|LIPASE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.39||||1.39||| 83690|EAP|0300|LIPASE|Access Direct Platinum|HEALTHFIRST TPA|1.39||||1.39||| 83690|EAP|0300|LIPASE|United Healthcare|TML GROUP BENEFITS|1.39||||1.39||| 83690|EAP|0300|LIPASE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.39||||1.39||| 83690|EAP|0300|LIPASE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||1.39||| 83690|EAP|0300|LIPASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.39||||1.39||| 83690|EAP|0300|LIPASE|Access Direct Platinum|HEALTHFIRST TPA UMR|1.39||||1.39||| 83690|EAP|0300|LIPASE|United Healthcare|UNITED HEALTHCARE OTHER|1.39||||1.39||| 83690|EAP|0300|LIPASE|United Medicare Advantage|UHC AARP MCR HMO MA|1.39||||1.39||| 83690|EAP|0300|LIPASE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.39||||1.39||| 83690|EAP|0300|LIPASE|Aetna|BOON CHAPMAN|1.39||||||| 83690|EAP|0300|LIPASE|Aetna|BH AETNA|1.39||||||| 83690|EAP|0300|LIPASE|Aetna|AETNA OTHER|1.39||||1.39||| 83690|EAP|0300|LIPASE|Aetna Value Network|AETNA VALUE NETWORK|||||1.39||| 83690|EAP|0300|LIPASE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.39||||1.39||| 83690|EAP|0300|LIPASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.39||||1.39||| 83690|EAP|0300|LIPASE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.39||||1.39||| 83690|EAP|0300|LIPASE|ChampVA|CHAMPVA CENTER|1.39||||1.39||| 83690|EAP|0300|LIPASE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.39||||1.39||| 83690|EAP|0300|LIPASE|Medicaid|SMITH COUNTY JAIL|1.39||||1.39||| 83690|EAP|0300|LIPASE|Aetna|AETNA PPO|1.39||||1.39||| 83690|EAP|0300|LIPASE|Blue Cross PPO Specialty|BCBSTX OTHER|1.39||||1.39||| 83690|EAP|0300|LIPASE|Blue Cross PPO Specialty|BCBSTX PPO|1.39||||1.39||| 83690|EAP|0300|LIPASE|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.39||||1.39||| 83690|EAP|0300|LIPASE|Medicaid|MEDICAID|1.39||||1.39||| 83690|EAP|0300|LIPASE|Blue Cross HMO Specialty|BCBSTX HMO|1.39||||1.39||| 83690|EAP|0300|LIPASE|Cigna|CIGNA OTHER|1.39||||1.39||| 83690|EAP|0300|LIPASE|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.39||||1.39||| 83690|EAP|0300|LIPASE|Cigna|CIGNA|1.39||||1.39||| 83690|EAP|0300|LIPASE|Humana Medicare Advantage|HUMANA MA|1.39||||1.39||| 83690|EAP|0300|LIPASE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.39||||||| 83690|EAP|0300|LIPASE|Managed Medicaid|MEDICAID AMERIGROUP|1.39||||1.39||| 83690|EAP|0300|LIPASE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.39||||1.39||| 83690|EAP|0300|LIPASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.39||||1.39||| 83690|EAP|0300|LIPASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.39||||1.39||| 83690|EAP|0300|LIPASE|Managed Medicaid|MEDICAID SUPERIOR|1.39||||1.39||| 837|DRG||CHEMO W ACUTE LEUKEMIA AS SDX OR W HIGH DOSE CHEMO AGENT W MCC|Blue Cross HMO Specialty|BCBSTX HMO|249,229.38|31019.31|34848.37|15366.6|||| 837|DRG||CHEMO W ACUTE LEUKEMIA AS SDX OR W HIGH DOSE CHEMO AGENT W MCC|Veterans Affairs|VETERANS ADMINISTRATION|37,512.70|34848.37|34848.37|15366.6|||| 837|DRG||CHEMO W ACUTE LEUKEMIA AS SDX OR W HIGH DOSE CHEMO AGENT W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|111,316.55|15366.6|34848.37|15366.6|||| 83718|EAP|0300|HDL CHOLESTEROL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.65||||||| 83718|EAP|0300|HDL CHOLESTEROL|Medicare|MEDICARE ACUTE|1.65||||||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.92||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|Blue Cross HMO Specialty|BCBSTX HMO|1.92||||1.92||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|Blue Cross PPO Specialty|BCBSTX PPO|1.92||||1.92||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.92||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|Humana Medicare Advantage|HUMANA MA|||||1.92||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|NON CONTRACTED|COMMERCIAL OTHER 1|1.92||||||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|PHCS|HUMANA|||||1.92||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|United Healthcare|TML GROUP BENEFITS|1.92||||||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|United Healthcare|UNITED HEALTHCARE|||||1.92||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|Medicare|MEDICARE ACUTE|1.92||||1.92||| 83721|EAP|0300|LDL CHOLESTEROL DIRECT|Medicare|UTSW MC KIDNEY PROGRAM|||||1.92||| 83735|EAP|0300|MAGNESIUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.35||| 83735|EAP|0300|MAGNESIUM|Managed Medicare|OTHER INSTITUTIONS|||||1.35||| 83735|EAP|0300|MAGNESIUM|Managed Medicare|MA PART B ONLY IP|1.35||||||| 83735|EAP|0300|MAGNESIUM|Managed Medicare|HEALTHSPRING MA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Managed Medicare|WELLCARE CHOICE MA|1.35||||||| 83735|EAP|0300|MAGNESIUM|Medicaid|MEDICAID HMO|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicaid|SMITH COUNTY JAIL|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicaid|MEDICAID BCBSTX|||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicaid|CRIME VICTIMS COMPENSATION|1.35||||||| 83735|EAP|0300|MAGNESIUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.35||||||| 83735|EAP|0300|MAGNESIUM|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicare|MEDICARE ACUTE|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicare|UTSW MC KIDNEY PROGRAM|||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.35||||||| 83735|EAP|0300|MAGNESIUM|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.35||||||| 83735|EAP|0300|MAGNESIUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|United Healthcare|UNITED HEALTHCARE|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|United Healthcare|GEHA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|United Healthcare|GOLDEN RULE|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|United Healthcare|TML GROUP BENEFITS|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|PHCS|HUMANA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|PHCS|GROUP AND PENSION|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|NON CONTRACTED|COMMERCIAL OTHER 1|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Tricare|TRICARE FOR LIFE|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Managed Medicaid|MEDICAID SUPERIOR|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Managed Medicaid|MEDICAID AMERIGROUP|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Cigna|CIGNA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|NON CONTRACTED|COMMERCIAL OTHER 2|1.35||||||| 83735|EAP|0300|MAGNESIUM|Cigna|CIGNA OTHER|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Humana Medicare Advantage|HUMANA MA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM RANDOM URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|PHCS|HUMANA INSURANCE|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Tricare|TRICARE EAST REGION|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Aetna Value Network|AETNA VALUE NETWORK|1.35||||||| 83735|EAP|0300|MAGNESIUM|Aetna|AETNA OTHER|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Aetna|BOON CHAPMAN|1.35||||||| 83735|EAP|0300|MAGNESIUM|PHCS|HUMANA INSURANCE|1.35||||||| 83735|EAP|0300|MAGNESIUM|Aetna|AETNA QHP HMO|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Aetna|AETNA PPO|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Rusk State Hospital|RUSK STATE HOSP|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Aenta Medicare Advantage|AETNA MEDICARE MA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicare|MEDICARE PART B ONLY IP|1.35||||||| 83735|EAP|0300|MAGNESIUM|ChampVA|CHAMPVA CENTER|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicaid|MEDICAID|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|United Healthcare|UNITED HEALTHCARE ERS|1.35||||||| 83735|EAP|0300|MAGNESIUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|United Healthcare|UNITED HEALTHCARE OTHER|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Blue Cross PPO Specialty|BCBSTX PPO|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Blue Cross PPO Specialty|BCBSTX OTHER|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Blue Cross HMO Specialty|BCBSTX HMO|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Medicaid|LAW ENFORCEMENT OTHER|1.35||||||| 83735|EAP|0300|MAGNESIUM|Access Direct Platinum|HEALTHFIRST TPA UMR|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Access Direct Platinum|HEALTHFIRST TPA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Workers Compensation|WORKERS COMPENSATION OTHER|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Veterans Affairs|VETERANS ADMINISTRATION|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|1.35||||||| 83735|EAP|0300|MAGNESIUM|Workers Compensation|UT EMPLOYEE INJURY|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Managed Medicare|BCBS MEDICARE PPO MA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Workers Compensation|ZURICH COMPANY|1.35||||||| 83735|EAP|0300|MAGNESIUM|United Medicare Advantage|UHC MEDICARE GOLD MA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Workers Compensation|TEXAS MUTUAL INSURANCE|1.35||||||| 83735|EAP|0300|MAGNESIUM|United Medicare Advantage|UHC AARP MCR HMO MA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Workers Compensation|BROOKSHIRES WORKERS COMP|1.35||||||| 83735|EAP|0300|MAGNESIUM|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.35||||||| 83735|EAP|0300|MAGNESIUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|1.35||||1.35||| 83735|EAP|0300|MAGNESIUM|Workers Compensation|TRAVELERS INSURANCE COMPANY|1.35||||||| 83789|EAP|0300|FATTY ACIDS VERY LONG CHA|Managed Medicaid|MEDICAID SUPERIOR|||||693.75||| 838|DRG||CHEMO W ACUTE LEUKEMIA AS SDX W CC OR HIGH DOSE CHEMO AGENT|United Healthcare|UNITED HEALTHCARE OTHER|134,494.75|25895.98|25895.98|13540.41|||| 838|DRG||CHEMO W ACUTE LEUKEMIA AS SDX W CC OR HIGH DOSE CHEMO AGENT|Veterans Affairs|VETERANS ADMINISTRATION|34,181.20|13540.41|25895.98|13540.41|||| 83825|EAP|0300|MERCURY URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|5.17||||||| 83835|EAP|0300|METANEPHRINES FRACTIONATE|Medicare|MEDICARE ACUTE|675.25||||||| 83835|EAP|0300|METANEPHRINES FRACTIONATE|United Healthcare|UNITED HEALTHCARE|675.25||||||| 83835|EAP|0300|METANEPHRINES FRACTIONATE|Humana Medicare Advantage|HUMANA MA|675.25||||675.25||| 83835|EAP|0300|METANEPHRINES FRACTIONATE|Blue Cross PPO Specialty|BCBSTX PPO|675.25||||675.25||| 83835|EAP|0300|METANEPHRINES FRACTIONATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|675.25||||675.25||| 83835|EAP|0300|METANEPHRINES FRACTIONATE|Aetna|AETNA OTHER|675.25||||||| 83873|EAP|0300|MYELIN BASIC PROTEIN|Veterans Affairs|VETERANS ADMINISTRATION|660.75||||||| 83873|EAP|0300|MYELIN BASIC PROTEIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||660.75||| 83873|EAP|0300|MYELIN BASIC PROTEIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|660.75||||||| 83873|EAP|0300|MYELIN BASIC PROTEIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||660.75||| 83873|EAP|0300|MYELIN BASIC PROTEIN|Blue Cross HMO Specialty|BCBSTX HMO|||||660.75||| 83873|EAP|0300|MYELIN BASIC PROTEIN|Blue Cross PPO Specialty|BCBSTX PPO|660.75||||660.75||| 83873|EAP|0300|MYELIN BASIC PROTEIN|Humana Medicare Advantage|HUMANA MA|||||660.75||| 83873|EAP|0300|MYELIN BASIC PROTEIN|Tricare|TRICARE FOR LIFE|660.75||||||| 83873|EAP|0300|MYELIN BASIC PROTEIN|PHCS|HUMANA|660.75||||||| 83873|EAP|0300|MYELIN BASIC PROTEIN|Medicare|MEDICARE ACUTE|660.75||||660.75||| 83873|EAP|0300|MYELIN BASIC PROTEIN|Medicaid|SMITH COUNTY JAIL|660.75||||||| 83873|EAP|0300|MYELIN BASIC PROTEIN|United Healthcare|UNITED HEALTHCARE|||||660.75||| 83873|EAP|0300|MYELIN BASIC PROTEIN|United Healthcare|TML GROUP BENEFITS|||||660.75||| 83874|EAP|0300|MYGLOBIN SERUM|Managed Medicare|HEALTHSPRING MA|514.50||||||| 83874|EAP|0300|MYGLOBIN SERUM|United Healthcare|UNITED HEALTHCARE OTHER|514.50||||||| 83874|EAP|0300|MYOGLOBIN QUAL URINE|Blue Cross HMO Specialty|BCBSTX HMO|2.60||||||| 83874|EAP|0300|MYOGLOBIN QUAL URINE|Blue Cross PPO Specialty|BCBSTX PPO|2.60||||||| 83874|EAP|0300|MYGLOBIN SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|514.50||||||| 83874|EAP|0300|MYGLOBIN SERUM|United Medicare Advantage|UHC AARP MCR HMO MA|514.50||||||| 83874|EAP|0300|MYGLOBIN SERUM|Blue Cross PPO Specialty|BCBSTX PPO|514.50||||||| 83874|EAP|0300|MYGLOBIN SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|514.50||||||| 83874|EAP|0300|MYGLOBIN SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|514.50||||||| 83874|EAP|0300|MYGLOBIN SERUM|Medicare|MEDICARE ACUTE|514.50||||||| 83874|EAP|0300|MYOGLOBIN QUAL URINE|Medicare|MEDICARE ACUTE|2.60||||||| 83874|EAP|0300|MYGLOBIN SERUM|Medicare|MEDICARE PART B ONLY IP|514.50||||||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Workers Compensation|UT EMPLOYEE INJURY|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Workers Compensation|GALLAGHER BASSETT|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Veterans Affairs|VETERANS ADMINISTRATION|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Access Direct Platinum|HEALTHFIRST TPA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|United Medicare Advantage|UHC MEDICARE GOLD MA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicaid|MEDICAID SUPERIOR|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicaid|MEDICAID AMERIGROUP|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Cigna|CIGNA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Humana Medicare Advantage|HUMANA MA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Aetna|AETNA QHP HMO|5.16||||||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Aetna|AETNA OTHER|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Aenta Medicare Advantage|AETNA MEDICARE MA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Blue Cross HMO Specialty|BCBSTX HMO|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Blue Cross PPO Specialty|BCBSTX PPO|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Blue Cross PPO Specialty|BCBSTX OTHER|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|ChampVA|CHAMPVA CENTER|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|5.16||||||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Multiplan|WEB TPA|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|NON CONTRACTED|COMMERCIAL OTHER 2|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|NON CONTRACTED|COMMERCIAL OTHER 1|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|United Medicare Advantage|UHC AARP MCR HMO MA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Tricare|TRICARE FOR LIFE|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Workers Compensation|WORKERS COMPENSATION OTHER|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Tricare|TRICARE EAST REGION|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Aetna|AETNA PPO|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|PHCS|HUMANA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Rusk State Hospital|RUSK STATE HOSP|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Cigna|CIGNA OTHER|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Access Direct Platinum|HEALTHFIRST TPA UMR|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Texas Workforce Commission|DIS DETER SERV (DDS)|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|PHCS|HUMANA INSURANCE|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|United Healthcare|GEHA|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|United Healthcare|UNITED HEALTHCARE|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|United Healthcare|UNITED HEALTHCARE OTHER|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|United Healthcare|TML GROUP BENEFITS|5.16||||||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|LAW ENFORCEMENT OTHER|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|MEDICAID HMO|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|SMITH COUNTY JAIL|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|United Healthcare|GOLDEN RULE|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|PHCS|GROUP AND PENSION|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|MEDICAID|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|CRIME VICTIMS COMPENSATION|5.16||||||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicare|MEDICARE ACUTE|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicare|HEALTHSPRING MA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicare|OTHER INSTITUTIONS|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Medicare|MEDICARE PART B ONLY IP|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicare|MA PART B ONLY IP|5.16||||||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicare|BCBS MEDICARE PPO MA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicare|WELLCARE CHOICE MA|5.16||||5.16||| 83880|EAP|0300|B-TYPE NATRIURETIC PEPTID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.16||||5.16||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Managed Medicare|HEALTHSPRING MA|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|541.50||||||| 83883|EAP|0300|PARVO VIRUS IGG & IGM ABS|Medicaid|MEDICAID|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Medicaid|MEDICAID|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Blue Cross PPO Specialty|BCBSTX PPO|541.50||||541.50||| 83883|EAP|0300|PARVO VIRUS IGG & IGM ABS|Blue Cross PPO Specialty|BCBSTX OTHER|541.50||||||| 83883|EAP|0300|PARVO VIRUS IGG & IGM ABS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Aenta Medicare Advantage|AETNA MEDICARE MA|541.50||||||| 83883|EAP|0300|PARVO VIRUS IGG & IGM ABS|Humana Medicare Advantage|HUMANA MA|541.50||||541.50||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Humana Medicare Advantage|HUMANA MA|541.50||||541.50||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Cigna|CIGNA|541.50||||||| 83883|EAP|0300|PARVO VIRUS IGG & IGM ABS|Blue Cross PPO Specialty|BCBSTX PPO|541.50||||541.50||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Managed Medicaid|MEDICAID SUPERIOR|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|NON CONTRACTED|COMMERCIAL OTHER 1|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|541.50||||||| 83883|EAP|0300|PARVO VIRUS IGG & IGM ABS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|United Medicare Advantage|UHC AARP MCR HMO MA|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Medicaid|COUNTY INDIGENT HEALTH OTHER|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|541.50||||||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Medicare|MEDICARE ACUTE|541.50||||541.50||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|United Medicare Advantage|UHC MEDICARE GOLD MA|541.50||||||| 83883|EAP|0300|PARVO VIRUS IGG & IGM ABS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|541.50||||||| 83883|EAP|0300|PARVO VIRUS IGG & IGM ABS|UTMB|UTMB CORRECTIONAL MANAGED CARE|541.50||||||| 83883|EAP|0300|PARVO VIRUS IGG & IGM ABS|Medicare|MEDICARE ACUTE|541.50||||541.50||| 83883|EAP|0300|KAPPA/LAMBDA LIGHT CHAINS|Veterans Affairs|VETERANS ADMINISTRATION|541.50||||||| 839|DRG||CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|42,239.32|8432.09|29620.825|5893.17|||| 839|DRG||CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|41,954.81|5893.17|29620.825|5893.17|||| 839|DRG||CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|46,620.11|29620.825|29620.825|5893.17|||| 839|DRG||CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC|Medicare|MEDICARE ACUTE|43,886.60|8258.74|29620.825|5893.17|||| 83915|EAP|0300|NUCLEOTIDASE 5-|Medicare|MEDICARE ACUTE|444.50||||||| 83918|EAP|0300|ORGANIC ACIDS TOTAL QUANT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|369.57||||||| 83921|EAP|0300|METHYLMALONIC ACID, QN, S|Medicare|MEDICARE ACUTE|6.56||||||| 83921|EAP|0300|METHYLMALONIC ACID, QN, S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.56||||||| 83921|EAP|0300|METHYLMALONIC ACID, QN, S|PHCS|HUMANA|6.56||||||| 83921|EAP|0300|METHYLMALONIC ACID, QN, S|Managed Medicare|HEALTHSPRING MA|6.56||||||| 83921|EAP|0300|METHYLMALONIC ACID, QN, S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.56||||||| 83921|EAP|0300|METHYLMALONIC ACID, QN, S|Blue Cross PPO Specialty|BCBSTX PPO|6.56||||||| 83921|EAP|0300|METHYLMALONIC ACID, QN, S|Managed Medicaid|MEDICAID SUPERIOR|6.56||||||| 83921|EAP|0300|METHYLMALONIC ACID, QN, S|Humana Medicare Advantage|HUMANA MA|6.56||||||| 83921|EAP|0300|METHYLMALONIC ACID, QN, S|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.56||| 83930|EAP|0300|OSMOLALITY SERUM|Veterans Affairs|VETERANS ADMINISTRATION|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Access Direct Platinum|HEALTHFIRST TPA UMR|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|1.09||||1.09||| 83930|EAP|0300|OSMOLALITY SERUM|Cigna|CIGNA|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Managed Medicaid|MEDICAID AMERIGROUP|||||1.09||| 83930|EAP|0300|OSMOLALITY SERUM|Blue Cross PPO Specialty|BCBSTX PPO|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Medicaid|MEDICAID|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Managed Medicare|BCBS MEDICARE PPO MA|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Managed Medicare|HEALTHSPRING MA|1.09||||1.09||| 83930|EAP|0300|OSMOLALITY SERUM|United Healthcare|GOLDEN RULE|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|United Healthcare|UNITED HEALTHCARE OTHER|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|United Healthcare|UNITED HEALTHCARE|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Aetna|AETNA PPO|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Aenta Medicare Advantage|AETNA MEDICARE MA|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Medicare|MEDICARE ACUTE|1.09||||1.09||| 83930|EAP|0300|OSMOLALITY SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Blue Cross HMO Specialty|BCBSTX HMO|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.09||||1.09||| 83930|EAP|0300|OSMOLALITY SERUM|Managed Medicaid|MEDICAID SUPERIOR|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Humana Medicare Advantage|HUMANA MA|1.09||||1.09||| 83930|EAP|0300|OSMOLALITY SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.09||||1.09||| 83930|EAP|0300|OSMOLALITY SERUM|United Medicare Advantage|UHC AARP MCR HMO MA|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|Cigna|CIGNA OTHER|1.09||||||| 83930|EAP|0300|OSMOLALITY SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.09||||1.09||| 83930|EAP|0300|OSMOLALITY SERUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.09||||1.09||| 83935|EAP|0300|OSMOLALITY URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.99||||0.99||| 83935|EAP|0300|OSMOLALITY URINE|United Healthcare|GOLDEN RULE|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|United Healthcare|UNITED HEALTHCARE|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|United Healthcare|UNITED HEALTHCARE OTHER|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Managed Medicare|BCBS MEDICARE PPO MA|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Managed Medicare|MA PART B ONLY IP|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Medicare|MEDICARE PART B ONLY IP|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Medicaid|MEDICAID|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Managed Medicare|HEALTHSPRING MA|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Medicare|MEDICARE ACUTE|0.99||||0.99||| 83935|EAP|0300|OSMOLALITY URINE|Aetna|AETNA OTHER|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Aetna|AETNA PPO|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Blue Cross PPO Specialty|BCBSTX PPO|0.99||||0.99||| 83935|EAP|0300|OSMOLALITY URINE|Blue Cross HMO Specialty|BCBSTX HMO|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Humana Medicare Advantage|HUMANA MA|0.99||||0.99||| 83935|EAP|0300|OSMOLALITY URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.99||||0.99||| 83935|EAP|0300|OSMOLALITY URINE|NON CONTRACTED|COMMERCIAL OTHER 1|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.99||||0.99||| 83935|EAP|0300|OSMOLALITY URINE|Cigna|CIGNA OTHER|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|United Medicare Advantage|UHC AARP MCR HMO MA|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Cigna|CIGNA|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Veterans Affairs|VETERANS ADMINISTRATION|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.99||||0.99||| 83935|EAP|0300|OSMOLALITY URINE|Blue Cross PPO Specialty|BCBSTX OTHER|0.99||||||| 83935|EAP|0300|OSMOLALITY URINE|Managed Medicaid|MEDICAID SUPERIOR|0.99||||||| 83945|EAP|0300|OXALATE URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.13||| 83970|EAP|0300|PARATHYROID (INTACT)|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Medicaid|MEDICAID|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Medicare|MEDICARE ACUTE|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Medicare|MEDICARE PART B ONLY IP|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Managed Medicare|HEALTHSPRING MA|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Managed Medicare|WELLCARE CHOICE MA|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Managed Medicare|BCBS MEDICARE PPO MA|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Tricare|TRICARE EAST REGION|||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Multiplan|WEB TPA|||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|PHCS|GROUP AND PENSION|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|NON CONTRACTED|COMMERCIAL OTHER 1|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Cigna|CIGNA|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Cigna|CIGNA|||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|United Healthcare|UNITED HEALTHCARE|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|United Healthcare|UNITED HEALTHCARE OTHER|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Managed Medicaid|MEDICAID SUPERIOR|||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|PHCS|HUMANA|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Blue Cross HMO Specialty|BCBSTX HMO|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Aenta Medicare Advantage|AETNA MEDICARE MA|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Aetna|AETNA PPO|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Medicaid|SMITH COUNTY JAIL|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Aetna|AETNA OTHER|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||||| 83970|EAP|0300|PARATHYROID (INTACT)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Access Direct Platinum|HEALTHFIRST TPA UMR|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.75||||7.75||| 83970|EAP|0300|PARATHYROID (INTACT)|Access Direct Platinum|HEALTHFIRST TPA|||||7.75||| 83986|EAP|0300|PH NON BLOOD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|142.25||||142.25||| 83986|EAP|0300|PH NON BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|||||142.25||| 83986|EAP|0300|PH NON BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|142.25||||||| 83986|EAP|0300|PH NON BLOOD|Humana Medicare Advantage|HUMANA MA|142.25||||||| 83986|EAP|0300|PH NON BLOOD|Medicare|MEDICARE ACUTE|142.25||||||| 83986|EAP|0300|PH NON BLOOD|Medicaid|MEDICAID|142.25||||||| 84|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|64,026.90|14246.44|14246.44|1124.33|||| 84|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|42,960.25|1124.33|14246.44|1124.33|||| 84|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|66,987.74|5066.5|14246.44|1124.33|||| 84|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|840.62|6269.21|14246.44|1124.33|||| 84|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|52,155.25|6179.6|14246.44|1124.33|||| 84|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC|Cigna|CIGNA|62,158.10|12908.22|14246.44|1124.33|||| 84|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC|Medicare|MEDICARE ACUTE|879.04|6207.76|14246.44|1124.33|||| 84|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|60,742.08|6309.08|14246.44|1124.33|||| 84|DRG||TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|75,397.31|6309.08|14246.44|1124.33|||| 840|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W MCC|Blue Cross HMO Specialty|BCBSTX HMO|94,758.96|19006.62|123678.39|340.2|||| 840|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|101,181.62|340.2|123678.39|340.2|||| 840|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W MCC|Blue Cross PPO Specialty|BCBSTX PPO|179,813.09|20267.95|123678.39|340.2|||| 840|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W MCC|Managed Medicare|HEALTHSPRING MA|164,666.60|18816.22|123678.39|340.2|||| 840|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|96,902.68|9298.38|123678.39|340.2|||| 840|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W MCC|Medicare|MEDICARE ACUTE|145,919.25|19184.4|123678.39|340.2|||| 840|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W MCC|United Healthcare|UNITED HEALTHCARE OTHER|422,384.51|123678.39|123678.39|340.2|||| 84030|EAP|0300|PKU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|219.50||||||| 84030|EAP|0300|PKU|NON CONTRACTED|COMMERCIAL OTHER 1|219.50||||||| 84030|EAP|0300|PKU|PHCS|GROUP AND PENSION|219.50||||||| 84030|EAP|0300|PKU|PHCS|HUMANA INSURANCE|219.50||||||| 84030|EAP|0300|PKU|United Healthcare|TML GROUP BENEFITS|219.50||||||| 84030|EAP|0300|PKU|United Healthcare|UNITED HEALTHCARE|219.50||||||| 84030|EAP|0300|PKU|Medicaid|MEDICAID|219.50||||||| 84030|EAP|0300|PKU|Medicaid|MOLINA HEALTHCARE OF TEXAS|219.50||||||| 84030|EAP|0300|PKU|Medicaid|SUPERIOR HEALTHPLAN CHIP|219.50||||||| 84030|EAP|0300|PKU|Medicaid|MEDICAID HMO|219.50||||||| 84030|EAP|0300|PKU|Access Direct Platinum|HEALTHFIRST TPA|219.50||||||| 84030|EAP|0300|PKU|Access Direct Platinum|HEALTHFIRST TPA UMR|219.50||||||| 84030|EAP|0300|PKU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|219.50||||||| 84030|EAP|0300|PKU|United Healthcare|UNITED HEALTHCARE OTHER|219.50||||||| 84030|EAP|0300|PKU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|219.50||||||| 84030|EAP|0300|PKU|Cigna|CIGNA|219.50||||||| 84030|EAP|0300|PKU|Tricare|TRICARE EAST REGION|219.50||||||| 84030|EAP|0300|PKU|Cigna|CIGNA OTHER|219.50||||||| 84030|EAP|0300|PKU|Managed Medicaid|MEDICAID AMERIGROUP|219.50||||219.50||| 84030|EAP|0300|PKU|Managed Medicaid|MEDICAID SUPERIOR|219.50||||||| 84030|EAP|0300|PKU|ChampVA|CHAMPVA CENTER|219.50||||||| 84030|EAP|0300|PKU|Blue Cross PPO Specialty|BCBSTX OTHER|219.50||||||| 84030|EAP|0300|PKU|Blue Cross PPO Specialty|BCBSTX PPO|219.50||||||| 84030|EAP|0300|PKU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|219.50||||||| 84030|EAP|0300|PKU|Blue Cross HMO Specialty|BCBSTX HMO|219.50||||||| 84030|EAP|0300|PKU|Aetna|AETNA OTHER|219.50||||||| 84030|EAP|0300|PKU|Aetna|AETNA PPO|219.50||||||| 84030|EAP|0300|PKU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|219.50||||||| 84030|EAP|0300|PKU|Aetna Value Network|AETNA VALUE NETWORK|219.50||||||| 84075|EAP|0300|PHOSPHATASE ALKALINE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.04||||||| 84075|EAP|0300|ALKALINE PHOSPHATASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.45||| 84075|EAP|0300|PHOSPHATASE ALKALINE|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.04||| 84075|EAP|0300|PHOSPHATASE ALKALINE|Medicare|MEDICARE ACUTE|1.04||||||| 84075|EAP|0300|PHOSPHATASE ALKALINE|Blue Cross PPO Specialty|BCBSTX PPO|1.04||||||| 84075|EAP|0300|ALKALINE PHOSPHATASE|Medicare|MEDICARE ACUTE|0.45||||||| 84080|EAP|0300|ALKALINE PHOSPHATASE ISOE|Medicare|MEDICARE ACUTE|1.77||||||| 84080|EAP|0300|ALKALINE PHOSPHATASE ISOE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.77||| 841|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W CC|Veterans Affairs|VETERANS ADMINISTRATION|27,024.50|10127.02|19076.08|10099.74|||| 841|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W CC|United Healthcare|UNITED HEALTHCARE OTHER|102,151.23|19076.08|19076.08|10099.74|||| 841|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W CC|Medicare|MEDICARE ACUTE|107,591.65|10127.9|19076.08|10099.74|||| 841|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|70,355.15|10099.74|19076.08|10099.74|||| 841|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W CC|Humana Medicare Advantage|HUMANA MA|62,937.01|10212.33|19076.08|10099.74|||| 841|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W CC|Blue Cross PPO Specialty|BCBSTX PPO|111,127.68|10666.79|19076.08|10099.74|||| 84100|EAP|0300|PHOSPHORUS|Managed Medicare|BCBS MEDICARE PPO MA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Medicaid|MEDICAID BCBSTX|||||0.96||| 84100|EAP|0300|PHOSPHORUS|Medicaid|SMITH COUNTY JAIL|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Medicaid|CRIME VICTIMS COMPENSATION|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Medicare|MEDICARE ACUTE|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Medicare|UTSW MC KIDNEY PROGRAM|||||0.96||| 84100|EAP|0300|PHOSPHORUS|PHCS|HUMANA|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Tricare|TRICARE FOR LIFE|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Tricare|TRICARE EAST REGION|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|NON CONTRACTED|COMMERCIAL OTHER 1|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|United Healthcare|UNITED HEALTHCARE ERS|0.96||||||| 84100|EAP|0300|PHOSPHORUS|United Healthcare|GEHA|0.96||||||| 84100|EAP|0300|PHOSPHORUS|NON CONTRACTED|COMMERCIAL OTHER 2|0.96||||||| 84100|EAP|0300|PHOSPHORUS|United Healthcare|TML GROUP BENEFITS|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|United Healthcare|UNITED HEALTHCARE|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Workers Compensation|BROOKSHIRES WORKERS COMP|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Workers Compensation|UT EMPLOYEE INJURY|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Veterans Affairs|VETERANS ADMINISTRATION|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|PHCS|GROUP AND PENSION|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|PHCS|HUMANA INSURANCE|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Rusk State Hospital|RUSK STATE HOSP|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Workers Compensation|TEXAS MUTUAL INSURANCE|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Texas Workforce Commission|DIS DETER SERV (DDS)|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Medicare|MEDICARE PART B ONLY IP|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Workers Compensation|WORKERS COMPENSATION OTHER|0.96||||||| 84100|EAP|0300|PHOSPHORUS|United Healthcare|UNITED HEALTHCARE OTHER|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|United Healthcare|GOLDEN RULE|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Access Direct Platinum|HEALTHFIRST TPA UMR|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Medicaid|MEDICAID HMO|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Access Direct Platinum|HEALTHFIRST TPA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Medicaid|LAW ENFORCEMENT OTHER|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|United Medicare Advantage|UHC MEDICARE GOLD MA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|United Medicare Advantage|UHC AARP MCR HMO MA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Managed Medicare|HEALTHSPRING MA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Aetna Value Network|AETNA VALUE NETWORK|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Aetna|AETNA PPO|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Aetna|AETNA OTHER|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Aetna|AETNA QHP HMO|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Aetna|BOON CHAPMAN|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Aenta Medicare Advantage|AETNA MEDICARE MA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|ChampVA|CHAMPVA CENTER|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Blue Cross PPO Specialty|BCBSTX PPO|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Cigna|CIGNA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.96||||||| 84100|EAP|0300|PHOSPHORUS|Cigna|CIGNA OTHER|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Humana Medicare Advantage|HUMANA MA|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Managed Medicaid|MEDICAID SUPERIOR|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Managed Medicaid|MEDICAID AMERIGROUP|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Blue Cross HMO Specialty|BCBSTX HMO|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Blue Cross PPO Specialty|BCBSTX OTHER|0.96||||0.96||| 84100|EAP|0300|PHOSPHORUS|Medicaid|MEDICAID|0.96||||0.96||| 84105|EAP|0300|PHOSPHORUS INORGANIC URIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.94||| 84105|EAP|0300|PHOSPHORUS 24 HR URINE|Blue Cross HMO Specialty|BCBSTX HMO|0.96||||||| 84105|EAP|0300|PHOSPHORUS 24 HR URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.96||| 84119|EAP|0300|PORPHOBILINOGEN QUANT URI|Medicare|MEDICARE ACUTE|||||1.74||| 84120|EAP|0300|PORPHYRINS FRACTIONATED U|Medicare|MEDICARE ACUTE|585.75||||585.75||| 84120|EAP|0300|PORPHYRINS FRACTIONATED U|Aenta Medicare Advantage|AETNA MEDICARE MA|585.75||||||| 84132|EAP|0300|POTASSIUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Texas Workforce Commission|DIS DETER SERV (DDS)|0.93||||||| 84132|EAP|0300|POTASSIUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|United Healthcare|TML GROUP BENEFITS|0.93||||||| 84132|EAP|0300|POTASSIUM|United Healthcare|UNITED HEALTHCARE|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|United Healthcare|GEHA|0.93||||||| 84132|EAP|0300|POTASSIUM|United Healthcare|AARP|0.93||||||| 84132|EAP|0300|POTASSIUM|NON CONTRACTED|COMMERCIAL OTHER 1|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.93||||||| 84132|EAP|0300|POTASSIUM|Multiplan|TRUSTMARK|0.93||||||| 84132|EAP|0300|POTASSIUM|Multiplan|WEB TPA|0.93||||||| 84132|EAP|0300|POTASSIUM|PHCS|HUMANA|0.93||||||| 84132|EAP|0300|POTASSIUM|Optum Behavioral Health|BH OPTUM UHC|0.93||||||| 84132|EAP|0300|POTASSIUM|PHCS|GROUP AND PENSION|||||0.93||| 84132|EAP|0300|POTASSIUM|Rusk State Hospital|RUSK STATE HOSP|0.93||||||| 84132|EAP|0300|POTASSIUM|Tricare|TRICARE EAST REGION|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Managed Medicare|JACKSONVILLE ACCESS|0.93||||||| 84132|EAP|0300|POTASSIUM|Managed Medicare|MA PART B ONLY IP|0.93||||||| 84132|EAP|0300|POTASSIUM|Managed Medicare|BCBS MEDICARE PPO MA|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Managed Medicare|HEALTHSPRING MA|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Managed Medicare|WELLCARE CHOICE MA|0.93||||||| 84132|EAP|0300|POTASSIUM|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Medicaid|MEDICAID HMO|0.93||||||| 84132|EAP|0300|POTASSIUM|Medicaid|MEDICAID|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Medicaid|CRIME VICTIMS COMPENSATION|0.93||||||| 84132|EAP|0300|POTASSIUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.93||||||| 84132|EAP|0300|POTASSIUM|Medicaid|SMITH COUNTY JAIL|0.93||||||| 84132|EAP|0300|POTASSIUM|Medicare|MEDICARE ACUTE|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Workers Compensation|WORKERS COMPENSATION OTHER|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.93||||||| 84132|EAP|0300|POTASSIUM|Workers Compensation|TEXAS MUTUAL INSURANCE|0.93||||||| 84132|EAP|0300|POTASSIUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Workers Compensation|UT EMPLOYEE INJURY|0.93||||||| 84132|EAP|0300|POTASSIUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Access Direct Platinum|HEALTHFIRST TPA UMR|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Access Direct Platinum|HEALTHFIRST TPA|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Access Direct Platinum|ANDREWS CENTER|0.93||||||| 84132|EAP|0300|POTASSIUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Managed Medicare|OTHER INSTITUTIONS|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Cigna|CIGNA OTHER|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Veterans Affairs|VETERANS ADMINISTRATION|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Cigna Behavioral Health|BH CIGNA|0.93||||||| 84132|EAP|0300|POTASSIUM|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.93||||||| 84132|EAP|0300|POTASSIUM|Cigna|CIGNA|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Humana Medicare Advantage|HUMANA MA|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Managed Medicaid|MEDICAID SUPERIOR|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|United Medicare Advantage|UHC MEDICARE GOLD MA|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.93||||||| 84132|EAP|0300|POTASSIUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Managed Medicaid|MEDICAID AMERIGROUP|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|ChampVA|CHAMPVA CENTER|0.93||||||| 84132|EAP|0300|POTASSIUM|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.93||||||| 84132|EAP|0300|POTASSIUM|United Medicare Advantage|UHC AARP MCR HMO MA|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Blue Cross PPO Specialty|BCBSTX OTHER|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|United Healthcare|UNITED HEALTHCARE OTHER|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|United Healthcare|GOLDEN RULE|0.93||||||| 84132|EAP|0300|POTASSIUM|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Blue Cross PPO Specialty|BCBSTX PPO|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Blue Cross HMO Specialty|BCBSTX HMO|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Medicaid|LAW ENFORCEMENT OTHER|0.93||||||| 84132|EAP|0300|POTASSIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Aetna|AETNA QHP HMO|0.93||||||| 84132|EAP|0300|POTASSIUM|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.93||||||| 84132|EAP|0300|POTASSIUM|Aetna|AETNA OTHER|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Aetna|AETNA PPO|0.93||||0.93||| 84132|EAP|0300|POTASSIUM|Aetna|BOON CHAPMAN|0.93||||||| 84132|EAP|0300|POTASSIUM|Medicare|MEDICARE PART B ONLY IP|0.93||||||| 84132|EAP|0300|POTASSIUM|Medicare|UTSW MC KIDNEY PROGRAM|||||0.93||| 84132|EAP|0300|POTASSIUM|Aenta Medicare Advantage|AETNA MEDICARE MA|0.93||||0.93||| 84133|EAP|0300|POTASSIUM URINE|Aetna|AETNA OTHER|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Aetna|AETNA PPO|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Blue Cross HMO Specialty|BCBSTX HMO|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Cigna|CIGNA|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Veterans Affairs|VETERANS ADMINISTRATION|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Medicare|MEDICARE ACUTE|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Tricare|TRICARE EAST REGION|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|United Healthcare|UNITED HEALTHCARE|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Managed Medicare|BCBS MEDICARE PPO MA|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Medicaid|MEDICAID|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|United Medicare Advantage|UHC AARP MCR HMO MA|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Managed Medicare|HEALTHSPRING MA|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.93||||0.93||| 84133|EAP|0300|POTASSIUM URINE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.93||| 84133|EAP|0300|POTASSIUM URINE|Humana Medicare Advantage|HUMANA MA|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Managed Medicaid|MEDICAID AMERIGROUP|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Blue Cross PPO Specialty|BCBSTX PPO|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Blue Cross PPO Specialty|BCBSTX OTHER|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.93||||||| 84133|EAP|0300|POTASSIUM URINE|Access Direct Platinum|HEALTHFIRST TPA|0.93||||||| 84134|EAP|0300|PREALBUMIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.70||||||| 84134|EAP|0300|PREALBUMIN|United Healthcare|UNITED HEALTHCARE OTHER|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|United Healthcare|UNITED HEALTHCARE|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|NON CONTRACTED|COMMERCIAL OTHER 1|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|PHCS|HUMANA|1.70||||||| 84134|EAP|0300|PREALBUMIN|Tricare|TRICARE EAST REGION|1.70||||||| 84134|EAP|0300|PREALBUMIN|Rusk State Hospital|RUSK STATE HOSP|1.70||||||| 84134|EAP|0300|PREALBUMIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Managed Medicare|HEALTHSPRING MA|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Medicaid|MEDICAID|1.70||||||| 84134|EAP|0300|PREALBUMIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.70||||||| 84134|EAP|0300|PREALBUMIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.70||||||| 84134|EAP|0300|PREALBUMIN|Medicaid|CRIME VICTIMS COMPENSATION|1.70||||||| 84134|EAP|0300|PREALBUMIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.70||||||| 84134|EAP|0300|PREALBUMIN|Medicare|MEDICARE PART B ONLY IP|1.70||||||| 84134|EAP|0300|PREALBUMIN|United Medicare Advantage|UHC MEDICARE GOLD MA|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Managed Medicare|WELLCARE CHOICE MA|1.70||||||| 84134|EAP|0300|PREALBUMIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|United Medicare Advantage|UHC AARP MCR HMO MA|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Managed Medicare|BCBS MEDICARE PPO MA|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.70||||||| 84134|EAP|0300|PREALBUMIN|Medicare|MEDICARE ACUTE|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Workers Compensation|WORKERS COMPENSATION OTHER|1.70||||||| 84134|EAP|0300|PREALBUMIN|Workers Compensation|TEXAS MUTUAL INSURANCE|1.70||||||| 84134|EAP|0300|PREALBUMIN|Medicaid|SMITH COUNTY JAIL|1.70||||||| 84134|EAP|0300|PREALBUMIN|Veterans Affairs|VETERANS ADMINISTRATION|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.70||||||| 84134|EAP|0300|PREALBUMIN|Access Direct Platinum|HEALTHFIRST TPA UMR|1.70||||||| 84134|EAP|0300|PREALBUMIN|Access Direct Platinum|HEALTHFIRST TPA|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Humana Medicare Advantage|HUMANA MA|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Cigna|CIGNA OTHER|1.70||||||| 84134|EAP|0300|PREALBUMIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Blue Cross PPO Specialty|BCBSTX OTHER|1.70||||||| 84134|EAP|0300|PREALBUMIN|Managed Medicaid|MEDICAID AMERIGROUP|1.70||||||| 84134|EAP|0300|PREALBUMIN|Blue Cross PPO Specialty|BCBSTX PPO|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|PHCS|GROUP AND PENSION|1.70||||||| 84134|EAP|0300|PREALBUMIN|Managed Medicaid|MEDICAID SUPERIOR|1.70||||||| 84134|EAP|0300|PREALBUMIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.70||| 84134|EAP|0300|PREALBUMIN|ChampVA|CHAMPVA CENTER|1.70||||||| 84134|EAP|0300|PREALBUMIN|United Healthcare|UNITED HEALTHCARE|||||1.70||| 84134|EAP|0300|PREALBUMIN|Blue Cross HMO Specialty|BCBSTX HMO|1.70||||||| 84134|EAP|0300|PREALBUMIN|Cigna|CIGNA|1.70||||||| 84134|EAP|0300|PREALBUMIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.70||||||| 84134|EAP|0300|PREALBUMIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.70||||||| 84134|EAP|0300|PREALBUMIN|Aetna|AETNA OTHER|1.70||||||| 84134|EAP|0300|PREALBUMIN|Aetna|AETNA QHP HMO|1.70||||||| 84134|EAP|0300|PREALBUMIN|Aenta Medicare Advantage|AETNA MEDICARE MA|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Aetna|BOON CHAPMAN|1.70||||||| 84134|EAP|0300|PREALBUMIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.70||||||| 84134|EAP|0300|PREALBUMIN|Aetna|AETNA PPO|1.70||||1.70||| 84134|EAP|0300|PREALBUMIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.70||||||| 84144|EAP|0300|PROGESTERONE|Managed Medicaid|MEDICAID AMERIGROUP|4.63||||||| 84144|EAP|0300|PROGESTERONE|Cigna|CIGNA|||||4.63||| 84144|EAP|0300|PROGESTERONE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.63||| 84145|EAP|0300|PROCALCITONIN (PCT)|Medicare|MEDICARE PART B ONLY IP|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Medicaid|MEDICAID|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Medicaid|MEDICAID HMO|||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Managed Medicare|BCBS MEDICARE PPO MA|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Managed Medicare|HEALTHSPRING MA|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Rusk State Hospital|RUSK STATE HOSP|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|NON CONTRACTED|COMMERCIAL OTHER 1|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|United Healthcare|UNITED HEALTHCARE|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|United Healthcare|TML GROUP BENEFITS|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|United Healthcare|UNITED HEALTHCARE|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|UTMB|UTMB CORRECTIONAL MANAGED CARE|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|United Medicare Advantage|UHC AARP MCR HMO MA|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|United Medicare Advantage|UHC MEDICARE GOLD MA|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|United Medicare Advantage|UHC AARP WELLMED HMO MA|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Workers Compensation|UT EMPLOYEE INJURY|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Veterans Affairs|VETERANS ADMINISTRATION|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Aetna|AETNA PPO|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|United Healthcare|UNITED HEALTHCARE OTHER|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Aetna|AETNA QHP HMO|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Aenta Medicare Advantage|AETNA MEDICARE MA|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Aetna|AETNA OTHER|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Medicaid|LAW ENFORCEMENT OTHER|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Blue Cross HMO Specialty|BCBSTX HMO|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Blue Cross PPO Specialty|BCBSTX OTHER|958.25||||||| 84145|EAP|0300|PROCALCITONIN (PCT)|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Cigna|CIGNA|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Medicare|MEDICARE ACUTE|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Managed Medicaid|MEDICAID SUPERIOR|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Cigna|CIGNA OTHER|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Managed Medicaid|MEDICAID AMERIGROUP|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Blue Cross PPO Specialty|BCBSTX PPO|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Humana Medicare Advantage|HUMANA MA|958.25||||958.25||| 84145|EAP|0300|PROCALCITONIN (PCT)|Access Direct Platinum|HEALTHFIRST TPA|||||958.25||| 84146|EAP|0300|PROLACTIN RIA|PHCS|HUMANA|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Tricare|TRICARE FOR LIFE|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Managed Medicare|BCBS MEDICARE PPO MA|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Medicare|MEDICARE ACUTE|4.30||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.30||||||| 84146|EAP|0300|PROLACTIN RIA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Blue Cross PPO Specialty|BCBSTX PPO|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Blue Cross PPO Specialty|BCBSTX OTHER|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Humana Medicare Advantage|HUMANA MA|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Blue Cross HMO Specialty|BCBSTX HMO|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.30||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Aetna|AETNA OTHER|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Aetna|AETNA PPO|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Access Direct Platinum|HEALTHFIRST TPA|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Access Direct Platinum|ANDREWS CENTER|4.30||||||| 84146|EAP|0300|PROLACTIN RIA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.30||||4.30||| 84146|EAP|0300|PROLACTIN RIA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|United Healthcare|UNITED HEALTHCARE|||||4.30||| 84146|EAP|0300|PROLACTIN RIA|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.30||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Medicare|UTSW MC KIDNEY PROGRAM|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Medicare|MEDICARE ACUTE|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Medicare|MEDICARE PART B ONLY IP|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Managed Medicare|BCBS MEDICARE PPO MA|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Managed Medicare|HEALTHSPRING MA|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|PHCS|HUMANA|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Tricare|TRICARE EAST REGION|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|PHCS|HUMANA INSURANCE|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Rusk State Hospital|RUSK STATE HOSP|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Multiplan|PACIFICARE|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Multiplan|WEB TPA|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Healthcare|AARP|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Healthcare|UNITED HEALTHCARE OTHER|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Healthcare|UNITED HEALTHCARE|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Healthcare|UNITED HEALTHCARE|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Healthcare|TML GROUP BENEFITS|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Healthcare|GEHA|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Medicare Advantage|UHC MEDICARE GOLD MA|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|United Medicare Advantage|UHC AARP MCR HMO MA|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Workers Compensation|WORKERS COMPENSATION OTHER|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Veterans Affairs|VETERANS ADMINISTRATION|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Access Direct Platinum|HEALTHFIRST TPA|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.08||||||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Tricare|TRICARE FOR LIFE|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Aenta Medicare Advantage|AETNA MEDICARE MA|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Aetna|AETNA QHP HMO|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Aetna|AETNA PPO|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Aetna|AETNA OTHER|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Aetna|ZZZZZ AETNA|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|PHCS|GROUP AND PENSION|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Aetna|BOON CHAPMAN|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Aetna Value Network|AETNA VALUE NETWORK|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Blue Cross HMO Specialty|BCBSTX HMO|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Blue Cross PPO Specialty|BCBSTX PPO|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Blue Cross PPO Specialty|BCBSTX OTHER|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Cigna|CIGNA OTHER|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Cigna|CIGNA|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Humana Medicare Advantage|HUMANA MA|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Managed Medicaid|MEDICAID AMERIGROUP|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.08||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.08||| 84153|EAP|0300|PROSTATIC SPECIFIC ANTIGE|Managed Medicaid|MEDICAID SUPERIOR|||||4.08||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|732.75||||||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Humana Medicare Advantage|HUMANA MA|732.75||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|732.75||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross PPO Specialty|BCBSTX OTHER|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross HMO Specialty|BCBSTX HMO|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Aetna Value Network|AETNA VALUE NETWORK|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|732.75||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Aetna|AETNA PPO|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Aetna|AETNA OTHER|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Aenta Medicare Advantage|AETNA MEDICARE MA|732.75||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|732.75||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Veterans Affairs|VETERANS ADMINISTRATION|732.75||||||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Medicare Advantage|UHC AARP MCR HMO MA|732.75||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|732.75||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Medicare Advantage|UHC MEDICARE GOLD MA|732.75||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Cigna|CIGNA|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|TML GROUP BENEFITS|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|AARP|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|UNITED HEALTHCARE OTHER|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|UNITED HEALTHCARE|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|732.75||||||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|NON CONTRACTED|COMMERCIAL OTHER 1|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Tricare|TRICARE EAST REGION|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|PHCS|HUMANA INSURANCE|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|PHCS|HUMANA|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicare|HEALTHSPRING MA|732.75||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicare|BCBS MEDICARE PPO MA|||||732.75||| 84154|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Medicare|MEDICARE ACUTE|732.75||||732.75||| 84155|EAP|0300|PROTEIN TOTAL|Medicaid|MEDICAID|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Medicare|MEDICARE ACUTE|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Medicare|MEDICARE PART B ONLY IP|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Managed Medicare|BCBS MEDICARE PPO MA|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Managed Medicare|WELLCARE CHOICE MA|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Managed Medicare|HEALTHSPRING MA|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|United Healthcare|UNITED HEALTHCARE OTHER|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|United Healthcare|UNITED HEALTHCARE|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|United Healthcare|TML GROUP BENEFITS|||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|United Medicare Advantage|UHC AARP MCR HMO MA|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Workers Compensation|ZURICH COMPANY|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Veterans Affairs|VETERANS ADMINISTRATION|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|United Healthcare|UNITED HEALTHCARE|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|PHCS|HUMANA|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Workers Compensation|WORKERS COMPENSATION OTHER|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA UMR|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Aetna|AETNA PPO|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|ChampVA|CHAMPVA CENTER|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Cigna|CIGNA|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Cigna|CIGNA OTHER|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Humana Medicare Advantage|HUMANA MA|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.74||||||| 84155|EAP|0300|PROTEIN TOTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.74||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Managed Medicaid|MEDICAID AMERIGROUP|||||0.74||| 84155|EAP|0300|PROTEIN TOTAL|Managed Medicaid|MEDICAID SUPERIOR|0.74||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|94.33||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Managed Medicaid|MEDICAID SUPERIOR|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE|Managed Medicaid|MEDICAID AMERIGROUP|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Managed Medicaid|MEDICAID AMERIGROUP|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Humana Medicare Advantage|HUMANA MA|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Humana Medicare Advantage|HUMANA MA|94.33||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Cigna|CIGNA OTHER|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Cigna|CIGNA OTHER|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|ChampVA|CHAMPVA CENTER|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Blue Cross PPO Specialty|BCBSTX PPO|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Blue Cross PPO Specialty|BCBSTX PPO|94.33||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Blue Cross PPO Specialty|BCBSTX OTHER|0.48||||||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Blue Cross HMO Specialty|BCBSTX HMO|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Blue Cross HMO Specialty|BCBSTX HMO|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Aetna|AETNA OTHER|94.33||||94.33||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Aetna|AETNA PPO|94.33||||||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|94.33||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Aetna|AETNA PPO|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Aetna|AETNA OTHER|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|94.33||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Access Direct Platinum|HEALTHFIRST TPA UMR|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Access Direct Platinum|HEALTHFIRST TPA|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Workers Compensation|TEXAS MUTUAL INSURANCE|94.33||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Veterans Affairs|VETERANS ADMINISTRATION|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Workers Compensation|WORKERS COMPENSATION OTHER|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|94.33||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|United Medicare Advantage|UHC AARP MCR HMO MA|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|United Medicare Advantage|UHC AARP MCR HMO MA|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Veterans Affairs|VETERANS ADMINISTRATION|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|United Medicare Advantage|UHC MEDICARE GOLD MA|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|United Healthcare|UNITED HEALTHCARE|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|United Healthcare|UNITED HEALTHCARE|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|United Healthcare|UNITED HEALTHCARE|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE|United Healthcare|UNITED HEALTHCARE OTHER|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|United Healthcare|UNITED HEALTHCARE|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE|United Healthcare|UNITED HEALTHCARE|94.33||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|United Healthcare|TML GROUP BENEFITS|94.33||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Aenta Medicare Advantage|AETNA MEDICARE MA|0.48||||||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|United Healthcare|UNITED HEALTHCARE OTHER|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|United Healthcare|UNITED HEALTHCARE OTHER|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|NON CONTRACTED|COMMERCIAL OTHER 1|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|NON CONTRACTED|COMMERCIAL OTHER 1|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|PHCS|HUMANA|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Tricare|TRICARE EAST REGION|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|PHCS|HUMANA|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|PHCS|HUMANA INSURANCE|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|PHCS|GROUP AND PENSION|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Rusk State Hospital|RUSK STATE HOSP|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE|Managed Medicare|BCBS MEDICARE PPO MA|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.48||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Managed Medicare|OTHER INSTITUTIONS|||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Humana Medicare Advantage|HUMANA MA|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Managed Medicaid|MEDICAID AMERIGROUP|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Managed Medicare|HEALTHSPRING MA|94.33||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Managed Medicare|HEALTHSPRING MA|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Managed Medicare|HEALTHSPRING MA|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Managed Medicare|WELLCARE CHOICE MA|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Managed Medicare|BCBS MEDICARE PPO MA|94.33||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Medicare|UTSW MC KIDNEY PROGRAM|||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Medicare|MEDICARE ACUTE|0.48||||0.48||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Medicare|MEDICARE ACUTE|94.33||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Medicare|MEDICARE ACUTE|0.48||||0.48||| 84156|EAP|0300|PROTEIN TOTAL URINE|Medicare|MEDICARE PART B ONLY IP|0.48||||||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Medicare|UTSW MC KIDNEY PROGRAM|||||94.33||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Medicaid|MEDICAID|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Medicaid|SMITH COUNTY JAIL|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.48||||||| 84156|EAP|0300|ASSAY OF PROTEIN URINE|Medicaid|MEDICAID|94.33||||||| 84156|EAP|0300|PROTEIN TOTAL URINE 24 HR|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.48||||||| 84156|EAP|0300|PROTEIN TOTAL URINE|Medicaid|MEDICAID|0.48||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Medicaid|SMITH COUNTY JAIL|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Medicare|MEDICARE ACUTE|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Managed Medicare|HEALTHSPRING MA|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Managed Medicare|BCBS MEDICARE PPO MA|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|PHCS|HUMANA|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Tricare|TRICARE FOR LIFE|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|NON CONTRACTED|COMMERCIAL OTHER 1|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|United Healthcare|TML GROUP BENEFITS|||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|United Healthcare|UNITED HEALTHCARE OTHER|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|United Healthcare|UNITED HEALTHCARE|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|United Medicare Advantage|UHC MEDICARE GOLD MA|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|United Medicare Advantage|UHC AARP MCR HMO MA|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Veterans Affairs|VETERANS ADMINISTRATION|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Access Direct Platinum|HEALTHFIRST TPA|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Aenta Medicare Advantage|AETNA MEDICARE MA|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Aetna|AETNA PPO|||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Aetna|AETNA QHP HMO|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Aetna|AETNA OTHER|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Medicare|MEDICARE PART B ONLY IP|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Blue Cross HMO Specialty|BCBSTX HMO|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Medicaid|MEDICAID|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|ChampVA|CHAMPVA CENTER|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Blue Cross PPO Specialty|BCBSTX PPO|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Cigna|CIGNA|0.74||||||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Cigna|CIGNA OTHER|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Humana Medicare Advantage|HUMANA MA|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Managed Medicaid|MEDICAID SUPERIOR|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.74||||0.74||| 84157|EAP|0300|PROTEIN TOTAL, OTHER SOUR|Managed Medicaid|MEDICAID AMERIGROUP|0.74||||0.74||| 84165|EAP|0300|PROT ELECTROPHORESIS|Managed Medicaid|MEDICAID SUPERIOR|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.28||||4.28||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Managed Medicaid|MEDICAID AMERIGROUP|||||4.28||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Humana Medicare Advantage|HUMANA MA|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Humana Medicare Advantage|HUMANA MA|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Cigna|CIGNA OTHER|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.28||||4.28||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Blue Cross PPO Specialty|BCBSTX PPO|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|ChampVA|CHAMPVA CENTER|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Blue Cross HMO Specialty|BCBSTX HMO|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Aenta Medicare Advantage|AETNA MEDICARE MA|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Aenta Medicare Advantage|AETNA MEDICARE MA|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Aetna|AETNA PPO|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Aetna|AETNA OTHER|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Access Direct Platinum|HEALTHFIRST TPA UMR|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Access Direct Platinum|HEALTHFIRST TPA|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Access Direct Platinum|HEALTHFIRST TPA UMR|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Veterans Affairs|VETERANS ADMINISTRATION|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Workers Compensation|ZURICH COMPANY|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Veterans Affairs|VETERANS ADMINISTRATION|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.28||||4.28||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|United Medicare Advantage|UHC MEDICARE GOLD MA|4.28||||4.28||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|United Medicare Advantage|UHC AARP MCR HMO MA|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|United Medicare Advantage|UHC AARP MCR HMO MA|4.28||||4.28||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|United Medicare Advantage|UHC MEDICARE GOLD MA|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|United Healthcare|UNITED HEALTHCARE OTHER|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|United Healthcare|UNITED HEALTHCARE|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|United Healthcare|UNITED HEALTHCARE|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Blue Cross PPO Specialty|BCBSTX PPO|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|United Healthcare|TML GROUP BENEFITS|||||4.28||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|United Healthcare|UNITED HEALTHCARE|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Cigna|CIGNA|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|NON CONTRACTED|COMMERCIAL OTHER 1|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|PHCS|HUMANA|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Managed Medicare|HEALTHSPRING MA|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Managed Medicare|WELLCARE CHOICE MA|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Managed Medicare|HEALTHSPRING MA|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Managed Medicare|BCBS MEDICARE PPO MA|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Medicare|MEDICARE PART B ONLY IP|4.28||||||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Medicare|MEDICARE ACUTE|4.28||||4.28||| 84165|EAP|0300|PROT ELECTROPHORESIS|Medicare|MEDICARE ACUTE|4.28||||4.28||| 84165|EAP|0300|PROTEIN ELECTROPHORETIC|Medicaid|MEDICAID|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Medicaid|MEDICAID|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.28||||||| 84165|EAP|0300|PROT ELECTROPHORESIS|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.28||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Medicaid|MEDICAID|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Medicare|MEDICARE ACUTE|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Managed Medicare|HEALTHSPRING MA|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|PHCS|HUMANA INSURANCE|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|PHCS|HUMANA|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|United Healthcare|UNITED HEALTHCARE|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|NON CONTRACTED|COMMERCIAL OTHER 1|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|United Medicare Advantage|UHC AARP MCR HMO MA|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|United Medicare Advantage|UHC MEDICARE GOLD MA|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Veterans Affairs|VETERANS ADMINISTRATION|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Access Direct Platinum|HEALTHFIRST TPA UMR|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Aenta Medicare Advantage|AETNA MEDICARE MA|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Aetna|AETNA OTHER|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Blue Cross PPO Specialty|BCBSTX PPO|1.46||||1.46||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|ChampVA|CHAMPVA CENTER|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Cigna|CIGNA OTHER|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Humana Medicare Advantage|HUMANA MA|1.46||||1.46||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.46||||||| 84166|EAP|0300|PROTEIN URINE ELECTROPHOR|Managed Medicaid|MEDICAID AMERIGROUP|||||1.46||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Humana Medicare Advantage|HUMANA MA|691.25||||691.25||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Blue Cross HMO Specialty|BCBSTX HMO|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Blue Cross PPO Specialty|BCBSTX PPO|691.25||||691.25||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Blue Cross PPO Specialty|BCBSTX OTHER|691.25||||||| 84182|EAP|0300|NEURONAL (HU) NUCLEAR AB|Blue Cross PPO Specialty|BCBSTX PPO|691.25||||3.63||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Aenta Medicare Advantage|AETNA MEDICARE MA|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Veterans Affairs|VETERANS ADMINISTRATION|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|United Medicare Advantage|UHC AARP MCR HMO MA|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|United Medicare Advantage|UHC MEDICARE GOLD MA|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|UTMB|UTMB CORRECTIONAL MANAGED CARE|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Tricare|TRICARE FOR LIFE|691.25||||||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Managed Medicare|HEALTHSPRING MA|||||691.25||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Medicare|MEDICARE ACUTE|3.63||||691.25||| 84182|EAP|0300|PARANEOPLASTIC AUTOAB WB|Medicare|MEDICARE ACUTE|691.25||||691.25||| 842|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|36,395.04|13571.16|13571.16|9760.75|||| 842|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|52,979.19|9760.75|13571.16|9760.75|||| 84206|EAP|0300|PROINSULIN|United Medicare Advantage|UHC MEDICARE GOLD MA|1,076.50||||||| 84206|EAP|0300|PROINSULIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,076.50||||||| 84206|EAP|0300|PROINSULIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,076.50||||||| 84207|EAP|0300|VITAMIN B6 PYRIDOXAL PHOS|Medicare|MEDICARE ACUTE|1,119.50||||1,119.50||| 84207|EAP|0300|VITAMIN B6 PYRIDOXAL PHOS|Tricare|TRICARE EAST REGION|||||1,119.50||| 84207|EAP|0300|VITAMIN B6 PYRIDOXAL PHOS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,119.50||| 84207|EAP|0300|VITAMIN B6 PYRIDOXAL PHOS|Blue Cross PPO Specialty|BCBSTX OTHER|1,119.50||||||| 84207|EAP|0300|VITAMIN B6 PYRIDOXAL PHOS|Blue Cross PPO Specialty|BCBSTX PPO|1,119.50||||||| 84207|EAP|0300|VITAMIN B6 PYRIDOXAL PHOS|Humana Medicare Advantage|HUMANA MA|1,119.50||||||| 84207|EAP|0300|VITAMIN B6 PYRIDOXAL PHOS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,119.50||| 84220|EAP|0300|PYRUVATE KINASE|Aetna|AETNA PPO|||||375.75||| 84244|EAP|0300|RENIN|United Healthcare|UNITED HEALTHCARE OTHER|||||4.88||| 84244|EAP|0300|RENIN|Medicaid|MEDICAID|4.88||||||| 84244|EAP|0300|RENIN|Medicare|MEDICARE ACUTE|4.88||||||| 84244|EAP|0300|RENIN|Access Direct Platinum|HEALTHFIRST TPA UMR|4.88||||||| 84244|EAP|0300|RENIN|United Medicare Advantage|UHC AARP MCR HMO MA|4.88||||||| 84244|EAP|0300|RENIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.88||||||| 84244|EAP|0300|RENIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.88||||||| 84244|EAP|0300|RENIN|Cigna|CIGNA|4.88||||||| 84244|EAP|0300|RENIN|Humana Medicare Advantage|HUMANA MA|4.88||||||| 84244|EAP|0300|RENIN|Blue Cross HMO Specialty|BCBSTX HMO|4.88||||||| 84244|EAP|0300|RENIN|Blue Cross PPO Specialty|BCBSTX PPO|4.88||||||| 84244|EAP|0300|RENIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.88||||||| 84244|EAP|0300|RENIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.88||| 84244|EAP|0300|RENIN|Aetna|AETNA OTHER|4.88||||||| 84260|EAP|0300|SEROTONIN|Blue Cross PPO Specialty|BCBSTX PPO|693.75||||||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicare|BCBS MEDICARE PPO MA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Medicare|MEDICARE ACUTE|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|NON CONTRACTED|COMMERCIAL OTHER 1|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|PHCS|HUMANA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Healthcare|UNITED HEALTHCARE OTHER|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Medicare Advantage|UHC AARP MCR HMO MA|150.25||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Veterans Affairs|VETERANS ADMINISTRATION|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Access Direct Platinum|HEALTHFIRST TPA UMR|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Healthcare|UNITED HEALTHCARE|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|150.25||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Access Direct Platinum|HEALTHFIRST TPA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Humana Medicare Advantage|HUMANA MA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicare|HEALTHSPRING MA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Cigna|CIGNA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|150.25||||||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Aenta Medicare Advantage|AETNA MEDICARE MA|150.25||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Aetna|AETNA OTHER|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Aetna|ZZZZZ AETNA|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Aetna|AETNA PPO|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Aetna Value Network|AETNA VALUE NETWORK|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross HMO Specialty|BCBSTX HMO|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross PPO Specialty|BCBSTX PPO|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross PPO Specialty|BCBSTX OTHER|||||150.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||150.25||| 84295|EAP|0300|SODIUM|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.97||| 84295|EAP|0300|SODIUM|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.97||| 84295|EAP|0300|SODIUM|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||0.97||| 84295|EAP|0300|SODIUM|Blue Cross HMO Specialty|BCBSTX HMO|0.97||||0.97||| 84295|EAP|0300|SODIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.97||||0.97||| 84295|EAP|0300|SODIUM|Aenta Medicare Advantage|AETNA MEDICARE MA|0.97||||0.97||| 84295|EAP|0300|SODIUM|Aetna|AETNA OTHER|0.97||||0.97||| 84295|EAP|0300|SODIUM|Aetna|AETNA QHP HMO|0.97||||||| 84295|EAP|0300|SODIUM|Aetna|BOON CHAPMAN|||||0.97||| 84295|EAP|0300|SODIUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.97||||0.97||| 84295|EAP|0300|SODIUM|Managed Medicaid|MEDICAID AMERIGROUP|0.97||||0.97||| 84295|EAP|0300|SODIUM|Managed Medicaid|MEDICAID SUPERIOR|0.97||||0.97||| 84295|EAP|0300|SODIUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.97||||0.97||| 84295|EAP|0300|SODIUM|Cigna|CIGNA OTHER|||||0.97||| 84295|EAP|0300|SODIUM|Cigna|CIGNA|0.97||||0.97||| 84295|EAP|0300|SODIUM|Humana Medicare Advantage|HUMANA MA|0.97||||0.97||| 84295|EAP|0300|SODIUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.97||| 84295|EAP|0300|SODIUM|Access Direct Platinum|HEALTHFIRST TPA UMR|0.97||||0.97||| 84295|EAP|0300|SODIUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.97||||0.97||| 84295|EAP|0300|SODIUM|Access Direct Platinum|HEALTHFIRST TPA|0.97||||0.97||| 84295|EAP|0300|SODIUM|Workers Compensation|BROOKSHIRES WORKERS COMP|0.97||||||| 84295|EAP|0300|SODIUM|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||0.97||| 84295|EAP|0300|SODIUM|Workers Compensation|UT EMPLOYEE INJURY|||||0.97||| 84295|EAP|0300|SODIUM|Veterans Affairs|VETERANS ADMINISTRATION|0.97||||0.97||| 84295|EAP|0300|SODIUM|Workers Compensation|TEXAS MUTUAL INSURANCE|||||0.97||| 84295|EAP|0300|SODIUM|United Medicare Advantage|UHC MEDICARE GOLD MA|0.97||||0.97||| 84295|EAP|0300|SODIUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.97||||0.97||| 84295|EAP|0300|SODIUM|United Medicare Advantage|UHC AARP MCR HMO MA|0.97||||0.97||| 84295|EAP|0300|SODIUM|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.97||| 84295|EAP|0300|SODIUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.97||||||| 84295|EAP|0300|SODIUM|United Healthcare|TML GROUP BENEFITS|0.97||||0.97||| 84295|EAP|0300|SODIUM|Workers Compensation|WORKERS COMPENSATION OTHER|0.97||||0.97||| 84295|EAP|0300|SODIUM|United Healthcare|UNITED HEALTHCARE|||||0.97||| 84295|EAP|0300|SODIUM|United Healthcare|UNITED HEALTHCARE|0.97||||0.97||| 84295|EAP|0300|SODIUM|United Healthcare|UNITED HEALTHCARE OTHER|0.97||||0.97||| 84295|EAP|0300|SODIUM|Tricare|TRICARE SOUTH PHYSICIAN|||||0.97||| 84295|EAP|0300|SODIUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.97||||0.97||| 84295|EAP|0300|SODIUM|Cigna|CIGNA|||||0.97||| 84295|EAP|0300|SODIUM|PHCS|HUMANA|||||0.97||| 84295|EAP|0300|SODIUM|Tricare|TRICARE EAST REGION|0.97||||0.97||| 84295|EAP|0300|SODIUM|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.97||| 84295|EAP|0300|SODIUM|Rusk State Hospital|RUSK STATE HOSP|||||0.97||| 84295|EAP|0300|SODIUM|PHCS|GROUP AND PENSION|||||0.97||| 84295|EAP|0300|SODIUM|PHCS|HUMANA INSURANCE|||||0.97||| 84295|EAP|0300|SODIUM|Multiplan|WEB TPA|||||0.97||| 84295|EAP|0300|SODIUM|NON CONTRACTED|COMMERCIAL OTHER 1|0.97||||0.97||| 84295|EAP|0300|SODIUM|Aetna|AETNA PPO|0.97||||0.97||| 84295|EAP|0300|SODIUM|NON CONTRACTED|COMMERCIAL OTHER 2|0.97||||0.97||| 84295|EAP|0300|SODIUM|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.97||||0.97||| 84295|EAP|0300|SODIUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.97||| 84295|EAP|0300|SODIUM|Medicaid|LAW ENFORCEMENT OTHER|||||0.97||| 84295|EAP|0300|SODIUM|Aetna Value Network|AETNA VALUE NETWORK|||||0.97||| 84295|EAP|0300|SODIUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.97||| 84295|EAP|0300|SODIUM|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.97||||||| 84295|EAP|0300|SODIUM|Medicaid|MEDICAID|0.97||||0.97||| 84295|EAP|0300|SODIUM|Medicaid|MEDICAID HMO|||||0.97||| 84295|EAP|0300|SODIUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.97||||0.97||| 84295|EAP|0300|SODIUM|Medicaid|CRIME VICTIMS COMPENSATION|0.97||||||| 84295|EAP|0300|SODIUM|Medicare|UTSW MC KIDNEY PROGRAM|||||0.97||| 84295|EAP|0300|SODIUM|Medicare|MEDICARE ACUTE|0.97||||0.97||| 84295|EAP|0300|SODIUM|Medicare|MEDICARE PART B ONLY IP|0.97||||||| 84295|EAP|0300|SODIUM|Managed Medicare|OTHER INSTITUTIONS|||||0.97||| 84295|EAP|0300|SODIUM|Managed Medicare|BCBS MEDICARE PPO MA|0.97||||0.97||| 84295|EAP|0300|SODIUM|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.97||| 84295|EAP|0300|SODIUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.97||||0.97||| 84295|EAP|0300|SODIUM|Managed Medicare|HEALTHSPRING MA|0.97||||0.97||| 84295|EAP|0300|SODIUM|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.97||| 843|DRG||OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W MCC|Medicare|MEDICARE ACUTE|118,748.77|11970.98|11970.98|11970.98|||| 84300|EAP|0300|SODIUM URINE|United Medicare Advantage|UHC AARP MCR HMO MA|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.97||||||| 84300|EAP|0300|SODIUM URINE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.97||||||| 84300|EAP|0300|SODIUM URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Access Direct Platinum|HEALTHFIRST TPA|0.97||||||| 84300|EAP|0300|SODIUM URINE|Humana Medicare Advantage|HUMANA MA|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Cigna|CIGNA|0.97||||||| 84300|EAP|0300|SODIUM URINE|Cigna|CIGNA OTHER|0.97||||||| 84300|EAP|0300|SODIUM URINE|Managed Medicaid|MEDICAID SUPERIOR|0.97||||||| 84300|EAP|0300|SODIUM URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Managed Medicaid|MEDICAID AMERIGROUP|0.97||||||| 84300|EAP|0300|SODIUM URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.97||||||| 84300|EAP|0300|SODIUM URINE|Aetna|AETNA PPO|0.97||||||| 84300|EAP|0300|SODIUM URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Blue Cross HMO Specialty|BCBSTX HMO|0.97||||||| 84300|EAP|0300|SODIUM URINE|Aetna|AETNA OTHER|0.97||||||| 84300|EAP|0300|SODIUM URINE|Blue Cross PPO Specialty|BCBSTX OTHER|0.97||||||| 84300|EAP|0300|SODIUM URINE|Blue Cross PPO Specialty|BCBSTX PPO|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.97||||||| 84300|EAP|0300|SODIUM URINE|NON CONTRACTED|COMMERCIAL OTHER 1|0.97||||||| 84300|EAP|0300|SODIUM URINE|Rusk State Hospital|RUSK STATE HOSP|0.97||||||| 84300|EAP|0300|SODIUM URINE|PHCS|HUMANA|0.97||||||| 84300|EAP|0300|SODIUM URINE|Magellan Behavioral Health|BH MAGELLAN|0.97||||||| 84300|EAP|0300|SODIUM URINE|PHCS|GROUP AND PENSION|0.97||||||| 84300|EAP|0300|SODIUM URINE|Tricare|TRICARE EAST REGION|0.97||||||| 84300|EAP|0300|SODIUM URINE|United Healthcare|UNITED HEALTHCARE OTHER|0.97||||||| 84300|EAP|0300|SODIUM URINE|United Healthcare|UNITED HEALTHCARE|0.97||||||| 84300|EAP|0300|SODIUM URINE|United Healthcare|GOLDEN RULE|0.97||||||| 84300|EAP|0300|SODIUM URINE|United Healthcare|UNITED HEALTHCARE|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.97||||187.25||| 84300|EAP|0300|SODIUM URINE|Veterans Affairs|VETERANS ADMINISTRATION|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|United Healthcare|TML GROUP BENEFITS|0.97||||||| 84300|EAP|0300|SODIUM URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Managed Medicare|BCBS MEDICARE PPO MA|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.97||||||| 84300|EAP|0300|SODIUM URINE|Managed Medicare|WELLCARE CHOICE MA|0.97||||||| 84300|EAP|0300|SODIUM URINE|Managed Medicare|MA PART B ONLY IP|0.97||||||| 84300|EAP|0300|SODIUM URINE|Managed Medicare|HEALTHSPRING MA|0.97||||||| 84300|EAP|0300|SODIUM URINE|Medicaid|SMITH COUNTY JAIL|0.97||||||| 84300|EAP|0300|SODIUM URINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.97||||||| 84300|EAP|0300|SODIUM URINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.97||||||| 84300|EAP|0300|SODIUM URINE|Medicaid|MEDICAID|0.97||||||| 84300|EAP|0300|SODIUM URINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.97||||||| 84300|EAP|0300|SODIUM URINE|Medicare|MEDICARE ACUTE|0.97||||0.97||| 84300|EAP|0300|SODIUM URINE|Medicare|MEDICARE PART B ONLY IP|0.97||||||| 84302|EAP|0300|SODIUM STOOL/PLEURAL FLUI|Medicare|MEDICARE ACUTE|26.53||||||| 84302|EAP|0300|SODIUM STOOL/PLEURAL FLUI|Blue Cross PPO Specialty|BCBSTX PPO|26.53||||||| 84302|EAP|0300|SODIUM STOOL/PLEURAL FLUI|Humana Medicare Advantage|HUMANA MA|26.53||||||| 84302|EAP|0300|SODIUM STOOL/PLEURAL FLUI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|26.53||||||| 84305|EAP|0300|SOMATOMEDIN C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.35||||||| 84392|EAP|0300|SULFATE URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||182.25||| 844|DRG||OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC|NON CONTRACTED|COMMERCIAL OTHER 1|45,429.20|15586.82|15586.82|6804.03|||| 844|DRG||OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC|Blue Cross HMO Specialty|BCBSTX HMO|60,229.11|6804.03|15586.82|6804.03|||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|United Medicare Advantage|UHC AARP MCR HMO MA|1,014.50||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Veterans Affairs|VETERANS ADMINISTRATION|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,014.50||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Access Direct Platinum|HEALTHFIRST TPA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,014.50||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Managed Medicaid|MEDICAID SUPERIOR|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Managed Medicaid|MEDICAID AMERIGROUP|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Cigna|CIGNA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Humana Medicare Advantage|HUMANA MA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Blue Cross HMO Specialty|BCBSTX HMO|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Blue Cross PPO Specialty|BCBSTX PPO|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Aenta Medicare Advantage|AETNA MEDICARE MA|1,014.50||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Aetna|AETNA PPO|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Aetna|ZZZZZ AETNA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Aetna|AETNA OTHER|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Aetna Value Network|AETNA VALUE NETWORK|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Managed Medicare|BCBS MEDICARE PPO MA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Managed Medicare|HEALTHSPRING MA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Medicare|MEDICARE PART B ONLY IP|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|Medicare|MEDICARE ACUTE|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|United Healthcare|UNITED HEALTHCARE OTHER|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|United Healthcare|UNITED HEALTHCARE|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|PHCS|HUMANA|||||1,014.50||| 84402|EAP|0300|TESTERONE, FREE AND WEAK|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,014.50||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Healthcare|UNITED HEALTHCARE OTHER|||||5.73||| 84403|EAP|0300|TESTOSTERONE TOTAL|Medicare|MEDICARE ACUTE|5.73||||||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.73||||||| 84403|EAP|0300|TESTOSTERONE TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.73||||||| 84403|EAP|0300|TESTOSTERONE TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|5.73||||||| 84403|EAP|0300||Blue Cross PPO Specialty|BCBSTX PPO|||||1,014.50||| 84403|EAP|0300|TESTOSTERONE TOTAL|Humana Medicare Advantage|HUMANA MA|||||5.73||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.73||||||| 84403|EAP|0300|TESTOSTERONE TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.73||| 84403|EAP|0300|TESTOSTERONE TOTAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.73||||||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Medicare Advantage|UHC AARP MCR HMO MA|5.73||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|United Medicare Advantage|UHC AARP MCR HMO MA|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.71||| 84425|EAP|0300|THIAMINE VITAMIN B1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|Managed Medicaid|MEDICAID AMERIGROUP|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|Cigna|CIGNA|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|Humana Medicare Advantage|HUMANA MA|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|Blue Cross PPO Specialty|BCBSTX PPO|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|Blue Cross PPO Specialty|BCBSTX OTHER|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|Aenta Medicare Advantage|AETNA MEDICARE MA|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.71||||2.71||| 84425|EAP|0300|THIAMINE VITAMIN B1|Medicare|MEDICARE ACUTE|2.71||||2.71||| 84425|EAP|0300|THIAMINE VITAMIN B1|NON CONTRACTED|COMMERCIAL OTHER 1|2.71||||||| 84425|EAP|0300|THIAMINE VITAMIN B1|Tricare|TRICARE EAST REGION|||||2.71||| 84436|EAP|0300|THYROXINE TOTAL T4|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|United Healthcare|GOLDEN RULE|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|United Healthcare|TML GROUP BENEFITS|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|United Healthcare|UNITED HEALTHCARE OTHER|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Tricare|TRICARE EAST REGION|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|PHCS|HUMANA|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Optum Behavioral Health|BH OPTUM UHC|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Managed Medicare|BCBS MEDICARE PPO MA|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Medicaid|CRIME VICTIMS COMPENSATION|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Medicaid|MEDICAID|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Medicare|MEDICARE ACUTE|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Medicare|MEDICARE PART B ONLY IP|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Aenta Medicare Advantage|AETNA MEDICARE MA|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Aetna|AETNA OTHER|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Aetna|AETNA PPO|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Blue Cross HMO Specialty|BCBSTX HMO|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Managed Medicare|HEALTHSPRING MA|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Blue Cross PPO Specialty|BCBSTX PPO|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|ChampVA|CHAMPVA CENTER|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Humana Medicare Advantage|HUMANA MA|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Magellan Behavioral Health|BH MAGELLAN|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|Cigna|CIGNA|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Managed Medicaid|MEDICAID SUPERIOR|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Managed Medicaid|MEDICAID AMERIGROUP|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Workers Compensation|TEXAS MUTUAL INSURANCE|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|United Healthcare|UNITED HEALTHCARE|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Veterans Affairs|VETERANS ADMINISTRATION|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|Access Direct Platinum|HEALTHFIRST TPA|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|United Medicare Advantage|UHC AARP MCR HMO MA|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.52||||||| 84436|EAP|0300|THYROXINE TOTAL T4|United Medicare Advantage|UHC MEDICARE GOLD MA|1.52||||1.52||| 84436|EAP|0300|THYROXINE TOTAL T4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.52||||1.52||| 84439|EAP|0300|THYROXINE FREE T4|United Medicare Advantage|UHC MEDICARE GOLD MA|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|United Medicare Advantage|UHC AARP MCR HMO MA|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Access Direct Platinum|HEALTHFIRST TPA|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Access Direct Platinum|HEALTHFIRST TPA UMR|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Access Direct Platinum|ANDREWS CENTER|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Workers Compensation|BROOKSHIRES WORKERS COMP|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Veterans Affairs|VETERANS ADMINISTRATION|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Managed Medicaid|MEDICAID AMERIGROUP|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Managed Medicaid|MEDICAID SUPERIOR|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Cigna Behavioral Health|BH CIGNA|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Cigna|CIGNA|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Magellan Behavioral Health|BH MAGELLAN|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Humana Medicare Advantage|HUMANA MA|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Blue Cross PPO Specialty|BCBSTX PPO|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Blue Cross PPO Specialty|BCBSTX OTHER|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|ChampVA|CHAMPVA CENTER|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Blue Cross HMO Specialty|BCBSTX HMO|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Aenta Medicare Advantage|AETNA MEDICARE MA|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Cigna|CIGNA|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Aetna|AETNA OTHER|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Aetna|AETNA PPO|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Aetna|BH AETNA|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Workers Compensation|WORKERS COMPENSATION OTHER|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Medicare|MEDICARE ACUTE|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Medicare|MEDICARE PART B ONLY IP|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Medicaid|MOLINA HEALTHCARE OF TEXAS|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Medicaid|MEDICAID|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Medicaid|BH TEXAS CHILDRENS MEDICAID|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Managed Medicare|HEALTHSPRING MA|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Managed Medicare|BCBS MEDICARE PPO MA|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Multiplan|WEB TPA|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|NON CONTRACTED|COMMERCIAL OTHER 1|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|NON CONTRACTED|COMMUNITY HEALTH CENTER|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|PHCS|HUMANA|||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|Optum Behavioral Health|BH OPTUM UHC|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|PHCS|HUMANA INSURANCE|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|Tricare|TRICARE EAST REGION|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|United Healthcare|GOLDEN RULE|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|United Healthcare|UNITED HEALTHCARE OTHER|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|United Healthcare|UNITED HEALTHCARE|359.25||||||| 84439|EAP|0300|THYROXINE FREE T4|United Healthcare|UNITED HEALTHCARE|359.25||||359.25||| 84439|EAP|0300|THYROXINE FREE T4|UTMB|UTMB CORRECTIONAL MANAGED CARE|359.25||||||| 84442|EAP|0300|THYROXINE BINDING GLOBULN|Medicare|MEDICARE ACUTE|589.25||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aenta Medicare Advantage|AETNA MEDICARE MA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aetna|AETNA OTHER|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aetna|BH AETNA|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aetna|AETNA PPO|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross PPO Specialty|BCBSTX PPO|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross PPO Specialty|BCBSTX OTHER|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|ChampVA|CHAMPVA CENTER|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Humana Medicare Advantage|HUMANA MA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Magellan Behavioral Health|BH MAGELLAN|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Cigna Behavioral Health|BH CIGNA|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Cigna|CIGNA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Cigna|CIGNA OTHER|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID AMERIGROUP|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Workers Compensation|TEXAS MUTUAL INSURANCE|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Workers Compensation|UT EMPLOYEE INJURY|||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Workers Compensation|WORKERS COMPENSATION OTHER|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Veterans Affairs|VETERANS ADMINISTRATION|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA UMR|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|ANDREWS CENTER|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC MEDICARE GOLD MA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC AARP MCR HMO MA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|TML GROUP BENEFITS|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|GEHA|||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|GOLDEN RULE|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|UNITED HEALTHCARE OTHER|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Workers Compensation|BROOKSHIRES WORKERS COMP|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|UNITED HEALTHCARE|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Rusk State Hospital|RUSK STATE HOSP|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Tricare|TRICARE EAST REGION|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|PHCS|HUMANA INSURANCE|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID SUPERIOR|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Optum Behavioral Health|BH OPTUM UHC|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|PHCS|GROUP AND PENSION|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|PHCS|HUMANA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|NON CONTRACTED|COMMERCIAL OTHER 1|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Multiplan|WEB TPA|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|NON CONTRACTED|COMMUNITY HEALTH CENTER|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|HEALTHSPRING MA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|JACKSONVILLE ACCESS|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|BCBS MEDICARE PPO MA|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|MA PART B ONLY IP|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross HMO Specialty|BCBSTX HMO|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aetna|AETNA QHP HMO|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|BH TEXAS CHILDRENS MEDICAID|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MEDICAID|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|SUPERIOR HEALTHPLAN CHIP|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|SMITH COUNTY JAIL|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MEDICAID HMO|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|CRIME VICTIMS COMPENSATION|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|LAW ENFORCEMENT OTHER|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.73||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicare|MEDICARE PART B ONLY IP|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicare|MEDICARE ACUTE|3.73||||3.73||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicare|UTSW MC KIDNEY PROGRAM|||||3.73||| 84445|EAP|0300|AB THYROID STIMULATING|Medicare|MEDICARE ACUTE|14.31||||14.31||| 84445|EAP|0300|AB THYROID STIMULATING|Managed Medicare|HEALTHSPRING MA|14.31||||||| 84445|EAP|0300|AB THYROID STIMULATING|UTMB|UTMB CORRECTIONAL MANAGED CARE|14.31||||||| 84445|EAP|0300|AB THYROID STIMULATING|United Medicare Advantage|UHC MEDICARE GOLD MA|14.31||||||| 84445|EAP|0300|AB THYROID STIMULATING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|14.31||||||| 84445|EAP|0300|AB THYROID STIMULATING|Managed Medicaid|MEDICAID SUPERIOR|14.31||||||| 84445|EAP|0300|AB THYROID STIMULATING|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|14.31||||||| 84445|EAP|0300|AB THYROID STIMULATING|Magellan Behavioral Health|BH MAGELLAN|14.31||||||| 84445|EAP|0300|AB THYROID STIMULATING|Blue Cross PPO Specialty|BCBSTX PPO|14.31||||||| 84446|EAP|0300|VITAMIN E|United Medicare Advantage|UHC AARP MCR HMO MA|564.75||||||| 84450|EAP|0300|SGOT (AST)|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.44||| 84450|EAP|0300|SGOT (AST)|Medicare|MEDICARE ACUTE|0.44||||0.44||| 84450|EAP|0300|SGOT (AST)|United Healthcare|UNITED HEALTHCARE|0.44||||||| 84450|EAP|0300|SGOT (AST)|United Healthcare|UNITED HEALTHCARE OTHER|0.44||||||| 84450|EAP|0300|SGOT (AST)|Managed Medicare|HEALTHSPRING MA|||||0.44||| 84450|EAP|0300|SGOT (AST)|Medicaid|MEDICAID|0.44||||||| 84450|EAP|0300|SGOT (AST)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.44||||0.44||| 84450|EAP|0300|SGOT (AST)|Blue Cross HMO Specialty|BCBSTX HMO|||||0.44||| 84450|EAP|0300|SGOT (AST)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.44||||||| 84450|EAP|0300|SGOT (AST)|Blue Cross PPO Specialty|BCBSTX PPO|0.44||||0.44||| 84450|EAP|0300|SGOT (AST)|Managed Medicaid|MEDICAID AMERIGROUP|0.44||||0.44||| 84450|EAP|0300|SGOT (AST)|Managed Medicaid|MEDICAID SUPERIOR|0.44||||0.44||| 84450|EAP|0300|SGOT (AST)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.44||||0.44||| 84450|EAP|0300|SGOT (AST)|United Medicare Advantage|UHC MEDICARE GOLD MA|0.44||||0.44||| 84460|EAP|0300|SGPT|United Medicare Advantage|UHC AARP MCR HMO MA|0.44||||||| 84460|EAP|0300|SGPT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.44||||0.44||| 84460|EAP|0300|SGPT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.44||||0.44||| 84460|EAP|0300|SGPT|Managed Medicaid|MEDICAID SUPERIOR|0.44||||0.44||| 84460|EAP|0300|SGPT|Managed Medicaid|MEDICAID AMERIGROUP|0.44||||0.44||| 84460|EAP|0300|SGPT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.44||||||| 84460|EAP|0300|SGPT|Blue Cross PPO Specialty|BCBSTX PPO|0.44||||0.44||| 84460|EAP|0300|SGPT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.44||| 84460|EAP|0300|SGPT|Medicaid|MEDICAID|0.44||||||| 84460|EAP|0300|SGPT|United Healthcare|UNITED HEALTHCARE|0.44||||||| 84460|EAP|0300|SGPT|United Healthcare|UNITED HEALTHCARE OTHER|0.44||||||| 84460|EAP|0300|SGPT|Medicare|MEDICARE ACUTE|0.44||||0.44||| 84460|EAP|0300|SGPT|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.44||| 84466|EAP|0300|TRANSFERRIN|Medicare|MEDICARE ACUTE|1.86||||1.86||| 84466|EAP|0300|TRANSFERRIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.86||||||| 84466|EAP|0300|TRANSFERRIN|Managed Medicare|HEALTHSPRING MA|1.86||||||| 84466|EAP|0300|TRANSFERRIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.86||||||| 84466|EAP|0300|TRANSFERRIN|Medicaid|MEDICAID|1.86||||||| 84466|EAP|0300|TRANSFERRIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.86||||||| 84466|EAP|0300|TRANSFERRIN|Humana Medicare Advantage|HUMANA MA|1.86||||||| 84466|EAP|0300|TRANSFERRIN|Managed Medicaid|MEDICAID AMERIGROUP|1.86||||||| 84466|EAP|0300|TRANSFERRIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.86||||||| 84466|EAP|0300|TRANSFERRIN|Veterans Affairs|VETERANS ADMINISTRATION|1.86||||||| 84466|EAP|0300|TRANSFERRIN|Access Direct Platinum|HEALTHFIRST TPA|1.86||||||| 84466|EAP|0300|TRANSFERRIN|United Medicare Advantage|UHC MEDICARE GOLD MA|1.86||||1.86||| 84466|EAP|0300|TRANSFERRIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.86||||||| 84478|EAP|0300|TRIGLYCERIDES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|United Medicare Advantage|UHC AARP MCR HMO MA|1.16||||1.16||| 84478|EAP|0300|TRIGLYCERIDES|United Medicare Advantage|UHC MEDICARE GOLD MA|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.16||| 84478|EAP|0300|TRIGLYCERIDES|Access Direct Platinum|HEALTHFIRST TPA|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Veterans Affairs|VETERANS ADMINISTRATION|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.16||||1.16||| 84478|EAP|0300|TRIGLYCERIDES|Humana Medicare Advantage|HUMANA MA|1.16||||1.16||| 84478|EAP|0300|TRIGLYCERIDES|Blue Cross HMO Specialty|BCBSTX HMO|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|ChampVA|CHAMPVA CENTER|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Blue Cross PPO Specialty|BCBSTX PPO|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Aetna|AETNA OTHER|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Aenta Medicare Advantage|AETNA MEDICARE MA|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Aetna|AETNA QHP HMO|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.16||||1.16||| 84478|EAP|0300|TRIGLYCERIDES|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.16||| 84478|EAP|0300|TRIGLYCERIDES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Medicaid|MEDICAID|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.16||||1.16||| 84478|EAP|0300|TRIGLYCERIDES|Managed Medicare|BCBS MEDICARE PPO MA|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Managed Medicare|HEALTHSPRING MA|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Managed Medicare|OTHER INSTITUTIONS|||||1.16||| 84478|EAP|0300|TRIGLYCERIDES|United Healthcare|UNITED HEALTHCARE|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|United Healthcare|UNITED HEALTHCARE OTHER|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|PHCS|HUMANA|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Medicare|MEDICARE ACUTE|1.16||||1.16||| 84478|EAP|0300|TRIGLYCERIDES|NON CONTRACTED|COMMERCIAL OTHER 1|1.16||||||| 84478|EAP|0300|TRIGLYCERIDES|Medicare|MEDICARE PART B ONLY IP|1.16||||||| 84479|EAP|0300|T3 UPTAKE|Medicare|MEDICARE ACUTE|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|NON CONTRACTED|COMMERCIAL OTHER 1|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Tricare|TRICARE EAST REGION|257.75||||||| 84479|EAP|0300|T3 UPTAKE|UTMB|UTMB CORRECTIONAL MANAGED CARE|257.75||||||| 84479|EAP|0300|T3 UPTAKE|United Healthcare|UNITED HEALTHCARE OTHER|||||257.75||| 84479|EAP|0300|T3 UPTAKE|United Healthcare|UNITED HEALTHCARE|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Managed Medicare|HEALTHSPRING MA|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Managed Medicare|BCBS MEDICARE PPO MA|257.75||||||| 84479|EAP|0300|T3 UPTAKE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Medicaid|MEDICAID|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Aenta Medicare Advantage|AETNA MEDICARE MA|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Aetna|AETNA OTHER|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Aetna|AETNA PPO|257.75||||||| 84479|EAP|0300|T3 UPTAKE|Blue Cross PPO Specialty|BCBSTX PPO|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Blue Cross PPO Specialty|BCBSTX OTHER|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Medicaid|CRIME VICTIMS COMPENSATION|257.75||||||| 84479|EAP|0300|T3 UPTAKE|ChampVA|CHAMPVA CENTER|257.75||||||| 84479|EAP|0300|T3 UPTAKE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Blue Cross HMO Specialty|BCBSTX HMO|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Cigna|CIGNA|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Cigna|CIGNA|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Humana Medicare Advantage|HUMANA MA|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Managed Medicaid|MEDICAID SUPERIOR|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|United Healthcare|GOLDEN RULE|257.75||||||| 84479|EAP|0300|T3 UPTAKE|Medicare|MEDICARE PART B ONLY IP|257.75||||||| 84479|EAP|0300|T3 UPTAKE|Managed Medicaid|MEDICAID AMERIGROUP|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Veterans Affairs|VETERANS ADMINISTRATION|257.75||||||| 84479|EAP|0300|T3 UPTAKE|Workers Compensation|TEXAS MUTUAL INSURANCE|257.75||||||| 84479|EAP|0300|T3 UPTAKE|Access Direct Platinum|HEALTHFIRST TPA|257.75||||||| 84479|EAP|0300|T3 UPTAKE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||257.75||| 84479|EAP|0300|T3 UPTAKE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|257.75||||||| 84479|EAP|0300|T3 UPTAKE|United Medicare Advantage|UHC AARP WELLMED HMO MA|257.75||||||| 84479|EAP|0300|T3 UPTAKE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|United Medicare Advantage|UHC MEDICARE GOLD MA|257.75||||257.75||| 84479|EAP|0300|T3 UPTAKE|United Medicare Advantage|UHC AARP MCR HMO MA|257.75||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Access Direct Platinum|ANDREWS CENTER|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Workers Compensation|BROOKSHIRES WORKERS COMP|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Humana Medicare Advantage|HUMANA MA|3.15||||3.15||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Magellan Behavioral Health|BH MAGELLAN|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|3.15||||3.15||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Aetna|AETNA PPO|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Medicaid|MEDICAID|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Managed Medicare|HEALTHSPRING MA|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|United Healthcare|UNITED HEALTHCARE OTHER|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|Medicare|MEDICARE ACUTE|3.15||||||| 84480|EAP|0300|TRIIODOTHYRONINE T3 TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|3.15||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Optum Behavioral Health|BH OPTUM UHC|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Medicare|MEDICARE ACUTE|675.25||||675.25||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|UTMB|UTMB CORRECTIONAL MANAGED CARE|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|United Healthcare|UNITED HEALTHCARE OTHER|||||675.25||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Managed Medicare|HEALTHSPRING MA|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|675.25||||675.25||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Aenta Medicare Advantage|AETNA MEDICARE MA|675.25||||675.25||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Aetna|AETNA PPO|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Aetna|BH AETNA|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Blue Cross PPO Specialty|BCBSTX PPO|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||675.25||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|ChampVA|CHAMPVA CENTER|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Medicaid|MEDICAID|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Blue Cross HMO Specialty|BCBSTX HMO|675.25||||675.25||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Cigna|CIGNA|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|United Healthcare|UNITED HEALTHCARE|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Humana Medicare Advantage|HUMANA MA|675.25||||675.25||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Magellan Behavioral Health|BH MAGELLAN|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Managed Medicaid|MEDICAID SUPERIOR|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|United Medicare Advantage|UHC AARP MCR HMO MA|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|United Medicare Advantage|UHC MEDICARE GOLD MA|675.25||||675.25||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Veterans Affairs|VETERANS ADMINISTRATION|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|675.25||||675.25||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Access Direct Platinum|HEALTHFIRST TPA UMR|675.25||||||| 84481|EAP|0300|TRIIODOTHYRONINE T3 FREE|Access Direct Platinum|HEALTHFIRST TPA|675.25||||||| 84482|EAP|0300|TRIIODOTHYRONINE T3 REVER|Humana Medicare Advantage|HUMANA MA|306.50||||||| 84482|EAP|0300|TRIIODOTHYRONINE T3 REVER|Medicare|MEDICARE ACUTE|306.50||||||| 84484|EAP|0300|TROPONIN QUANT|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|MEDICAID BCBSTX|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|MEDICAID|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|CRIME VICTIMS COMPENSATION|1.99||||||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|MEDICAID HMO|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|SMITH COUNTY JAIL|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|LAW ENFORCEMENT OTHER|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.99||||||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicare|WELLCARE CHOICE MA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicare|BCBS MEDICARE PPO MA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicare|HEALTHSPRING MA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicare|MA PART B ONLY IP|1.99||||||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicare|OTHER INSTITUTIONS|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|United Healthcare|UNITED HEALTHCARE|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|United Healthcare|GEHA|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|United Healthcare|UNITED HEALTHCARE OTHER|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|United Healthcare|GOLDEN RULE|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|United Healthcare|TML GROUP BENEFITS|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Tricare|TRICARE EAST REGION|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|PHCS|HUMANA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|PHCS|HUMANA INSURANCE|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Rusk State Hospital|RUSK STATE HOSP|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|PHCS|GROUP AND PENSION|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicare|MEDICARE ACUTE|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicare|MEDICARE PART B ONLY IP|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|NON CONTRACTED|COMMERCIAL OTHER 1|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|NON CONTRACTED|COMMERCIAL OTHER 2|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Multiplan|WEB TPA|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Tricare|TRICARE FOR LIFE|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Access Direct Platinum|HEALTHFIRST TPA UMR|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Access Direct Platinum|HEALTHFIRST TPA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Workers Compensation|BROOKSHIRES WORKERS COMP|1.99||||||| 84484|EAP|0300|TROPONIN QUANT|Workers Compensation|WORKERS COMPENSATION OTHER|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Workers Compensation|UT EMPLOYEE INJURY|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Veterans Affairs|VETERANS ADMINISTRATION|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Workers Compensation|GALLAGHER BASSETT|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|United Medicare Advantage|UHC MEDICARE GOLD MA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|United Medicare Advantage|UHC AARP MCR HMO MA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Blue Cross HMO Specialty|BCBSTX HMO|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Blue Cross PPO Specialty|BCBSTX PPO|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Blue Cross PPO Specialty|BCBSTX OTHER|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|ChampVA|CHAMPVA CENTER|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Aetna|AETNA PPO|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Aetna|AETNA OTHER|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Aetna|BOON CHAPMAN|1.99||||||| 84484|EAP|0300|TROPONIN QUANT|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Aetna|AETNA QHP HMO|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Aetna|BH AETNA|1.99||||||| 84484|EAP|0300|TROPONIN QUANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Aetna Value Network|AETNA VALUE NETWORK|||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicaid|MEDICAID AMERIGROUP|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicaid|MEDICAID SUPERIOR|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.99||||||| 84484|EAP|0300|TROPONIN QUANT|Cigna|CIGNA OTHER|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Cigna|CIGNA|1.99||||1.99||| 84484|EAP|0300|TROPONIN QUANT|Humana Medicare Advantage|HUMANA MA|1.99||||1.99||| 84520|EAP|0300|BUN|Humana Medicare Advantage|HUMANA MA|0.38||||0.38||| 84520|EAP|0300|BUN|Cigna|CIGNA OTHER|0.38||||0.38||| 84520|EAP|0300|BUN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.38||||0.38||| 84520|EAP|0300|BUN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.38||||0.38||| 84520|EAP|0300|BUN|Managed Medicaid|MEDICAID AMERIGROUP|0.38||||0.38||| 84520|EAP|0300|BUN|Managed Medicaid|MEDICAID SUPERIOR|0.38||||0.38||| 84520|EAP|0300|BUN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.38||||0.38||| 84520|EAP|0300|BUN|Aenta Medicare Advantage|AETNA MEDICARE MA|0.38||||0.38||| 84520|EAP|0300|BUN|Aetna|AETNA PPO|0.38||||0.38||| 84520|EAP|0300|BUN|Blue Cross PPO Specialty|BCBSTX PPO|0.38||||0.38||| 84520|EAP|0300|BUN|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.38||| 84520|EAP|0300|BUN|ChampVA|CHAMPVA CENTER|||||0.38||| 84520|EAP|0300|BUN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.38||| 84520|EAP|0300|BUN|Blue Cross HMO Specialty|BCBSTX HMO|0.38||||0.38||| 84520|EAP|0300|BUN|United Medicare Advantage|UHC MEDICARE GOLD MA|0.38||||0.38||| 84520|EAP|0300|BUN|United Medicare Advantage|UHC AARP MCR HMO MA|0.38||||0.38||| 84520|EAP|0300|BUN|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.38||| 84520|EAP|0300|BUN|Workers Compensation|WORKERS COMPENSATION OTHER|0.38||||0.38||| 84520|EAP|0300|BUN|Workers Compensation|BROOKSHIRES WORKERS COMP|0.38||||||| 84520|EAP|0300|BUN|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||0.38||| 84520|EAP|0300|BUN|Veterans Affairs|VETERANS ADMINISTRATION|0.38||||0.38||| 84520|EAP|0300|BUN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.38||||0.38||| 84520|EAP|0300|BUN|Workers Compensation|UT EMPLOYEE INJURY|||||0.38||| 84520|EAP|0300|BUN|Access Direct Platinum|HEALTHFIRST TPA UMR|0.38||||0.38||| 84520|EAP|0300|BUN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.38||| 84520|EAP|0300|BUN|Access Direct Platinum|HEALTHFIRST TPA|0.38||||0.38||| 84520|EAP|0300|BUN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.38||||0.38||| 84520|EAP|0300|BUN|Medicare|MEDICARE ACUTE|0.38||||0.38||| 84520|EAP|0300|BUN|Multiplan|WEB TPA|||||0.38||| 84520|EAP|0300|BUN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.38||||0.38||| 84520|EAP|0300|BUN|Medicare|MEDICARE PART B ONLY IP|0.38||||||| 84520|EAP|0300|BUN|NON CONTRACTED|COMMERCIAL OTHER 2|0.38||||||| 84520|EAP|0300|BUN|NON CONTRACTED|COMMERCIAL OTHER 1|0.38||||0.38||| 84520|EAP|0300|BUN|Tricare|TRICARE EAST REGION|||||0.38||| 84520|EAP|0300|BUN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.38||||0.38||| 84520|EAP|0300|BUN|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.38||| 84520|EAP|0300|BUN|Rusk State Hospital|RUSK STATE HOSP|||||0.38||| 84520|EAP|0300|BUN|PHCS|GROUP AND PENSION|||||0.38||| 84520|EAP|0300|BUN|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.38||||||| 84520|EAP|0300|BUN|Aetna|AETNA OTHER|0.38||||0.38||| 84520|EAP|0300|BUN|United Healthcare|UNITED HEALTHCARE|0.38||||0.38||| 84520|EAP|0300|BUN|United Healthcare|GOLDEN RULE|0.38||||||| 84520|EAP|0300|BUN|United Healthcare|TML GROUP BENEFITS|0.38||||0.38||| 84520|EAP|0300|BUN|United Healthcare|UNITED HEALTHCARE OTHER|0.38||||0.38||| 84520|EAP|0300|BUN|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.38||| 84520|EAP|0300|BUN|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.38||||||| 84520|EAP|0300|BUN|Managed Medicare|BCBS MEDICARE PPO MA|0.38||||0.38||| 84520|EAP|0300|BUN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.38||||0.38||| 84520|EAP|0300|BUN|Cigna|CIGNA|0.38||||0.38||| 84520|EAP|0300|BUN|Managed Medicare|HEALTHSPRING MA|0.38||||0.38||| 84520|EAP|0300|BUN|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.38||| 84520|EAP|0300|BUN|Medicaid|SMITH COUNTY JAIL|||||0.38||| 84520|EAP|0300|BUN|Medicaid|MEDICAID|0.38||||0.38||| 84520|EAP|0300|BUN|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.38||||||| 84520|EAP|0300|BUN|Medicaid|LAW ENFORCEMENT OTHER|||||0.38||| 84520|EAP|0300|BUN|Medicaid|CRIME VICTIMS COMPENSATION|0.38||||||| 84520|EAP|0300|BUN|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.38||| 84520|EAP|0300|BUN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.38||| 84520|EAP|0300|BUN|Medicaid|MEDICAID HMO|||||0.38||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicaid|MEDICAID|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicaid|MEDICAID HMO|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN RANDOM URIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.96||||||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicaid|LAW ENFORCEMENT OTHER|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicaid|CRIME VICTIMS COMPENSATION|0.80||||||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicaid|SMITH COUNTY JAIL|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicare|HEALTHSPRING MA|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN RANDOM URIN|Managed Medicare|WELLCARE CHOICE MA|0.96||||||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicare|HEALTHSPRING MA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicare|BCBS MEDICARE PPO MA|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Healthcare|UNITED HEALTHCARE|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Healthcare|TML GROUP BENEFITS|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Healthcare|UNITED HEALTHCARE OTHER|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Healthcare|GOLDEN RULE|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|PHCS|GROUP AND PENSION|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|PHCS|HUMANA INSURANCE|0.80||||||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Tricare|TRICARE EAST REGION|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Rusk State Hospital|RUSK STATE HOSP|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|PHCS|HUMANA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicare|MEDICARE ACUTE|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN RANDOM URIN|Medicare|MEDICARE PART B ONLY IP|0.96||||||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicare|UTSW MC KIDNEY PROGRAM|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|NON CONTRACTED|COMMERCIAL OTHER 1|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicare|MEDICARE PART B ONLY IP|0.80||||||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Access Direct Platinum|HEALTHFIRST TPA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN RANDOM URIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.96||||0.96||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Access Direct Platinum|HEALTHFIRST TPA|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Workers Compensation|BROOKSHIRES WORKERS COMP|0.80||||||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Workers Compensation|UT EMPLOYEE INJURY|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Workers Compensation|WORKERS COMPENSATION OTHER|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Access Direct Platinum|HEALTHFIRST TPA UMR|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Access Direct Platinum|HEALTHFIRST TPA UMR|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicare|MEDICARE ACUTE|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Workers Compensation|TEXAS MUTUAL INSURANCE|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Veterans Affairs|VETERANS ADMINISTRATION|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Veterans Affairs|VETERANS ADMINISTRATION|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Medicare Advantage|UHC MEDICARE GOLD MA|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Medicare Advantage|UHC AARP MCR HMO MA|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Medicare Advantage|UHC MEDICARE GOLD MA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Medicare Advantage|UHC AARP MCR HMO MA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Tricare|TRICARE FOR LIFE|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Blue Cross HMO Specialty|BCBSTX HMO|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Healthcare|UNITED HEALTHCARE|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Blue Cross HMO Specialty|BCBSTX HMO|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Blue Cross PPO Specialty|BCBSTX PPO|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Blue Cross PPO Specialty|BCBSTX OTHER|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Blue Cross PPO Specialty|BCBSTX PPO|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Blue Cross PPO Specialty|BCBSTX OTHER|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|ChampVA|CHAMPVA CENTER|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|United Healthcare|UNITED HEALTHCARE OTHER|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Aenta Medicare Advantage|AETNA MEDICARE MA|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Aenta Medicare Advantage|AETNA MEDICARE MA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicare|OTHER INSTITUTIONS|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Aetna|AETNA OTHER|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Aetna|AETNA PPO|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Aetna Value Network|AETNA VALUE NETWORK|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Medicaid|MEDICAID|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicaid|MEDICAID SUPERIOR|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicaid|MEDICAID SUPERIOR|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicaid|MEDICAID AMERIGROUP|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Cigna|CIGNA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Cigna|CIGNA OTHER|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Cigna|CIGNA|0.96||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Cigna|CIGNA|||||0.80||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Humana Medicare Advantage|HUMANA MA|0.80||||0.80||| 84540|EAP|0300|UREA NITROGEN RANDOM URIN|Humana Medicare Advantage|HUMANA MA|0.96||||0.96||| 84540|EAP|0300|UREA NITROGEN URINE TIMED|Magellan Behavioral Health|BH MAGELLAN|||||0.80||| 84550|EAP|0300|URIC ACID|Cigna|CIGNA|0.91||||||| 84550|EAP|0300|URIC ACID|Cigna|CIGNA|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Cigna|CIGNA OTHER|0.91||||||| 84550|EAP|0300|URIC ACID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Managed Medicaid|MEDICAID AMERIGROUP|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Managed Medicaid|MEDICAID SUPERIOR|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.91||||||| 84550|EAP|0300|URIC ACID|Aenta Medicare Advantage|AETNA MEDICARE MA|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Aetna|AETNA OTHER|||||0.91||| 84550|EAP|0300|URIC ACID|Aetna|AETNA PPO|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Blue Cross PPO Specialty|BCBSTX OTHER|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.91||||||| 84550|EAP|0300|URIC ACID|Blue Cross HMO Specialty|BCBSTX HMO|0.91||||||| 84550|EAP|0300|URIC ACID|United Medicare Advantage|UHC MEDICARE GOLD MA|0.91||||0.91||| 84550|EAP|0300|URIC ACID|United Medicare Advantage|UHC AARP MCR HMO MA|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Workers Compensation|BROOKSHIRES WORKERS COMP|0.91||||||| 84550|EAP|0300|URIC ACID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Veterans Affairs|VETERANS ADMINISTRATION|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Access Direct Platinum|HEALTHFIRST TPA|0.91||||||| 84550|EAP|0300|URIC ACID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Access Direct Platinum|HEALTHFIRST TPA UMR|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Medicare|MEDICARE ACUTE|0.91||||0.91||| 84550|EAP|0300|URIC ACID|NON CONTRACTED|COMMERCIAL OTHER 1|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Tricare|TRICARE EAST REGION|0.91||||||| 84550|EAP|0300|URIC ACID|PHCS|GROUP AND PENSION|0.91||||||| 84550|EAP|0300|URIC ACID|Rusk State Hospital|RUSK STATE HOSP|0.91||||||| 84550|EAP|0300|URIC ACID|PHCS|HUMANA INSURANCE|0.91||||||| 84550|EAP|0300|URIC ACID|Humana Medicare Advantage|HUMANA MA|0.91||||0.91||| 84550|EAP|0300|URIC ACID|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.91||||||| 84550|EAP|0300|URIC ACID|United Healthcare|UNITED HEALTHCARE OTHER|0.91||||0.91||| 84550|EAP|0300|URIC ACID|United Healthcare|TML GROUP BENEFITS|0.91||||0.91||| 84550|EAP|0300|URIC ACID|United Healthcare|UNITED HEALTHCARE|0.91||||||| 84550|EAP|0300|URIC ACID|Managed Medicare|HEALTHSPRING MA|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Managed Medicare|BCBS MEDICARE PPO MA|0.91||||||| 84550|EAP|0300|URIC ACID|Medicaid|MEDICAID HMO|0.91||||0.91||| 84550|EAP|0300|URIC ACID|Medicaid|MEDICAID|0.91||||||| 84550|EAP|0300|URIC ACID|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.91||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Medicaid|MEDICAID|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Managed Medicare|BCBS MEDICARE PPO MA|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Managed Medicare|HEALTHSPRING MA|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|United Healthcare|UNITED HEALTHCARE OTHER|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Medicare|MEDICARE ACUTE|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Access Direct Platinum|HEALTHFIRST TPA|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||189.25||| 84560|EAP|0300|URIC ACID URINE QUANT|Access Direct Platinum|HEALTHFIRST TPA UMR|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|NON CONTRACTED|COMMERCIAL OTHER 1|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Veterans Affairs|VETERANS ADMINISTRATION|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|United Medicare Advantage|UHC AARP MCR HMO MA|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|United Medicare Advantage|UHC MEDICARE GOLD MA|189.25||||189.25||| 84560|EAP|0300|URIC ACID URINE QUANT|Blue Cross HMO Specialty|BCBSTX HMO|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Blue Cross PPO Specialty|BCBSTX PPO|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Blue Cross PPO Specialty|BCBSTX OTHER|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Aenta Medicare Advantage|AETNA MEDICARE MA|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|189.25||||||| 84560|EAP|0300|URIC ACID OTHER SOURCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.91||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Managed Medicaid|MEDICAID AMERIGROUP|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Cigna|CIGNA|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Cigna|CIGNA OTHER|189.25||||||| 84560|EAP|0300|URIC ACID URINE QUANT|Humana Medicare Advantage|HUMANA MA|189.25||||||| 84585|EAP|0300|VANILLYMANDELIC ACID URIN|Blue Cross PPO Specialty|BCBSTX PPO|617.50||||617.50||| 84588|EAP|0300|ANTIDIURETIC HORMONE (ADH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,363.25||| 84588|EAP|0300|ANTIDIURETIC HORMONE (ADH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,363.25||||||| 84590|EAP|0300|VITAMIN A|Tricare|TRICARE EAST REGION|||||4.62||| 84590|EAP|0300|VITAMIN A|Medicare|MEDICARE ACUTE|4.62||||||| 84590|EAP|0300|VITAMIN A|Humana Medicare Advantage|HUMANA MA|4.62||||||| 84590|EAP|0300|VITAMIN A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.62||||||| 84590|EAP|0300|VITAMIN A|Blue Cross PPO Specialty|BCBSTX PPO|4.62||||||| 84597|EAP|0300|VITAMIN K|Veterans Affairs|VETERANS ADMINISTRATION|264.25||||||| 84597|EAP|0300|VITAMIN K|UTMB|UTMB CORRECTIONAL MANAGED CARE|264.25||||||| 846|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W MCC|Medicare|MEDICARE ACUTE|559,739.98|34581.38|34581.38|272.16|||| 846|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|73,653.93|272.16|34581.38|272.16|||| 846|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W MCC|Managed Medicare|HEALTHSPRING MA|32,837.51|15678.52|34581.38|272.16|||| 846|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42,321.06|9932.67|34581.38|272.16|||| 84630|EAP|0300|ZINC|United Medicare Advantage|UHC AARP MCR HMO MA|2.30||||||| 84630|EAP|0300|ZINC|Humana Medicare Advantage|HUMANA MA|||||2.30||| 84630|EAP|0300|ZINC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.30||||||| 84630|EAP|0300|ZINC|Blue Cross PPO Specialty|BCBSTX PPO|2.30||||||| 84630|EAP|0300|ZINC|Aenta Medicare Advantage|AETNA MEDICARE MA|2.30||||||| 84630|EAP|0300|ZINC|Medicare|MEDICARE ACUTE|2.30||||2.30||| 84630|EAP|0300|ZINC|Tricare|TRICARE EAST REGION|||||2.30||| 84630|EAP|0300|ZINC|United Healthcare|UNITED HEALTHCARE OTHER|2.30||||||| 84681|EAP|0300|C-PEPTIDE|UTMB|UTMB CORRECTIONAL MANAGED CARE|829.25||||||| 84681|EAP|0300|C-PEPTIDE|United Healthcare|UNITED HEALTHCARE|829.25||||||| 84681|EAP|0300|C-PEPTIDE|Medicare|MEDICARE ACUTE|829.25||||||| 84681|EAP|0300|C-PEPTIDE|Medicare|UTSW MC KIDNEY PROGRAM|||||829.25||| 84681|EAP|0300|C-PEPTIDE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|829.25||||||| 84681|EAP|0300|C-PEPTIDE|United Medicare Advantage|UHC AARP MCR HMO MA|829.25||||||| 84681|EAP|0300|C-PEPTIDE|United Medicare Advantage|UHC MEDICARE GOLD MA|829.25||||829.25||| 84681|EAP|0300|C-PEPTIDE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|829.25||||829.25||| 847|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|41,664.11|11014.94|23510.31|107.16|||| 847|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|547.12|107.16|23510.31|107.16|||| 847|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC|Blue Cross HMO Specialty|BCBSTX HMO|67,532.08|7656.56|23510.31|107.16|||| 847|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC|Cigna|CIGNA|51,923.19|23510.31|23510.31|107.16|||| 847|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC|Managed Medicaid|MEDICAID AMERIGROUP|64,730.58|8131.245|23510.31|107.16|||| 847|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC|Medicaid|MEDICAID|86,827.94|3981.02|23510.31|107.16|||| 847|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC|Medicare|MEDICARE ACUTE|57,661.59|8481.44|23510.31|107.16|||| 847|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC|Tricare|TRICARE EAST REGION|43,556.57|5860.76|23510.31|107.16|||| 847|DRG||CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC|United Healthcare|UNITED HEALTHCARE OTHER|31,501.06|15574.99|23510.31|107.16|||| 84702|EAP|0300|HCG QUANT|United Healthcare|UNITED HEALTHCARE OTHER|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|United Healthcare|UNITED HEALTHCARE|||||1.94||| 84702|EAP|0300|HCG QUANT|Medicare|MEDICARE ACUTE|1.94||||1.94||| 84702|EAP|0300|HCG TUMOR MARKER|Medicare|MEDICARE ACUTE|348.50||||1.94||| 84702|EAP|0300|HCG QUANT|Medicare|UTSW MC KIDNEY PROGRAM|||||1.94||| 84702|EAP|0300|HCG QUANT|Tricare|TRICARE EAST REGION|||||1.94||| 84702|EAP|0300|HCG QUANT|Medicaid|MEDICAID BCBSTX|||||1.94||| 84702|EAP|0300|HCG QUANT|Medicaid|MEDICAID HMO|||||1.94||| 84702|EAP|0300|HCG TUMOR MARKER|Medicaid|MEDICAID|348.50||||1.94||| 84702|EAP|0300|HCG QUANT|Medicaid|SMITH COUNTY JAIL|||||1.94||| 84702|EAP|0300|HCG QUANT|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|348.50||||1.94||| 84702|EAP|0300|HCG QUANT|Managed Medicaid|MEDICAID SUPERIOR|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Managed Medicaid|MEDICAID AMERIGROUP|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.94||||||| 84702|EAP|0300|HCG QUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.94||| 84702|EAP|0300|HCG QUANT|Magellan Behavioral Health|BH MAGELLAN|1.94||||||| 84702|EAP|0300|HCG QUANT|Medicaid|MEDICAID|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.94||| 84702|EAP|0300|HCG TUMOR MARKER|Cigna|CIGNA|348.50||||348.50||| 84702|EAP|0300|HCG QUANT|Cigna|CIGNA|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Cigna|CIGNA|348.50||||1.94||| 84702|EAP|0300|HCG QUANT|Cigna|CIGNA OTHER|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|NON CONTRACTED|COMMERCIAL OTHER 1|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Blue Cross HMO Specialty|BCBSTX HMO|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Blue Cross PPO Specialty|BCBSTX PPO|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.94||| 84702|EAP|0300|HCG QUANT|Aetna|AETNA PPO|1.94||||||| 84702|EAP|0300|HCG QUANT|Aetna|AETNA OTHER|||||1.94||| 84702|EAP|0300|HCG QUANT|Aetna Value Network|AETNA VALUE NETWORK|||||1.94||| 84702|EAP|0300|HCG QUANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.94||| 84702|EAP|0300|HCG QUANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Veterans Affairs|VETERANS ADMINISTRATION|||||1.94||| 84702|EAP|0300|HCG QUANT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.94||| 84702|EAP|0300|HCG QUANT|Access Direct Platinum|HEALTHFIRST TPA|||||1.94||| 84702|EAP|0300|HCG QUANT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.94||| 84702|EAP|0300|HCG QUANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.94||||1.94||| 84702|EAP|0300|HCG QUANT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.94||||1.94||| 84703|EAP|0300|HCG QUAL|Access Direct Platinum|HEALTHFIRST TPA|||||1.52||| 84703|EAP|0300|HCG QUAL|Access Direct Platinum|ANDREWS CENTER|1.52||||||| 84703|EAP|0300|HCG QUAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.52||| 84703|EAP|0300|HCG QUAL|United Medicare Advantage|UHC AARP MCR HMO MA|1.52||||||| 84703|EAP|0300|HCG QUAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Aenta Medicare Advantage|AETNA MEDICARE MA|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Aetna|AETNA OTHER|||||1.52||| 84703|EAP|0300|HCG QUAL|Aetna|AETNA QHP HMO|||||1.52||| 84703|EAP|0300|HCG QUAL|Aetna|AETNA PPO|||||1.52||| 84703|EAP|0300|HCG QUAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.52||||||| 84703|EAP|0300|HCG QUAL|Blue Cross PPO Specialty|BCBSTX PPO|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.52||| 84703|EAP|0300|HCG QUAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.52||| 84703|EAP|0300|HCG QUAL|Blue Cross HMO Specialty|BCBSTX HMO|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Cigna|CIGNA OTHER|||||1.52||| 84703|EAP|0300|HCG QUAL|Cigna|CIGNA|||||1.52||| 84703|EAP|0300|HCG QUAL|Cigna Behavioral Health|BH CIGNA|1.52||||||| 84703|EAP|0300|HCG QUAL|Cigna|CIGNA|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Humana Medicare Advantage|HUMANA MA|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Aetna|BH AETNA|1.52||||||| 84703|EAP|0300|HCG QUAL|Magellan Behavioral Health|BH MAGELLAN|1.52||||||| 84703|EAP|0300|HCG QUAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Managed Medicaid|MEDICAID AMERIGROUP|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.52||||||| 84703|EAP|0300|HCG QUAL|Managed Medicaid|MEDICAID SUPERIOR|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.52||| 84703|EAP|0300|HCG QUAL|Managed Medicare|HEALTHSPRING MA|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.52||| 84703|EAP|0300|HCG QUAL|Medicaid|MEDICAID|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Medicaid|LAW ENFORCEMENT OTHER|||||1.52||| 84703|EAP|0300|HCG QUAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.52||| 84703|EAP|0300|HCG QUAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Medicaid|MEDICAID HMO|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Tricare|TRICARE EAST REGION|||||1.52||| 84703|EAP|0300|HCG QUAL|Tricare|TRICARE FOR LIFE|||||1.52||| 84703|EAP|0300|HCG QUAL|Multiplan|WEB TPA|1.52||||||| 84703|EAP|0300|HCG QUAL|NON CONTRACTED|COMMERCIAL OTHER 1|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|Medicare|UTSW MC KIDNEY PROGRAM|||||1.52||| 84703|EAP|0300|HCG QUAL|Medicare|MEDICARE PART B ONLY IP|1.52||||||| 84703|EAP|0300|HCG QUAL|Medicare|MEDICARE ACUTE|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|United Healthcare|UNITED HEALTHCARE|||||1.52||| 84703|EAP|0300|HCG QUAL|United Healthcare|UNITED HEALTHCARE OTHER|1.52||||1.52||| 84703|EAP|0300|HCG QUAL|United Healthcare|UNITED HEALTHCARE|1.52||||||| 84999|EAP|0300|OSMOLALITY, FECES|Medicare|MEDICARE ACUTE|6.47||||||| 84999|EAP|0300|POTASSIUM FECES/PLEURAL F|Medicare|MEDICARE ACUTE|0.42||||||| 84999|EAP|0300|OSMOLALITY, FECES|Medicaid|MEDICAID|6.47||||||| 84999|EAP|0300|POTASSIUM FECES/PLEURAL F|Humana Medicare Advantage|HUMANA MA|0.42||||||| 84999|EAP|0300|OSMOLALITY, FECES|Blue Cross PPO Specialty|BCBSTX PPO|6.47||||||| 84999|EAP|0300|POTASSIUM FECES/PLEURAL F|Blue Cross PPO Specialty|BCBSTX PPO|0.42||||||| 84999|EAP|0300|OSMOLALITY, FECES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.47||| 84999|EAP|0300|OSMOLALITY, FECES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.47||||||| 84999|EAP|0300|POTASSIUM FECES/PLEURAL F|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.42||| 84999|EAP|0300|OSMOLALITY, FECES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.47||||||| 84999|EAP|0300|POTASSIUM FECES/PLEURAL F|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.42||||||| 85|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC|Veterans Affairs|VETERANS ADMINISTRATION|88,809.12|13864.83|30207.29|1683.15|||| 85|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC|Blue Cross PPO Specialty|BCBSTX PPO|125,111.72|14802.2|30207.29|1683.15|||| 85|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC|Blue Cross PPO Specialty|BCBSTX OTHER|132,233.65|14802.2|30207.29|1683.15|||| 85|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|426,508.20|1683.15|30207.29|1683.15|||| 85|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC|Medicare|MEDICARE ACUTE|111,436.91|13864.83|30207.29|1683.15|||| 85|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|39,115.11|16153.84|30207.29|1683.15|||| 85|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|56,659.85|30207.29|30207.29|1683.15|||| 85007|EAP|0300|DIFFERENTIAL COUNT|PHCS|GROUP AND PENSION|180.55||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Tricare|TRICARE FOR LIFE|||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Tricare|TRICARE EAST REGION|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Rusk State Hospital|RUSK STATE HOSP|180.55||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|PHCS|HUMANA|180.55||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicare|UTSW MC KIDNEY PROGRAM|||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicare|MEDICARE ACUTE|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Multiplan|NALC|1.57||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicare|MEDICARE PART B ONLY IP|1.57||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|NON CONTRACTED|COMMERCIAL OTHER 1|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|NON CONTRACTED|COMMERCIAL OTHER 1|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|United Healthcare|UNITED HEALTHCARE|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|United Healthcare|GOLDEN RULE|180.55||||||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|United Healthcare|UNITED HEALTHCARE OTHER|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|United Healthcare|TML GROUP BENEFITS|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|United Healthcare|UNITED HEALTHCARE OTHER|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|UTMB|UTMB CORRECTIONAL MANAGED CARE|180.55||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicare|OTHER INSTITUTIONS|||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicare|HEALTHSPRING MA|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicare|JACKSONVILLE ACCESS|1.57||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicare|MA PART B ONLY IP|1.57||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicare|BCBS MEDICARE PPO MA|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicare|WELLCARE CHOICE MA|180.55||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Managed Medicare|BCBS MEDICARE PPO MA|1.57||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Medicaid|MEDICAID|180.55||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicaid|SMITH COUNTY JAIL|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicaid|MOLINA HEALTHCARE OF TEXAS|168.78||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicaid|MEDICAID HMO|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicaid|COUNTY INDIGENT HEALTH OTHER|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.57||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Managed Medicaid|MEDICAID SUPERIOR|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.57||||||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|180.55||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Managed Medicaid|MEDICAID AMERIGROUP|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicaid|MEDICAID AMERIGROUP|180.55||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicaid|MEDICAID SUPERIOR|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Cigna|CIGNA OTHER|1.57||||168.78||| 85007|EAP|0300|DIFFERENTIAL COUNT|Cigna|CIGNA|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Cigna|CIGNA|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Humana Medicare Advantage|HUMANA MA|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicaid|CRIME VICTIMS COMPENSATION|180.55||||||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Humana Medicare Advantage|HUMANA MA|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Magellan Behavioral Health|BH MAGELLAN|||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Aetna|BOON CHAPMAN|180.55||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Medicaid|MEDICAID|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Aetna|AETNA OTHER|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Aetna|BH AETNA|1.57||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Aetna|AETNA PPO|1.57||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Aenta Medicare Advantage|AETNA MEDICARE MA|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.57||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Aetna|AETNA QHP HMO|180.55||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.55||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Managed Medicare|HEALTHSPRING MA|1.57||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Aetna Value Network|AETNA VALUE NETWORK|||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Blue Cross PPO Specialty|BCBSTX PPO|168.78||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Blue Cross PPO Specialty|BCBSTX PPO|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Blue Cross PPO Specialty|BCBSTX OTHER|1.57||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Blue Cross PPO Specialty|BCBSTX OTHER|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|United Healthcare|GEHA|||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|ChampVA|CHAMPVA CENTER|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Brinson Benefits|THE HEALTH PLAN SMITH CO|180.55||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|ChampVA|CHAMPVA CENTER|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Multiplan|WEB TPA|1.57||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Blue Cross HMO Specialty|BCBSTX HMO|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Blue Cross HMO Specialty|BCBSTX HMO|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Workers Compensation|TEXAS MUTUAL INSURANCE|168.78||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.57||||1.57||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Medicare|MEDICARE ACUTE|1.57||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Veterans Affairs|VETERANS ADMINISTRATION|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Workers Compensation|WORKERS COMPENSATION OTHER|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Veterans Affairs|VETERANS ADMINISTRATION|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.57||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Access Direct Platinum|HEALTHFIRST TPA|180.55||||1.57||| 85007|EAP|0300|DIFFERENTIAL COUNT|Access Direct Platinum|HEALTHFIRST TPA UMR|1.57||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|Access Direct Platinum|ANDREWS CENTER|1.57||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|United Medicare Advantage|UHC AARP WELLMED HMO MA|180.55||||||| 85007|EAP|0300|DIFFERENTIAL COUNT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|United Medicare Advantage|UHC AARP MCR HMO MA|180.55||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|United Medicare Advantage|UHC MEDICARE GOLD MA|1.57||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|United Medicare Advantage|UHC AARP MCR HMO MA|180.55||||180.55||| 85007|EAP|0300|PERIPHERL BLOOD SMEAR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|180.55||||180.55||| 85007|EAP|0300|DIFFERENTIAL COUNT|United Medicare Advantage|UHC MEDICARE GOLD MA|1.57||||1.57||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC MEDICARE GOLD MA|1.31||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC MEDICARE GOLD MA|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|150.65||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC AARP WELLMED HMO MA|124.20||||116.10||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC AARP MCR HMO MA|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.31||||116.10||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA UMR|150.65||||124.20||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.31||||1.08||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.31||||1.08||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA|116.10||||1.08||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA UMR|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||124.20||| 85014|EAP|0300|HEMATOCRIT|Workers Compensation|TEXAS MUTUAL INSURANCE|1.08||||124.20||| 85014|EAP|0300|HEMATOCRIT|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||1.08||| 85014|EAP|0300|HEMATOCRIT|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.08||||||| 85014|EAP|0300|HEMATOCRIT|Workers Compensation|ZURICH COMPANY|124.20||||||| 85014|EAP|0300|HEMATOCRIT|Workers Compensation|UT EMPLOYEE INJURY|||||124.20||| 85014|EAP|0300|HEMATOCRIT|Veterans Affairs|VETERANS ADMINISTRATION|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|Veterans Affairs|VETERANS ADMINISTRATION|140.83||||124.20||| 85014|EAP|0300|HEMATOCRIT|Veterans Affairs|VETERANS ADMINISTRATION|1.08||||124.20||| 85014|EAP|0300|HEMATOCRIT|Blue Cross HMO Specialty|BCBSTX HMO|150.65||||124.20||| 85014|EAP|0300|HEMATOCRIT|ChampVA|CHAMPVA CENTER|124.20||||||| 85014|EAP|0300|HEMATOCRIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|116.10||||124.20||| 85014|EAP|0300|HEMATOCRIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.31||||124.20||| 85014|EAP|0300|HEMATOCRIT|Blue Cross PPO Specialty|BCBSTX OTHER|150.65||||124.20||| 85014|EAP|0300|HEMATOCRIT|Blue Cross PPO Specialty|BCBSTX OTHER|116.10||||124.20||| 85014|EAP|0300|HEMATOCRIT|Blue Cross PPO Specialty|BCBSTX PPO|1.31||||150.65||| 85014|EAP|0300|HEMATOCRIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.08||||124.20||| 85014|EAP|0300|HEMATOCRIT|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.08||||124.20||| 85014|EAP|0300|HEMATOCRIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|150.65||||124.20||| 85014|EAP|0300|HEMATOCRIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Aetna Value Network|AETNA VALUE NETWORK|116.10||||1.08||| 85014|EAP|0300|HEMATOCRIT|Aetna|AETNA PPO|1.31||||124.20||| 85014|EAP|0300|HEMATOCRIT|Aetna|AETNA QHP HMO|124.20||||||| 85014|EAP|0300|HEMATOCRIT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.31||||124.20||| 85014|EAP|0300|HEMATOCRIT|Aetna|AETNA PPO|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|Aetna|BOON CHAPMAN|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Aetna|AETNA OTHER|1.31||||1.08||| 85014|EAP|0300|HEMATOCRIT|Aetna|AETNA QHP HMO|150.65||||||| 85014|EAP|0300|HEMATOCRIT|Humana Medicare Advantage|HUMANA MA|150.65||||1.08||| 85014|EAP|0300|HEMATOCRIT|Cigna|CIGNA OTHER|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Cigna|CIGNA OTHER|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Cigna|CIGNA OTHER|150.65||||1.08||| 85014|EAP|0300|HEMATOCRIT|Cigna|CIGNA|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Cigna|CIGNA|150.65||||1.08||| 85014|EAP|0300|HEMATOCRIT|Cigna|CIGNA|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|116.10||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID AMERIGROUP|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID SUPERIOR|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID SUPERIOR|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|150.65||||124.20||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|150.65||||124.20||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID AMERIGROUP|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|Cigna|CIGNA|150.65||||124.20||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID AMERIGROUP|1.31||||124.20||| 85014|EAP|0300|HEMATOCRIT|Medicaid|LAW ENFORCEMENT OTHER|||||124.20||| 85014|EAP|0300|HEMATOCRIT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.08||| 85014|EAP|0300|HEMATOCRIT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.08||| 85014|EAP|0300|HEMATOCRIT|Medicaid|SMITH COUNTY JAIL|1.08||||||| 85014|EAP|0300|HEMATOCRIT|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.31||||116.10||| 85014|EAP|0300|HEMATOCRIT|Humana Medicare Advantage|HUMANA MA|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.08||||116.10||| 85014|EAP|0300|HEMATOCRIT|Medicaid|MOLINA HEALTHCARE OF TEXAS|116.10||||1.08||| 85014|EAP|0300|HEMATOCRIT|Medicaid|MEDICAID HMO|116.10||||1.08||| 85014|EAP|0300|HEMATOCRIT|Medicaid|MEDICAID|1.31||||124.20||| 85014|EAP|0300|HEMATOCRIT|Aetna|AETNA OTHER|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Medicaid|MEDICAID|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|Medicaid|CRIME VICTIMS COMPENSATION|124.20||||||| 85014|EAP|0300|HEMATOCRIT|Medicaid|CRIME VICTIMS COMPENSATION|1.08||||||| 85014|EAP|0300|HEMATOCRIT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||116.10||| 85014|EAP|0300|HEMATOCRIT|Aenta Medicare Advantage|AETNA MEDICARE MA|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|HEALTHSPRING MA|1.31||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|BCBS MEDICARE PPO MA|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|BCBS MEDICARE PPO MA|140.83||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|HEALTHSPRING MA|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|BCBS MEDICARE PPO MA|116.10||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|ETMC REHABILITATION HOSPITAL|1.08||||116.10||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|WELLCARE CHOICE MA|124.20||||||| 85014|EAP|0300|HEMATOCRIT|ChampVA|CHAMPVA CENTER|116.10||||||| 85014|EAP|0300|HEMATOCRIT|Blue Cross PPO Specialty|BCBSTX PPO|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.31||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|ETMC REHABILITATION HOSPITAL|1.08||||124.20||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|OTHER INSTITUTIONS|||||1.08||| 85014|EAP|0300|HEMATOCRIT|Blue Cross HMO Specialty|BCBSTX HMO|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.08||||||| 85014|EAP|0300|HEMATOCRIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|124.20||||||| 85014|EAP|0300|HEMATOCRIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.31||||||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|GEHA|124.20||||116.10||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE OTHER|1.31||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE OTHER|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE OTHER|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE|150.65||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE|140.83||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Workers Compensation|WORKERS COMPENSATION OTHER|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Workers Compensation|BROOKSHIRES WORKERS COMP|124.20||||||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|TML GROUP BENEFITS|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|GOLDEN RULE|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|Multiplan|NALC|1.08||||||| 85014|EAP|0300|HEMATOCRIT|Medicare|UTSW MC KIDNEY PROGRAM|||||124.20||| 85014|EAP|0300|HEMATOCRIT|Multiplan|WEB TPA|||||124.20||| 85014|EAP|0300|HEMATOCRIT|Medicare|MEDICARE ACUTE|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Medicare|MEDICARE PART B ONLY IP|124.20||||||| 85014|EAP|0300|HEMATOCRIT|Medicare|MEDICARE ACUTE|124.20||||150.65||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC AARP MCR HMO MA|150.65||||124.20||| 85014|EAP|0300|HEMATOCRIT|NON CONTRACTED|COMMERCIAL OTHER 2|||||124.20||| 85014|EAP|0300|HEMATOCRIT|Medicare|MEDICARE ACUTE|150.65||||150.65||| 85014|EAP|0300|HEMATOCRIT|NON CONTRACTED|COMMERCIAL OTHER 1|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|NON CONTRACTED|COMMERCIAL OTHER 2|||||1.08||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|NON CONTRACTED|COMMERCIAL OTHER 1|150.65||||1.08||| 85014|EAP|0300|HEMATOCRIT|Tricare|TRICARE EAST REGION|124.20||||116.10||| 85014|EAP|0300|HEMATOCRIT|PHCS|GROUP AND PENSION|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|PHCS|HUMANA INSURANCE|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|PHCS|GROUP AND PENSION|116.10||||1.08||| 85014|EAP|0300|HEMATOCRIT|PHCS|HUMANA|1.08||||1.08||| 85014|EAP|0300|HEMATOCRIT|Tricare|TRICARE EAST REGION|116.10||||1.08||| 85014|EAP|0300|HEMATOCRIT|Tricare|TRICARE EAST REGION|150.65||||116.10||| 85014|EAP|0300|HEMATOCRIT|Texas Workforce Commission|DIS DETER SERV (DDS)|124.20||||124.20||| 85014|EAP|0300|HEMATOCRIT|Rusk State Hospital|RUSK STATE HOSP|124.20||||1.08||| 85014|EAP|0300|HEMATOCRIT|PHCS|GROUP AND PENSION|1.31||||124.20||| 85014|EAP|0300|HEMATOCRIT|Tricare|TRICARE SOUTH PHYSICIAN|||||124.20||| 85014|EAP|0300|HEMATOCRIT|Tricare|TRICARE FOR LIFE|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|PHCS|GROUP AND PENSION|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|PHCS|GROUP AND PENSION|116.10||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Tricare|TRICARE FOR LIFE|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Rusk State Hospital|RUSK STATE HOSP|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|Tricare|TRICARE EAST REGION|116.10||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Tricare|TRICARE EAST REGION|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|PHCS|HUMANA INSURANCE|1.08||||||| 85018|EAP|0300|HEMOGLOBIN|PHCS|HUMANA|1.08||||||| 85018|EAP|0300|HEMOGLOBIN|NON CONTRACTED|COMMERCIAL OTHER 2|||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Medicare|MEDICARE ACUTE|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Multiplan|NALC|1.08||||||| 85018|EAP|0300|HEMOGLOBIN|NON CONTRACTED|COMMERCIAL OTHER 1|1.08||||124.20||| 85018|EAP|0300|HEMOGLOBIN|NON CONTRACTED|COMMERCIAL OTHER 1|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|UNITED HEALTHCARE OTHER|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|UNITED HEALTHCARE OTHER|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|UNITED HEALTHCARE|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|TML GROUP BENEFITS|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|GOLDEN RULE|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|GEHA|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|OTHER INSTITUTIONS|||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|BCBS MEDICARE PPO MA|116.10||||116.10||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|OTHER INSTITUTIONS|||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|ETMC REHABILITATION HOSPITAL|1.08||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|HEALTHSPRING MA|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|BCBS MEDICARE PPO MA|124.20||||116.10||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.08||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|CRIME VICTIMS COMPENSATION|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|CRIME VICTIMS COMPENSATION|1.08||||||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|MEDICAID|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|MEDICAID HMO|116.10||||||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID AMERIGROUP|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID SUPERIOR|1.08||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID SUPERIOR|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID AMERIGROUP|1.08||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.08||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Cigna|CIGNA OTHER|116.10||||||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|SMITH COUNTY JAIL|1.08||||||| 85018|EAP|0300|HEMOGLOBIN|Cigna|CIGNA|116.10||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Cigna|CIGNA|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Cigna|CIGNA OTHER|1.08||||||| 85018|EAP|0300|HEMOGLOBIN|Humana Medicare Advantage|HUMANA MA|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Aenta Medicare Advantage|AETNA MEDICARE MA|1.08||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Aetna|BOON CHAPMAN|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|Aetna|AETNA QHP HMO|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|Aetna|AETNA OTHER|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|HEALTHSPRING MA|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Aetna|AETNA PPO|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Aenta Medicare Advantage|AETNA MEDICARE MA|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Aetna Value Network|AETNA VALUE NETWORK|116.10||||||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.08||||||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross PPO Specialty|BCBSTX OTHER|116.10||||||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross PPO Specialty|BCBSTX OTHER|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|UNITED HEALTHCARE|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Medicare|MEDICARE PART B ONLY IP|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross PPO Specialty|BCBSTX PPO|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross PPO Specialty|BCBSTX PPO|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.08||||124.20||| 85018|EAP|0300|HEMOGLOBIN|ChampVA|CHAMPVA CENTER|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|116.10||||||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross HMO Specialty|BCBSTX HMO|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross HMO Specialty|BCBSTX HMO|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Medicare|MEDICARE ACUTE|124.20||||116.10||| 85018|EAP|0300|HEMOGLOBIN|Workers Compensation|WORKERS COMPENSATION OTHER|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.08||||||| 85018|EAP|0300|HEMOGLOBIN|Workers Compensation|TEXAS MUTUAL INSURANCE|1.08||||||| 85018|EAP|0300|HEMOGLOBIN|Workers Compensation|ZURICH COMPANY|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|Texas Workforce Commission|DIS DETER SERV (DDS)|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Veterans Affairs|VETERANS ADMINISTRATION|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Access Direct Platinum|HEALTHFIRST TPA UMR|1.08||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|Access Direct Platinum|HEALTHFIRST TPA|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|124.20||||||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|124.20||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC MEDICARE GOLD MA|1.08||||1.08||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC MEDICARE GOLD MA|124.20||||124.20||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC AARP MCR HMO MA|124.20||||124.20||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Medicare Advantage|UHC MEDICARE GOLD MA|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Medicare Advantage|UHC AARP WELLMED HMO MA|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Access Direct Platinum|HEALTHFIRST TPA UMR|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Access Direct Platinum|HEALTHFIRST TPA|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|WORKERS COMPENSATION OTHER|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|GALLAGHER BASSETT|||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|WORKERS COMP PHYSICIAN|||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|UT EMPLOYEE INJURY|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|185.15||||173.08||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|ZURICH COMPANY|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|BROOKSHIRES WORKERS COMP|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|TEXAS MUTUAL INSURANCE|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Blue Cross HMO Specialty|BCBSTX HMO|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Blue Cross PPO Specialty|BCBSTX OTHER|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|ChampVA|CHAMPVA CENTER|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Aetna Value Network|AETNA VALUE NETWORK|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Aetna|AETNA OTHER|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Aetna|AETNA PPO|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Aetna|BH AETNA|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Aetna|AETNA QHP HMO|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Humana Medicare Advantage|HUMANA MA|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Cigna|CIGNA OTHER|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Cigna|CIGNA|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Cigna|CIGNA|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Cigna Behavioral Health|BH CIGNA|185.15||||||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicaid|MEDICAID AMERIGROUP|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicaid|MEDICAID SUPERIOR|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|CRIME VICTIMS COMPENSATION|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|LAW ENFORCEMENT OTHER|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|SMITH COUNTY JAIL|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|MOLINA HEALTHCARE OF TEXAS|173.08||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|MEDICAID HMO|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|COUNTY INDIGENT HEALTH OTHER|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|BH TEXAS CHILDRENS MEDICAID|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|MEDICAID|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicaid|MEDICAID BCBSTX|||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicare|WELLCARE CHOICE MA|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Magellan Behavioral Health|BH MAGELLAN|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicare|OTHER INSTITUTIONS|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicare|HEALTHSPRING MA|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicare|MA PART B ONLY IP|1.61||||||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Aetna|BOON CHAPMAN|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicare|ETMC REHABILITATION HOSPITAL|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicare|JACKSONVILLE ACCESS|1.61||||||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Managed Medicare|BCBS MEDICARE PPO MA|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|UTMB|UTMB CORRECTIONAL MANAGED CARE|185.15||||173.08||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Healthcare|UNITED HEALTHCARE ERS|1.61||||||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Healthcare|UNITED HEALTHCARE OTHER|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Blue Cross PPO Specialty|BCBSTX PPO|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Veterans Affairs|VETERANS ADMINISTRATION|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Healthcare|UNITED HEALTHCARE|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Healthcare|UNITED HEALTHCARE|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Healthcare|TML GROUP BENEFITS|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Healthcare|GOLDEN RULE|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Healthcare|GEHA|173.08||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Healthcare|AARP|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicare|MEDICARE PART B ONLY IP|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|NON CONTRACTED|COMMERCIAL OTHER 2|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Workers Compensation|TRAVELERS INSURANCE COMPANY|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Multiplan|WEB TPA|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Multiplan|PACIFICARE|185.15||||||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Multiplan|TRUSTMARK|185.15||||||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Multiplan|MUTUAL OF OMAHA|||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Access Direct Platinum|ANDREWS CENTER|1.61||||||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Multiplan|NALC|1.61||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicare|UTSW MC KIDNEY PROGRAM|||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Medicare|MEDICARE ACUTE|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|NON CONTRACTED|COMMERCIAL OTHER 1|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|United Medicare Advantage|UHC AARP MCR HMO MA|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|NON CONTRACTED|COMMERCIAL OTHER 4|||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||309.75||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Optum Behavioral Health|BH OPTUM UHC|1.61||||||| 85025|EAP|0300|COMPLETE BLOOD COUNT|PHCS|GROUP AND PENSION|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|PHCS|HUMANA INSURANCE|185.15||||||| 85025|EAP|0300|COMPLETE BLOOD COUNT|PHCS|HUMANA INSURANCE|173.08||||173.08||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Tricare|TRICARE SOUTH PHYSICIAN|||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Texas Workforce Commission|DIS DETER SERV (DDS)|1.61||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Tricare|TRICARE EAST REGION|185.15||||185.15||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Tricare|TRICARE FOR LIFE|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|Rusk State Hospital|RUSK STATE HOSP|185.15||||1.61||| 85025|EAP|0300|COMPLETE BLOOD COUNT|PHCS|HUMANA|185.15||||173.08||| 85025|EAP|0300|COMPLETE BLOOD COUNT|PHCS|MULTIPLAN PHCS|||||185.15||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Tricare|TRICARE EAST REGION|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|NON CONTRACTED|COMMERCIAL OTHER 1|340.40||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicare|MEDICARE ACUTE|2.96||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|United Healthcare|UNITED HEALTHCARE OTHER|340.40||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|United Healthcare|UNITED HEALTHCARE|2.96||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|United Healthcare|UNITED HEALTHCARE|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|United Healthcare|TML GROUP BENEFITS|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|United Healthcare|GOLDEN RULE|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.96||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Managed Medicare|HEALTHSPRING MA|2.96||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Managed Medicare|BCBS MEDICARE PPO MA|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicaid|CRIME VICTIMS COMPENSATION|318.20||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicaid|MEDICAID HMO|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicaid|SMITH COUNTY JAIL|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|340.40||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Managed Medicaid|MEDICAID AMERIGROUP|340.40||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|340.40||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Managed Medicaid|MEDICAID SUPERIOR|340.40||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Cigna|CIGNA|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Cigna|CIGNA OTHER|||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Cigna|CIGNA|340.40||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Magellan Behavioral Health|BH MAGELLAN|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Humana Medicare Advantage|HUMANA MA|2.96||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Aenta Medicare Advantage|AETNA MEDICARE MA|340.40||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Aetna|AETNA OTHER|318.20||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicaid|MEDICAID|2.96||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Aetna|AETNA PPO|2.96||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Aetna|BH AETNA|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Aetna|AETNA QHP HMO|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|318.20||||2.96||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Blue Cross PPO Specialty|BCBSTX PPO|340.40||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Blue Cross PPO Specialty|BCBSTX OTHER|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|ChampVA|CHAMPVA CENTER|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Blue Cross HMO Specialty|BCBSTX HMO|2.96||||318.20||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Workers Compensation|TEXAS MUTUAL INSURANCE|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Workers Compensation|WORKERS COMPENSATION OTHER|340.40||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Medicare|MEDICARE PART B ONLY IP|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Workers Compensation|ZURICH COMPANY|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Veterans Affairs|VETERANS ADMINISTRATION|340.40||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|340.40||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Access Direct Platinum|HEALTHFIRST TPA UMR|2.96||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.96||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|340.40||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|Access Direct Platinum|HEALTHFIRST TPA|318.20||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|United Medicare Advantage|UHC MEDICARE GOLD MA|2.96||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|United Medicare Advantage|UHC AARP WELLMED HMO MA|340.40||||||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|340.40||||340.40||| 85027|EAP|0300|COMPLETE BLOOD COUNT WO D|United Medicare Advantage|UHC AARP MCR HMO MA|340.40||||340.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|United Medicare Advantage|UHC MEDICARE GOLD MA|1.96||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|United Medicare Advantage|UHC AARP WELLMED HMO MA|225.40||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|United Medicare Advantage|UHC AARP MCR HMO MA|225.40||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|225.40||||210.70||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Access Direct Platinum|HEALTHFIRST TPA UMR|||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.96||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Access Direct Platinum|HEALTHFIRST TPA|1.96||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Workers Compensation|WORKERS COMPENSATION OTHER|225.40||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Veterans Affairs|VETERANS ADMINISTRATION|225.40||||1.96||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Blue Cross HMO Specialty|BCBSTX HMO|1.96||||1.96||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Blue Cross PPO Specialty|BCBSTX OTHER|1.96||||1.96||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Blue Cross PPO Specialty|BCBSTX PPO|1.96||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.96||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Brinson Benefits|THE HEALTH PLAN SMITH CO|225.40||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|ChampVA|CHAMPVA CENTER|225.40||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.96||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Aenta Medicare Advantage|AETNA MEDICARE MA|1.96||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Aetna|AETNA PPO|210.70||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Humana Medicare Advantage|HUMANA MA|1.96||||1.96||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Cigna|CIGNA|225.40||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Workers Compensation|ZURICH COMPANY|225.40||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Cigna|CIGNA OTHER|1.96||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|225.40||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Managed Medicaid|MEDICAID SUPERIOR|225.40||||1.96||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|225.40||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|225.40||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|225.40||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Managed Medicaid|MEDICAID AMERIGROUP|225.40||||1.96||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Medicaid|MEDICAID HMO|||||210.70||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Medicaid|SMITH COUNTY JAIL|1.96||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Medicaid|MEDICAID|1.96||||1.96||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Managed Medicare|HEALTHSPRING MA|225.40||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.96||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Managed Medicare|BCBS MEDICARE PPO MA|225.40||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|UTMB|UTMB CORRECTIONAL MANAGED CARE|225.40||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|United Healthcare|UNITED HEALTHCARE|1.96||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|United Healthcare|UNITED HEALTHCARE OTHER|1.96||||1.96||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|United Healthcare|UNITED HEALTHCARE|225.40||||1.96||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Medicare|MEDICARE ACUTE|225.40||||225.40||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Medicare|MEDICARE PART B ONLY IP|210.70||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|NON CONTRACTED|COMMERCIAL OTHER 1|210.70||||||| 85045|EAP|0300|AUTOMATED RETICULOCYTE CO|Tricare|TRICARE EAST REGION|225.40||||||| 85048|EAP|0300|EOSINOPHIL COUNT|Medicare|MEDICARE ACUTE|233.28||||||| 85048|EAP|0300|WHITEBLOOD CELLS COUNT|Medicare|MEDICARE ACUTE|289.80||||||| 85048|EAP|0300|WHITEBLOOD CELLS COUNT|Humana Medicare Advantage|HUMANA MA|270.90||||||| 85048|EAP|0300|EOSINOPHIL COUNT|Blue Cross PPO Specialty|BCBSTX OTHER|2.17||||||| 85048|EAP|0300|EOSINOPHIL COUNT|Blue Cross PPO Specialty|BCBSTX PPO|2.17||||||| 85048|EAP|0300|EOSINOPHIL COUNT|Veterans Affairs|VETERANS ADMINISTRATION|249.55||||||| 85048|EAP|0300|EOSINOPHIL COUNT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||249.55||| 85048|EAP|0300|WHITEBLOOD CELLS COUNT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|289.80||||||| 85048|EAP|0300|EOSINOPHIL COUNT|United Medicare Advantage|UHC MEDICARE GOLD MA|2.17||||2.17||| 85049|EAP|0300|PLATELET COUNT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.96||||110.40||| 85049|EAP|0300|PLATELET COUNT|United Medicare Advantage|UHC AARP MCR HMO MA|110.40||||||| 85049|EAP|0300|PLATELET COUNT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.96||||||| 85049|EAP|0300|PLATELET COUNT|Access Direct Platinum|HEALTHFIRST TPA UMR|110.40||||||| 85049|EAP|0300|PLATELET COUNT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|110.40||||||| 85049|EAP|0300|PLATELET COUNT|Veterans Affairs|VETERANS ADMINISTRATION|0.96||||||| 85049|EAP|0300|PLATELET COUNT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.96||||||| 85049|EAP|0300|PLATELET COUNT|Aetna|AETNA OTHER|0.96||||||| 85049|EAP|0300|PLATELET COUNT|Aetna|AETNA PPO|0.96||||0.96||| 85049|EAP|0300|PLATELET COUNT|Aetna|AETNA QHP HMO|110.40||||||| 85049|EAP|0300|PLATELET COUNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.40||||110.40||| 85049|EAP|0300|PLATELET COUNT|Blue Cross HMO Specialty|BCBSTX HMO|0.96||||0.96||| 85049|EAP|0300|PLATELET COUNT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|110.40||||||| 85049|EAP|0300|PLATELET COUNT|Blue Cross PPO Specialty|BCBSTX PPO|110.40||||0.96||| 85049|EAP|0300|PLATELET COUNT|Blue Cross PPO Specialty|BCBSTX OTHER|110.40||||||| 85049|EAP|0300|PLATELET COUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|110.40||||0.96||| 85049|EAP|0300|PLATELET COUNT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|110.40||||0.96||| 85049|EAP|0300|PLATELET COUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|110.40||||0.96||| 85049|EAP|0300|PLATELET COUNT|Cigna|CIGNA|110.40||||||| 85049|EAP|0300|PLATELET COUNT|Cigna|CIGNA OTHER|110.40||||||| 85049|EAP|0300|PLATELET COUNT|Humana Medicare Advantage|HUMANA MA|0.96||||0.96||| 85049|EAP|0300|PLATELET COUNT|Managed Medicare|BCBS MEDICARE PPO MA|103.20||||||| 85049|EAP|0300|PLATELET COUNT|Managed Medicare|HEALTHSPRING MA|110.40||||103.20||| 85049|EAP|0300|PLATELET COUNT|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.96||||0.96||| 85049|EAP|0300|PLATELET COUNT|Medicaid|MEDICAID|0.96||||||| 85049|EAP|0300|PLATELET COUNT|United Healthcare|UNITED HEALTHCARE|110.40||||||| 85049|EAP|0300|PLATELET COUNT|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.20||||||| 85049|EAP|0300|PLATELET COUNT|NON CONTRACTED|COMMERCIAL OTHER 1|110.40||||||| 85049|EAP|0300|PLATELET COUNT|Medicare|MEDICARE ACUTE|110.40||||0.96||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|United Healthcare|UNITED HEALTHCARE OTHER|1,244.30||||||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|United Healthcare|UNITED HEALTHCARE|||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Medicaid|MEDICAID|10.82||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Managed Medicare|HEALTHSPRING MA|1,244.30||||10.82||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.82||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Managed Medicare|WELLCARE CHOICE MA|1,244.30||||||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Medicaid|COUNTY INDIGENT HEALTH OTHER|1,244.30||||||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Humana Medicare Advantage|HUMANA MA|1,163.15||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Cigna|CIGNA|1,163.15||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,244.30||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,244.30||||10.82||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|ChampVA|CHAMPVA CENTER|1,244.30||||||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Blue Cross PPO Specialty|BCBSTX PPO|1,244.30||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Blue Cross HMO Specialty|BCBSTX HMO|1,163.15||||10.82||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,244.30||||1,163.15||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Medicare|UTSW MC KIDNEY PROGRAM|||||10.82||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Aenta Medicare Advantage|AETNA MEDICARE MA|10.82||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Veterans Affairs|VETERANS ADMINISTRATION|1,244.30||||10.82||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.82||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||10.82||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,244.30||||1,163.15||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,244.30||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Medicare|MEDICARE ACUTE|1,244.30||||1,163.15||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|Tricare|TRICARE EAST REGION|1,244.30||||||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|NON CONTRACTED|COMMERCIAL OTHER 1|||||10.82||| 85097|EAP|0300|BONE MARROW SMEAR INTERPR|PHCS|HUMANA INSURANCE|1,244.30||||||| 85210|EAP|0300|FACTOR II|Blue Cross PPO Specialty|BCBSTX PPO|638.55||||638.55||| 85210|EAP|0300|FACTOR II|United Healthcare|UNITED HEALTHCARE OTHER|683.10||||||| 85210|EAP|0300|FACTOR II|Medicare|MEDICARE ACUTE|5.94||||5.94||| 85210|EAP|0300|FACTOR II|Medicaid|MEDICAID|683.10||||||| 85210|EAP|0300|FACTOR II|Veterans Affairs|VETERANS ADMINISTRATION|683.10||||5.94||| 85210|EAP|0300|FACTOR II|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.94||||||| 85210|EAP|0300|FACTOR II|United Medicare Advantage|UHC MEDICARE GOLD MA|5.94||||683.10||| 85210|EAP|0300|FACTOR II|Humana Medicare Advantage|HUMANA MA|683.10||||5.94||| 85210|EAP|0300|FACTOR II|United Medicare Advantage|UHC AARP MCR HMO MA|683.10||||||| 85210|EAP|0300|FACTOR II|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.94||| 85210|EAP|0300|FACTOR II|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|683.10||||||| 85220|EAP|0300|FACTOR V|Humana Medicare Advantage|HUMANA MA|8.07||||8.07||| 85220|EAP|0300|FACTOR V|Medicare|MEDICARE ACUTE|8.07||||8.07||| 85220|EAP|0300|FACTOR V|Medicaid|MEDICAID|867.53||||||| 85220|EAP|0300|FACTOR V|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.07||| 85220|EAP|0300|FACTOR V|Veterans Affairs|VETERANS ADMINISTRATION|928.05||||8.07||| 85220|EAP|0300|FACTOR V|United Medicare Advantage|UHC MEDICARE GOLD MA|||||928.05||| 85220|EAP|0300|FACTOR V|Blue Cross PPO Specialty|BCBSTX PPO|867.53||||867.53||| 85220|EAP|0300|FACTOR V|Blue Cross HMO Specialty|BCBSTX HMO|928.05||||||| 85220|EAP|0300|FACTOR V|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.07||||928.05||| 85220|EAP|0300|FACTOR V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|928.05||||||| 85230|EAP|0300|FACTOR VII|United Medicare Advantage|UHC AARP MCR HMO MA|941.85||||||| 85230|EAP|0300|FACTOR VII|Cigna|CIGNA|||||8.19||| 85230|EAP|0300|FACTOR VII|Medicare|MEDICARE ACUTE|880.43||||8.19||| 85230|EAP|0300|FACTOR VII|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.19||||8.19||| 85230|EAP|0300|FACTOR VII|Blue Cross PPO Specialty|BCBSTX PPO|941.85||||8.19||| 85230|EAP|0300|FACTOR VII|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.19||||||| 85230|EAP|0300|FACTOR VII|Medicaid|MEDICAID|941.85||||||| 85230|EAP|0300|FACTOR VII|United Medicare Advantage|UHC MEDICARE GOLD MA|8.19||||941.85||| 85230|EAP|0300|FACTOR VII|Humana Medicare Advantage|HUMANA MA|941.85||||880.43||| 85230|EAP|0300|FACTOR VII|United Healthcare|UNITED HEALTHCARE OTHER|941.85||||||| 85230|EAP|0300|FACTOR VII|Veterans Affairs|VETERANS ADMINISTRATION|||||8.19||| 85230|EAP|0300|FACTOR VII|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|941.85||||||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|302.75||||302.75||| 85240|EAP|0300|FACTOR VIII|Managed Medicaid|MEDICAID AMERIGROUP|||||399.05||| 85240|EAP|0300|FACTOR VIII|Humana Medicare Advantage|HUMANA MA|373.03||||3.47||| 85240|EAP|0300|CLOTTING FACTOR VIII AHG|Managed Medicare|HEALTHSPRING MA|3.47||||855.60||| 85240|EAP|0300|FACTOR VIII|Cigna|CIGNA|399.05||||||| 85240|EAP|0300|FACTOR VIII|Managed Medicare|HEALTHSPRING MA|3.47||||373.03||| 85240|EAP|0300|FACTOR VIII|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.47||||3.47||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|302.75||||302.75||| 85240|EAP|0300|FACTOR VIII|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.47||||3.47||| 85240|EAP|0300|FACTOR VIII|Medicaid|MEDICAID|373.03||||||| 85240|EAP|0300|FACTOR VIII|Managed Medicaid|MEDICAID UNITED HEALTHCARE|399.05||||399.05||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|Cigna|CIGNA|||||302.75||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|Blue Cross PPO Specialty|BCBSTX OTHER|302.75||||||| 85240|EAP|0300|FACTOR VIII|United Medicare Advantage|UHC MEDICARE GOLD MA|3.47||||||| 85240|EAP|0300|FACTOR VIII|Managed Medicaid|MEDICAID SUPERIOR|||||3.47||| 85240|EAP|0300|FACTOR VIII|Blue Cross PPO Specialty|BCBSTX PPO|3.47||||3.47||| 85240|EAP|0300|FACTOR VIII|Medicare|UTSW MC KIDNEY PROGRAM|||||399.05||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|302.75||||3.47||| 85240|EAP|0300|FACTOR VIII|Blue Cross PPO Specialty|BCBSTX OTHER|399.05||||||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|Medicare|MEDICARE ACUTE|302.75||||302.75||| 85240|EAP|0300|FACTOR VIII|Medicare|MEDICARE ACUTE|399.05||||399.05||| 85240|EAP|0300|FACTOR VIII|Aetna|AETNA PPO|||||3.47||| 85240|EAP|0300|FACTOR VIII|United Healthcare|UNITED HEALTHCARE OTHER|399.05||||399.05||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|United Medicare Advantage|UHC AARP MCR HMO MA|399.05||||302.75||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|Managed Medicaid|MEDICAID AMERIGROUP|||||302.75||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||302.75||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|Medicare|MEDICARE PART B ONLY IP|302.75||||||| 85240|EAP|0300|CLOTTING FACTOR VIII AHG|Humana Medicare Advantage|HUMANA MA|373.03||||7.44||| 85240|EAP|0300|FACTOR VIII|Veterans Affairs|VETERANS ADMINISTRATION|399.05||||3.47||| 85240|EAP|0300|FACTOR VIII VON WILLEBRAN|Blue Cross PPO Specialty|BCBSTX PPO|302.75||||302.75||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|Blue Cross PPO Specialty|BCBSTX OTHER|3.26||||||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||374.90||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|United Medicare Advantage|UHC AARP MCR HMO MA|||||374.90||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|374.90||||374.90||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|Medicare|MEDICARE PART B ONLY IP|3.26||||||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|374.90||||||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|374.90||||374.90||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|Blue Cross PPO Specialty|BCBSTX PPO|374.90||||374.90||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|Managed Medicaid|MEDICAID AMERIGROUP|||||374.90||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|Medicare|MEDICARE ACUTE|3.26||||3.26||| 85245|EAP|0300|FACTOR VIII RISTOCETIN CO|Cigna|CIGNA|||||3.26||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Medicare|MEDICARE ACUTE|1,072.95||||3.04||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|349.60||||349.60||| 85246|EAP|0300|FACTOR VIII RELATED ANTIG|Blue Cross PPO Specialty|BCBSTX PPO|349.60||||1,072.95||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||349.60||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Cigna|CIGNA|||||3.04||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Medicare|MEDICARE ACUTE|3.04||||3.04||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Medicare|MEDICARE PART B ONLY IP|3.04||||||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|349.60||||||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Blue Cross PPO Specialty|BCBSTX OTHER|3.04||||||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|349.60||||349.60||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Managed Medicaid|MEDICAID AMERIGROUP|||||349.60||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|349.60||||349.60||| 85246|EAP|0300|FACTOR VIII VW ANTIGEN|United Medicare Advantage|UHC AARP MCR HMO MA|||||349.60||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|Managed Medicaid|MEDICAID AMERIGROUP|||||379.21||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|Blue Cross PPO Specialty|BCBSTX PPO|379.21||||||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|379.21||||||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||379.21||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|379.21||||379.21||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|Cigna|CIGNA|||||329.75||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|Blue Cross PPO Specialty|BCBSTX OTHER|329.75||||||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|379.21||||||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|Medicare|MEDICARE ACUTE|354.48||||329.75||| 85247|EAP|0300|FACTOR VIII MULTIMETRIC A|Medicare|MEDICARE PART B ONLY IP|329.75||||||| 85250|EAP|0300|FACTOR IX|Managed Medicaid|MEDICAID AMERIGROUP|||||1,000.50||| 85250|EAP|0300|FACTOR IX|Cigna|CIGNA|1,000.50||||8.70||| 85250|EAP|0300|FACTOR IX|Medicare|MEDICARE ACUTE|1,000.50||||1,000.50||| 85250|EAP|0300|FACTOR IX|Managed Medicare|HEALTHSPRING MA|||||8.70||| 85250|EAP|0300|FACTOR IX|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.70||||8.70||| 85250|EAP|0300|FACTOR IX|Humana Medicare Advantage|HUMANA MA|1,000.50||||8.70||| 85250|EAP|0300|FACTOR IX|Blue Cross PPO Specialty|BCBSTX PPO|8.70||||8.70||| 85250|EAP|0300|FACTOR IX|United Medicare Advantage|UHC AARP MCR HMO MA|1,000.50||||||| 85250|EAP|0300|FACTOR IX|Medicaid|MEDICAID|935.25||||||| 85250|EAP|0300|FACTOR IX|Veterans Affairs|VETERANS ADMINISTRATION|8.70||||8.70||| 85250|EAP|0300|FACTOR IX|Aetna|AETNA PPO|||||8.70||| 85250|EAP|0300|FACTOR IX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|935.25||||8.70||| 85250|EAP|0300|FACTOR IX|United Healthcare|UNITED HEALTHCARE OTHER|1,000.50||||1,000.50||| 85250|EAP|0300|FACTOR IX|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.70||||1,000.50||| 85250|EAP|0300|FACTOR IX|Managed Medicaid|MEDICAID SUPERIOR|||||8.70||| 85250|EAP|0300|FACTOR IX|Cigna|CIGNA|||||8.70||| 85260|EAP|0300|FACTOR X|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|941.85||||||| 85260|EAP|0300|FACTOR X|Medicaid|MEDICAID|880.43||||||| 85260|EAP|0300|FACTOR X|Medicare|MEDICARE ACUTE|880.43||||8.19||| 85260|EAP|0300|FACTOR X|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.19||| 85260|EAP|0300|FACTOR X|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.19||||||| 85260|EAP|0300|FACTOR X|Veterans Affairs|VETERANS ADMINISTRATION|941.85||||8.19||| 85260|EAP|0300|FACTOR X|Blue Cross PPO Specialty|BCBSTX PPO|880.43||||880.43||| 85260|EAP|0300|FACTOR X|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.19||||||| 85260|EAP|0300|FACTOR X|Humana Medicare Advantage|HUMANA MA|941.85||||8.19||| 85260|EAP|0300|FACTOR X|United Medicare Advantage|UHC MEDICARE GOLD MA|8.19||||941.85||| 85270|EAP|0300|FACTOR XI|Cigna|CIGNA|941.85||||||| 85270|EAP|0300|FACTOR XI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.19||||941.85||| 85270|EAP|0300|FACTOR XI|United Medicare Advantage|UHC AARP MCR HMO MA|941.85||||||| 85270|EAP|0300|FACTOR XI|Humana Medicare Advantage|HUMANA MA|8.19||||8.19||| 85270|EAP|0300|FACTOR XI|Medicaid|MEDICAID|880.43||||||| 85270|EAP|0300|FACTOR XI|Blue Cross PPO Specialty|BCBSTX PPO|8.19||||8.19||| 85270|EAP|0300|FACTOR XI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.19||||8.19||| 85270|EAP|0300|FACTOR XI|Managed Medicare|HEALTHSPRING MA|||||8.19||| 85270|EAP|0300|FACTOR XI|United Healthcare|UNITED HEALTHCARE OTHER|941.85||||941.85||| 85270|EAP|0300|FACTOR XI|Aetna|AETNA PPO|||||8.19||| 85270|EAP|0300|FACTOR XI|Managed Medicaid|MEDICAID SUPERIOR|||||8.19||| 85270|EAP|0300|FACTOR XI|Medicare|MEDICARE ACUTE|941.85||||941.85||| 85270|EAP|0300|FACTOR XI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|880.43||||8.19||| 85270|EAP|0300|FACTOR XI|Veterans Affairs|VETERANS ADMINISTRATION|941.85||||8.19||| 85280|EAP|0300|FACTOR XII HAGEMAN|Cigna|CIGNA|1,017.75||||||| 85280|EAP|0300|FACTOR XII HAGEMAN|United Healthcare|UNITED HEALTHCARE OTHER|1,017.75||||1,017.75||| 85280|EAP|0300|FACTOR XII HAGEMAN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.85||||||| 85280|EAP|0300|FACTOR XII HAGEMAN|Medicare|MEDICARE ACUTE|1,017.75||||1,017.75||| 85280|EAP|0300|FACTOR XII HAGEMAN|Humana Medicare Advantage|HUMANA MA|8.85||||8.85||| 85280|EAP|0300|FACTOR XII HAGEMAN|Medicaid|MEDICAID|951.38||||||| 85280|EAP|0300|FACTOR XII HAGEMAN|Veterans Affairs|VETERANS ADMINISTRATION|1,017.75||||8.85||| 85280|EAP|0300|FACTOR XII HAGEMAN|Aetna|AETNA PPO|||||8.85||| 85280|EAP|0300|FACTOR XII HAGEMAN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.85||||8.85||| 85280|EAP|0300|FACTOR XII HAGEMAN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|951.38||||8.85||| 85280|EAP|0300|FACTOR XII HAGEMAN|Managed Medicare|HEALTHSPRING MA|||||8.85||| 85280|EAP|0300|FACTOR XII HAGEMAN|Blue Cross PPO Specialty|BCBSTX PPO|8.85||||8.85||| 85280|EAP|0300|FACTOR XII HAGEMAN|United Medicare Advantage|UHC AARP MCR HMO MA|1,017.75||||||| 85291|EAP|0300|FACTOR XIII SCREEN|Medicare|MEDICARE ACUTE|859.05||||7.47||| 85291|EAP|0300|FACTOR XIII SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|||||859.05||| 85292|EAP|0300|PREKALLIKREIN ASSAY|Veterans Affairs|VETERANS ADMINISTRATION|370.01||||||| 85292|EAP|0300|PREKALLIKREIN ASSAY|Aetna|AETNA PPO|||||321.75||| 85292|EAP|0300|PREKALLIKREIN ASSAY|Humana Medicare Advantage|HUMANA MA|||||370.01||| 85292|EAP|0300|PREKALLIKREIN ASSAY|Medicare|MEDICARE ACUTE|||||321.75||| 85293|EAP|0300|HIGH MOLECULAR WEIGHT KIN|Medicare|MEDICARE ACUTE|||||3.30||| 85293|EAP|0300|HIGH MOLECULAR WEIGHT KIN|Veterans Affairs|VETERANS ADMINISTRATION|379.50||||||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|209,883.13|55179.82|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|210,984.94|321.48|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Veterans Affairs|VETERANS ADMINISTRATION|141,608.30|29261.7|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Humana Medicare Advantage|HUMANA MA|216,321.50|29264.11|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|288,018.27|971.01|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|772,508.10|50623.73|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Medicare|MEDICARE ACUTE|199,501.05|29260.82|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Access Direct Platinum|HEALTHFIRST TPA|294,917.91|37312.47|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Cigna|CIGNA|136,746.59|51481.435|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|United Healthcare|UNITED HEALTHCARE|232,781.45|60347.03|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|234,368.30|38604.22|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Medicaid|SMITH COUNTY INDIGENT HEALTH|175,489.85|16531.03|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Blue Cross PPO Specialty|BCBSTX OTHER|360,511.21|1458.73|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|260,046.67|29233.54|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|488,229.83|52502.575|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|154,713.29|55179.82|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|183,597.54|29849.3|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Managed Medicare|HEALTHSPRING MA|435,419.30|29260.82|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|United Healthcare|UNITED HEALTHCARE|756,694.43|123311.03|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Managed Medicare|BCBS MEDICARE PPO MA|76,687.63|29233.54|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|210,872.16|29849.3|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|190,079.03|29849.3|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|Medicaid|MEDICAID|261,173.52|34704.29|123311.03|321.48|||| 853|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|125,518.50|29149.66|123311.03|321.48|||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|623.30||||623.30||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||623.30||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Managed Medicare|HEALTHSPRING MA|472.50||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Tricare|TRICARE EAST REGION|623.30||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|623.30||||623.30||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Medicaid|MEDICAID|5.42||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|United Healthcare|UNITED HEALTHCARE OTHER|5.42||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Medicare|MEDICARE ACUTE|5.42||||623.30||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.42||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Humana Medicare Advantage|HUMANA MA|5.42||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|United Medicare Advantage|UHC MEDICARE GOLD MA|5.42||||623.30||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|United Medicare Advantage|UHC AARP MCR HMO MA|623.30||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Managed Medicaid|MEDICAID SUPERIOR|623.30||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Cigna|CIGNA|623.30||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|623.30||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|27.50||||5.42||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|623.30||||5.42||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|United Healthcare|UNITED HEALTHCARE|5.42||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|623.30||||623.30||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|United Healthcare|UNITED HEALTHCARE|623.30||||5.42||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Blue Cross PPO Specialty|BCBSTX OTHER|5.42||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Blue Cross HMO Specialty|BCBSTX HMO|623.30||||5.42||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Access Direct Platinum|HEALTHFIRST TPA|5.42||||||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|623.30||||5.42||| 85300|EAP|0300|ANTITHROMBIN III ACTIVITY|Aetna|AETNA PPO|5.42||||623.30||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|United Medicare Advantage|UHC AARP MCR HMO MA|||||495.36||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|495.36||||||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Managed Medicare|HEALTHSPRING MA|430.75||||||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Humana Medicare Advantage|HUMANA MA|430.75||||||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Medicaid|MEDICAID|430.75||||||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Blue Cross PPO Specialty|BCBSTX OTHER|430.75||||||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|430.75||||||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|430.75||||495.36||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA|430.75||||||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Medicare|MEDICARE ACUTE|430.75||||||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Managed Medicaid|MEDICAID AMERIGROUP|495.36||||||| 85301|EAP|0300|ANTI-THROMBIN III ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|430.75||||||| 85302|EAP|0300|PROTEIN C ANTIGEN|United Medicare Advantage|UHC AARP MCR HMO MA|||||550.56||| 85302|EAP|0300|PROTEIN C ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|514.66||||550.56||| 85302|EAP|0300|PROTEIN C ANTIGEN|Medicare|MEDICARE ACUTE|550.56||||||| 85302|EAP|0300|PROTEIN C ANTIGEN|Managed Medicare|HEALTHSPRING MA|478.75||||||| 85302|EAP|0300|PROTEIN C ANTIGEN|Blue Cross HMO Specialty|BCBSTX HMO|550.56||||||| 85302|EAP|0300|PROTEIN C ANTIGEN|United Healthcare|UNITED HEALTHCARE|478.75||||||| 85302|EAP|0300|PROTEIN C ANTIGEN|Managed Medicaid|MEDICAID AMERIGROUP|550.56||||||| 85303|EAP|0300|PROTEIN S ACTIVITY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||550.75||| 85303|EAP|0300|PROTEIN C ACTIVITY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|633.36||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|550.75||||550.75||| 85303|EAP|0300|PROTEIN C ACTIVITY|United Medicare Advantage|UHC MEDICARE GOLD MA|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|United Medicare Advantage|UHC AARP MCR HMO MA|550.75||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Medicaid|MEDICAID|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Managed Medicare|ETMC AFFILIATE HOSPITALS|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Managed Medicare|HEALTHSPRING MA|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Medicare|MEDICARE ACUTE|550.75||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|550.75||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|United Healthcare|UNITED HEALTHCARE OTHER|550.75||||||| 85303|EAP|0300|PROTEIN S ACTIVITY|United Healthcare|UNITED HEALTHCARE|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Medicaid|MEDICAID|550.75||||||| 85303|EAP|0300|PROTEIN S ACTIVITY|United Medicare Advantage|UHC AARP MCR HMO MA|550.75||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Medicare|MEDICARE ACUTE|550.75||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Tricare|TRICARE EAST REGION|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|550.75||||550.75||| 85303|EAP|0300|PROTEIN C ACTIVITY|United Healthcare|UNITED HEALTHCARE OTHER|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Tricare|TRICARE EAST REGION|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Medicare|UTSW MC KIDNEY PROGRAM|||||633.36||| 85303|EAP|0300|PROTEIN S ACTIVITY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|633.36||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Managed Medicare|HEALTHSPRING MA|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|United Healthcare|UNITED HEALTHCARE|550.75||||||| 85303|EAP|0300|PROTEIN S ACTIVITY|United Medicare Advantage|UHC MEDICARE GOLD MA|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|633.36||||633.36||| 85303|EAP|0300|PROTEIN S ACTIVITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|550.75||||||| 85303|EAP|0300|PROTEIN S ACTIVITY|Blue Cross HMO Specialty|BCBSTX HMO|||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|550.75||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Blue Cross PPO Specialty|BCBSTX OTHER|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|550.75||||550.75||| 85303|EAP|0300|PROTEIN C ACTIVITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|550.75||||633.36||| 85303|EAP|0300|PROTEIN C ACTIVITY|Aetna|AETNA PPO|550.75||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|550.75||||633.36||| 85303|EAP|0300|PROTEIN C ACTIVITY|Cigna|CIGNA|633.36||||||| 85303|EAP|0300|PROTEIN S ACTIVITY|Cigna|CIGNA|633.36||||||| 85303|EAP|0300|PROTEIN S ACTIVITY|Aetna|AETNA PPO|550.75||||550.75||| 85303|EAP|0300|PROTEIN C ACTIVITY|Humana Medicare Advantage|HUMANA MA|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|633.36||||633.36||| 85303|EAP|0300|PROTEIN C ACTIVITY|Managed Medicaid|MEDICAID AMERIGROUP|633.36||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Humana Medicare Advantage|HUMANA MA|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Blue Cross HMO Specialty|BCBSTX HMO|||||550.75||| 85303|EAP|0300|PROTEIN S ACTIVITY|Managed Medicaid|MEDICAID AMERIGROUP|633.36||||550.75||| 85303|EAP|0300|PROTEIN C ACTIVITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Blue Cross PPO Specialty|BCBSTX OTHER|550.75||||||| 85303|EAP|0300|PROTEIN C ACTIVITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|550.75||||550.75||| 85306|EAP|0300|PROTEIN S AG FREE|Medicare|UTSW MC KIDNEY PROGRAM|||||13.02||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||632.21||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||549.75||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Blue Cross PPO Specialty|BCBSTX OTHER|549.75||||||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|United Medicare Advantage|UHC AARP MCR HMO MA|||||632.21||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|632.21||||632.21||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Blue Cross PPO Specialty|BCBSTX PPO|632.21||||549.75||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|632.21||||590.98||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Aetna|AETNA PPO|||||632.21||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Medicare|UTSW MC KIDNEY PROGRAM|||||632.21||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Blue Cross HMO Specialty|BCBSTX HMO|||||549.75||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Cigna|CIGNA|632.21||||||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Medicare|MEDICARE ACUTE|549.75||||590.98||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Managed Medicare|ETMC AFFILIATE HOSPITALS|549.75||||||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|632.21||||||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|Tricare|TRICARE EAST REGION|632.21||||||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|United Healthcare|UNITED HEALTHCARE OTHER|549.75||||||| 85307|EAP|0300|ACTIVATED PROTEIN C RESIS|United Healthcare|UNITED HEALTHCARE|632.21||||549.75||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|NON CONTRACTED|COMMERCIAL OTHER 1|677.35||||||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Medicaid|MEDICAID|5.89||||||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.89||||5.89||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Aetna|AETNA PPO|||||5.89||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Medicare|MEDICARE ACUTE|5.89||||677.35||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|677.35||||||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|United Healthcare|UNITED HEALTHCARE|||||5.89||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.89||||5.89||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Managed Medicare|HEALTHSPRING MA|677.35||||677.35||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Cigna|CIGNA|677.35||||||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Humana Medicare Advantage|HUMANA MA|5.89||||5.89||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|677.35||||633.18||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Blue Cross PPO Specialty|BCBSTX PPO|5.89||||5.89||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|United Medicare Advantage|UHC AARP MCR HMO MA|677.35||||||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|677.35||||677.35||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|United Medicare Advantage|UHC MEDICARE GOLD MA|5.89||||677.35||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|United Healthcare|UNITED HEALTHCARE OTHER|677.35||||677.35||| 85335|EAP|0300|FACTOR INHIBITOR (MIXING|Veterans Affairs|VETERANS ADMINISTRATION|5.89||||5.89||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicare|BCBS MEDICARE PPO MA|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|271.40||||253.70||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicaid|MEDICAID UNITED HEALTHCARE|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Access Direct Platinum|HEALTHFIRST TPA UMR|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Medicare Advantage|UHC MEDICARE GOLD MA|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Medicare Advantage|UHC AARP MCR HMO MA|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Cigna|CIGNA|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Cigna|CIGNA OTHER|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Aetna|AETNA OTHER|253.70||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Blue Cross PPO Specialty|BCBSTX OTHER|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Blue Cross HMO Specialty|BCBSTX HMO|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Blue Cross PPO Specialty|BCBSTX PPO|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Blue Cross PPO Specialty|BCBSTX OTHER|271.40||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Humana Medicare Advantage|HUMANA MA|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Cigna|CIGNA|271.40||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Cigna|CIGNA|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicare|HEALTHSPRING MA|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.36||||253.70||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Access Direct Platinum|HEALTHFIRST TPA UMR|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Blue Cross HMO Specialty|BCBSTX HMO|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Blue Cross PPO Specialty|BCBSTX PPO|2.36||||271.40||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Healthcare|UNITED HEALTHCARE|271.40||||271.40||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Humana Medicare Advantage|HUMANA MA|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Access Direct Platinum|HEALTHFIRST TPA|2.36||||271.40||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Aetna|AETNA OTHER|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Veterans Affairs|VETERANS ADMINISTRATION|2.36||||271.40||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Aenta Medicare Advantage|AETNA MEDICARE MA|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Medicaid|MEDICAID|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|UTMB|UTMB CORRECTIONAL MANAGED CARE|271.40||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Healthcare|UNITED HEALTHCARE OTHER|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Veterans Affairs|VETERANS ADMINISTRATION|253.70||||271.40||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Aetna|AETNA QHP HMO|271.40||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Healthcare|TML GROUP BENEFITS|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|PHCS|GROUP AND PENSION|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|PHCS|HUMANA|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Medicare|MEDICARE ACUTE|271.40||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Aetna|AETNA PPO|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Medicare|MEDICARE PART B ONLY IP|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|NON CONTRACTED|COMMERCIAL OTHER 1|271.40||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Medicare|MEDICARE ACUTE|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Tricare|TRICARE EAST REGION|271.40||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Texas Workforce Commission|DIS DETER SERV (DDS)|||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicaid|MEDICAID AMERIGROUP|2.36||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|NON CONTRACTED|COMMERCIAL OTHER 1|2.36||||||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Healthcare|UNITED HEALTHCARE|253.70||||271.40||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.36||| 85347|EAP|0300|ACTIVATED CLOTTING TIME|United Healthcare|UNITED HEALTHCARE|2.36||||271.40||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Medicare|MEDICARE ACUTE|362.25||||338.63||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Blue Cross HMO Specialty|BCBSTX HMO|3.15||||362.25||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|338.63||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.15||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Managed Medicare|HEALTHSPRING MA|3.15||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|362.25||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Blue Cross PPO Specialty|BCBSTX PPO|362.25||||362.25||| 85362|EAP|0300|FIBRIN DEGRAD PROD|United Healthcare|UNITED HEALTHCARE|362.25||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Managed Medicaid|MEDICAID SUPERIOR|338.63||||3.15||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Cigna|CIGNA|3.15||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Humana Medicare Advantage|HUMANA MA|3.15||||3.15||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Medicaid|MEDICAID|3.15||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|338.63||||362.25||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Managed Medicare|BCBS MEDICARE PPO MA|3.15||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Aenta Medicare Advantage|AETNA MEDICARE MA|3.15||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|362.25||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|United Medicare Advantage|UHC MEDICARE GOLD MA|3.15||||||| 85362|EAP|0300|FIBRIN DEGRAD PROD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|362.25||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Medicare Advantage|UHC AARP MCR HMO MA|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Managed Medicaid|MEDICAID AMERIGROUP|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Access Direct Platinum|HEALTHFIRST TPA|3.26||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Workers Compensation|UT EMPLOYEE INJURY|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Workers Compensation|WORKERS COMPENSATION OTHER|3.26||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Medicare Advantage|UHC MEDICARE GOLD MA|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Medicare Advantage|UHC AARP WELLMED HMO MA|374.90||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Workers Compensation|TEXAS MUTUAL INSURANCE|374.90||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Access Direct Platinum|HEALTHFIRST TPA UMR|3.26||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Workers Compensation|GALLAGHER BASSETT|||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Veterans Affairs|VETERANS ADMINISTRATION|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Cigna|CIGNA|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Managed Medicaid|MEDICAID SUPERIOR|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.26||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Humana Medicare Advantage|HUMANA MA|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Blue Cross PPO Specialty|BCBSTX OTHER|374.90||||350.45||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Blue Cross HMO Specialty|BCBSTX HMO|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|NON CONTRACTED|COMMERCIAL OTHER 1|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Aetna|AETNA OTHER|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Rusk State Hospital|RUSK STATE HOSP|374.90||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid|SUPERIOR HEALTHPLAN CHIP|374.90||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Managed Medicare|HEALTHSPRING MA|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid|MEDICAID|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid|CRIME VICTIMS COMPENSATION|3.26||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid|LAW ENFORCEMENT OTHER|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Blue Cross PPO Specialty|BCBSTX PPO|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.26||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid|MEDICAID HMO|||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Aetna|AETNA QHP HMO|374.90||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Healthcare|TML GROUP BENEFITS|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid|SMITH COUNTY JAIL|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Healthcare|UNITED HEALTHCARE OTHER|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Healthcare|UNITED HEALTHCARE|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.26||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.26||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Managed Medicare|BCBS MEDICARE PPO MA|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Healthcare|GOLDEN RULE|374.90||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicare|MEDICARE ACUTE|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Healthcare|GEHA|||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|United Healthcare|UNITED HEALTHCARE|374.90||||350.45||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Managed Medicare|MA PART B ONLY IP|3.26||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|PHCS|HUMANA|374.90||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Tricare|TRICARE FOR LIFE|374.90||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Aetna|AETNA PPO|374.90||||350.45||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|UTMB|UTMB CORRECTIONAL MANAGED CARE|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Cigna|CIGNA OTHER|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.26||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Aenta Medicare Advantage|AETNA MEDICARE MA|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|NON CONTRACTED|COMMERCIAL OTHER 2|||||3.26||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Multiplan|WEB TPA|||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicare|MEDICARE PART B ONLY IP|374.90||||||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Tricare|TRICARE EAST REGION|374.90||||374.90||| 85379|EAP|0300|D-DIMERS QUANTITATIVE|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.26||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|United Healthcare|UNITED HEALTHCARE OTHER|446.20||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.88||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Tricare|TRICARE EAST REGION|||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Medicare|MEDICARE ACUTE|446.20||||3.88||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|NON CONTRACTED|COMMERCIAL OTHER 2|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|United Healthcare|TML GROUP BENEFITS|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Medicaid|SMITH COUNTY INDIGENT HEALTH|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.88||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Medicaid|MEDICAID|3.88||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|NON CONTRACTED|COMMERCIAL OTHER 1|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|446.20||||3.88||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Humana Medicare Advantage|HUMANA MA|417.10||||3.88||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Blue Cross HMO Specialty|BCBSTX HMO|446.20||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Managed Medicaid|MEDICAID SUPERIOR|446.20||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|446.20||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Cigna|CIGNA OTHER|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Cigna|CIGNA|3.88||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.88||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Aenta Medicare Advantage|AETNA MEDICARE MA|3.88||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|446.20||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Access Direct Platinum|HEALTHFIRST TPA UMR|3.88||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Veterans Affairs|VETERANS ADMINISTRATION|446.20||||3.88||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Workers Compensation|UT EMPLOYEE INJURY|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Managed Medicare|BCBS MEDICARE PPO MA|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|446.20||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|417.10||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|United Healthcare|UNITED HEALTHCARE|3.88||||3.88||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|United Healthcare|UNITED HEALTHCARE|||||3.88||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|United Medicare Advantage|UHC MEDICARE GOLD MA|3.88||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Managed Medicare|HEALTHSPRING MA|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|446.20||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|United Medicare Advantage|UHC AARP MCR HMO MA|446.20||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Cigna|CIGNA|446.20||||3.88||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Blue Cross PPO Specialty|BCBSTX OTHER|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Managed Medicare|WELLCARE CHOICE MA|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|446.20||||417.10||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Medicare|MEDICARE PART B ONLY IP|446.20||||||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Managed Medicaid|MEDICAID AMERIGROUP|446.20||||446.20||| 85384|EAP|0300|FIBRINOGEN ACTIVITY|Aetna|AETNA PPO|446.20||||||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Humana Medicare Advantage|HUMANA MA|3.14||||||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Veterans Affairs|VETERANS ADMINISTRATION|3.14||||||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Managed Medicare|BCBS MEDICARE PPO MA|||||3.14||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Aetna|AETNA PPO|||||3.14||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Blue Cross PPO Specialty|BCBSTX OTHER|3.14||||||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|3.14||||||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.14||||||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.14||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.14||||||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.14||||||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.14||||||| 85397|EAP|0300|ADAMTS-13 ACTIVITY|Medicare|MEDICARE ACUTE|3.14||||||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Humana Medicare Advantage|HUMANA MA|174,874.71|13390.8|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Managed Medicare|HEALTHSPRING MA|125,263.93|13142.3|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|119,750.66|16831.56|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Cigna|CIGNA|124,623.51|21179.76|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|104,934.63|13390.8|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|49,986.15|17124.14|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|NON CONTRACTED|COMMERCIAL OTHER 1|43,157.75|36740.4|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|United Medicare Advantage|UHC AARP MCR HMO MA|95,969.94|13390.8|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|158,543.28|13128.66|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|165,494.45|13107.63|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Medicare|MEDICARE ACUTE|150,557.25|13143.18|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Medicaid|MEDICAID|73,304.30|9722.705|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Blue Cross HMO Specialty|BCBSTX HMO|41,472.61|12714.56|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|PHCS|HUMANA INSURANCE|35,145.95|35145.95|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|131,405.64|214.32|36740.4|214.32|||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Blue Cross PPO Specialty|BCBSTX PPO|74,463.33|14957.01|36740.4|214.32|||| 85460|EAP|0300|FETAL CELL COUNT|Veterans Affairs|VETERANS ADMINISTRATION|407.10||||||| 85460|EAP|0300|FETAL CELL COUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.54||| 85460|EAP|0300|FETAL CELL COUNT|Managed Medicaid|MEDICAID SUPERIOR|||||3.54||| 85460|EAP|0300|FETAL CELL COUNT|Managed Medicaid|MEDICAID AMERIGROUP|||||3.54||| 85460|EAP|0300|FETAL CELL COUNT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||407.10||| 85460|EAP|0300|FETAL CELL COUNT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.54||| 85460|EAP|0300|FETAL CELL COUNT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|407.10||||407.10||| 85460|EAP|0300|FETAL CELL COUNT|Blue Cross PPO Specialty|BCBSTX PPO|380.55||||3.54||| 85460|EAP|0300|FETAL CELL COUNT|Blue Cross PPO Specialty|BCBSTX OTHER|407.10||||||| 85460|EAP|0300|FETAL CELL COUNT|Medicare|MEDICARE ACUTE|407.10||||||| 85460|EAP|0300|FETAL CELL COUNT|Medicaid|MEDICAID|3.54||||||| 85461|EAP|0300|FETAL CELL SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|3.03||||3.03||| 85461|EAP|0300|FETAL CELL SCREEN|United Healthcare|UNITED HEALTHCARE OTHER|325.73||||||| 85461|EAP|0300|FETAL CELL SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|325.73||||||| 85461|EAP|0300|FETAL CELL SCREEN|Medicaid|MEDICAID|||||348.45||| 85461|EAP|0300|FETAL CELL SCREEN|Aetna|AETNA PPO|3.03||||||| 85461|EAP|0300|FETAL CELL SCREEN|Tricare|TRICARE EAST REGION|348.45||||||| 85461|EAP|0300|FETAL CELL SCREEN|United Healthcare|UNITED HEALTHCARE|3.03||||||| 85461|EAP|0300|FETAL CELL SCREEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|348.45||||||| 85461|EAP|0300|FETAL CELL SCREEN|Cigna|CIGNA OTHER|||||348.45||| 85461|EAP|0300|FETAL CELL SCREEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||348.45||| 85461|EAP|0300|FETAL CELL SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|3.03||||||| 85461|EAP|0300|FETAL CELL SCREEN|Managed Medicaid|MEDICAID SUPERIOR|348.45||||||| 85461|EAP|0300|FETAL CELL SCREEN|United Healthcare|UNITED HEALTHCARE|348.45||||||| 85461|EAP|0300|FETAL CELL SCREEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.03||||||| 85461|EAP|0300|FETAL CELL SCREEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|348.45||||||| 85461|EAP|0300|FETAL CELL SCREEN|Blue Cross HMO Specialty|BCBSTX HMO|348.45||||||| 85461|EAP|0300|FETAL CELL SCREEN|Access Direct Platinum|HEALTHFIRST TPA UMR|325.73||||||| 85461|EAP|0300|FETAL CELL SCREEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|348.45||||||| 85461|EAP|0300|FETAL CELL SCREEN|Access Direct Platinum|HEALTHFIRST TPA|3.03||||||| 85461|EAP|0300|FETAL CELL SCREEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.03||||||| 85475|EAP|0300|ACID HEMOLYSIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|406.24||||||| 85475|EAP|0300|ACID HEMOLYSIS|United Medicare Advantage|UHC MEDICARE GOLD MA|406.24||||||| 85475|EAP|0300|ACID HEMOLYSIS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|406.24||||||| 85475|EAP|0300|ACID HEMOLYSIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|406.24||||||| 85475|EAP|0300|ACID HEMOLYSIS|Humana Medicare Advantage|HUMANA MA|||||353.25||| 85475|EAP|0300|ACID HEMOLYSIS|United Healthcare|UNITED HEALTHCARE OTHER|353.25||||||| 85475|EAP|0300|ACID HEMOLYSIS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||353.25||| 85475|EAP|0300|ACID HEMOLYSIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||406.24||| 85475|EAP|0300|ACID HEMOLYSIS|Blue Cross PPO Specialty|BCBSTX OTHER|353.25||||||| 85475|EAP|0300|ACID HEMOLYSIS|Medicare|MEDICARE ACUTE|353.25||||406.24||| 85475|EAP|0300|ACID HEMOLYSIS|Medicaid|MEDICAID|353.25||||||| 85475|EAP|0300|ACID HEMOLYSIS|Managed Medicare|HEALTHSPRING MA|353.25||||||| 85475|EAP|0300|ACID HEMOLYSIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|406.24||||406.24||| 85475|EAP|0300|ACID HEMOLYSIS|Blue Cross PPO Specialty|BCBSTX PPO|406.24||||||| 85475|EAP|0300|ACID HEMOLYSIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|353.25||||||| 85520|EAP|0300|HEPARIN ANTI-Xa|UTMB|UTMB CORRECTIONAL MANAGED CARE|642.85||||||| 85520|EAP|0300|HEPARIN ANTI-Xa|NON CONTRACTED|COMMERCIAL OTHER 1|687.70||||||| 85520|EAP|0300|HEPARIN ANTI-Xa|Medicare|MEDICARE ACUTE|687.70||||||| 85520|EAP|0300|HEPARIN ANTI-Xa|Humana Medicare Advantage|HUMANA MA|5.98||||||| 85520|EAP|0300|HEPARIN ANTI-Xa|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|687.70||||||| 85520|EAP|0300|HEPARIN ANTI-Xa|Managed Medicaid|MEDICAID UNITED HEALTHCARE|687.70||||||| 85520|EAP|0300|HEPARIN ANTI-Xa|United Medicare Advantage|UHC MEDICARE GOLD MA|687.70||||||| 85549|EAP|0300|MURAMIDASE|UTMB|UTMB CORRECTIONAL MANAGED CARE|747.25||||||| 85576|EAP|0300|PLATELET FUNCTION TEST|Veterans Affairs|VETERANS ADMINISTRATION|1,129.30||||1,055.65||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Workers Compensation|WORKERS COMPENSATION OTHER|9.82||||||| 85576|EAP|0300|PLATELET FUNCTION TEST|Workers Compensation|WORKERS COMPENSATION OTHER|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|Workers Compensation|WORKERS COMPENSATION OTHER|9.82||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|Workers Compensation|BROOKSHIRES WORKERS COMP|||||9.82||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Access Direct Platinum|HEALTHFIRST TPA UMR|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.82||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Veterans Affairs|VETERANS ADMINISTRATION|1,129.30||||1,055.65||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,129.30||||1,055.65||| 85576|EAP|0300|PLATELET FUNCTION TEST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.82||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|United Medicare Advantage|UHC AARP MCR HMO MA|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|United Medicare Advantage|UHC MEDICARE GOLD MA|1,129.30||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,055.65||||9.82||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|United Medicare Advantage|UHC AARP MCR HMO MA|1,129.30||||1,055.65||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Aenta Medicare Advantage|AETNA MEDICARE MA|1,129.30||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Aetna|AETNA PPO|9.82||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Aetna|AETNA OTHER|||||9.82||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Aetna|AETNA QHP HMO|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Aetna|AETNA PPO|9.82||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Aenta Medicare Advantage|AETNA MEDICARE MA|1,055.65||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Blue Cross HMO Specialty|BCBSTX HMO|1,129.30||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Blue Cross PPO Specialty|BCBSTX PPO|1,129.30||||1,055.65||| 85576|EAP|0300|PLATELET FUNCTION TEST|Managed Medicare|BCBS MEDICARE PPO MA|9.82||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Blue Cross PPO Specialty|BCBSTX OTHER|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.82||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION TEST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,129.30||||1,055.65||| 85576|EAP|0300|PLATELET FUNCTION TEST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,055.65||||1,055.65||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Blue Cross PPO Specialty|BCBSTX OTHER|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION TEST|Managed Medicaid|MEDICAID AMERIGROUP|||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Cigna|CIGNA OTHER|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Humana Medicare Advantage|HUMANA MA|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|Cigna|CIGNA|||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Humana Medicare Advantage|HUMANA MA|9.82||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,129.30||||1,055.65||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|Humana Medicare Advantage|HUMANA MA|9.82||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|Medicaid|MEDICAID|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,055.65||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Managed Medicare|HEALTHSPRING MA|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Managed Medicare|BCBS MEDICARE PPO MA|9.82||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Managed Medicare|HEALTHSPRING MA|9.82||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|Blue Cross PPO Specialty|BCBSTX OTHER|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION TEST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.82||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Managed Medicare|OTHER INSTITUTIONS|||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,129.30||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|Tricare|TRICARE EAST REGION|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Blue Cross PPO Specialty|BCBSTX PPO|1,129.30||||9.82||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Medicare|MEDICARE ACUTE|9.82||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|United Medicare Advantage|UHC AARP MCR HMO MA|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|Access Direct Platinum|HEALTHFIRST TPA|||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Medicare|MEDICARE PART B ONLY IP|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|Blue Cross HMO Specialty|BCBSTX HMO|1,129.30||||9.82||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|Blue Cross HMO Specialty|BCBSTX HMO|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|Medicare|MEDICARE PART B ONLY IP|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION TEST|Medicare|MEDICARE ACUTE|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|Medicare|MEDICARE PART B ONLY IP|9.82||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|United Medicare Advantage|UHC MEDICARE GOLD MA|1,129.30||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|NON CONTRACTED|COMMERCIAL OTHER 1|1,129.30||||9.82||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|Medicare|MEDICARE ACUTE|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|United Healthcare|UNITED HEALTHCARE ERS|9.82||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|NON CONTRACTED|COMMERCIAL OTHER 1|1,129.30||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|United Healthcare|UNITED HEALTHCARE|1,055.65||||9.82||| 85576|EAP|0300|PLATELET FUNCTION ASSAY A|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,129.30||||||| 85576|EAP|0300|PLATELET FUNCTION TEST|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,055.65||||||| 85576|EAP|0300|PLATELET FUNCTION ASSAY P|United Healthcare|UNITED HEALTHCARE|9.82||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|United Healthcare|UNITED HEALTHCARE|9.82||||9.82||| 85576|EAP|0300|PLATELET FUNCTION TEST|United Healthcare|UNITED HEALTHCARE|1,129.30||||1,129.30||| 85576|EAP|0300|PLATELET FUNCTION TEST|United Healthcare|UNITED HEALTHCARE OTHER|1,129.30||||1,055.65||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|142,866.58|25577.5|60255.765|357.2|||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|119,363.67|357.2|60255.765|357.2|||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|ChampVA|CHAMPVA CENTER|290,187.63|60255.765|60255.765|357.2|||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|Blue Cross PPO Specialty|BCBSTX PPO|376,921.10|2356.41|60255.765|357.2|||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|Humana Medicare Advantage|HUMANA MA|176,051.20|25859.41|60255.765|357.2|||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|Medicaid|MEDICAID|259,154.83|30053.5|60255.765|357.2|||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|202,752.90|20194.05|60255.765|357.2|||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|Medicare|MEDICARE ACUTE|163,430.60|25569.26|60255.765|357.2|||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|Managed Medicare|HEALTHSPRING MA|193,254.67|26132.51|60255.765|357.2|||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|108,539.18|32621.29|60255.765|357.2|||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|TEXAS MUTUAL INSURANCE|1.07||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicaid|MEDICAID AMERIGROUP|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|ChampVA|CHAMPVA CENTER|1.07||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|WORKERS COMPENSATION OTHER|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|GALLAGHER BASSETT|||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.07||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|United Medicare Advantage|UHC AARP MCR HMO MA|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|UT EMPLOYEE INJURY|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|123.05||||||| 85610|EAP|0300|PROTHROMBIN TIME|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Access Direct Platinum|HEALTHFIRST TPA UMR|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Access Direct Platinum|HEALTHFIRST TPA|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Aetna|AETNA OTHER|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|TRAVELERS INSURANCE COMPANY|115.03||||||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Aenta Medicare Advantage|AETNA MEDICARE MA|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Aetna Value Network|AETNA VALUE NETWORK|||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Blue Cross HMO Specialty|BCBSTX HMO|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Blue Cross PPO Specialty|BCBSTX OTHER|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|MEDICAID|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Cigna|CIGNA|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.07||||||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|United Medicare Advantage|UHC AARP WELLMED HMO MA|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Humana Medicare Advantage|HUMANA MA|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Cigna|CIGNA|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Tricare|TRICARE FOR LIFE|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Veterans Affairs|VETERANS ADMINISTRATION|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|SUPERIOR HEALTHPLAN CHIP|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicare|ETMC REHABILITATION HOSPITAL|1.07||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|LAW ENFORCEMENT OTHER|||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|MEDICAID HMO|115.03||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicare|OTHER INSTITUTIONS|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicare|HEALTHSPRING MA|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.07||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicare|MA PART B ONLY IP|1.07||||||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|SMITH COUNTY JAIL|1.07||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicare|WELLCARE CHOICE MA|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicaid|MEDICAID SUPERIOR|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|United Medicare Advantage|UHC MEDICARE GOLD MA|1.07||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Managed Medicare|BCBS MEDICARE PPO MA|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|MEDICAID BCBSTX|||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|NON CONTRACTED|COMMERCIAL OTHER 2|123.05||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Multiplan|PACIFICARE|123.05||||||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|MOLINA HEALTHCARE OF TEXAS|123.05||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Medicare|UTSW MC KIDNEY PROGRAM|||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Blue Cross PPO Specialty|BCBSTX PPO|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|CRIME VICTIMS COMPENSATION|1.07||||||| 85610|EAP|0300|PROTHROMBIN TIME|Aetna|BH AETNA|1.07||||||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.07||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Aetna|AETNA PPO|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|BROOKSHIRES WORKERS COMP|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Aetna|BOON CHAPMAN|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Aetna|AETNA QHP HMO|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|115.03||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|PHCS|HUMANA INSURANCE|1.07||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Medicare|MEDICARE ACUTE|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|NON CONTRACTED|COMMERCIAL OTHER 1|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||156.50||| 85610|EAP|0300|PROTHROMBIN TIME|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|PHCS|GROUP AND PENSION|115.03||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Medicare|MEDICARE PART B ONLY IP|1.07||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|PHCS|HUMANA INSURANCE|123.05||||||| 85610|EAP|0300|PROTHROMBIN TIME|Rusk State Hospital|RUSK STATE HOSP|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Workers Compensation|ZURICH COMPANY|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|NON CONTRACTED|COMMERCIAL OTHER 4|||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Multiplan|NALC|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Cigna|CIGNA OTHER|1.07||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Tricare|TRICARE EAST REGION|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Tricare|TRICARE SOUTH PHYSICIAN|||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|UTMB|UTMB CORRECTIONAL MANAGED CARE|123.05||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|PHCS|HUMANA|123.05||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Multiplan|MUTUAL OF OMAHA|||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|United Healthcare|UNITED HEALTHCARE|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|United Healthcare|UNITED HEALTHCARE OTHER|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|United Healthcare|TML GROUP BENEFITS|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|Optum Behavioral Health|BH OPTUM UHC|1.07||||||| 85610|EAP|0300|PROTHROMBIN TIME|United Healthcare|GOLDEN RULE|123.05||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|United Healthcare|AARP|1.07||||1.07||| 85610|EAP|0300|PROTHROMBIN TIME|United Healthcare|UNITED HEALTHCARE ERS|1.07||||||| 85610|EAP|0300|PROTHROMBIN TIME|United Healthcare|GEHA|123.05||||123.05||| 85610|EAP|0300|PROTHROMBIN TIME|Multiplan|WEB TPA|||||115.03||| 85610|EAP|0300|PROTHROMBIN TIME|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.07||||123.05||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicaid|MEDICAID SUPERIOR|3.68||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Medicare|MEDICARE ACUTE|3.20||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|United Healthcare|UNITED HEALTHCARE|3.20||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Tricare|TRICARE EAST REGION|3.44||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|United Healthcare|UNITED HEALTHCARE|3.68||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|PHCS|HUMANA|3.20||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|NON CONTRACTED|COMMERCIAL OTHER 1|3.68||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Medicaid|MEDICAID|3.20||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Medicare|UTSW MC KIDNEY PROGRAM|||||3.44||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicare|HEALTHSPRING MA|278.75||||3.68||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Cigna|CIGNA|3.68||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.20||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.68||||3.68||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicaid|MEDICAID AMERIGROUP|3.68||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Humana Medicare Advantage|HUMANA MA|3.20||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.68||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|United Healthcare|UNITED HEALTHCARE OTHER|3.20||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Blue Cross PPO Specialty|BCBSTX PPO|3.20||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Blue Cross PPO Specialty|BCBSTX OTHER|3.20||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Blue Cross HMO Specialty|BCBSTX HMO|||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|United Medicare Advantage|UHC MEDICARE GOLD MA|3.20||||3.68||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.68||||3.68||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Aetna|AETNA PPO|3.20||||3.68||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.68||||3.68||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Veterans Affairs|VETERANS ADMINISTRATION|||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Access Direct Platinum|HEALTHFIRST TPA|3.20||||||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.68||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.20||| 85613|EAP|0300|LUPUS ANTICOAGULANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.68||||3.68||| 85613|EAP|0300|LUPUS ANTICOAGULANT|United Medicare Advantage|UHC AARP MCR HMO MA|3.68||||3.68||| 85652|EAP|0300|SEDIMENTATION RATE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|186.30||||174.15||| 85652|EAP|0300|SEDIMENTATION RATE|United Medicare Advantage|UHC MEDICARE GOLD MA|186.30||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|United Medicare Advantage|UHC AARP MCR HMO MA|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Veterans Affairs|VETERANS ADMINISTRATION|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.62||||||| 85652|EAP|0300|SEDIMENTATION RATE|Cigna|CIGNA|174.15||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|Workers Compensation|WORKERS COMPENSATION OTHER|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Access Direct Platinum|HEALTHFIRST TPA|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Workers Compensation|UT EMPLOYEE INJURY|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.62||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Blue Cross PPO Specialty|BCBSTX PPO|186.30||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|Access Direct Platinum|HEALTHFIRST TPA UMR|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.62||||174.15||| 85652|EAP|0300|SEDIMENTATION RATE|Aetna|AETNA OTHER|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|ChampVA|CHAMPVA CENTER|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Blue Cross HMO Specialty|BCBSTX HMO|1.62||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Blue Cross PPO Specialty|BCBSTX OTHER|1.62||||||| 85652|EAP|0300|SEDIMENTATION RATE|Managed Medicaid|MEDICAID AMERIGROUP|186.30||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|Managed Medicaid|MEDICAID SUPERIOR|1.62||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.62||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Workers Compensation|ZURICH COMPANY|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Cigna|CIGNA OTHER|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Medicaid|SMITH COUNTY JAIL|1.62||||||| 85652|EAP|0300|SEDIMENTATION RATE|Medicaid|LAW ENFORCEMENT OTHER|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.62||||||| 85652|EAP|0300|SEDIMENTATION RATE|United Medicare Advantage|UHC AARP WELLMED HMO MA|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Cigna|CIGNA|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Medicaid|MEDICAID HMO|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Aetna|AETNA QHP HMO|186.30||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|186.30||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.62||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|Medicaid|MEDICAID|1.62||||174.15||| 85652|EAP|0300|SEDIMENTATION RATE|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.62||||||| 85652|EAP|0300|SEDIMENTATION RATE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|186.30||||174.15||| 85652|EAP|0300|SEDIMENTATION RATE|Medicaid|CRIME VICTIMS COMPENSATION|1.62||||||| 85652|EAP|0300|SEDIMENTATION RATE|Managed Medicare|BCBS MEDICARE PPO MA|1.62||||||| 85652|EAP|0300|SEDIMENTATION RATE|United Healthcare|UNITED HEALTHCARE|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Managed Medicare|WELLCARE CHOICE MA|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Managed Medicare|HEALTHSPRING MA|186.30||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|NON CONTRACTED|COMMERCIAL OTHER 1|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Medicaid|COUNTY INDIGENT HEALTH OTHER|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Humana Medicare Advantage|HUMANA MA|186.30||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|United Healthcare|UNITED HEALTHCARE OTHER|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Aetna|AETNA PPO|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Tricare|TRICARE EAST REGION|1.62||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|PHCS|HUMANA|186.30||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Rusk State Hospital|RUSK STATE HOSP|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|PHCS|HUMANA INSURANCE|174.15||||||| 85652|EAP|0300|SEDIMENTATION RATE|Optum Behavioral Health|BH OPTUM UHC|1.62||||||| 85652|EAP|0300|SEDIMENTATION RATE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.62||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|Medicare|MEDICARE PART B ONLY IP|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|Tricare|TRICARE FOR LIFE|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|PHCS|GROUP AND PENSION|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.62||||174.15||| 85652|EAP|0300|SEDIMENTATION RATE|United Healthcare|TML GROUP BENEFITS|1.62||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|Medicare|MEDICARE ACUTE|186.30||||1.62||| 85652|EAP|0300|SEDIMENTATION RATE|United Healthcare|GOLDEN RULE|186.30||||||| 85652|EAP|0300|SEDIMENTATION RATE|United Healthcare|GEHA|||||186.30||| 85652|EAP|0300|SEDIMENTATION RATE|United Healthcare|UNITED HEALTHCARE|1.62||||1.62||| 85660|EAP|0300|SICKLE CELL|UTMB|UTMB CORRECTIONAL MANAGED CARE|289.80||||||| 85670|EAP|0300|THROMBIN TIME|Medicare|MEDICARE ACUTE|283.80||||||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Veterans Affairs|VETERANS ADMINISTRATION|138,752.92|12674.18|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Medicare|MEDICARE ACUTE|120,402.22|12430.37|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,768.97|14975.22|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|85,993.35|13540.195|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Humana Medicare Advantage|HUMANA MA|88,293.37|12558.445|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|198,273.64|28689.68|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Managed Medicare|HEALTHSPRING MA|199,479.91|12674.18|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Blue Cross PPO Specialty|BCBSTX PPO|104,540.18|13964.99|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Blue Cross HMO Specialty|BCBSTX HMO|48,194.24|11871.27|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|78,271.76|15942.46|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|122,469.30|17750.89|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|106,006.12|267.9|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|74,612.80|12674.18|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|United Medicare Advantage|UHC AARP MCR HMO MA|106,711.27|12413.21|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Cigna|CIGNA|61,745.57|26709.16|28689.68|267.9|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|United Healthcare|UNITED HEALTHCARE|100,706.12|24066.14|28689.68|267.9|||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Aenta Medicare Advantage|AETNA MEDICARE MA|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|PHCS|HUMANA|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Tricare|TRICARE EAST REGION|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Optum Behavioral Health|BH OPTUM UHC|1.49||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Tricare|TRICARE FOR LIFE|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Rusk State Hospital|RUSK STATE HOSP|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|PHCS|HUMANA INSURANCE|1.49||||160.18||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|PHCS|GROUP AND PENSION|160.18||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|NON CONTRACTED|COMMERCIAL OTHER 1|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Tricare|TRICARE SOUTH PHYSICIAN|||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|PHCS|HUMANA INSURANCE|171.35||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicare|MEDICARE PART B ONLY IP|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Multiplan|NALC|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicare|MEDICARE ACUTE|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|NON CONTRACTED|COMMERCIAL OTHER 2|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicare|HEALTHSPRING MA|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|UTMB|UTMB CORRECTIONAL MANAGED CARE|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Healthcare|TML GROUP BENEFITS|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Healthcare|UNITED HEALTHCARE OTHER|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicare|ETMC REHABILITATION HOSPITAL|1.49||||160.18||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Healthcare|AARP|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Healthcare|GEHA|160.18||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicare|BCBS MEDICARE PPO MA|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicare|MA PART B ONLY IP|1.49||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicare|UTSW MC KIDNEY PROGRAM|||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicare|WELLCARE CHOICE MA|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Multiplan|WEB TPA|||||160.18||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||160.18||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|MEDICAID|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|CRIME VICTIMS COMPENSATION|171.35||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|SUPERIOR HEALTHPLAN CHIP|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|GALLAGHER BASSETT|||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|MEDICAID HMO|160.18||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|LAW ENFORCEMENT OTHER|||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||160.18||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|ZURICH COMPANY|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Medicare Advantage|UHC AARP MCR HMO MA|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Medicare Advantage|UHC MEDICARE GOLD MA|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Multiplan|PACIFICARE|171.35||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Healthcare|UNITED HEALTHCARE|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Medicare Advantage|UHC AARP WELLMED HMO MA|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|160.18||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|MEDICAID BCBSTX|||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|BROOKSHIRES WORKERS COMP|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|NON CONTRACTED|COMMERCIAL OTHER 4|||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicare|OTHER INSTITUTIONS|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|TEXAS MUTUAL INSURANCE|1.49||||160.18||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Healthcare|GOLDEN RULE|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|United Healthcare|UNITED HEALTHCARE ERS|1.49||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Veterans Affairs|VETERANS ADMINISTRATION|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|TRAVELERS INSURANCE COMPANY|160.18||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Medicaid|SMITH COUNTY JAIL|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Access Direct Platinum|HEALTHFIRST TPA UMR|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Aetna|BH AETNA|1.49||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|171.35||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Aetna|AETNA QHP HMO|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Aetna|BOON CHAPMAN|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Access Direct Platinum|HEALTHFIRST TPA|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Aetna|AETNA OTHER|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Humana Medicare Advantage|HUMANA MA|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|WORKERS COMPENSATION OTHER|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Aetna Value Network|AETNA VALUE NETWORK|||||160.18||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|ChampVA|CHAMPVA CENTER|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Multiplan|MUTUAL OF OMAHA|||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Blue Cross PPO Specialty|BCBSTX PPO|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Blue Cross PPO Specialty|BCBSTX OTHER|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.49||||||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Blue Cross HMO Specialty|BCBSTX HMO|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicaid|MEDICAID AMERIGROUP|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicaid|MEDICAID SUPERIOR|171.35||||160.18||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Cigna|CIGNA OTHER|160.18||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Workers Compensation|UT EMPLOYEE INJURY|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Cigna|CIGNA|171.35||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||239.25||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|171.35||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.49||||171.35||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Aetna|AETNA PPO|1.49||||1.49||| 85730|EAP|0300|PARTIAL THROMBOPLASTIN TI|Cigna|CIGNA|1.49||||171.35||| 858|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|668.88|8818.04|68028.41|7214.38|||| 858|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|65,979.69|8836.29|68028.41|7214.38|||| 858|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|94,622.07|8993.51|68028.41|7214.38|||| 858|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|25,008.94|12636.53|68028.41|7214.38|||| 858|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC|Aetna|AETNA PPO|48,279.89|17759.69|68028.41|7214.38|||| 858|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC|Medicaid|CRIME VICTIMS COMPENSATION|163,927.71|7214.38|68028.41|7214.38|||| 858|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|68,028.41|68028.41|68028.41|7214.38|||| 85810|EAP|0300|VISCOSITY|Humana Medicare Advantage|HUMANA MA|465.50||||||| 85810|EAP|0300|VISCOSITY|United Healthcare|UNITED HEALTHCARE OTHER|535.33||||||| 85810|EAP|0300|VISCOSITY|Medicare|MEDICARE ACUTE|465.50||||||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|Managed Medicare|HEALTHSPRING MA|148,485.75|13607.43|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|Veterans Affairs|VETERANS ADMINISTRATION|51,079.50|5665.44|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|Workers Compensation|WORKERS COMPENSATION OTHER|32,326.25|11547.69|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|94,879.31|8075.31|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|Humana Medicare Advantage|HUMANA MA|63,548.18|6872.3|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|Blue Cross PPO Specialty|BCBSTX PPO|94,317.44|7792.325|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|United Healthcare|UNITED HEALTHCARE|223,474.20|24000.6|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|United Healthcare|UNITED HEALTHCARE OTHER|85,226.50|18276.6|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|63,664.56|8007.39|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|NON CONTRACTED|COMMERCIAL OTHER 1|79,081.45|21042.6|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|Medicare|MEDICARE ACUTE|55,201.78|8061.67|24000.6|711.3|||| 86|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W CC|Medicare|MEDICARE PART B ONLY IP|37,903.51|711.3|24000.6|711.3|||| 86003|EAP|0300|REGION X (TX,OK) IGE PANE|Medicare|MEDICARE ACUTE|2.42||||||| 86022|EAP|0300|SEROTONIN RELEASE ASSAY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,130.75||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Aenta Medicare Advantage|AETNA MEDICARE MA|3.90||||||| 86022|EAP|0300|SEROTONIN RELEASE ASSAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,130.75||||||| 86022|EAP|0300|SEROTONIN RELEASE ASSAY|Blue Cross PPO Specialty|BCBSTX PPO|1,130.75||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Managed Medicare|HEALTHSPRING MA|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Blue Cross PPO Specialty|BCBSTX PPO|3.90||||||| 86022|EAP|0300|PLATLET ANTIBODIES|Blue Cross PPO Specialty|BCBSTX PPO|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.90||||3.90||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|United Medicare Advantage|UHC MEDICARE GOLD MA|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.90||||||| 86022|EAP|0300|SEROTONIN RELEASE ASSAY|Managed Medicare|HEALTHSPRING MA|1,130.75||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Medicaid|MEDICAID|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Humana Medicare Advantage|HUMANA MA|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Managed Medicare|BCBS MEDICARE PPO MA|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|United Healthcare|UNITED HEALTHCARE OTHER|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|United Healthcare|UNITED HEALTHCARE|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Rusk State Hospital|RUSK STATE HOSP|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Veterans Affairs|VETERANS ADMINISTRATION|3.90||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|Medicare|MEDICARE ACUTE|3.90||||||| 86022|EAP|0300|SEROTONIN RELEASE ASSAY|Medicare|MEDICARE ACUTE|1,130.75||||||| 86022|EAP|0300|HEPARIN INDUCED PLATELET|NON CONTRACTED|COMMERCIAL OTHER 1|3.90||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Veterans Affairs|VETERANS ADMINISTRATION|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Blue Cross PPO Specialty|BCBSTX OTHER|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Aetna|BOON CHAPMAN|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Aenta Medicare Advantage|AETNA MEDICARE MA|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Aetna|AETNA PPO|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Cigna|CIGNA|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Humana Medicare Advantage|HUMANA MA|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Medicare|MEDICARE ACUTE|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Optum Behavioral Health|BH OPTUM UHC|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Tricare|TRICARE FOR LIFE|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|PHCS|HUMANA|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Texas Workforce Commission|DIS DETER SERV (DDS)|||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Tricare|TRICARE EAST REGION|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|United Healthcare|UNITED HEALTHCARE OTHER|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|United Healthcare|UNITED HEALTHCARE|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|United Healthcare|UNITED HEALTHCARE|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|United Healthcare|GOLDEN RULE|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Medicare|MEDICARE PART B ONLY IP|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Medicaid|MEDICAID|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Managed Medicare|HEALTHSPRING MA|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Managed Medicare|WELLCARE CHOICE MA|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Managed Medicare|BCBS MEDICARE PPO MA|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|United Medicare Advantage|UHC AARP MCR HMO MA|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|United Medicare Advantage|UHC MEDICARE GOLD MA|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.38||||2.38||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.38||||||| 86038|EAP|0300|ANTINUCLEAR ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UMR|2.38||||2.38||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|Humana Medicare Advantage|HUMANA MA|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|Aetna|AETNA PPO|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|Blue Cross PPO Specialty|BCBSTX PPO|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|United Medicare Advantage|UHC AARP MCR HMO MA|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|United Medicare Advantage|UHC MEDICARE GOLD MA|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|Medicaid|MEDICAID|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|United Healthcare|UNITED HEALTHCARE OTHER|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|United Healthcare|UNITED HEALTHCARE|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|NON CONTRACTED|COMMERCIAL OTHER 1|1.44||||||| 86060|EAP|0300|ANTI-STREPTOLYSIN O|Medicare|MEDICARE ACUTE|1.44||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|PHCS|HUMANA INSURANCE|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Tricare|TRICARE FOR LIFE|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Tricare|TRICARE EAST REGION|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Rusk State Hospital|RUSK STATE HOSP|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|PHCS|HUMANA|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|PHCS|GROUP AND PENSION|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Multiplan|WEB TPA|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicare|MEDICARE PART B ONLY IP|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|United Healthcare|UNITED HEALTHCARE|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|United Healthcare|TML GROUP BENEFITS|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|United Healthcare|UNITED HEALTHCARE OTHER|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|United Healthcare|GOLDEN RULE|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Managed Medicare|BCBS MEDICARE PPO MA|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Managed Medicare|WELLCARE CHOICE MA|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Managed Medicare|HEALTHSPRING MA|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicaid|CRIME VICTIMS COMPENSATION|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicaid|MEDICAID|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicaid|SMITH COUNTY JAIL|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Veterans Affairs|VETERANS ADMINISTRATION|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Workers Compensation|UT EMPLOYEE INJURY|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicaid|MEDICAID HMO|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Workers Compensation|TEXAS MUTUAL INSURANCE|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Workers Compensation|WORKERS COMPENSATION OTHER|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Workers Compensation|BROOKSHIRES WORKERS COMP|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST TPA UMR|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST TPA|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicaid|LAW ENFORCEMENT OTHER|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Medicare|MEDICARE ACUTE|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|United Medicare Advantage|UHC MEDICARE GOLD MA|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|United Healthcare|GEHA|||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|United Medicare Advantage|UHC AARP MCR HMO MA|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Blue Cross HMO Specialty|BCBSTX HMO|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|ChampVA|CHAMPVA CENTER|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|NON CONTRACTED|COMMERCIAL OTHER 1|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Blue Cross PPO Specialty|BCBSTX OTHER|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Blue Cross PPO Specialty|BCBSTX PPO|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Aetna|AETNA PPO|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Aetna|AETNA QHP HMO|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Aetna|BOON CHAPMAN|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Aenta Medicare Advantage|AETNA MEDICARE MA|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Aetna|AETNA OTHER|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID SUPERIOR|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID AMERIGROUP|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Cigna|CIGNA|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Cigna|CIGNA|1.02||||||| 86140|EAP|0300|C-REACTIVE PROTEIN|Cigna|CIGNA OTHER|1.02||||1.02||| 86140|EAP|0300|C-REACTIVE PROTEIN|Humana Medicare Advantage|HUMANA MA|1.02||||1.02||| 86141|EAP|0300|C-REACTIVE PROTEIN HSCRP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.06||| 86141|EAP|0300|C-REACTIVE PROTEIN HSCRP|NON CONTRACTED|COMMERCIAL OTHER 1|5.06||||||| 86141|EAP|0300|C-REACTIVE PROTEIN HSCRP|Medicare|MEDICARE ACUTE|5.06||||5.06||| 86141|EAP|0300|C-REACTIVE PROTEIN HSCRP|United Healthcare|UNITED HEALTHCARE|||||5.06||| 86141|EAP|0300|C-REACTIVE PROTEIN HSCRP|Managed Medicare|HEALTHSPRING MA|5.06||||||| 86141|EAP|0300|C-REACTIVE PROTEIN HSCRP|Medicaid|MEDICAID|5.06||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Medicare|MEDICARE ACUTE|301.50||||301.50||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|Medicare|MEDICARE ACUTE|2.81||||2.81||| 86146|EAP|0300|AB GLYCOPROTEIN|NON CONTRACTED|COMMERCIAL OTHER 1|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|United Healthcare|UNITED HEALTHCARE OTHER|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|United Healthcare|UNITED HEALTHCARE|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Managed Medicare|HEALTHSPRING MA|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Humana Medicare Advantage|HUMANA MA|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|301.50||||301.50||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.81||||301.50||| 86146|EAP|0300|AB GLYCOPROTEIN|Aenta Medicare Advantage|AETNA MEDICARE MA|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Aetna|AETNA PPO|301.50||||301.50||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|Aetna|AETNA PPO|301.50||||2.81||| 86146|EAP|0300|AB GLYCOPROTEIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|301.50||||301.50||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|301.50||||2.81||| 86146|EAP|0300|AB GLYCOPROTEIN|Managed Medicaid|MEDICAID SUPERIOR|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Blue Cross PPO Specialty|BCBSTX OTHER|301.50||||||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|Blue Cross PPO Specialty|BCBSTX PPO|2.81||||2.81||| 86146|EAP|0300|AB GLYCOPROTEIN|Blue Cross PPO Specialty|BCBSTX PPO|301.50||||301.50||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|Humana Medicare Advantage|HUMANA MA|2.81||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Blue Cross HMO Specialty|BCBSTX HMO|||||301.50||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|Blue Cross HMO Specialty|BCBSTX HMO|||||2.81||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.81||||301.50||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|United Healthcare|UNITED HEALTHCARE|2.81||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Tricare|TRICARE EAST REGION|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|United Medicare Advantage|UHC AARP MCR HMO MA|301.50||||||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|United Medicare Advantage|UHC MEDICARE GOLD MA|301.50||||2.81||| 86146|EAP|0300|AB GLYCOPROTEIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|301.50||||301.50||| 86146|EAP|0300|AB GLYCOPROTEIN|Veterans Affairs|VETERANS ADMINISTRATION|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|United Medicare Advantage|UHC MEDICARE GOLD MA|301.50||||301.50||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|Access Direct Platinum|HEALTHFIRST TPA|2.81||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||301.50||| 86146|EAP|0300|AB GLYCOPROTEIN|Access Direct Platinum|HEALTHFIRST TPA|301.50||||||| 86146|EAP|0300|AB GLYCOPROTEIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|301.50||||301.50||| 86146|EAP|0300|AB GLYCOPROTEIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|301.50||||301.50||| 86146|EAP|0300|BETA-2 GLYCOPROTEIN IGA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.81||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Access Direct Platinum|HEALTHFIRST TPA|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Access Direct Platinum|HEALTHFIRST TPA|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Access Direct Platinum|HEALTHFIRST TPA|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Veterans Affairs|VETERANS ADMINISTRATION|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Veterans Affairs|VETERANS ADMINISTRATION|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|United Medicare Advantage|UHC AARP MCR HMO MA|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|United Medicare Advantage|UHC AARP MCR HMO MA|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|United Medicare Advantage|UHC MEDICARE GOLD MA|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|United Medicare Advantage|UHC MEDICARE GOLD MA|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|United Medicare Advantage|UHC MEDICARE GOLD MA|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Blue Cross HMO Specialty|BCBSTX HMO|||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Blue Cross HMO Specialty|BCBSTX HMO|||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Blue Cross PPO Specialty|BCBSTX OTHER|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Blue Cross PPO Specialty|BCBSTX OTHER|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Blue Cross PPO Specialty|BCBSTX OTHER|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Blue Cross PPO Specialty|BCBSTX PPO|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Blue Cross PPO Specialty|BCBSTX PPO|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Aenta Medicare Advantage|AETNA MEDICARE MA|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Aenta Medicare Advantage|AETNA MEDICARE MA|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Aetna|AETNA PPO|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Aetna|AETNA PPO|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Aetna|AETNA PPO|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Managed Medicaid|MEDICAID AMERIGROUP|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Managed Medicaid|MEDICAID SUPERIOR|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Blue Cross PPO Specialty|BCBSTX PPO|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Managed Medicaid|MEDICAID AMERIGROUP|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Managed Medicaid|MEDICAID SUPERIOR|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Managed Medicaid|MEDICAID AMERIGROUP|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Humana Medicare Advantage|HUMANA MA|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Medicaid|MEDICAID|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|United Medicare Advantage|UHC AARP MCR HMO MA|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Medicaid|MEDICAID|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Humana Medicare Advantage|HUMANA MA|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Medicaid|MEDICAID|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Humana Medicare Advantage|HUMANA MA|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Managed Medicare|HEALTHSPRING MA|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Veterans Affairs|VETERANS ADMINISTRATION|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Managed Medicare|HEALTHSPRING MA|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|United Healthcare|UNITED HEALTHCARE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|United Healthcare|UNITED HEALTHCARE OTHER|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|United Healthcare|UNITED HEALTHCARE OTHER|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|United Healthcare|UNITED HEALTHCARE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|United Healthcare|UNITED HEALTHCARE|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|United Healthcare|UNITED HEALTHCARE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|United Healthcare|UNITED HEALTHCARE|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|United Healthcare|UNITED HEALTHCARE OTHER|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|United Healthcare|UNITED HEALTHCARE|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Medicare|MEDICARE ACUTE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Medicare|MEDICARE ACUTE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Medicare|MEDICARE ACUTE|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|NON CONTRACTED|COMMERCIAL OTHER 1|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|NON CONTRACTED|COMMERCIAL OTHER 1|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGA|Tricare|TRICARE EAST REGION|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGM|Tricare|TRICARE EAST REGION|3.13||||||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|NON CONTRACTED|COMMERCIAL OTHER 1|3.13||||3.13||| 86147|EAP|0300|PHOSPHOLIPID AB IGG|Tricare|TRICARE EAST REGION|3.13||||||| 86148|EAP|0300|PHOSPHOLIPIDS|Tricare|TRICARE EAST REGION|3.13||||||| 86148|EAP|0300|PHOSPHOLIPIDS|Medicare|UTSW MC KIDNEY PROGRAM|||||3.13||| 86157|EAP|0300|COLD AGGLUTININS|Humana Medicare Advantage|HUMANA MA|153.75||||||| 86157|EAP|0300|COLD AGGLUTININS|Blue Cross PPO Specialty|BCBSTX PPO|||||153.75||| 86157|EAP|0300|COLD AGGLUTININS|United Medicare Advantage|UHC MEDICARE GOLD MA|153.75||||153.75||| 86157|EAP|0300|COLD AGGLUTININS|Medicare|MEDICARE ACUTE|153.75||||153.75||| 86157|EAP|0300|COLD AGGLUTININS|Tricare|TRICARE EAST REGION|||||153.75||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|United Healthcare|UNITED HEALTHCARE|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Medicare|UTSW MC KIDNEY PROGRAM|||||2.36||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Access Direct Platinum|HEALTHFIRST TPA UMR|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Medicaid|MEDICAID|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|United Medicare Advantage|UHC MEDICARE GOLD MA|2.36||||||| 86160|EAP|0300|ESTERASE INHIBITOR C-1|UTMB|UTMB CORRECTIONAL MANAGED CARE|478.50||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Medicare|MEDICARE ACUTE|2.36||||||| 86160|EAP|0300|ESTERASE INHIBITOR C-1|Medicare|MEDICARE ACUTE|478.50||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|United Medicare Advantage|UHC AARP MCR HMO MA|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Managed Medicare|WELLCARE CHOICE MA|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Aenta Medicare Advantage|AETNA MEDICARE MA|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Blue Cross PPO Specialty|BCBSTX PPO|2.36||||2.36||| 86160|EAP|0300|ESTERASE INHIBITOR C-1|Blue Cross PPO Specialty|BCBSTX PPO|478.50||||2.36||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Managed Medicaid|MEDICAID AMERIGROUP|||||2.36||| 86160|EAP|0300|COMPLEMENT C1Q|Managed Medicaid|MEDICAID UNITED HEALTHCARE|478.50||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.36||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Managed Medicare|HEALTHSPRING MA|2.36||||||| 86160|EAP|0300|ESTERASE INHIBITOR C-1|Cigna|CIGNA|||||478.50||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.36||||||| 86160|EAP|0300|COMPLEMENT C1Q|Cigna|CIGNA|||||478.50||| 86160|EAP|0300|ESTERASE INHIBITOR C-1|Humana Medicare Advantage|HUMANA MA|478.50||||||| 86160|EAP|0300|COMPLEMENT ANTIGENN ACTIV|Humana Medicare Advantage|HUMANA MA|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Humana Medicare Advantage|HUMANA MA|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Cigna|CIGNA|2.36||||2.36||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Blue Cross HMO Specialty|BCBSTX HMO|2.36||||2.36||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.36||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Blue Cross PPO Specialty|BCBSTX PPO|2.36||||2.36||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Aenta Medicare Advantage|AETNA MEDICARE MA|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Aetna|AETNA PPO|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.36||||2.36||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Veterans Affairs|VETERANS ADMINISTRATION|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Access Direct Platinum|HEALTHFIRST TPA|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|United Medicare Advantage|UHC AARP MCR HMO MA|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.36||||2.36||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|United Medicare Advantage|UHC MEDICARE GOLD MA|2.36||||2.36||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|PHCS|HUMANA|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Medicare|UTSW MC KIDNEY PROGRAM|||||2.36||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Medicare|MEDICARE ACUTE|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|United Healthcare|UNITED HEALTHCARE OTHER|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|United Healthcare|UNITED HEALTHCARE|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|United Healthcare|UNITED HEALTHCARE|||||2.36||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|United Healthcare|GOLDEN RULE|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Medicaid|MEDICAID|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Managed Medicare|BCBS MEDICARE PPO MA|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|Managed Medicare|HEALTHSPRING MA|2.36||||||| 86161|EAP|0300|COMPLEMENT/FUNCTION ACTIV|NON CONTRACTED|COMMERCIAL OTHER 1|2.36||||||| 86162|EAP|0300|COMPLEMENT TOTAL (CH50)|Humana Medicare Advantage|HUMANA MA|3.69||||||| 86180|EAP|0300|T PALLIDIUM IGG/CSF|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.10||||||| 862|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|78,373.46|10549.48|23410.09|428.64|||| 862|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC|Access Direct Platinum|HEALTHFIRST TPA|123,617.19|14823.42|23410.09|428.64|||| 862|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|87,799.27|11650.5|23410.09|428.64|||| 862|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC|Aetna|AETNA PPO|67,577.90|23410.09|23410.09|428.64|||| 862|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|222,078.27|428.64|23410.09|428.64|||| 862|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC|Humana Medicare Advantage|HUMANA MA|123,362.12|11643.77|23410.09|428.64|||| 862|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC|Medicare|MEDICARE ACUTE|82,130.42|11438.39|23410.09|428.64|||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|United Healthcare|UNITED HEALTHCARE|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Humana Medicare Advantage|HUMANA MA|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Aenta Medicare Advantage|AETNA MEDICARE MA|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|United Medicare Advantage|UHC AARP MCR HMO MA|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Veterans Affairs|VETERANS ADMINISTRATION|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Medicare|MEDICARE ACUTE|5.16||||5.16||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Blue Cross PPO Specialty|BCBSTX PPO|5.16||||||| 86200|EAP|0300|AB CYCLIC CITRULLINATED|Blue Cross HMO Specialty|BCBSTX HMO|5.16||||||| 86215|EAP|0300|AB ANTI-DNASE|Blue Cross PPO Specialty|BCBSTX PPO|5.28||||||| 86215|EAP|0300|AB ANTI-DNASE|Blue Cross HMO Specialty|BCBSTX HMO|5.28||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|United Healthcare|UNITED HEALTHCARE OTHER|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Medicaid|MEDICAID|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Medicaid|COUNTY INDIGENT HEALTH OTHER|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Tricare|TRICARE FOR LIFE|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Medicare|UTSW MC KIDNEY PROGRAM|||||547.50||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Medicare|MEDICARE ACUTE|547.50||||547.50||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|NON CONTRACTED|COMMERCIAL OTHER 1|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|United Healthcare|UNITED HEALTHCARE|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|UTMB|UTMB CORRECTIONAL MANAGED CARE|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Access Direct Platinum|HEALTHFIRST TPA|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|547.50||||547.50||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Veterans Affairs|VETERANS ADMINISTRATION|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|United Medicare Advantage|UHC MEDICARE GOLD MA|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Managed Medicare|HEALTHSPRING MA|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|PHCS|HUMANA|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Managed Medicare|WELLCARE CHOICE MA|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|United Medicare Advantage|UHC AARP MCR HMO MA|547.50||||547.50||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Humana Medicare Advantage|HUMANA MA|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Managed Medicaid|MEDICAID AMERIGROUP|||||547.50||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Aetna|AETNA PPO|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Blue Cross HMO Specialty|BCBSTX HMO|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Blue Cross PPO Specialty|BCBSTX PPO|547.50||||547.50||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Aenta Medicare Advantage|AETNA MEDICARE MA|547.50||||||| 86225|EAP|0300|DNA ANTIBODIES DOUBLE-STR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|547.50||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Blue Cross PPO Specialty|BCBSTX PPO|854.25||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|854.25||||||| 86235|EAP|0300|SMITH AB|Blue Cross PPO Specialty|BCBSTX PPO|222.50||||||| 86235|EAP|0300|AB SCLERODERMA|Blue Cross PPO Specialty|BCBSTX PPO|714.75||||||| 86235|EAP|0300|CENTROMERE ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|152.53||||||| 86235|EAP|0300|AB JO-1|Blue Cross PPO Specialty|BCBSTX PPO|714.75||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|854.25||||||| 86235|EAP|0300|SMITH AB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|222.50||||||| 86235|EAP|0300|CENTROMERE ANTIBODY|Aenta Medicare Advantage|AETNA MEDICARE MA|152.53||||||| 86235|EAP|0300|AB SCLERODERMA|Aenta Medicare Advantage|AETNA MEDICARE MA|714.75||||||| 86235|EAP|0300|AB JO-1|Aenta Medicare Advantage|AETNA MEDICARE MA|714.75||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Aenta Medicare Advantage|AETNA MEDICARE MA|854.25||||||| 86235|EAP|0300|CMV BY PCE/PARAFIN BLOCK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|357.50||||||| 86235|EAP|0300|CENTROMERE ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|152.53||||||| 86235|EAP|0300|AB SCLERODERMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|714.75||||||| 86235|EAP|0300|AB JO-1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|714.75||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|854.25||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|854.25||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Humana Medicare Advantage|HUMANA MA|854.25||||||| 86235|EAP|0300|CENTROMERE ANTIBODY|Humana Medicare Advantage|HUMANA MA|152.53||||||| 86235|EAP|0300|ANTI HISTONE|Humana Medicare Advantage|HUMANA MA|3.58||||||| 86235|EAP|0300|SMITH AB|United Medicare Advantage|UHC MEDICARE GOLD MA|222.50||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|United Medicare Advantage|UHC MEDICARE GOLD MA|854.25||||||| 86235|EAP|0300|SMITH AB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|222.50||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|United Medicare Advantage|UHC AARP MCR HMO MA|854.25||||||| 86235|EAP|0300|AB SCLERODERMA|United Medicare Advantage|UHC AARP MCR HMO MA|714.75||||||| 86235|EAP|0300|AB JO-1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|714.75||||||| 86235|EAP|0300|CENTROMERE ANTIBODY|United Medicare Advantage|UHC AARP MCR HMO MA|152.53||||||| 86235|EAP|0300|AB JO-1|United Medicare Advantage|UHC AARP MCR HMO MA|714.75||||||| 86235|EAP|0300|AB SCLERODERMA|United Medicare Advantage|UHC MEDICARE GOLD MA|714.75||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|854.25||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Veterans Affairs|VETERANS ADMINISTRATION|854.25||||||| 86235|EAP|0300|AB JO-1|Humana Medicare Advantage|HUMANA MA|714.75||||||| 86235|EAP|0300|SMITH AB|Veterans Affairs|VETERANS ADMINISTRATION|222.50||||||| 86235|EAP|0300|AB SCLERODERMA|Veterans Affairs|VETERANS ADMINISTRATION|714.75||||||| 86235|EAP|0300|AB JO-1|Veterans Affairs|VETERANS ADMINISTRATION|714.75||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|854.25||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Access Direct Platinum|HEALTHFIRST TPA|854.25||||||| 86235|EAP|0300|AB SCLERODERMA|Humana Medicare Advantage|HUMANA MA|714.75||||||| 86235|EAP|0300|SMITH AB|Humana Medicare Advantage|HUMANA MA|222.50||||||| 86235|EAP|0300|AB SCLERODERMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|714.75||||||| 86235|EAP|0300|AB JO-1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|714.75||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Access Direct Platinum|HEALTHFIRST TPA UMR|854.25||||||| 86235|EAP|0300|AB SCLERODERMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|714.75||||||| 86235|EAP|0300|SMITH AB|Access Direct Platinum|HEALTHFIRST TPA|222.50||||||| 86235|EAP|0300|AB JO-1|UTMB|UTMB CORRECTIONAL MANAGED CARE|714.75||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|United Healthcare|UNITED HEALTHCARE OTHER|854.25||||||| 86235|EAP|0300|AB JO-1|United Healthcare|UNITED HEALTHCARE|714.75||||||| 86235|EAP|0300|SMITH AB|NON CONTRACTED|COMMERCIAL OTHER 1|222.50||||||| 86235|EAP|0300|SMITH AB|Medicare|MEDICARE ACUTE|222.50||||854.25||| 86235|EAP|0300|SMITH AB|Aenta Medicare Advantage|AETNA MEDICARE MA|222.50||||||| 86235|EAP|0300|AB SCLERODERMA|Medicare|MEDICARE ACUTE|714.75||||714.75||| 86235|EAP|0300|AB JO-1|Medicare|MEDICARE ACUTE|714.75||||714.75||| 86235|EAP|0300|SMITH AB|Medicare|MEDICARE ACUTE|3.58||||222.50||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|PHCS|HUMANA|854.25||||||| 86235|EAP|0300|SMITH AB|Managed Medicare|HEALTHSPRING MA|222.50||||||| 86235|EAP|0300|SMITH AB|Medicaid|MEDICAID|222.50||||||| 86235|EAP|0300|SMITH AB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|222.50||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Managed Medicare|HEALTHSPRING MA|854.25||||||| 86235|EAP|0300|AB SCLERODERMA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|714.75||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|854.25||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|NON CONTRACTED|COMMERCIAL OTHER 1|854.25||||||| 86235|EAP|0300|AB SCLERODERMA|PHCS|HUMANA|714.75||||||| 86235|EAP|0300|SMITH AB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|222.50||||||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Medicare|MEDICARE ACUTE|854.25||||854.25||| 86235|EAP|0300|SSA/SSB(SJOGREN'S)ANTIBOD|Medicare|MEDICARE ACUTE|152.53||||854.25||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|Medicaid|MEDICAID|714.75||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Medicaid|MEDICAID|480.50||||||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|Managed Medicare|HEALTHSPRING MA|480.50||||462.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|480.50||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Managed Medicare|HEALTHSPRING MA|480.50||||462.50||| 86255|EAP|0300|FLORESCENT NONINFECT AB S|Managed Medicare|HEALTHSPRING MA|431.25||||462.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Managed Medicare|BCBS MEDICARE PPO MA|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Managed Medicare|WELLCARE CHOICE MA|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Tricare|TRICARE FOR LIFE|480.50||||||| 86255|EAP|0300|NEUROMYELITIS OPTICA, CSF|Tricare|TRICARE FOR LIFE|1,241.25||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Tricare|TRICARE FOR LIFE|462.50||||||| 86255|EAP|0300|NMDA RECEPTOR AB|Medicare|MEDICARE ACUTE|6,008.25||||6.25||| 86255|EAP|0300|NMDA IGG WITH REFLEX TITE|Medicare|MEDICARE ACUTE|462.50||||6,008.25||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|Medicare|MEDICARE ACUTE|480.50||||480.50||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|Medicare|MEDICARE ACUTE|714.75||||714.75||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Medicare|UTSW MC KIDNEY PROGRAM|||||480.50||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|NON CONTRACTED|COMMERCIAL OTHER 1|714.75||||||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|NON CONTRACTED|COMMERCIAL OTHER 1|480.50||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|United Healthcare|UNITED HEALTHCARE|462.50||||480.50||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|United Healthcare|UNITED HEALTHCARE|714.75||||480.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|United Healthcare|UNITED HEALTHCARE OTHER|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|United Healthcare|UNITED HEALTHCARE|480.50||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|462.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|480.50||||480.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|480.50||||480.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|UTMB|UTMB CORRECTIONAL MANAGED CARE|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|480.50||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|462.50||||480.50||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|United Healthcare|UNITED HEALTHCARE|480.50||||480.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Veterans Affairs|VETERANS ADMINISTRATION|462.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|NON CONTRACTED|COMMERCIAL OTHER 1|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Veterans Affairs|VETERANS ADMINISTRATION|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|United Medicare Advantage|UHC MEDICARE GOLD MA|480.50||||480.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|United Medicare Advantage|UHC MEDICARE GOLD MA|462.50||||714.75||| 86255|EAP|0300|FLORESCENT NONINFECT AB S|United Medicare Advantage|UHC MEDICARE GOLD MA|431.25||||714.75||| 86255|EAP|0300|FLUORESCENT AB SCREEN|United Medicare Advantage|UHC AARP MCR HMO MA|462.50||||||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|714.75||||||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|United Medicare Advantage|UHC MEDICARE GOLD MA|714.75||||714.75||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|United Healthcare|UNITED HEALTHCARE|480.50||||480.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Access Direct Platinum|HEALTHFIRST TPA UMR|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Access Direct Platinum|HEALTHFIRST TPA|480.50||||||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|480.50||||714.75||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|United Medicare Advantage|UHC AARP MCR HMO MA|714.75||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|462.50||||||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|480.50||||||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|480.50||||480.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|United Medicare Advantage|UHC AARP MCR HMO MA|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Cigna|CIGNA|480.50||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Humana Medicare Advantage|HUMANA MA|480.50||||462.50||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|Humana Medicare Advantage|HUMANA MA|480.50||||462.50||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|Humana Medicare Advantage|HUMANA MA|714.75||||462.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Humana Medicare Advantage|HUMANA MA|462.50||||462.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|462.50||||||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|714.75||||462.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Medicare|MEDICARE ACUTE|480.50||||480.50||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|480.50||||462.50||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|480.50||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Aenta Medicare Advantage|AETNA MEDICARE MA|462.50||||||| 86255|EAP|0300|AB STRIATED MUSCLE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.40||||||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|480.50||||462.50||| 86255|EAP|0300|NMDA IGG WITH REFLEX TITE|Humana Medicare Advantage|HUMANA MA|6,008.25||||462.50||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|480.50||||480.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Medicare|MEDICARE ACUTE|431.25||||462.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|PHCS|HUMANA|480.50||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Blue Cross HMO Specialty|BCBSTX HMO|462.50||||480.50||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|Blue Cross HMO Specialty|BCBSTX HMO|714.75||||480.50||| 86255|EAP|0300|NMDA IGG WITH REFLEX TITE|Blue Cross PPO Specialty|BCBSTX PPO|480.50||||6,008.25||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Blue Cross PPO Specialty|BCBSTX PPO|480.50||||480.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|462.50||||6,008.25||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|480.50||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|714.75||||462.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Managed Medicare|HEALTHSPRING MA|462.50||||462.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Blue Cross HMO Specialty|BCBSTX HMO|480.50||||480.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Blue Cross PPO Specialty|BCBSTX OTHER|462.50||||480.50||| 86255|EAP|0300|FLORESCENT NONINFECT AB S|ChampVA|CHAMPVA CENTER|431.25||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||480.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|714.75||||462.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Medicaid|COUNTY INDIGENT HEALTH OTHER|480.50||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Aenta Medicare Advantage|AETNA MEDICARE MA|480.50||||||| 86255|EAP|0300|AB ANTI-SMOOTH MUSCLE|Aenta Medicare Advantage|AETNA MEDICARE MA|714.75||||||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Aetna|AETNA PPO|480.50||||480.50||| 86255|EAP|0300|AB ANTIMITOCHONDRIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|480.50||||||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|462.50||||462.50||| 86255|EAP|0300|AB ANTI-NEUTROPHIL CYTOPL|Managed Medicaid|MEDICAID AMERIGROUP|480.50||||480.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|480.50||||462.50||| 86255|EAP|0300|FLUORESCENT AB SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|462.50||||462.50||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Humana Medicare Advantage|HUMANA MA|462.50||||462.50||| 86256|EAP|0300|PARANEOPLASTIC PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|United Medicare Advantage|UHC AARP MCR HMO MA|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Medicare|MEDICARE ACUTE|480.50||||462.50||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Medicare|MEDICARE ACUTE|462.50||||462.50||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Tricare|TRICARE FOR LIFE|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Veterans Affairs|VETERANS ADMINISTRATION|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Managed Medicare|HEALTHSPRING MA|||||462.50||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Blue Cross HMO Specialty|BCBSTX HMO|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Blue Cross PPO Specialty|BCBSTX OTHER|462.50||||||| 86256|EAP|0300|PARANEOPLASTIC PANEL|Blue Cross PPO Specialty|BCBSTX PPO|462.50||||462.50||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Medicare|MEDICARE PART B ONLY IP|34.26|239.53|29553.15|104.61|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Medicare|MEDICARE ACUTE|52,063.65|6817.28|29553.15|104.61|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Medicaid|MEDICAID|81,656.41|4306.28|29553.15|104.61|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|29,553.15|29553.15|29553.15|104.61|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|58,919.25|6677.3|29553.15|104.61|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|42,796.82|8655.06|29553.15|104.61|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Managed Medicare|HEALTHSPRING MA|44,886.75|6709.09|29553.15|104.61|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|419.86|6704.58|29553.15|104.61|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34,393.53|104.61|29553.15|104.61|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|47,292.52|9190.47|29553.15|104.61|||| 86300|EAP|0300|TUMOR ANTIGEN CA 27.29|Blue Cross PPO Specialty|BCBSTX PPO|829.25||||829.25||| 86300|EAP|0300|TUMOR ANTIGEN CA 15-3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|829.25||||||| 86300|EAP|0300|TUMOR ANTIGEN CA 15-3|Cigna|CIGNA|829.25||||||| 86300|EAP|0300|TUMOR ANTIGEN CA 15-3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|829.25||||||| 86300|EAP|0300|TUMOR ANTIGEN CA 15-3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||829.25||| 86300|EAP|0300|TUMOR ANTIGEN CA 15-3|Medicare|MEDICARE ACUTE|829.25||||||| 86300|EAP|0300|TUMOR ANTIGEN CA 15-3|NON CONTRACTED|COMMERCIAL OTHER 1|829.25||||||| 86300|EAP|0300|TUMOR ANTIGEN CA 15-3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Humana Medicare Advantage|HUMANA MA|829.25||||829.25||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Managed Medicare|HEALTHSPRING MA|829.25||||829.25||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|UTMB|UTMB CORRECTIONAL MANAGED CARE|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|United Healthcare|UNITED HEALTHCARE|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Tricare|TRICARE EAST REGION|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Medicare|MEDICARE ACUTE|829.25||||829.25||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|United Healthcare|UNITED HEALTHCARE OTHER|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Medicare|MEDICARE ACUTE|2.14||||829.25||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|NON CONTRACTED|COMMERCIAL OTHER 1|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|United Medicare Advantage|UHC MEDICARE GOLD MA|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Medicaid|MEDICAID|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Managed Medicaid|MEDICAID UNITED HEALTHCARE|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Humana Medicare Advantage|HUMANA MA|2.14||||829.25||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Cigna|CIGNA|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Aetna|AETNA OTHER|829.25||||||| 86301|EAP|0300||Aetna|AETNA OTHER|2.14||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Aetna|AETNA PPO|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Blue Cross PPO Specialty|BCBSTX PPO|829.25||||829.25||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|829.25||||||| 86301|EAP|0300|TUMOR ANTIGEN CA 19-9|Blue Cross PPO Specialty|BCBSTX PPO|2.14||||829.25||| 86304|EAP|0300|CANCER ANTIGEN 125|Cigna|CIGNA|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|Blue Cross HMO Specialty|BCBSTX HMO|||||4.50||| 86304|EAP|0300|CANCER ANTIGEN 125|Blue Cross PPO Specialty|BCBSTX PPO|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.50||||4.50||| 86304|EAP|0300|CANCER ANTIGEN 125|Aetna|AETNA OTHER|||||4.50||| 86304|EAP|0300|CANCER ANTIGEN 125|Humana Medicare Advantage|HUMANA MA|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|Medicare|MEDICARE ACUTE|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|NON CONTRACTED|COMMERCIAL OTHER 1|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|Medicaid|MEDICAID|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|Managed Medicare|HEALTHSPRING MA|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.50||||||| 86304|EAP|0300|CANCER ANTIGEN 125|United Healthcare|UNITED HEALTHCARE|4.50||||||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|United Healthcare|UNITED HEALTHCARE|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Tricare|TRICARE EAST REGION|2.00||||||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Veterans Affairs|VETERANS ADMINISTRATION|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Managed Medicaid|MEDICAID AMERIGROUP|2.00||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.00||||||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Medicare|MEDICARE ACUTE|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Humana Medicare Advantage|HUMANA MA|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.00||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| 86308|EAP|0300|MONONUCLEOSIS SCREENING|Blue Cross PPO Specialty|BCBSTX PPO|2.00||||2.00||| 86316|EAP|0300|CHROMAGRANIN A|Managed Medicare|HEALTHSPRING MA|829.25||||||| 86316|EAP|0300|CHROMAGRANIN A|Medicare|MEDICARE ACUTE|829.25||||||| 86316|EAP|0300|CHROMAGRANIN A|Blue Cross PPO Specialty|BCBSTX PPO|829.25||||||| 86316|EAP|0300|CHROMAGRANIN A|Humana Medicare Advantage|HUMANA MA|||||829.25||| 86316|EAP|0300|CHROMAGRANIN A|United Medicare Advantage|UHC AARP MCR HMO MA|829.25||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|United Healthcare|UNITED HEALTHCARE|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|United Healthcare|TML GROUP BENEFITS|||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|United Healthcare|UNITED HEALTHCARE|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|PHCS|HUMANA|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Medicare|MEDICARE ACUTE|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|NON CONTRACTED|COMMERCIAL OTHER 1|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Medicaid|COUNTY INDIGENT HEALTH OTHER|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Managed Medicare|HEALTHSPRING MA|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Veterans Affairs|VETERANS ADMINISTRATION|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Medicaid|MEDICAID|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|United Medicare Advantage|UHC MEDICARE GOLD MA|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Managed Medicaid|MEDICAID AMERIGROUP|||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|United Medicare Advantage|UHC AARP MCR HMO MA|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Cigna|CIGNA|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Cigna|CIGNA OTHER|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Humana Medicare Advantage|HUMANA MA|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Aetna|AETNA PPO|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Aenta Medicare Advantage|AETNA MEDICARE MA|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Blue Cross PPO Specialty|BCBSTX PPO|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Access Direct Platinum|HEALTHFIRST TPA UMR|892.75||||892.75||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|ChampVA|CHAMPVA CENTER|892.75||||||| 86334|EAP|0300|IMMUNOELECTROPHORSIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|892.75||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|NON CONTRACTED|COMMERCIAL OTHER 1|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Managed Medicare|HEALTHSPRING MA|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Blue Cross PPO Specialty|BCBSTX PPO|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|ChampVA|CHAMPVA CENTER|2.43||||||| 86335|EAP|0300|BETA-2 TRANSFERRIN|Cigna|CIGNA|1,050.50||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Humana Medicare Advantage|HUMANA MA|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Managed Medicaid|MEDICAID AMERIGROUP|||||2.43||| 86335|EAP|0300|BETA-2 TRANSFERRIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,050.50||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Cigna|CIGNA OTHER|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|United Medicare Advantage|UHC MEDICARE GOLD MA|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|United Medicare Advantage|UHC AARP MCR HMO MA|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Veterans Affairs|VETERANS ADMINISTRATION|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Access Direct Platinum|HEALTHFIRST TPA UMR|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Aenta Medicare Advantage|AETNA MEDICARE MA|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Medicaid|MEDICAID|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|Medicare|MEDICARE ACUTE|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|PHCS|HUMANA INSURANCE|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|PHCS|HUMANA|2.43||||||| 86335|EAP|0300|IMMUNFIX E-PHORSIS/URINE/|United Healthcare|UNITED HEALTHCARE|2.43||||||| 86337|EAP|0300|AB INSULIN|Blue Cross PPO Specialty|BCBSTX PPO|||||689.25||| 86340|EAP|0300|AB INTRINSIC FACTOR|Medicare|MEDICARE ACUTE|600.50||||||| 86340|EAP|0300|AB INTRINSIC FACTOR|UTMB|UTMB CORRECTIONAL MANAGED CARE|600.50||||||| 86340|EAP|0300|AB INTRINSIC FACTOR|Managed Medicare|HEALTHSPRING MA|600.50||||||| 86341|EAP|0300|AB ISLET CELL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|664.50||||||| 86341|EAP|0300|AB ISLET CELL|United Medicare Advantage|UHC MEDICARE GOLD MA|664.50||||||| 86341|EAP|0300|AB ISLET CELL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|664.50||||||| 86341|EAP|0300|AB ISLET CELL|Blue Cross HMO Specialty|BCBSTX HMO|664.50||||||| 86341|EAP|0300|AB ISLET CELL|Tricare|TRICARE FOR LIFE|664.50||||||| 86341|EAP|0300|AB ISLET CELL|UTMB|UTMB CORRECTIONAL MANAGED CARE|664.50||||||| 86341|EAP|0300|AB ISLET CELL|Managed Medicare|HEALTHSPRING MA|||||664.50||| 86341|EAP|0300|AB ISLET CELL|Blue Cross PPO Specialty|BCBSTX PPO|664.50||||664.50||| 86341|EAP|0300|AB ISLET CELL|Blue Cross PPO Specialty|BCBSTX OTHER|664.50||||||| 86341|EAP|0300|AB ISLET CELL|Medicare|MEDICARE ACUTE|664.50||||664.50||| 86341|EAP|0300|AB ISLET CELL|Aenta Medicare Advantage|AETNA MEDICARE MA|664.50||||||| 86341|EAP|0300|AB ISLET CELL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|664.50||||||| 86341|EAP|0300|AB ISLET CELL|Humana Medicare Advantage|HUMANA MA|664.50||||664.50||| 86341|EAP|0300|AB ISLET CELL|United Medicare Advantage|UHC AARP MCR HMO MA|664.50||||||| 86341|EAP|0300|AB ISLET CELL|Veterans Affairs|VETERANS ADMINISTRATION|664.50||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Multiplan|WEB TPA|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Medicare|MEDICARE ACUTE|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|UTMB|UTMB CORRECTIONAL MANAGED CARE|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Medicare|MEDICARE PART B ONLY IP|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|NON CONTRACTED|COMMUNITY HEALTH CENTER|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Tricare|TRICARE FOR LIFE|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Texas Workforce Commission|DIS DETER SERV (DDS)|||||209.62||| 86359|EAP|0300|T CELLS TOTAL COUNT|Medicaid|MEDICAID|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Humana Medicare Advantage|HUMANA MA|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|United Healthcare|UNITED HEALTHCARE OTHER|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||209.62||| 86359|EAP|0300|T CELLS TOTAL COUNT|United Medicare Advantage|UHC AARP MCR HMO MA|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|209.62||||||| 86359|EAP|0300|T CELLS TOTAL COUNT|Managed Medicaid|MEDICAID AMERIGROUP|209.62||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|United Medicare Advantage|UHC AARP MCR HMO MA|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Humana Medicare Advantage|HUMANA MA|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Managed Medicaid|MEDICAID UNITED HEALTHCARE|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Managed Medicaid|MEDICAID AMERIGROUP|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||310.48||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Medicaid|MEDICAID|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Tricare|TRICARE FOR LIFE|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Texas Workforce Commission|DIS DETER SERV (DDS)|||||310.48||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|NON CONTRACTED|COMMUNITY HEALTH CENTER|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Medicare|MEDICARE PART B ONLY IP|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Medicare|MEDICARE ACUTE|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|Multiplan|WEB TPA|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|UTMB|UTMB CORRECTIONAL MANAGED CARE|310.48||||||| 86360|EAP|0300|T-CELL HPR/SUP CD4/CD8|United Healthcare|UNITED HEALTHCARE OTHER|310.48||||||| 86376|EAP|0300|THYROID PEROXIDE(MICROSOM|Medicare|MEDICARE ACUTE|2.86||||579.75||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|NON CONTRACTED|COMMUNITY HEALTH CENTER|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Optum Behavioral Health|BH OPTUM UHC|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Medicaid|MEDICAID|2.86||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Medicaid|MEDICAID|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Medicaid|SMITH COUNTY JAIL|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Blue Cross PPO Specialty|BCBSTX PPO|2.86||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Blue Cross HMO Specialty|BCBSTX HMO|||||558.75||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Aenta Medicare Advantage|AETNA MEDICARE MA|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Aetna|BH AETNA|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Medicare|MEDICARE ACUTE|558.75||||579.75||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Humana Medicare Advantage|HUMANA MA|2.86||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|United Medicare Advantage|UHC MEDICARE GOLD MA|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Humana Medicare Advantage|HUMANA MA|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Blue Cross PPO Specialty|BCBSTX PPO|558.75||||||| 86376|EAP|0300|AB MICROSOMAL LIVER KIDNE|Managed Medicare|HEALTHSPRING MA|558.75||||||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|NON CONTRACTED|COMMERCIAL OTHER 1|29,584.50|29584.5|29584.5|103.76|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Managed Medicare|HEALTHSPRING MA|38,895.51|5933.93|29584.5|103.76|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|50,441.71|103.76|29584.5|103.76|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Blue Cross PPO Specialty|BCBSTX PPO|21,734.45|5868.6|29584.5|103.76|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Medicare|MEDICARE ACUTE|44,988.05|5933.93|29584.5|103.76|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Humana Medicare Advantage|HUMANA MA|61,995.25|5905.45|29584.5|103.76|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|United Medicare Advantage|UHC AARP MCR HMO MA|94,118.52|5937.06|29584.5|103.76|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|United Healthcare|UNITED HEALTHCARE|46,795.86|10029.83|29584.5|103.76|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|United Healthcare|UNITED HEALTHCARE OTHER|81,377.72|10029.83|29584.5|103.76|||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|United Healthcare|UNITED HEALTHCARE|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|NON CONTRACTED|COMMERCIAL OTHER 1|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Medicare|MEDICARE ACUTE|2.00||||2.00||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Medicare|MEDICARE ACUTE|406.50||||2.00||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|United Healthcare|UNITED HEALTHCARE OTHER|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Managed Medicare|HEALTHSPRING MA|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.00||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Medicaid|SMITH COUNTY JAIL|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Medicaid|MEDICAID|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Veterans Affairs|VETERANS ADMINISTRATION|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Blue Cross HMO Specialty|BCBSTX HMO|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Humana Medicare Advantage|HUMANA MA|406.50||||2.00||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Humana Medicare Advantage|HUMANA MA|2.00||||2.00||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||||| 86403|EAP|0300|CRYPTOCOCCAL ANTIGEN|Cigna|CIGNA OTHER|2.00||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Humana Medicare Advantage|HUMANA MA|1.11||||1.11||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.11||||1.11||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Aetna|AETNA PPO|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|United Medicare Advantage|UHC MEDICARE GOLD MA|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Medicaid|MEDICAID|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|United Healthcare|UNITED HEALTHCARE|1.11||||1.11||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|United Healthcare|TML GROUP BENEFITS|||||1.11||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Medicare|MEDICARE ACUTE|1.11||||1.11||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Managed Medicare|HEALTHSPRING MA|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Veterans Affairs|VETERANS ADMINISTRATION|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.11||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|United Medicare Advantage|UHC AARP MCR HMO MA|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Blue Cross PPO Specialty|BCBSTX PPO|1.11||||1.11||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.11||||1.11||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|United Healthcare|UNITED HEALTHCARE OTHER|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Managed Medicaid|MEDICAID SUPERIOR|1.11||||||| 86431|EAP|0300|RHEUMATOID FACTOR QUANT|Managed Medicaid|MEDICAID AMERIGROUP|1.11||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Blue Cross HMO Specialty|BCBSTX HMO|||||1,475.25||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|PHCS|HUMANA|||||1,475.25||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|NON CONTRACTED|COMMERCIAL OTHER 1|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|United Healthcare|UNITED HEALTHCARE|||||1,475.25||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Medicare|MEDICARE ACUTE|1,475.25||||1,475.25||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Managed Medicare|HEALTHSPRING MA|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Medicare|UTSW MC KIDNEY PROGRAM|||||1,475.25||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Veterans Affairs|VETERANS ADMINISTRATION|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,475.25||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|United Medicare Advantage|UHC AARP MCR HMO MA|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,475.25||||1,475.25||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|United Medicare Advantage|UHC MEDICARE GOLD MA|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Blue Cross PPO Specialty|BCBSTX PPO|1,475.25||||1,475.25||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Aenta Medicare Advantage|AETNA MEDICARE MA|1,475.25||||1,475.25||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Aetna|AETNA PPO|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Managed Medicaid|MEDICAID SUPERIOR|1,475.25||||||| 86480|EAP|0300|TUBERCULOSIS SPOT TEST|Humana Medicare Advantage|HUMANA MA|1,475.25||||1,475.25||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|Humana Medicare Advantage|HUMANA MA|1.41||||1.41||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|United Medicare Advantage|UHC MEDICARE GOLD MA|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|Managed Medicare|HEALTHSPRING MA|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|Medicare|MEDICARE ACUTE|1.41||||1.41||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|United Healthcare|UNITED HEALTHCARE|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|Medicaid|MEDICAID|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|United Medicare Advantage|UHC AARP MCR HMO MA|1.41||||||| 86481|EAP|0300|TB AG RESPONSE T-CELL SUS|Blue Cross PPO Specialty|BCBSTX PPO|1.41||||||| 865|DRG||VIRAL ILLNESS W MCC|United Healthcare|UNITED HEALTHCARE OTHER|29,569.20|16491.1|16491.1|8929.46|||| 865|DRG||VIRAL ILLNESS W MCC|Medicare|MEDICARE ACUTE|130,596.67|8994.755|16491.1|8929.46|||| 865|DRG||VIRAL ILLNESS W MCC|Managed Medicare|HEALTHSPRING MA|47,772.07|8929.46|16491.1|8929.46|||| 86592|EAP|0300|RPR SERUM|Blue Cross PPO Specialty|BCBSTX PPO|0.84||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|282.25||||0.84||| 86592|EAP|0300|RPR SERUM|Access Direct Platinum|ANDREWS CENTER|0.84||||||| 86592|EAP|0300|RPR SERUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|Veterans Affairs|VETERANS ADMINISTRATION|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.84||| 86592|EAP|0300|RPR SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.84||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|United Medicare Advantage|UHC MEDICARE GOLD MA|282.25||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|282.25||||0.84||| 86592|EAP|0300|RPR SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|Blue Cross HMO Specialty|BCBSTX HMO|282.25||||0.84||| 86592|EAP|0300|RPR SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|0.84||||||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Blue Cross PPO Specialty|BCBSTX PPO|282.25||||282.25||| 86592|EAP|0300|RPR SERUM|ChampVA|CHAMPVA CENTER|||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Aenta Medicare Advantage|AETNA MEDICARE MA|282.25||||0.84||| 86592|EAP|0300|RPR SERUM|Aenta Medicare Advantage|AETNA MEDICARE MA|0.84||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|282.25||||||| 86592|EAP|0300|RPR SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.84||||||| 86592|EAP|0300|RPR SERUM|Aetna Value Network|AETNA VALUE NETWORK|0.84||||||| 86592|EAP|0300|RPR SERUM|Managed Medicaid|MEDICAID AMERIGROUP|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.84||||||| 86592|EAP|0300|RPR SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.84||||||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Humana Medicare Advantage|HUMANA MA|282.25||||282.25||| 86592|EAP|0300|RPR SERUM|Managed Medicare|HEALTHSPRING MA|0.84||||||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Managed Medicaid|MEDICAID AMERIGROUP|282.25||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Managed Medicare|ETMC AFFILIATE HOSPITALS|282.25||||||| 86592|EAP|0300|RPR SERUM|Managed Medicare|BCBS MEDICARE PPO MA|0.84||||||| 86592|EAP|0300|RPR SERUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.84||||||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Managed Medicare|HEALTHSPRING MA|282.25||||||| 86592|EAP|0300|RPR SERUM|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.84||||||| 86592|EAP|0300|RPR SERUM|Medicaid|MEDICAID HMO|0.84||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Medicaid|SMITH COUNTY JAIL|282.25||||||| 86592|EAP|0300|RPR SERUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.84||||||| 86592|EAP|0300|RPR SERUM|Access Direct Platinum|HEALTHFIRST TPA UMR|0.84||||||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|United Medicare Advantage|UHC AARP MCR HMO MA|282.25||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Veterans Affairs|VETERANS ADMINISTRATION|282.25||||0.84||| 86592|EAP|0300|RPR SERUM|Tricare|TRICARE FOR LIFE|0.84||||||| 86592|EAP|0300|RPR SERUM|United Medicare Advantage|UHC AARP MCR HMO MA|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|Medicaid|MEDICAID|0.84||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Tricare|TRICARE FOR LIFE|282.25||||||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Medicaid|MEDICAID|282.25||||0.84||| 86592|EAP|0300|RPR SERUM|PHCS|HUMANA|282.25||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|Medicare|MEDICARE ACUTE|282.25||||282.25||| 86592|EAP|0300|RPR SERUM|Medicare|UTSW MC KIDNEY PROGRAM|||||0.84||| 86592|EAP|0300|RPR SERUM|Medicare|MEDICARE ACUTE|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.84||||||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|NON CONTRACTED|COMMERCIAL OTHER 1|282.25||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|United Healthcare|UNITED HEALTHCARE|282.25||||0.84||| 86592|EAP|0300|RPR SERUM|United Healthcare|UNITED HEALTHCARE|0.84||||0.84||| 86592|EAP|0300|VDRL CEREBROSPINAL FLUID|United Healthcare|UNITED HEALTHCARE OTHER|282.25||||||| 86592|EAP|0300|RPR SERUM|Managed Medicaid|MEDICAID SUPERIOR|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.84||||||| 86592|EAP|0300|RPR SERUM|United Healthcare|GOLDEN RULE|0.84||||||| 86592|EAP|0300|RPR SERUM|Humana Medicare Advantage|HUMANA MA|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|United Healthcare|UNITED HEALTHCARE OTHER|0.84||||||| 86592|EAP|0300|RPR SERUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.84||||0.84||| 86592|EAP|0300|RPR SERUM|Cigna|CIGNA|||||0.84||| 866|DRG||VIRAL ILLNESS W/O MCC|Medicare|MEDICARE ACUTE|39,859.96|5822.565|10769.66|3619.5|||| 866|DRG||VIRAL ILLNESS W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|51,397.05|5775.57|10769.66|3619.5|||| 866|DRG||VIRAL ILLNESS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36,951.95|3619.5|10769.66|3619.5|||| 866|DRG||VIRAL ILLNESS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|68,084.39|3619.5|10769.66|3619.5|||| 866|DRG||VIRAL ILLNESS W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27,297.35|7474.77|10769.66|3619.5|||| 866|DRG||VIRAL ILLNESS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|118,140.50|7474.77|10769.66|3619.5|||| 866|DRG||VIRAL ILLNESS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|61,361.45|10769.66|10769.66|3619.5|||| 86606|EAP|0300|AB ASPERGILLUS|United Medicare Advantage|UHC AARP MCR HMO MA|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|Veterans Affairs|VETERANS ADMINISTRATION|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|Aenta Medicare Advantage|AETNA MEDICARE MA|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|Blue Cross PPO Specialty|BCBSTX PPO|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|Medicare|MEDICARE ACUTE|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|United Medicare Advantage|UHC MEDICARE GOLD MA|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|NON CONTRACTED|COMMERCIAL OTHER 1|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|Managed Medicare|HEALTHSPRING MA|1.61||||||| 86606|EAP|0300|AB ASPERGILLUS|Medicaid|MEDICAID|1.61||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Medicaid|MEDICAID|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Medicaid|MEDICAID|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Managed Medicare|HEALTHSPRING MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|United Healthcare|UNITED HEALTHCARE|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|United Healthcare|UNITED HEALTHCARE|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Medicare|MEDICARE ACUTE|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Humana Medicare Advantage|HUMANA MA|3.26||||3.26||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Managed Medicaid|MEDICAID SUPERIOR|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Blue Cross HMO Specialty|BCBSTX HMO|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Blue Cross HMO Specialty|BCBSTX HMO|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Blue Cross PPO Specialty|BCBSTX PPO|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Managed Medicaid|MEDICAID SUPERIOR|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Blue Cross PPO Specialty|BCBSTX PPO|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Humana Medicare Advantage|HUMANA MA|3.26||||3.26||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Managed Medicare|HEALTHSPRING MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|NON CONTRACTED|COMMERCIAL OTHER 1|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Veterans Affairs|VETERANS ADMINISTRATION|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|NON CONTRACTED|COMMERCIAL OTHER 1|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|Veterans Affairs|VETERANS ADMINISTRATION|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|United Medicare Advantage|UHC MEDICARE GOLD MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|United Medicare Advantage|UHC AARP MCR HMO MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|United Medicare Advantage|UHC MEDICARE GOLD MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|United Medicare Advantage|UHC AARP MCR HMO MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA HENSELAE IG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.26||||||| 86611|EAP|0300|AB BARTONELLA QUINTANA IG|Medicare|MEDICARE ACUTE|3.26||||||| 86612|EAP|0300|BLASTOMYCES AB BY ID|United Medicare Advantage|UHC MEDICARE GOLD MA|292.75||||||| 86612|EAP|0300|BLASTOMYCES AB BY ID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|292.75||||||| 86612|EAP|0300|BLASTOMYCES AB BY ID|Blue Cross PPO Specialty|BCBSTX PPO|292.75||||||| 86612|EAP|0300|BLASTOMYCES AB BY ID|United Medicare Advantage|UHC AARP MCR HMO MA|292.75||||||| 86612|EAP|0300|BLASTOMYCES AB BY ID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|292.75||||||| 86612|EAP|0300|BLASTOMYCES AB BY ID|Humana Medicare Advantage|HUMANA MA|292.75||||||| 86612|EAP|0300|BLASTOMYCES AB BY ID|Medicare|MEDICARE ACUTE|292.75||||||| 86612|EAP|0300|BLASTOMYCES AB BY ID|Aenta Medicare Advantage|AETNA MEDICARE MA|292.75||||||| 86612|EAP|0300|BLASTOMYCES AB BY ID|Managed Medicare|HEALTHSPRING MA|292.75||||||| 86615|EAP|0300|BORDETELLA IGG|Veterans Affairs|VETERANS ADMINISTRATION|506.50||||||| 86618|EAP|0300|AB LYME CSF|United Healthcare|UNITED HEALTHCARE|678.75||||678.75||| 86618|EAP|0300|AB LYME CSF|United Healthcare|UNITED HEALTHCARE OTHER|678.75||||||| 86618|EAP|0300|AB LYME CSF|PHCS|HUMANA|678.75||||||| 86618|EAP|0300|AB LYME DISEASE|Medicare|MEDICARE ACUTE|3.35||||678.75||| 86618|EAP|0300|AB LYME CSF|Medicare|MEDICARE ACUTE|678.75||||678.75||| 86618|EAP|0300|AB LYME DISEASE|NON CONTRACTED|COMMERCIAL OTHER 1|3.35||||||| 86618|EAP|0300|AB LYME DISEASE|Managed Medicaid|MEDICAID SUPERIOR|3.35||||||| 86618|EAP|0300|AB LYME DISEASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.35||||||| 86618|EAP|0300|AB LYME CSF|Blue Cross HMO Specialty|BCBSTX HMO|||||678.75||| 86618|EAP|0300|AB LYME CSF|Humana Medicare Advantage|HUMANA MA|3.35||||678.75||| 86618|EAP|0300|AB LYME CSF|Blue Cross PPO Specialty|BCBSTX PPO|678.75||||678.75||| 86618|EAP|0300|AB LYME DISEASE|Blue Cross PPO Specialty|BCBSTX PPO|3.35||||3.35||| 86618|EAP|0300|AB LYME CSF|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||678.75||| 86618|EAP|0300|AB LYME CSF|ChampVA|CHAMPVA CENTER|678.75||||||| 86618|EAP|0300|AB LYME DISEASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.35||||||| 86618|EAP|0300|AB LYME DISEASE|Aenta Medicare Advantage|AETNA MEDICARE MA|3.35||||||| 86618|EAP|0300|AB LYME CSF|Aenta Medicare Advantage|AETNA MEDICARE MA|678.75||||||| 86618|EAP|0300|AB LYME CSF|United Medicare Advantage|UHC MEDICARE GOLD MA|678.75||||||| 86618|EAP|0300|AB LYME DISEASE|United Medicare Advantage|UHC AARP MCR HMO MA|3.35||||||| 86618|EAP|0300|AB LYME DISEASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.35||||||| 86618|EAP|0300|AB LYME CSF|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.35||||678.75||| 86618|EAP|0300|AB LYME CSF|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|678.75||||678.75||| 86618|EAP|0300|AB LYME DISEASE|Veterans Affairs|VETERANS ADMINISTRATION|3.35||||||| 86618|EAP|0300|AB LYME DISEASE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.35||||678.75||| 86618|EAP|0300|AB LYME CSF|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|678.75||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|Blue Cross PPO Specialty|BCBSTX PPO|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|Blue Cross HMO Specialty|BCBSTX HMO|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|Medicaid|MEDICAID|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|Managed Medicare|HEALTHSPRING MA|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|Medicare|MEDICARE ACUTE|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|United Medicare Advantage|UHC AARP MCR HMO MA|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|Managed Medicaid|MEDICAID SUPERIOR|2.56||||||| 86622|EAP|0300|BRUCELLA AB, IGG&IGM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.56||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|United Healthcare|UNITED HEALTHCARE OTHER|1.61||||1.61||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Medicare|MEDICARE ACUTE|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Medicaid|MEDICAID|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Cigna|CIGNA OTHER|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Managed Medicaid|MEDICAID SUPERIOR|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Managed Medicaid|MEDICAID AMERIGROUP|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Blue Cross PPO Specialty|BCBSTX PPO|1.61||||1.61||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Humana Medicare Advantage|HUMANA MA|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Managed Medicare|BCBS MEDICARE PPO MA|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|United Medicare Advantage|UHC AARP MCR HMO MA|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Veterans Affairs|VETERANS ADMINISTRATION|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Managed Medicare|HEALTHSPRING MA|1.61||||||| 86631|EAP|0300|AB CHLAMYDIA PNEUMO PANEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Veterans Affairs|VETERANS ADMINISTRATION|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|United Medicare Advantage|UHC AARP MCR HMO MA|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Aenta Medicare Advantage|AETNA MEDICARE MA|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Blue Cross PPO Specialty|BCBSTX PPO|1.61||||1.61||| 86632|EAP|0300|AB CHLAMYDIA IGM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|United Medicare Advantage|UHC MEDICARE GOLD MA|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Managed Medicaid|MEDICAID AMERIGROUP|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Managed Medicaid|MEDICAID SUPERIOR|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Humana Medicare Advantage|HUMANA MA|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Cigna|CIGNA OTHER|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Medicaid|MEDICAID|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Managed Medicare|HEALTHSPRING MA|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Managed Medicare|BCBS MEDICARE PPO MA|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|Medicare|MEDICARE ACUTE|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|NON CONTRACTED|COMMERCIAL OTHER 1|1.61||||||| 86632|EAP|0300|AB CHLAMYDIA IGM|United Healthcare|UNITED HEALTHCARE OTHER|1.61||||1.61||| 86632|EAP|0300|AB CHLAMYDIA IGM|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.61||||||| 86635|EAP|0300|AB COCCIDIODES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|United Healthcare|UNITED HEALTHCARE OTHER|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Medicare|MEDICARE ACUTE|3.26||||3.26||| 86635|EAP|0300|AB COCCIDIODES|Medicare|UTSW MC KIDNEY PROGRAM|||||3.26||| 86635|EAP|0300|AB COCCIDIODES|NON CONTRACTED|COMMERCIAL OTHER 1|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Managed Medicare|HEALTHSPRING MA|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Medicaid|MEDICAID|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Humana Medicare Advantage|HUMANA MA|3.26||||3.26||| 86635|EAP|0300|AB COCCIDIODES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Blue Cross HMO Specialty|BCBSTX HMO|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Blue Cross PPO Specialty|BCBSTX PPO|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Aenta Medicare Advantage|AETNA MEDICARE MA|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|United Medicare Advantage|UHC MEDICARE GOLD MA|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|United Medicare Advantage|UHC AARP MCR HMO MA|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Veterans Affairs|VETERANS ADMINISTRATION|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.26||||||| 86635|EAP|0300|AB COCCIDIODES|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.26||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|Veterans Affairs|VETERANS ADMINISTRATION|8.23||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|United Medicare Advantage|UHC MEDICARE GOLD MA|8.23||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.23||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.23||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.23||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|Managed Medicaid|MEDICAID SUPERIOR|8.23||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|Humana Medicare Advantage|HUMANA MA|8.23||||8.23||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|Medicaid|MEDICAID|8.23||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|Managed Medicare|HEALTHSPRING MA|8.23||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|Medicare|MEDICARE ACUTE|8.23||||||| 86638|EAP|0300|AB Q FEVER (COXIELIA BURN|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.23||||||| 86641|EAP|0300|CRYPTOCOCCAL/CSF|Medicare|MEDICARE ACUTE|357.50||||||| 86644|EAP|0300|CMV ANTIBODY|Humana Medicare Advantage|HUMANA MA|2.83||||33.29||| 86644|EAP|0300|AB CMV IGG IGM|Managed Medicaid|MEDICAID AMERIGROUP|||||2.83||| 86644|EAP|0300|CMV ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|2.83||||33.29||| 86644|EAP|0300|CMV ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|33.29||||33.29||| 86644|EAP|0300|AB CMV IGG IGM|Humana Medicare Advantage|HUMANA MA|2.83||||2.83||| 86644|EAP|0300|CMV ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||33.29||| 86644|EAP|0300|CMV ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.29||||||| 86644|EAP|0300|AB CMV IGG IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.83||||||| 86644|EAP|0300|CMV ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||33.29||| 86644|EAP|0300|AB CMV IGG IGM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.83||||||| 86644|EAP|0300|AB CMV IGG IGM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.83||||||| 86644|EAP|0300|AB CMV IGG IGM|Medicaid|MEDICAID|2.83||||||| 86644|EAP|0300|CMV ANTIBODY|United Healthcare|UNITED HEALTHCARE|2.83||||33.29||| 86644|EAP|0300|CMV ANTIBODY|PHCS|HUMANA|||||33.29||| 86644|EAP|0300|CMV ANTIBODY|Medicare|UTSW MC KIDNEY PROGRAM|||||33.29||| 86644|EAP|0300|CMV ANTIBODY|Medicare|MEDICARE ACUTE|2.83||||33.29||| 86644|EAP|0300|AB CMV IGG IGM|NON CONTRACTED|COMMERCIAL OTHER 1|2.83||||||| 86645|EAP|0300|CMV ANTIBODY IGM|Medicare|MEDICARE ACUTE|168.75||||||| 86645|EAP|0300|CMV ANTIBODY IGM|NON CONTRACTED|COMMERCIAL OTHER 1|168.75||||||| 86645|EAP|0300|CMV ANTIBODY IGM|United Healthcare|UNITED HEALTHCARE|168.75||||||| 86645|EAP|0300|CMV ANTIBODY IGM|Medicaid|MEDICAID|168.75||||||| 86645|EAP|0300|CMV ANTIBODY IGM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|168.75||||||| 86645|EAP|0300|CMV ANTIBODY IGM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|168.75||||168.75||| 86645|EAP|0300|CMV ANTIBODY IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|168.75||||||| 86645|EAP|0300|CMV ANTIBODY IGM|Blue Cross PPO Specialty|BCBSTX OTHER|168.75||||||| 86645|EAP|0300|CMV ANTIBODY IGM|Blue Cross PPO Specialty|BCBSTX PPO|168.75||||||| 86645|EAP|0300|CMV ANTIBODY IGM|Managed Medicaid|MEDICAID AMERIGROUP|||||168.75||| 86645|EAP|0300|CMV ANTIBODY IGM|Humana Medicare Advantage|HUMANA MA|168.75||||168.75||| 86658|EAP|0300|COXSACKIE A TITER|Humana Medicare Advantage|HUMANA MA|3.26||||||| 86658|EAP|0300|AB COXSACKIE B VIRUS STUD|Humana Medicare Advantage|HUMANA MA|3.26||||||| 86658|EAP|0300|COXSACKIE A TITER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.26||||||| 86658|EAP|0300|AB COXSACKIE B VIRUS STUD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.26||||||| 86658|EAP|0300|AB COXSACKIE B VIRUS STUD|Managed Medicare|BCBS MEDICARE PPO MA|3.26||||||| 86658|EAP|0300|COXSACKIE A TITER|Managed Medicare|BCBS MEDICARE PPO MA|3.26||||||| 86658|EAP|0300|AB COXSACKIE B VIRUS STUD|Medicaid|MEDICAID|3.26||||||| 86658|EAP|0300|COXSACKIE A TITER|Medicaid|MEDICAID|3.26||||||| 86658|EAP|0300|AB COXSACKIE B VIRUS STUD|PHCS|HUMANA|3.26||||||| 86658|EAP|0300|COXSACKIE A TITER|PHCS|HUMANA|3.26||||||| 86658|EAP|0300|COXSACKIE A TITER|Medicare|MEDICARE ACUTE|3.26||||||| 86658|EAP|0300|AB COXSACKIE B VIRUS STUD|NON CONTRACTED|COMMERCIAL OTHER 1|3.26||||||| 86658|EAP|0300|AB COXSACKIE B VIRUS STUD|Medicare|MEDICARE ACUTE|3.26||||||| 86658|EAP|0300|COXSACKIE A TITER|NON CONTRACTED|COMMERCIAL OTHER 1|3.26||||||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|UTMB|UTMB CORRECTIONAL MANAGED CARE|609.50||||||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Medicare|UTSW MC KIDNEY PROGRAM|||||609.50||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|United Healthcare|UNITED HEALTHCARE|609.50||||609.50||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Medicare|MEDICARE ACUTE|609.50||||609.50||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|PHCS|HUMANA|||||609.50||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Medicaid|MEDICAID|609.50||||||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Managed Medicare|HEALTHSPRING MA|609.50||||||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||609.50||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|609.50||||609.50||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Blue Cross HMO Specialty|BCBSTX HMO|609.50||||609.50||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Blue Cross PPO Specialty|BCBSTX PPO|609.50||||609.50||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Aenta Medicare Advantage|AETNA MEDICARE MA|609.50||||609.50||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|609.50||||||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Managed Medicaid|MEDICAID SUPERIOR|609.50||||||| 86664|EAP|0300|AB EPSTEIN-BARR VIRUS EBN|Humana Medicare Advantage|HUMANA MA|609.50||||609.50||| 86665|EAP|0300|AB EPSTEIN-BARR VIRUS VCA|Managed Medicaid|MEDICAID AMERIGROUP|||||722.75||| 86665|EAP|0300|AB EPSTEIN-BARR VCA IGM|Managed Medicaid|MEDICAID AMERIGROUP|||||722.75||| 86665|EAP|0300|AG EPSTEIN-BARR VIRUS EAR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|522.25||||||| 86665|EAP|0300|AB EPSTEIN-BARR VIRUS VCA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|722.75||||||| 86665|EAP|0300|AB EPSTEIN-BARR VCA IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|722.75||||||| 86666|EAP|0300|EHRLICHIA ANTIBODY PANEL|Medicare|MEDICARE ACUTE|2,194.50||||||| 86666|EAP|0300|EHRLICHIA ANTIBODY PANEL|United Healthcare|UNITED HEALTHCARE OTHER|2,194.50||||||| 86666|EAP|0300|EHRLICHIA ANTIBODY PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,194.50||||||| 86666|EAP|0300|EHRLICHIA ANTIBODY PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,194.50||||||| 86666|EAP|0300|EHRLICHIA ANTIBODY PANEL|Humana Medicare Advantage|HUMANA MA|2,194.50||||||| 86671|EAP|0300|AB FUNGUS NOS 86671|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.14||||3.14||| 86671|EAP|0300|AB FUNGUS NOS 86671|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.14||||||| 86671|EAP|0300|AB FUNGUS NOS 86671|Humana Medicare Advantage|HUMANA MA|||||3.14||| 86671|EAP|0300|AB FUNGUS NOS 86671|Blue Cross PPO Specialty|BCBSTX PPO|3.14||||||| 86671|EAP|0300|AB FUNGUS NOS 86671|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.14||| 86671|EAP|0300|AB FUNGUS NOS 86671|Managed Medicare|HEALTHSPRING MA|3.14||||||| 86671|EAP|0300|AB FUNGUS NOS 86671|United Healthcare|UNITED HEALTHCARE|3.14||||||| 86671|EAP|0300|AB FUNGUS NOS 86671|Medicare|MEDICARE ACUTE|3.14||||||| 86682|EAP|0300|FILARIA IGG4 LEVEL|Medicare|MEDICARE ACUTE|1.05||||3.14||| 86682|EAP|0300|STRONGYLOIDES IGG|Medicare|UTSW MC KIDNEY PROGRAM|||||3.26||| 86682|EAP|0300|STRONGYLOIDES IGG|Medicare|MEDICARE ACUTE|1.05||||3.26||| 86682|EAP|0300|STRONGYLOIDES IGG|NON CONTRACTED|COMMERCIAL OTHER 1|3.26||||||| 86682|EAP|0300|AB CYSTICERCUS IGG|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.61||||||| 86682|EAP|0300|CYSTICERCOSIS IGG CSF|United Healthcare|UNITED HEALTHCARE OTHER|3.26||||||| 86682|EAP|0300|STRONGYLOIDES IGG|Medicaid|MEDICAID|3.26||||||| 86682|EAP|0300|STRONGYLOIDES IGG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.26||||||| 86682|EAP|0300|CYSTICERCOSIS IGG CSF|United Medicare Advantage|UHC MEDICARE GOLD MA|3.26||||||| 86682|EAP|0300|AB CYSTICERCUS IGG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.14||||1.61||| 86682|EAP|0300|CYSTICERCOSIS IGG CSF|Blue Cross PPO Specialty|BCBSTX PPO|||||3.26||| 86682|EAP|0300|FILARIA IGG4 LEVEL|Blue Cross PPO Specialty|BCBSTX OTHER|3.14||||||| 86682|EAP|0300|FILARIA IGG4 LEVEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.14||| 86694|EAP|0300|AB HERPES SIMPLEX NON SPE|Managed Medicaid|MEDICAID SUPERIOR|573.50||||573.50||| 86694|EAP|0300|AB HERPES SIMPLEX NON SPE|Blue Cross PPO Specialty|BCBSTX PPO|573.50||||||| 86694|EAP|0300|AB HERPES SIMPLEX NON SPE|Managed Medicare|BCBS MEDICARE PPO MA|573.50||||||| 86694|EAP|0300|AB HERPES SIMPLEX NON SPE|United Healthcare|UNITED HEALTHCARE|573.50||||||| 86694|EAP|0300|AB HERPES SIMPLEX NON SPE|UTMB|UTMB CORRECTIONAL MANAGED CARE|573.50||||||| 86694|EAP|0300|AB HERPES SIMPLEX NON SPE|Medicare|MEDICARE ACUTE|573.50||||||| 86695|EAP|0300|HERPES I-II AB (IGG)|Medicare|UTSW MC KIDNEY PROGRAM|||||525.50||| 86695|EAP|0300|HERPES I-II AB (IGG)|Medicare|MEDICARE ACUTE|525.50||||525.50||| 86695|EAP|0300|HERPES I-II AB (IGG)|UTMB|UTMB CORRECTIONAL MANAGED CARE|525.50||||||| 86695|EAP|0300|HERPES I-II AB (IGG)|PHCS|HUMANA|||||525.50||| 86695|EAP|0300|HERPES I-II AB (IGG)|United Healthcare|UNITED HEALTHCARE|525.50||||525.50||| 86695|EAP|0300|HERPES I-II AB (IGG)|Medicaid|MEDICAID|525.50||||||| 86695|EAP|0300|HERPES I-II AB (IGG)|Managed Medicare|BCBS MEDICARE PPO MA|525.50||||||| 86695|EAP|0300|HERPES I-II AB (IGG)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||525.50||| 86695|EAP|0300|HERPES I-II AB (IGG)|Aenta Medicare Advantage|AETNA MEDICARE MA|||||525.50||| 86695|EAP|0300|HERPES I-II AB (IGG)|Blue Cross HMO Specialty|BCBSTX HMO|||||525.50||| 86695|EAP|0300|HERPES I-II AB (IGG)|Blue Cross PPO Specialty|BCBSTX PPO|525.50||||525.50||| 86695|EAP|0300|HERPES I-II AB (IGG)|Humana Medicare Advantage|HUMANA MA|525.50||||525.50||| 86695|EAP|0300|HERPES I-II AB (IGG)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|525.50||||||| 86695|EAP|0300|HERPES I-II AB (IGG)|Managed Medicaid|MEDICAID SUPERIOR|525.50||||525.50||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|56.29||||||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Managed Medicaid|MEDICAID SUPERIOR|56.29||||56.29||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Humana Medicare Advantage|HUMANA MA|56.29||||56.29||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Blue Cross PPO Specialty|BCBSTX PPO|56.29||||56.29||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Blue Cross HMO Specialty|BCBSTX HMO|||||56.29||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Aenta Medicare Advantage|AETNA MEDICARE MA|||||56.29||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||56.29||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Managed Medicare|BCBS MEDICARE PPO MA|56.29||||||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Medicaid|MEDICAID|56.29||||||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|United Healthcare|UNITED HEALTHCARE|56.29||||56.29||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|UTMB|UTMB CORRECTIONAL MANAGED CARE|56.29||||||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Medicare|MEDICARE ACUTE|56.29||||56.29||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|Medicare|UTSW MC KIDNEY PROGRAM|||||56.29||| 86696|EAP|0300|AB HERPES SIMPLEX TYPE 2|PHCS|HUMANA|||||56.29||| 86698|EAP|0300|AB HISTOPLASMA|NON CONTRACTED|COMMERCIAL OTHER 1|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|Medicare|MEDICARE ACUTE|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|Managed Medicare|HEALTHSPRING MA|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|United Medicare Advantage|UHC MEDICARE GOLD MA|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|United Medicare Advantage|UHC AARP MCR HMO MA|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|Aenta Medicare Advantage|AETNA MEDICARE MA|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|Blue Cross PPO Specialty|BCBSTX PPO|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|Humana Medicare Advantage|HUMANA MA|3.26||||||| 86698|EAP|0300|AB HISTOPLASMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.26||||||| 867|DRG||OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|83,984.54|14482.39|14482.39|13525.29|||| 867|DRG||OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|105,542.92|13525.29|14482.39|13525.29|||| 86703|EAP|0300|HIV-1 A (RAPID)|United Healthcare|UNITED HEALTHCARE OTHER|1.92||||||| 86703|EAP|0300|HIV-1 A (RAPID)|United Healthcare|UNITED HEALTHCARE|1.92||||||| 86703|EAP|0300|HIV-1 A (RAPID)|United Healthcare|UNITED HEALTHCARE|||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|NON CONTRACTED|COMMERCIAL OTHER 1|1.92||||||| 86703|EAP|0300|HIV-1 A (RAPID)|Medicaid|MEDICAID HMO|1.92||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|Medicaid|MEDICAID|1.92||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|Medicare|MEDICARE ACUTE|||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.92||||||| 86703|EAP|0300|HIV-1 A (RAPID)|Access Direct Platinum|HEALTHFIRST TPA UMR|1.92||||||| 86703|EAP|0300|HIV-1 A (RAPID)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.92||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.92||||||| 86703|EAP|0300|HIV-1 A (RAPID)|Managed Medicaid|MEDICAID AMERIGROUP|1.92||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|Managed Medicaid|MEDICAID SUPERIOR|1.92||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|Cigna|CIGNA|||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.92||||||| 86703|EAP|0300|HIV-1 A (RAPID)|Aetna Value Network|AETNA VALUE NETWORK|1.92||||||| 86703|EAP|0300|HIV-1 A (RAPID)|Blue Cross PPO Specialty|BCBSTX PPO|1.92||||1.92||| 86703|EAP|0300|HIV-1 A (RAPID)|Blue Cross HMO Specialty|BCBSTX HMO|||||1.92||| 86704|EAP|0300|AB HEPATITIS B CORE|Blue Cross HMO Specialty|BCBSTX HMO|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Blue Cross PPO Specialty|BCBSTX PPO|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Humana Medicare Advantage|HUMANA MA|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Managed Medicaid|MEDICAID SUPERIOR|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|United Medicare Advantage|UHC AARP MCR HMO MA|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Access Direct Platinum|HEALTHFIRST TPA|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Veterans Affairs|VETERANS ADMINISTRATION|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Workers Compensation|WORKERS COMPENSATION OTHER|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Managed Medicare|HEALTHSPRING MA|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Managed Medicare|WELLCARE CHOICE MA|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Managed Medicare|BCBS MEDICARE PPO MA|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Medicaid|MEDICAID|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|PHCS|HUMANA|||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Rusk State Hospital|RUSK STATE HOSP|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|Medicare|UTSW MC KIDNEY PROGRAM|||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|Medicare|MEDICARE ACUTE|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|United Healthcare|UNITED HEALTHCARE|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|United Healthcare|UNITED HEALTHCARE OTHER|2.61||||2.61||| 86704|EAP|0300|AB HEPATITIS B CORE|United Healthcare|UNITED HEALTHCARE|2.61||||||| 86704|EAP|0300|AB HEPATITIS B CORE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.61||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|United Healthcare|UNITED HEALTHCARE|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|United Healthcare|UNITED HEALTHCARE OTHER|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|United Healthcare|UNITED HEALTHCARE|468.75||||468.75||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Medicare|MEDICARE ACUTE|468.75||||468.75||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Medicaid|MEDICAID|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|UTMB|UTMB CORRECTIONAL MANAGED CARE|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Managed Medicare|HEALTHSPRING MA|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Managed Medicare|WELLCARE CHOICE MA|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|United Medicare Advantage|UHC AARP MCR HMO MA|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|468.75||||468.75||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|United Medicare Advantage|UHC MEDICARE GOLD MA|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||468.75||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Humana Medicare Advantage|HUMANA MA|468.75||||468.75||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|468.75||||||| 86705|EAP|0300|AB HEPATITIS B CORE IGM|Blue Cross PPO Specialty|BCBSTX PPO|468.75||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Blue Cross HMO Specialty|BCBSTX HMO|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Blue Cross PPO Specialty|BCBSTX PPO|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Aetna|AETNA PPO|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Humana Medicare Advantage|HUMANA MA|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Managed Medicaid|MEDICAID SUPERIOR|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Workers Compensation|WORKERS COMPENSATION OTHER|||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Veterans Affairs|VETERANS ADMINISTRATION|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Access Direct Platinum|HEALTHFIRST TPA UMR|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Access Direct Platinum|HEALTHFIRST TPA|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|United Medicare Advantage|UHC MEDICARE GOLD MA|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|United Medicare Advantage|UHC AARP MCR HMO MA|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Managed Medicare|WELLCARE CHOICE MA|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Cigna|CIGNA|||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Managed Medicare|HEALTHSPRING MA|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Managed Medicare|BCBS MEDICARE PPO MA|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Medicaid|MEDICAID HMO|||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Medicaid|MEDICAID|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|PHCS|HUMANA|||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Rusk State Hospital|RUSK STATE HOSP|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|NON CONTRACTED|COMMERCIAL OTHER 1|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Medicare|MEDICARE ACUTE|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Medicare|MEDICARE PART B ONLY IP|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|Medicare|UTSW MC KIDNEY PROGRAM|||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|United Healthcare|UNITED HEALTHCARE OTHER|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|United Healthcare|UNITED HEALTHCARE|4.28||||4.28||| 86706|EAP|0300|AB HEPATITIS B SURFACE|United Healthcare|UNITED HEALTHCARE|4.28||||||| 86706|EAP|0300|AB HEPATITIS B SURFACE|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.28||||||| 86707|EAP|0300|AB HEPATITIS BE|Medicare|MEDICARE ACUTE|2.50||||||| 86707|EAP|0300|AB HEPATITIS BE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 86707|EAP|0300|AB HEPATITIS BE|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||||| 86707|EAP|0300|AB HEPATITIS BE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 86707|EAP|0300|AB HEPATITIS BE|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 86708|EAP|0300|AB HEPATITIS A|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.68||||||| 86708|EAP|0300|AB HEPATITIS A|Humana Medicare Advantage|HUMANA MA|2.68||||2.68||| 86708|EAP|0300|AB HEPATITIS A|Blue Cross HMO Specialty|BCBSTX HMO|||||2.68||| 86708|EAP|0300|AB HEPATITIS A|Blue Cross PPO Specialty|BCBSTX PPO|2.68||||2.68||| 86708|EAP|0300|AB HEPATITIS A|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.68||| 86708|EAP|0300|AB HEPATITIS A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.68||||||| 86708|EAP|0300|AB HEPATITIS A|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.68||| 86708|EAP|0300|AB HEPATITIS A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.68||| 86708|EAP|0300|AB HEPATITIS A|United Medicare Advantage|UHC AARP MCR HMO MA|2.68||||||| 86708|EAP|0300|AB HEPATITIS A|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.68||| 86708|EAP|0300|AB HEPATITIS A|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.68||| 86708|EAP|0300|AB HEPATITIS A|Managed Medicare|WELLCARE CHOICE MA|2.68||||||| 86708|EAP|0300|AB HEPATITIS A|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.68||||||| 86708|EAP|0300|AB HEPATITIS A|United Healthcare|UNITED HEALTHCARE|||||2.68||| 86708|EAP|0300|AB HEPATITIS A|PHCS|HUMANA|||||2.68||| 86708|EAP|0300|AB HEPATITIS A|Medicare|UTSW MC KIDNEY PROGRAM|||||2.68||| 86708|EAP|0300|AB HEPATITIS A|Medicare|MEDICARE ACUTE|2.68||||2.68||| 86709|EAP|0300|AB HEPATITIS A IGM|Medicare|MEDICARE ACUTE|2.44||||2.44||| 86709|EAP|0300|AB HEPATITIS A IGM|Medicare|UTSW MC KIDNEY PROGRAM|||||2.44||| 86709|EAP|0300|AB HEPATITIS A IGM|United Healthcare|UNITED HEALTHCARE|||||2.44||| 86709|EAP|0300|AB HEPATITIS A IGM|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.44||||||| 86709|EAP|0300|AB HEPATITIS A IGM|Managed Medicare|WELLCARE CHOICE MA|2.44||||||| 86709|EAP|0300|AB HEPATITIS A IGM|United Medicare Advantage|UHC AARP MCR HMO MA|2.44||||||| 86709|EAP|0300|AB HEPATITIS A IGM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.44||| 86709|EAP|0300|AB HEPATITIS A IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.44||||||| 86709|EAP|0300|AB HEPATITIS A IGM|Blue Cross PPO Specialty|BCBSTX PPO|2.44||||||| 86709|EAP|0300|AB HEPATITIS A IGM|Humana Medicare Advantage|HUMANA MA|2.44||||2.44||| 86709|EAP|0300|AB HEPATITIS A IGM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.44||||2.44||| 86709|EAP|0300|AB HEPATITIS A IGM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.44||||||| 86710|EAP|0300|AB INFLUENZA A|Medicare|MEDICARE ACUTE|2.67||||||| 86720|EAP|0300|AB LEPTOSPIRA|Medicare|MEDICARE ACUTE|1.32||||||| 86735|EAP|0300|AB MUMPS IGG|Humana Medicare Advantage|HUMANA MA|||||2.57||| 86735|EAP|0300|AB MUMPS IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||2.57||| 86735|EAP|0300|AB MUMPS IGG|Blue Cross PPO Specialty|BCBSTX PPO|2.57||||2.57||| 86735|EAP|0300|AB MUMPS IGG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.57||| 86735|EAP|0300|AB MUMPS IGG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.57||| 86735|EAP|0300|AB MUMPS IGG|United Healthcare|UNITED HEALTHCARE|||||2.57||| 86735|EAP|0300|AB MUMPS IGG|PHCS|HUMANA|||||2.57||| 86735|EAP|0300|AB MUMPS IGG|Medicare|MEDICARE ACUTE|||||2.57||| 86735|EAP|0300|AB MUMPS IGG|Medicare|UTSW MC KIDNEY PROGRAM|||||2.57||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Medicaid|MEDICAID|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Managed Medicare|BCBS MEDICARE PPO MA|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Medicare|MEDICARE ACUTE|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|NON CONTRACTED|COMMERCIAL OTHER 1|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Tricare|TRICARE EAST REGION|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|United Healthcare|UNITED HEALTHCARE OTHER|2.60||||2.60||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Veterans Affairs|VETERANS ADMINISTRATION|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Managed Medicare|HEALTHSPRING MA|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|United Medicare Advantage|UHC AARP MCR HMO MA|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|United Medicare Advantage|UHC MEDICARE GOLD MA|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Aenta Medicare Advantage|AETNA MEDICARE MA|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Aetna|AETNA PPO|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Blue Cross PPO Specialty|BCBSTX PPO|2.60||||2.60||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Blue Cross HMO Specialty|BCBSTX HMO|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Managed Medicaid|MEDICAID AMERIGROUP|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Cigna|CIGNA OTHER|2.60||||||| 86738|EAP|0300|AB MYCOPLASMA PNEUMONIA I|Humana Medicare Advantage|HUMANA MA|2.60||||||| 86753|EAP|0300|TRYPANOSOMA CRUZI IGG|United Medicare Advantage|UHC MEDICARE GOLD MA|0.44||||||| 86753|EAP|0300|AB AMOEBIC|United Healthcare|UNITED HEALTHCARE OTHER|326.25||||||| 86753|EAP|0300|TRYPANOSOMA CRUZI IGG|Medicare|UTSW MC KIDNEY PROGRAM|||||0.44||| 86753|EAP|0300|TRYPANOSOMA CRUZI IGG|Medicare|MEDICARE ACUTE|326.25||||0.44||| 86753|EAP|0300|AB AMOEBIC|Medicaid|MEDICAID|326.25||||||| 86757|EAP|0300|AB RICKETTSIA PANEL|Medicaid|MEDICAID|771.25||||||| 86757|EAP|0300|AB RICKETTSIA PANEL|Medicare|MEDICARE ACUTE|771.25||||||| 86757|EAP|0300|AB RICKETTSIA PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|771.25||||||| 86757|EAP|0300|AB RICKETTSIA PANEL|Humana Medicare Advantage|HUMANA MA|771.25||||||| 86757|EAP|0300|AB RICKETTSIA PANEL|Blue Cross PPO Specialty|BCBSTX PPO|771.25||||||| 86757|EAP|0300|AB RICKETTSIA PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|771.25||||||| 86757|EAP|0300|AB RICKETTSIA PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|771.25||||||| 86762|EAP|0300|AB RUBELLA IGG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.83||||||| 86762|EAP|0300|AB RUBELLA IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|Blue Cross PPO Specialty|BCBSTX PPO|2.83||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|Managed Medicaid|MEDICAID AMERIGROUP|2.83||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|Managed Medicaid|MEDICAID SUPERIOR|2.83||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|Humana Medicare Advantage|HUMANA MA|||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|United Healthcare|UNITED HEALTHCARE OTHER|2.83||||||| 86762|EAP|0300|AB RUBELLA IGG|United Healthcare|UNITED HEALTHCARE|2.83||||||| 86762|EAP|0300|AB RUBELLA IGG|United Healthcare|UNITED HEALTHCARE|||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|United Healthcare|TML GROUP BENEFITS|2.83||||||| 86762|EAP|0300|AB RUBELLA IGG|PHCS|HUMANA|||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|NON CONTRACTED|COMMERCIAL OTHER 1|2.83||||||| 86762|EAP|0300|AB RUBELLA IGG|Medicare|UTSW MC KIDNEY PROGRAM|||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|Medicare|MEDICARE ACUTE|||||2.83||| 86762|EAP|0300|AB RUBELLA IGG|Medicaid|MEDICAID|2.83||||||| 86762|EAP|0300|AB RUBELLA IGG|Medicaid|MEDICAID HMO|2.83||||||| 86765|EAP|0300|AB RUBEOLA|Medicare|MEDICARE ACUTE|||||513.25||| 86765|EAP|0300|AB RUBEOLA|Medicare|UTSW MC KIDNEY PROGRAM|||||513.25||| 86765|EAP|0300|AB RUBEOLA|PHCS|HUMANA|||||513.25||| 86765|EAP|0300|AB RUBEOLA|United Healthcare|UNITED HEALTHCARE|||||513.25||| 86765|EAP|0300|AB RUBEOLA|Humana Medicare Advantage|HUMANA MA|||||513.25||| 86765|EAP|0300|AB RUBEOLA|Blue Cross PPO Specialty|BCBSTX PPO|513.25||||513.25||| 86765|EAP|0300|AB RUBEOLA|Blue Cross HMO Specialty|BCBSTX HMO|||||513.25||| 86765|EAP|0300|AB RUBEOLA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||513.25||| 86765|EAP|0300|AB RUBEOLA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||513.25||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|84.26||||||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|United Medicare Advantage|UHC AARP MCR HMO MA|84.26||||||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|84.26||||||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Blue Cross PPO Specialty|BCBSTX PPO|84.26||||||| 86777|EAP|0300|AB TOXOPLASMOSIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.54||||||| 86777|EAP|0300|AB TOXOPLASMOSIS|United Healthcare|UNITED HEALTHCARE OTHER|0.54||||||| 86777|EAP|0300|AB TOXOPLASMOSIS|PHCS|HUMANA|||||0.54||| 86777|EAP|0300|AB TOXOPLASMOSIS|Medicare|UTSW MC KIDNEY PROGRAM|||||0.54||| 86777|EAP|0300|AB TOXOPLASMOSIS|Medicare|MEDICARE ACUTE|0.54||||0.54||| 86777|EAP|0300|AB TOXOPLASMOSIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.54||||||| 86777|EAP|0300|AB TOXOPLASMOSIS|Humana Medicare Advantage|HUMANA MA|0.54||||0.54||| 86777|EAP|0300|AB TOXOPLASMOSIS|Blue Cross HMO Specialty|BCBSTX HMO|||||0.54||| 86777|EAP|0300|AB TOXOPLASMOSIS|Blue Cross PPO Specialty|BCBSTX PPO|0.54||||0.54||| 86777|EAP|0300|AB TOXOPLASMOSIS|Blue Cross PPO Specialty|BCBSTX OTHER|0.54||||||| 86777|EAP|0300|AB TOXOPLASMOSIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.54||||||| 86777|EAP|0300|AB TOXOPLASMOSIS|United Medicare Advantage|UHC MEDICARE GOLD MA|0.54||||||| 86777|EAP|0300|AB TOXOPLASMOSIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.54||| 86777|EAP|0300|AB TOXOPLASMOSIS|United Medicare Advantage|UHC AARP MCR HMO MA|0.54||||||| 86777|EAP|0300|AB TOXOPLASMOSIS|Veterans Affairs|VETERANS ADMINISTRATION|0.54||||||| 86778|EAP|0300|AB TOXOPLASMA IGM|Veterans Affairs|VETERANS ADMINISTRATION|2.51||||||| 86778|EAP|0300|AB TOXOPLASMA IGM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.51||| 86778|EAP|0300|AB TOXOPLASMA IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.51||||||| 86778|EAP|0300|AB TOXOPLASMA IGM|Blue Cross PPO Specialty|BCBSTX PPO|2.51||||||| 86778|EAP|0300|AB TOXOPLASMA IGM|Blue Cross PPO Specialty|BCBSTX OTHER|2.51||||||| 86778|EAP|0300|AB TOXOPLASMA IGM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.51||||||| 86778|EAP|0300|AB TOXOPLASMA IGM|Medicare|UTSW MC KIDNEY PROGRAM|||||2.51||| 86778|EAP|0300|AB TOXOPLASMA IGM|Medicare|MEDICARE ACUTE|2.51||||||| 86778|EAP|0300|AB TOXOPLASMA IGM|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.51||||||| 86780|EAP|0300|AB FTA-ABS TREPONEMAL|Medicare|MEDICARE ACUTE|348.75||||||| 86780|EAP|0300|AB FTA-ABS TREPONEMAL|Humana Medicare Advantage|HUMANA MA|||||348.75||| 86780|EAP|0300|AB FTA-ABS TREPONEMAL|Aenta Medicare Advantage|AETNA MEDICARE MA|348.75||||||| 86780|EAP|0300|AB FTA-ABS TREPONEMAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|348.75||||||| 86787|EAP|0300|AB VARICELLA ZOSTER IGG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.26||| 86787|EAP|0300|AB VARICELLA ZOSTER IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||3.26||| 86787|EAP|0300|AB VARICELLA ZOSTER IGG|Blue Cross PPO Specialty|BCBSTX PPO|3.26||||3.26||| 86787|EAP|0300|AB VARICELLA ZOSTER IGG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3.26||| 86787|EAP|0300|AB VARICELLA ZOSTER IGG|Humana Medicare Advantage|HUMANA MA|3.26||||3.26||| 86787|EAP|0300|AB VARICELLA ZOSTER IGG|United Healthcare|UNITED HEALTHCARE|||||3.26||| 86787|EAP|0300|AB VARICELLA ZOSTER IGG|PHCS|HUMANA|||||3.26||| 86787|EAP|0300|AB VARICELLA ZOSTER IGM|Medicare|UTSW MC KIDNEY PROGRAM|||||137.83||| 86787|EAP|0300|AB VARICELLA ZOSTER IGG|Medicare|UTSW MC KIDNEY PROGRAM|||||3.26||| 86787|EAP|0300|AB VARICELLA ZOSTER IGG|Medicare|MEDICARE ACUTE|3.26||||3.26||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|Managed Medicare|HEALTHSPRING MA|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|Medicare|MEDICARE ACUTE|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|PHCS|HUMANA|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|United Healthcare|UNITED HEALTHCARE|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|Cigna|CIGNA|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|Humana Medicare Advantage|HUMANA MA|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|Aenta Medicare Advantage|AETNA MEDICARE MA|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|Blue Cross PPO Specialty|BCBSTX PPO|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|Blue Cross HMO Specialty|BCBSTX HMO|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|Veterans Affairs|VETERANS ADMINISTRATION|3.14||||||| 86788|EAP|0300|AB WEST NILE VIRUS IGM|United Medicare Advantage|UHC MEDICARE GOLD MA|3.14||||||| 86789|EAP|0300|AB WEST NILE VIRUS|United Medicare Advantage|UHC MEDICARE GOLD MA|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|Veterans Affairs|VETERANS ADMINISTRATION|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|Blue Cross HMO Specialty|BCBSTX HMO|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|Blue Cross PPO Specialty|BCBSTX PPO|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|Aenta Medicare Advantage|AETNA MEDICARE MA|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|Humana Medicare Advantage|HUMANA MA|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|Cigna|CIGNA|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|United Healthcare|UNITED HEALTHCARE|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|PHCS|HUMANA|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|Medicare|MEDICARE ACUTE|5.53||||||| 86789|EAP|0300|AB WEST NILE VIRUS|Managed Medicare|HEALTHSPRING MA|5.53||||||| 86790|EAP|0300|HTLV I/II W REFLEX TO WB|Medicaid|MEDICAID|3.26||||||| 86790|EAP|0300|AB DENGUE FEVER|Blue Cross PPO Specialty|BCBSTX PPO|||||480.50||| 86800|EAP|0300|AB THYROGLOBULIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|United Medicare Advantage|UHC MEDICARE GOLD MA|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Humana Medicare Advantage|HUMANA MA|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Aenta Medicare Advantage|AETNA MEDICARE MA|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Aetna|BH AETNA|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Blue Cross HMO Specialty|BCBSTX HMO|||||6.11||| 86800|EAP|0300|AB THYROGLOBULIN|Blue Cross PPO Specialty|BCBSTX PPO|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Medicare|MEDICARE ACUTE|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|NON CONTRACTED|COMMUNITY HEALTH CENTER|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Optum Behavioral Health|BH OPTUM UHC|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Managed Medicare|HEALTHSPRING MA|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Medicaid|MEDICAID|6.11||||||| 86800|EAP|0300|AB THYROGLOBULIN|Medicaid|SMITH COUNTY JAIL|6.11||||||| 86803|EAP|0300|AB HEPATITIS C|Medicaid|MEDICAID HMO|||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Medicaid|MEDICAID|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Managed Medicare|WELLCARE CHOICE MA|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Managed Medicare|HEALTHSPRING MA|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Managed Medicare|BCBS MEDICARE PPO MA|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|United Healthcare|UNITED HEALTHCARE OTHER|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|United Healthcare|UNITED HEALTHCARE|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|NON CONTRACTED|COMMERCIAL OTHER 1|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Blue Cross PPO Specialty|BCBSTX PPO|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Medicare|MEDICARE ACUTE|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Blue Cross HMO Specialty|BCBSTX HMO|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Aenta Medicare Advantage|AETNA MEDICARE MA|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Cigna|CIGNA|||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Humana Medicare Advantage|HUMANA MA|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Managed Medicaid|MEDICAID SUPERIOR|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Managed Medicaid|MEDICAID AMERIGROUP|||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|United Medicare Advantage|UHC AARP MCR HMO MA|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|United Medicare Advantage|UHC MEDICARE GOLD MA|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Veterans Affairs|VETERANS ADMINISTRATION|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.09||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.09||| 86803|EAP|0300|AB HEPATITIS C|Access Direct Platinum|HEALTHFIRST TPA UMR|3.09||||||| 86803|EAP|0300|AB HEPATITIS C|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.09||||3.09||| 86812|EAP|0300|HUMAN LEUKOCYTE ANTG B27|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,028.25||||||| 86812|EAP|0300|HUMAN LEUKOCYTE ANTG B27|Blue Cross PPO Specialty|BCBSTX PPO|1,028.25||||||| 86812|EAP|0300|HUMAN LEUKOCYTE ANTG B27|Medicare|MEDICARE ACUTE|1,028.25||||||| 86812|EAP|0300|HUMAN LEUKOCYTE ANTG B27|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,028.25||||||| 86849|EAP|0300|CA 19-9 BODY FLUID|Medicare|MEDICARE ACUTE|||||2.14||| 86860|EAP|0300|RBC ELUATE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|883.20||||||| 86860|EAP|0300|RBC ELUATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|883.20||||||| 86860|EAP|0300|RBC ELUATE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.36||||||| 86860|EAP|0300|RBC ELUATE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|883.20||||||| 86860|EAP|0300|RBC ELUATE|Managed Medicaid|MEDICAID SUPERIOR|809.60||||||| 86860|EAP|0300|RBC ELUATE|Managed Medicaid|MEDICAID AMERIGROUP|883.20||||||| 86860|EAP|0300|RBC ELUATE|Blue Cross HMO Specialty|BCBSTX HMO|809.60||||||| 86860|EAP|0300|RBC ELUATE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.36||||||| 86860|EAP|0300|RBC ELUATE|Blue Cross PPO Specialty|BCBSTX PPO|7.36||||||| 86860|EAP|0300|RBC ELUATE|Aenta Medicare Advantage|AETNA MEDICARE MA|883.20||||||| 86860|EAP|0300|RBC ELUATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|883.20||||||| 86860|EAP|0300|RBC ELUATE|Managed Medicare|HEALTHSPRING MA|809.60||||||| 86860|EAP|0300|RBC ELUATE|Medicaid|MEDICAID|7.36||||||| 86860|EAP|0300|RBC ELUATE|United Healthcare|UNITED HEALTHCARE OTHER|883.20||||||| 86860|EAP|0300|RBC ELUATE|Medicare|MEDICARE ACUTE|7.36||||||| 86860|EAP|0300|RBC ELUATE|NON CONTRACTED|COMMERCIAL OTHER 1|7.36||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Medicare|MEDICARE ACUTE|883.20||||883.20||| 86870|EAP|0300|ANITBODY IDENTIFICATION|UTMB|UTMB CORRECTIONAL MANAGED CARE|883.20||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|United Healthcare|UNITED HEALTHCARE OTHER|||||7.36||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Medicaid|MEDICAID|||||883.20||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.36||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Managed Medicare|HEALTHSPRING MA|7.36||||883.20||| 86870|EAP|0300|ANITBODY IDENTIFICATION|United Healthcare|UNITED HEALTHCARE|883.20||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|883.20||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Aenta Medicare Advantage|AETNA MEDICARE MA|883.20||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Blue Cross PPO Specialty|BCBSTX PPO|7.36||||883.20||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.36||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Blue Cross HMO Specialty|BCBSTX HMO|883.20||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Humana Medicare Advantage|HUMANA MA|883.20||||883.20||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|883.20||||7.36||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Managed Medicaid|MEDICAID SUPERIOR|7.36||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|883.20||||883.20||| 86870|EAP|0300|ANITBODY IDENTIFICATION|United Medicare Advantage|UHC MEDICARE GOLD MA|883.20||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.36||||7.36||| 86870|EAP|0300|ANITBODY IDENTIFICATION|United Medicare Advantage|UHC AARP MCR HMO MA|7.36||||||| 86870|EAP|0300|ANITBODY IDENTIFICATION|Veterans Affairs|VETERANS ADMINISTRATION|7.36||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Access Direct Platinum|HEALTHFIRST TPA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Access Direct Platinum|HEALTHFIRST TPA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Access Direct Platinum|HEALTHFIRST TPA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Access Direct Platinum|HEALTHFIRST TPA UMR|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|United Medicare Advantage|UHC MEDICARE GOLD MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|United Medicare Advantage|UHC MEDICARE GOLD MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|United Medicare Advantage|UHC AARP MCR HMO MA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|United Medicare Advantage|UHC AARP MCR HMO MA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|United Medicare Advantage|UHC AARP MCR HMO MA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Managed Medicaid|MEDICAID SUPERIOR|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Managed Medicaid|MEDICAID SUPERIOR|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Managed Medicaid|MEDICAID AMERIGROUP|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Managed Medicaid|MEDICAID SUPERIOR|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Cigna|CIGNA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Cigna|CIGNA OTHER|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Humana Medicare Advantage|HUMANA MA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Humana Medicare Advantage|HUMANA MA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Blue Cross HMO Specialty|BCBSTX HMO|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|ChampVA|CHAMPVA CENTER|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|ChampVA|CHAMPVA CENTER|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|ChampVA|CHAMPVA CENTER|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Blue Cross PPO Specialty|BCBSTX PPO|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Blue Cross PPO Specialty|BCBSTX OTHER|2.29||||2.29||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Blue Cross PPO Specialty|BCBSTX PPO|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Blue Cross PPO Specialty|BCBSTX PPO|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Blue Cross PPO Specialty|BCBSTX OTHER|2.29||||2.29||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Aetna|AETNA OTHER|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Blue Cross PPO Specialty|BCBSTX OTHER|2.29||||2.29||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Aenta Medicare Advantage|AETNA MEDICARE MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Aenta Medicare Advantage|AETNA MEDICARE MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Aenta Medicare Advantage|AETNA MEDICARE MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Aetna|AETNA PPO|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Aetna Value Network|AETNA VALUE NETWORK|251.90||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Humana Medicare Advantage|HUMANA MA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Cigna|CIGNA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Managed Medicare|HEALTHSPRING MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Managed Medicare|HEALTHSPRING MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Managed Medicare|HEALTHSPRING MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Medicaid|MEDICAID HMO|251.90||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Medicaid|MEDICAID|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Medicaid|COUNTY INDIGENT HEALTH OTHER|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Medicaid|COUNTY INDIGENT HEALTH OTHER|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|United Medicare Advantage|UHC MEDICARE GOLD MA|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Medicaid|MEDICAID|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Medicaid|MOLINA HEALTHCARE OF TEXAS|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Medicaid|MEDICAID|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Medicaid|COUNTY INDIGENT HEALTH OTHER|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|United Healthcare|UNITED HEALTHCARE OTHER|274.80||||2.29||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|United Healthcare|UNITED HEALTHCARE OTHER|274.80||||2.29||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|United Healthcare|UNITED HEALTHCARE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|United Healthcare|TML GROUP BENEFITS|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|United Healthcare|UNITED HEALTHCARE OTHER|274.80||||2.29||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|UTMB|UTMB CORRECTIONAL MANAGED CARE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|UTMB|UTMB CORRECTIONAL MANAGED CARE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|UTMB|UTMB CORRECTIONAL MANAGED CARE|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Tricare|TRICARE EAST REGION|274.80||||274.80||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|PHCS|GROUP AND PENSION|251.90||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Tricare|TRICARE EAST REGION|274.80||||274.80||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|PHCS|HUMANA INSURANCE|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Tricare|TRICARE EAST REGION|274.80||||274.80||| 86880|EAP|0300|ANTIHUMAN GLOB TEST C3|Medicare|MEDICARE ACUTE|251.90||||274.80||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|NON CONTRACTED|COMMERCIAL OTHER 1|2.29||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Multiplan|WEB TPA|274.80||||||| 86880|EAP|0300|ANTIHUMAN GLOB TEST POLYS|Medicare|MEDICARE ACUTE|251.90||||274.80||| 86880|EAP|0300|ANTIHUMAN GLOB TEST IGG|Medicare|MEDICARE ACUTE|251.90||||274.80||| 86885|EAP|0300|COOMBS INDIRECT|Medicare|MEDICARE ACUTE|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Multiplan|NALC|2.44||||||| 86885|EAP|0300|COOMBS INDIRECT|Multiplan|WEB TPA|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|NON CONTRACTED|COMMERCIAL OTHER 4|||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|NON CONTRACTED|COMMERCIAL OTHER 1|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|PHCS|HUMANA|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Tricare|TRICARE EAST REGION|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Rusk State Hospital|RUSK STATE HOSP|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|PHCS|GROUP AND PENSION|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|Tricare|TRICARE FOR LIFE|||||268.40||| 86885|EAP|0300|COOMBS INDIRECT|UTMB|UTMB CORRECTIONAL MANAGED CARE|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|United Healthcare|UNITED HEALTHCARE|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|United Healthcare|TML GROUP BENEFITS|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.44||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|SUPERIOR HEALTHPLAN CHIP|268.40||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|MEDICAID|2.44||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|LAW ENFORCEMENT OTHER|2.44||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|MEDICAID HMO|2.44||||||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|MEDICAID BCBSTX|||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|CRIME VICTIMS COMPENSATION|2.44||||||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.44||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|COUNTY INDIGENT HEALTH OTHER|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicare|HEALTHSPRING MA|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicare|BCBS MEDICARE PPO MA|2.44||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicare|OTHER INSTITUTIONS|||||268.40||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicare|ETMC REHABILITATION HOSPITAL|2.44||||268.40||| 86885|EAP|0300|COOMBS INDIRECT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Aetna|AETNA QHP HMO|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|Aenta Medicare Advantage|AETNA MEDICARE MA|2.44||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Aetna|AETNA PPO|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.44||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Aetna|BH AETNA|2.44||||||| 86885|EAP|0300|COOMBS INDIRECT|Aetna|BOON CHAPMAN|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|Aetna|AETNA OTHER|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Blue Cross PPO Specialty|BCBSTX PPO|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Brinson Benefits|THE HEALTH PLAN SMITH CO|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|Blue Cross PPO Specialty|BCBSTX OTHER|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|ChampVA|CHAMPVA CENTER|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.44||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Medicaid|SMITH COUNTY JAIL|2.44||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Blue Cross HMO Specialty|BCBSTX HMO|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Humana Medicare Advantage|HUMANA MA|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Cigna|CIGNA OTHER|268.40||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Cigna|CIGNA|292.80||||268.40||| 86885|EAP|0300|COOMBS INDIRECT|United Healthcare|UNITED HEALTHCARE OTHER|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Cigna|CIGNA|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicaid|MEDICAID SUPERIOR|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Managed Medicaid|MEDICAID AMERIGROUP|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|United Medicare Advantage|UHC AARP WELLMED HMO MA|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|United Medicare Advantage|UHC AARP MCR HMO MA|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|United Medicare Advantage|UHC MEDICARE GOLD MA|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Workers Compensation|WORKERS COMPENSATION OTHER|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Workers Compensation|ZURICH COMPANY|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|Workers Compensation|TRAVELERS INSURANCE COMPANY|2.44||||||| 86885|EAP|0300|COOMBS INDIRECT|NON CONTRACTED|COMMERCIAL OTHER 2|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Medicare|MEDICARE PART B ONLY IP|292.80||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|2.44||||||| 86885|EAP|0300|COOMBS INDIRECT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|292.80||||||| 86885|EAP|0300|COOMBS INDIRECT|Veterans Affairs|VETERANS ADMINISTRATION|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Workers Compensation|TEXAS MUTUAL INSURANCE|2.44||||||| 86885|EAP|0300|COOMBS INDIRECT|Workers Compensation|UT EMPLOYEE INJURY|2.44||||||| 86885|EAP|0300|COOMBS INDIRECT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.44||||2.44||| 86885|EAP|0300|COOMBS INDIRECT|Access Direct Platinum|HEALTHFIRST TPA UMR|2.44||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|292.80||||292.80||| 86885|EAP|0300|COOMBS INDIRECT|Access Direct Platinum|HEALTHFIRST TPA|292.80||||2.44||| 86900|EAP|0300|BLOOD TYPE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| 86900|EAP|0300|BLOOD TYPE|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||152.40||| 86900|EAP|0300|BLOOD TYPE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Access Direct Platinum|HEALTHFIRST TPA|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|152.40||||||| 86900|EAP|0300|BLOOD TYPE|Workers Compensation|TRAVELERS INSURANCE COMPANY|1.27||||||| 86900|EAP|0300|BLOOD TYPE|Workers Compensation|ZURICH COMPANY|152.40||||||| 86900|EAP|0300|BLOOD TYPE|Workers Compensation|UT EMPLOYEE INJURY|1.27||||||| 86900|EAP|0300|BLOOD TYPE|Veterans Affairs|VETERANS ADMINISTRATION|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.27||||||| 86900|EAP|0300|BLOOD TYPE|Workers Compensation|TEXAS MUTUAL INSURANCE|1.27||||||| 86900|EAP|0300|BLOOD TYPE|Workers Compensation|BROOKSHIRES WORKERS COMP|1.27||||||| 86900|EAP|0300|BLOOD TYPE|United Medicare Advantage|UHC AARP WELLMED HMO MA|152.40||||||| 86900|EAP|0300|BLOOD TYPE|United Medicare Advantage|UHC AARP MCR HMO MA|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Managed Medicaid|MEDICAID SUPERIOR|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Managed Medicaid|MEDICAID AMERIGROUP|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Cigna|CIGNA|152.40||||139.70||| 86900|EAP|0300|BLOOD TYPE|Cigna|CIGNA|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|Cigna|CIGNA OTHER|1.27||||152.40||| 86900|EAP|0300|BLOOD TYPE|Humana Medicare Advantage|HUMANA MA|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Blue Cross PPO Specialty|BCBSTX OTHER|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|ChampVA|CHAMPVA CENTER|152.40||||||| 86900|EAP|0300|BLOOD TYPE|Brinson Benefits|THE HEALTH PLAN SMITH CO|152.40||||||| 86900|EAP|0300|BLOOD TYPE|Aetna|AETNA OTHER|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||152.40||| 86900|EAP|0300|BLOOD TYPE|Aetna|AETNA QHP HMO|152.40||||||| 86900|EAP|0300|BLOOD TYPE|Aetna|BH AETNA|1.27||||||| 86900|EAP|0300|BLOOD TYPE|Aetna|AETNA PPO|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|Aetna|BOON CHAPMAN|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Aetna Value Network|AETNA VALUE NETWORK|139.70||||1.27||| 86900|EAP|0300|BLOOD TYPE|Managed Medicare|HEALTHSPRING MA|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.27||| 86900|EAP|0300|BLOOD TYPE|Blue Cross PPO Specialty|BCBSTX PPO|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Blue Cross HMO Specialty|BCBSTX HMO|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Managed Medicare|ETMC REHABILITATION HOSPITAL|1.27||||139.70||| 86900|EAP|0300|BLOOD TYPE|Managed Medicare|OTHER INSTITUTIONS|||||139.70||| 86900|EAP|0300|BLOOD TYPE|Managed Medicare|WELLCARE CHOICE MA|152.40||||||| 86900|EAP|0300|BLOOD TYPE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| 86900|EAP|0300|BLOOD TYPE|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||152.40||| 86900|EAP|0300|BLOOD TYPE|Medicaid|MEDICAID BCBSTX|||||152.40||| 86900|EAP|0300|BLOOD TYPE|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.27||||1.27||| 86900|EAP|0300|BLOOD TYPE|Medicaid|MEDICAID HMO|1.27||||1.27||| 86900|EAP|0300|BLOOD TYPE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Medicaid|LAW ENFORCEMENT OTHER|1.27||||152.40||| 86900|EAP|0300|BLOOD TYPE|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.27||||152.40||| 86900|EAP|0300|BLOOD TYPE|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.27||||1.27||| 86900|EAP|0300|BLOOD TYPE|Medicaid|SMITH COUNTY JAIL|1.27||||1.27||| 86900|EAP|0300|BLOOD TYPE|United Medicare Advantage|UHC MEDICARE GOLD MA|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Medicaid|CRIME VICTIMS COMPENSATION|1.27||||||| 86900|EAP|0300|BLOOD TYPE|Medicaid|COUNTY INDIGENT HEALTH OTHER|152.40||||||| 86900|EAP|0300|BLOOD TYPE|Medicaid|MEDICAID|1.27||||152.40||| 86900|EAP|0300|BLOOD TYPE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.27||||1.27||| 86900|EAP|0300|BLOOD TYPE|Workers Compensation|WORKERS COMPENSATION OTHER|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|United Healthcare|UNITED HEALTHCARE OTHER|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|United Healthcare|UNITED HEALTHCARE|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|United Healthcare|UNITED HEALTHCARE|139.70||||1.27||| 86900|EAP|0300|BLOOD TYPE|United Healthcare|TML GROUP BENEFITS|152.40||||||| 86900|EAP|0300|BLOOD TYPE|UTMB|UTMB CORRECTIONAL MANAGED CARE|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||152.40||| 86900|EAP|0300|BLOOD TYPE|Rusk State Hospital|RUSK STATE HOSP|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|Tricare|TRICARE EAST REGION|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Tricare|TRICARE FOR LIFE|||||139.70||| 86900|EAP|0300|BLOOD TYPE|PHCS|HUMANA|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|PHCS|GROUP AND PENSION|152.40||||||| 86900|EAP|0300|BLOOD TYPE|PHCS|HUMANA INSURANCE|1.27||||||| 86900|EAP|0300|BLOOD TYPE|Medicare|UTSW MC KIDNEY PROGRAM|||||1.27||| 86900|EAP|0300|BLOOD TYPE|Medicare|MEDICARE PART B ONLY IP|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|Medicare|MEDICARE ACUTE|152.40||||152.40||| 86900|EAP|0300|BLOOD TYPE|Multiplan|NALC|1.27||||||| 86900|EAP|0300|BLOOD TYPE|NON CONTRACTED|COMMERCIAL OTHER 2|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|Multiplan|WEB TPA|152.40||||1.27||| 86900|EAP|0300|BLOOD TYPE|NON CONTRACTED|COMMERCIAL OTHER 4|||||152.40||| 86901|EAP|0300|RH TYPE|Medicare|UTSW MC KIDNEY PROGRAM|||||1.27||| 86901|EAP|0300|RH TYPE|Medicare|MEDICARE PART B ONLY IP|152.40||||1.27||| 86901|EAP|0300|RH TYPE|Medicare|MEDICARE ACUTE|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Multiplan|NALC|1.27||||||| 86901|EAP|0300|RH TYPE|Multiplan|WEB TPA|152.40||||1.27||| 86901|EAP|0300|RH TYPE|NON CONTRACTED|COMMERCIAL OTHER 4|||||152.40||| 86901|EAP|0300|RH TYPE|Rusk State Hospital|RUSK STATE HOSP|152.40||||1.27||| 86901|EAP|0300|RH TYPE|PHCS|HUMANA|152.40||||152.40||| 86901|EAP|0300|RH TYPE|PHCS|HUMANA INSURANCE|1.27||||||| 86901|EAP|0300|RH TYPE|PHCS|GROUP AND PENSION|152.40||||||| 86901|EAP|0300|RH TYPE|Tricare|TRICARE FOR LIFE|||||139.70||| 86901|EAP|0300|RH TYPE|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||152.40||| 86901|EAP|0300|RH TYPE|UTMB|UTMB CORRECTIONAL MANAGED CARE|152.40||||152.40||| 86901|EAP|0300|RH TYPE|United Healthcare|UNITED HEALTHCARE|152.40||||1.27||| 86901|EAP|0300|RH TYPE|United Healthcare|UNITED HEALTHCARE|139.70||||1.27||| 86901|EAP|0300|RH TYPE|United Healthcare|TML GROUP BENEFITS|152.40||||||| 86901|EAP|0300|RH TYPE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.27||||1.27||| 86901|EAP|0300|RH TYPE|Medicaid|SMITH COUNTY JAIL|1.27||||1.27||| 86901|EAP|0300|RH TYPE|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.27||||152.40||| 86901|EAP|0300|RH TYPE|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.27||||1.27||| 86901|EAP|0300|RH TYPE|Medicaid|LAW ENFORCEMENT OTHER|1.27||||152.40||| 86901|EAP|0300|RH TYPE|Medicaid|CRIME VICTIMS COMPENSATION|1.27||||||| 86901|EAP|0300|RH TYPE|Medicaid|MEDICAID HMO|1.27||||1.27||| 86901|EAP|0300|RH TYPE|Medicaid|COUNTY INDIGENT HEALTH OTHER|152.40||||||| 86901|EAP|0300|RH TYPE|Medicaid|MEDICAID BCBSTX|||||152.40||| 86901|EAP|0300|RH TYPE|Managed Medicare|OTHER INSTITUTIONS|||||139.70||| 86901|EAP|0300|RH TYPE|Managed Medicare|HEALTHSPRING MA|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.27||| 86901|EAP|0300|RH TYPE|Managed Medicare|ETMC REHABILITATION HOSPITAL|1.27||||139.70||| 86901|EAP|0300|RH TYPE|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||152.40||| 86901|EAP|0300|RH TYPE|Managed Medicare|WELLCARE CHOICE MA|152.40||||||| 86901|EAP|0300|RH TYPE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Aetna Value Network|AETNA VALUE NETWORK|139.70||||1.27||| 86901|EAP|0300|RH TYPE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| 86901|EAP|0300|RH TYPE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||152.40||| 86901|EAP|0300|RH TYPE|Aetna|AETNA OTHER|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Aetna|AETNA QHP HMO|152.40||||||| 86901|EAP|0300|RH TYPE|Aetna|BOON CHAPMAN|152.40||||1.27||| 86901|EAP|0300|RH TYPE|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.27||||1.27||| 86901|EAP|0300|RH TYPE|Aetna|BH AETNA|1.27||||||| 86901|EAP|0300|RH TYPE|Aetna|AETNA PPO|152.40||||1.27||| 86901|EAP|0300|RH TYPE|ChampVA|CHAMPVA CENTER|152.40||||||| 86901|EAP|0300|RH TYPE|Blue Cross PPO Specialty|BCBSTX PPO|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Medicaid|MEDICAID|1.27||||152.40||| 86901|EAP|0300|RH TYPE|Blue Cross PPO Specialty|BCBSTX OTHER|152.40||||1.27||| 86901|EAP|0300|RH TYPE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Brinson Benefits|THE HEALTH PLAN SMITH CO|152.40||||||| 86901|EAP|0300|RH TYPE|Blue Cross HMO Specialty|BCBSTX HMO|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Humana Medicare Advantage|HUMANA MA|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Cigna|CIGNA OTHER|1.27||||152.40||| 86901|EAP|0300|RH TYPE|Cigna|CIGNA|152.40||||1.27||| 86901|EAP|0300|RH TYPE|Cigna|CIGNA|152.40||||139.70||| 86901|EAP|0300|RH TYPE|United Healthcare|UNITED HEALTHCARE OTHER|152.40||||1.27||| 86901|EAP|0300|RH TYPE|Tricare|TRICARE EAST REGION|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Managed Medicaid|MEDICAID SUPERIOR|152.40||||1.27||| 86901|EAP|0300|RH TYPE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Managed Medicaid|MEDICAID AMERIGROUP|152.40||||152.40||| 86901|EAP|0300|RH TYPE|NON CONTRACTED|COMMERCIAL OTHER 2|152.40||||1.27||| 86901|EAP|0300|RH TYPE|United Medicare Advantage|UHC AARP MCR HMO MA|152.40||||152.40||| 86901|EAP|0300|RH TYPE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|152.40||||152.40||| 86901|EAP|0300|RH TYPE|United Medicare Advantage|UHC AARP WELLMED HMO MA|152.40||||||| 86901|EAP|0300|RH TYPE|United Medicare Advantage|UHC MEDICARE GOLD MA|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.27||||||| 86901|EAP|0300|RH TYPE|Workers Compensation|WORKERS COMPENSATION OTHER|152.40||||1.27||| 86901|EAP|0300|RH TYPE|Workers Compensation|TEXAS MUTUAL INSURANCE|1.27||||||| 86901|EAP|0300|RH TYPE|Veterans Affairs|VETERANS ADMINISTRATION|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Workers Compensation|TRAVELERS INSURANCE COMPANY|1.27||||||| 86901|EAP|0300|RH TYPE|Workers Compensation|UT EMPLOYEE INJURY|1.27||||||| 86901|EAP|0300|RH TYPE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|152.40||||||| 86901|EAP|0300|RH TYPE|Workers Compensation|BROOKSHIRES WORKERS COMP|1.27||||||| 86901|EAP|0300|RH TYPE|Workers Compensation|ZURICH COMPANY|152.40||||||| 86901|EAP|0300|RH TYPE|Access Direct Platinum|HEALTHFIRST TPA|152.40||||1.27||| 86901|EAP|0300|RH TYPE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|152.40||||152.40||| 86901|EAP|0300|RH TYPE|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||152.40||| 86901|EAP|0300|RH TYPE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|483.60||||4.03||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|United Medicare Advantage|UHC AARP MCR HMO MA|4.03||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|483.60||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|483.60||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Managed Medicaid|MEDICAID SUPERIOR|4.03||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Humana Medicare Advantage|HUMANA MA|4.03||||483.60||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|483.60||||483.60||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Blue Cross HMO Specialty|BCBSTX HMO|483.60||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Blue Cross PPO Specialty|BCBSTX OTHER|||||4.03||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Blue Cross PPO Specialty|BCBSTX PPO|4.03||||483.60||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|483.60||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|483.60||||4.03||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Managed Medicare|HEALTHSPRING MA|4.03||||483.60||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.03||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Medicaid|MEDICAID|||||483.60||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|United Healthcare|UNITED HEALTHCARE OTHER|||||4.03||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|United Healthcare|UNITED HEALTHCARE|483.60||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|483.60||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Medicare|MEDICARE PART B ONLY IP|4.03||||||| 86902|EAP|0300|ANTIGEN SCREEN EA UNIT|Medicare|MEDICARE ACUTE|483.60||||483.60||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Medicare|MEDICARE ACUTE|195.60||||179.30||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|United Healthcare|UNITED HEALTHCARE OTHER|||||1.63||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|United Healthcare|UNITED HEALTHCARE|195.60||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Managed Medicare|HEALTHSPRING MA|195.60||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.63||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|195.60||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Aenta Medicare Advantage|AETNA MEDICARE MA|195.60||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Blue Cross PPO Specialty|BCBSTX PPO|195.60||||195.60||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Blue Cross HMO Specialty|BCBSTX HMO|195.60||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Humana Medicare Advantage|HUMANA MA|195.60||||195.60||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Managed Medicaid|MEDICAID SUPERIOR|1.63||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|195.60||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|United Medicare Advantage|UHC MEDICARE GOLD MA|195.60||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|United Medicare Advantage|UHC AARP MCR HMO MA|1.63||||||| 86905|EAP|0300|ANTIGEN SCREEN EA AG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.63||||||| 86920|EAP|0300|CROSS MATCH|Access Direct Platinum|HEALTHFIRST TPA|507.60||||||| 86920|EAP|0300|CROSS MATCH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|465.30||||507.60||| 86920|EAP|0300|CROSS MATCH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.23||||||| 86920|EAP|0300|CROSS MATCH|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|4.23||||||| 86920|EAP|0300|CROSS MATCH|Veterans Affairs|VETERANS ADMINISTRATION|507.60||||||| 86920|EAP|0300|CROSS MATCH|Workers Compensation|WORKERS COMPENSATION OTHER|507.60||||||| 86920|EAP|0300|CROSS MATCH|United Medicare Advantage|UHC AARP MCR HMO MA|507.60||||507.60||| 86920|EAP|0300|CROSS MATCH|United Medicare Advantage|UHC AARP WELLMED HMO MA|507.60||||||| 86920|EAP|0300|CROSS MATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|4.23||||507.60||| 86920|EAP|0300|CROSS MATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|507.60||||507.60||| 86920|EAP|0300|CROSS MATCH|Managed Medicaid|MEDICAID SUPERIOR|507.60||||4.23||| 86920|EAP|0300|CROSS MATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|507.60||||507.60||| 86920|EAP|0300|CROSS MATCH|Managed Medicaid|MEDICAID AMERIGROUP|507.60||||507.60||| 86920|EAP|0300|CROSS MATCH|Cigna|CIGNA OTHER|4.23||||||| 86920|EAP|0300|CROSS MATCH|Cigna|CIGNA|507.60||||465.30||| 86920|EAP|0300|CROSS MATCH|Humana Medicare Advantage|HUMANA MA|507.60||||507.60||| 86920|EAP|0300|CROSS MATCH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.23||||||| 86920|EAP|0300|CROSS MATCH|ChampVA|CHAMPVA CENTER|4.23||||||| 86920|EAP|0300|CROSS MATCH|Blue Cross PPO Specialty|BCBSTX PPO|507.60||||507.60||| 86920|EAP|0300|CROSS MATCH|Blue Cross PPO Specialty|BCBSTX OTHER|507.60||||||| 86920|EAP|0300|CROSS MATCH|Aetna|AETNA PPO|507.60||||4.23||| 86920|EAP|0300|CROSS MATCH|Aetna|AETNA QHP HMO|507.60||||||| 86920|EAP|0300|CROSS MATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|4.23||||465.30||| 86920|EAP|0300|CROSS MATCH|Blue Cross HMO Specialty|BCBSTX HMO|507.60||||4.23||| 86920|EAP|0300|CROSS MATCH|Aetna|AETNA OTHER|4.23||||507.60||| 86920|EAP|0300|CROSS MATCH|Aetna|BOON CHAPMAN|507.60||||||| 86920|EAP|0300|CROSS MATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|507.60||||465.30||| 86920|EAP|0300|CROSS MATCH|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.23||||||| 86920|EAP|0300|CROSS MATCH|Cigna|CIGNA|507.60||||||| 86920|EAP|0300|CROSS MATCH|Medicaid|CRIME VICTIMS COMPENSATION|4.23||||||| 86920|EAP|0300|CROSS MATCH|Medicaid|LAW ENFORCEMENT OTHER|||||507.60||| 86920|EAP|0300|CROSS MATCH|Medicaid|MEDICAID|4.23||||507.60||| 86920|EAP|0300|CROSS MATCH|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.23||||4.23||| 86920|EAP|0300|CROSS MATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|507.60||||4.23||| 86920|EAP|0300|CROSS MATCH|Medicaid|COUNTY INDIGENT HEALTH OTHER|507.60||||||| 86920|EAP|0300|CROSS MATCH|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.23||||507.60||| 86920|EAP|0300|CROSS MATCH|Medicaid|SMITH COUNTY JAIL|||||4.23||| 86920|EAP|0300|CROSS MATCH|Managed Medicare|BCBS MEDICARE PPO MA|4.23||||||| 86920|EAP|0300|CROSS MATCH|Access Direct Platinum|HEALTHFIRST TPA UMR|4.23||||507.60||| 86920|EAP|0300|CROSS MATCH|Managed Medicare|OTHER INSTITUTIONS|||||4.23||| 86920|EAP|0300|CROSS MATCH|Managed Medicare|HEALTHSPRING MA|4.23||||507.60||| 86920|EAP|0300|CROSS MATCH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.23||||4.23||| 86920|EAP|0300|CROSS MATCH|Tricare|TRICARE EAST REGION|507.60||||||| 86920|EAP|0300|CROSS MATCH|UTMB|UTMB CORRECTIONAL MANAGED CARE|507.60||||4.23||| 86920|EAP|0300|CROSS MATCH|United Healthcare|UNITED HEALTHCARE OTHER|507.60||||507.60||| 86920|EAP|0300|CROSS MATCH|United Healthcare|UNITED HEALTHCARE|507.60||||465.30||| 86920|EAP|0300|CROSS MATCH|United Healthcare|UNITED HEALTHCARE|507.60||||4.23||| 86920|EAP|0300|CROSS MATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|507.60||||507.60||| 86920|EAP|0300|CROSS MATCH|PHCS|HUMANA|507.60||||||| 86920|EAP|0300|CROSS MATCH|NON CONTRACTED|COMMERCIAL OTHER 1|465.30||||||| 86920|EAP|0300|CROSS MATCH|PHCS|GROUP AND PENSION|4.23||||||| 86920|EAP|0300|CROSS MATCH|Rusk State Hospital|RUSK STATE HOSP|507.60||||||| 86920|EAP|0300|CROSS MATCH|Medicare|MEDICARE PART B ONLY IP|507.60||||||| 86920|EAP|0300|CROSS MATCH|Medicare|MEDICARE ACUTE|507.60||||507.60||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Medicare|MEDICARE PART B ONLY IP|7.36||||||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Medicare|MEDICARE ACUTE|883.20||||883.20||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|United Healthcare|UNITED HEALTHCARE|883.20||||||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|United Healthcare|UNITED HEALTHCARE OTHER|||||7.36||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|UTMB|UTMB CORRECTIONAL MANAGED CARE|883.20||||||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicare|HEALTHSPRING MA|7.36||||883.20||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.36||||||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Medicaid|MEDICAID|||||883.20||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|883.20||||7.36||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Aenta Medicare Advantage|AETNA MEDICARE MA|883.20||||||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Blue Cross PPO Specialty|BCBSTX OTHER|7.36||||7.36||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Blue Cross PPO Specialty|BCBSTX PPO|7.36||||883.20||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Blue Cross HMO Specialty|BCBSTX HMO|883.20||||||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Humana Medicare Advantage|HUMANA MA|7.36||||883.20||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicaid|MEDICAID SUPERIOR|7.36||||||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|883.20||||883.20||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|883.20||||883.20||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|809.60||||7.36||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|United Medicare Advantage|UHC MEDICARE GOLD MA|883.20||||||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|United Medicare Advantage|UHC AARP MCR HMO MA|7.36||||||| 86922|EAP|0300|COMPATABILITY TEST EA UNI|Veterans Affairs|VETERANS ADMINISTRATION|7.36||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Access Direct Platinum|HEALTHFIRST TPA UMR|4.23||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|507.60||||465.30||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Access Direct Platinum|HEALTHFIRST TPA|507.60||||4.23||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Veterans Affairs|VETERANS ADMINISTRATION|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Workers Compensation|WORKERS COMPENSATION OTHER|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Workers Compensation|TEXAS MUTUAL INSURANCE|4.23||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Workers Compensation|ZURICH COMPANY|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|4.23||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|United Medicare Advantage|UHC AARP WELLMED HMO MA|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|United Medicare Advantage|UHC MEDICARE GOLD MA|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicaid|MEDICAID SUPERIOR|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Cigna|CIGNA OTHER|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Cigna|CIGNA|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Humana Medicare Advantage|HUMANA MA|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Blue Cross HMO Specialty|BCBSTX HMO|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Blue Cross PPO Specialty|BCBSTX PPO|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Blue Cross PPO Specialty|BCBSTX OTHER|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|ChampVA|CHAMPVA CENTER|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Cigna|CIGNA|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Aetna|AETNA OTHER|507.60||||4.23||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Aetna|AETNA PPO|4.23||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Aetna|BOON CHAPMAN|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Aenta Medicare Advantage|AETNA MEDICARE MA|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicaid|MEDICAID AMERIGROUP|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.23||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Medicaid|MEDICAID|4.23||||4.23||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Medicaid|COUNTY INDIGENT HEALTH OTHER|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|United Medicare Advantage|UHC AARP MCR HMO MA|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Medicaid|CRIME VICTIMS COMPENSATION|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Medicaid|SMITH COUNTY JAIL|4.23||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicare|OTHER INSTITUTIONS|||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicare|HEALTHSPRING MA|507.60||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.23||||4.23||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Managed Medicare|BCBS MEDICARE PPO MA|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.23||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Tricare|TRICARE EAST REGION|465.30||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.23||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|United Healthcare|UNITED HEALTHCARE OTHER|507.60||||4.23||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|United Healthcare|UNITED HEALTHCARE|4.23||||4.23||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|United Healthcare|TML GROUP BENEFITS|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|NON CONTRACTED|COMMERCIAL OTHER 1|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Rusk State Hospital|RUSK STATE HOSP|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|PHCS|GROUP AND PENSION|507.60||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|PHCS|HUMANA|||||507.60||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Medicare|MEDICARE PART B ONLY IP|4.23||||||| 86923|EAP|0300|COMPATABILITY TEST EA UNI|Medicare|MEDICARE ACUTE|507.60||||507.60||| 86965|EAP|0390|CRYO POOLING FEE|Medicare|MEDICARE ACUTE|1.30||||||| 86965|EAP|0390|CRYO POOLING FEE|United Healthcare|UNITED HEALTHCARE OTHER|1.56||||||| 86965|EAP|0390|CRYO POOLING FEE|United Healthcare|UNITED HEALTHCARE|1.30||||||| 86965|EAP|0390|CRYO POOLING FEE|Managed Medicare|HEALTHSPRING MA|1.30||||||| 86965|EAP|0390|CRYO POOLING FEE|Medicaid|MEDICAID|1.30||||||| 86965|EAP|0390|CRYO POOLING FEE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.56||||||| 86965|EAP|0390|CRYO POOLING FEE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.30||||||| 86965|EAP|0390|CRYO POOLING FEE|Blue Cross PPO Specialty|BCBSTX PPO|1.43||||||| 86965|EAP|0390|CRYO POOLING FEE|Blue Cross HMO Specialty|BCBSTX HMO|1.30||||||| 86965|EAP|0390|CRYO POOLING FEE|Humana Medicare Advantage|HUMANA MA|1.56||||||| 86965|EAP|0390|CRYO POOLING FEE|Cigna|CIGNA|1.30||||||| 86965|EAP|0390|CRYO POOLING FEE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.56||||||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|47,044.31|8556.47|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|42,024.87|5983.54|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|52,180.55|5892.96|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|108,350.50|5739.59|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|Medicare|MEDICARE ACUTE|42,346.24|5888.05|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|47,814.82|579.5|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|Medicaid|MEDICAID|61,258.50|3186.48|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|35,498.80|5969.21|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|27,333.05|5868.57|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|54,329.97|5888.93|8556.47|579.5|||| 87|DRG||TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|34,527.66|4879.07|8556.47|579.5|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Rusk State Hospital|RUSK STATE HOSP|393,852.57|192987.76|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|United Medicare Advantage|UHC MEDICARE GOLD MA|7.11|100.04|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|228,207.98|18379.75|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|United Medicare Advantage|UHC AARP MCR HMO MA|333,752.60|39547.43|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|United Healthcare|TML GROUP BENEFITS|593,393.70|92026.41|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|United Healthcare|UNITED HEALTHCARE|254,242.84|74854.41|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Medicaid|MOLINA HEALTHCARE OF TEXAS|285,755.34|17791.06|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Medicaid|MEDICAID|331,442.35|17791.06|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Medicare|MEDICARE ACUTE|305,087.50|35987.51|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|222,860.18|321.48|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Blue Cross PPO Specialty|BCBSTX PPO|552,186.62|2019.78|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|255,437.74|28287.79|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|309,276.51|28287.79|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Humana Medicare Advantage|HUMANA MA|341,139.91|35987.4|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Cigna|CIGNA|515,683.09|257814.4|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Managed Medicare|HEALTHSPRING MA|388,029.19|36837.2|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Veterans Affairs|VETERANS ADMINISTRATION|402,768.14|36716.99|257814.4|100.04|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Aenta Medicare Advantage|AETNA MEDICARE MA|289,876.35|28874.925|257814.4|100.04|||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Veterans Affairs|VETERANS ADMINISTRATION|362.25||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.15||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|338.63||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Access Direct Platinum|HEALTHFIRST TPA|3.15||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|362.25||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|United Medicare Advantage|UHC MEDICARE GOLD MA|3.15||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|United Medicare Advantage|UHC AARP MCR HMO MA|362.25||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.15||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Managed Medicaid|MEDICAID SUPERIOR|362.25||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Managed Medicaid|MEDICAID SUPERIOR|3.15||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.15||||338.63||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Managed Medicaid|MEDICAID AMERIGROUP|362.25||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Cigna|CIGNA OTHER|||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Humana Medicare Advantage|HUMANA MA|362.25||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|362.25||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Cigna|CIGNA|3.15||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Blue Cross PPO Specialty|BCBSTX PPO|3.15||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Blue Cross HMO Specialty|BCBSTX HMO|3.15||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Aetna|AETNA QHP HMO|362.25||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Aenta Medicare Advantage|AETNA MEDICARE MA|3.15||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Aetna|AETNA OTHER|362.25||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|362.25||||338.63||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Medicaid|CRIME VICTIMS COMPENSATION|362.25||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Medicaid|MEDICAID HMO|||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|362.25||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Medicaid|MEDICAID|3.15||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.15||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Medicaid|SMITH COUNTY JAIL|3.15||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.15||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.15||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Managed Medicare|HEALTHSPRING MA|362.25||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Managed Medicare|BCBS MEDICARE PPO MA|338.63||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.15||||3.15||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.15||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Tricare|TRICARE EAST REGION|362.25||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|United Healthcare|UNITED HEALTHCARE OTHER|338.63||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|United Healthcare|UNITED HEALTHCARE|362.25||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|United Healthcare|UNITED HEALTHCARE|3.15||||338.63||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Medicare|MEDICARE PART B ONLY IP|362.25||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|Medicare|MEDICARE ACUTE|362.25||||362.25||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|PHCS|HUMANA|362.25||||||| 87015|EAP|0300|SPECIMEN INFECT AGNT CONC|NON CONTRACTED|COMMERCIAL OTHER 1|362.25||||338.63||| 87040|EAP|0300|CULTURE BLOOD|NON CONTRACTED|COMMERCIAL OTHER 1|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|PHCS|HUMANA|524.60||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Rusk State Hospital|RUSK STATE HOSP|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|PHCS|GROUP AND PENSION|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|PHCS|HUMANA INSURANCE|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|Medicare|MEDICARE PART B ONLY IP|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Medicare|MEDICARE ACUTE|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|United Healthcare|UNITED HEALTHCARE OTHER|4.88||||561.20||| 87040|EAP|0300|CULTURE BLOOD|United Healthcare|UNITED HEALTHCARE|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|United Healthcare|UNITED HEALTHCARE|561.20||||524.60||| 87040|EAP|0300|CULTURE BLOOD|United Healthcare|GEHA|524.60||||561.20||| 87040|EAP|0300|CULTURE BLOOD|United Healthcare|AARP|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Tricare|TRICARE EAST REGION|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.88||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicare|BCBS MEDICARE PPO MA|4.88||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicare|WELLCARE CHOICE MA|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicare|OTHER INSTITUTIONS|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicare|ETMC AFFILIATE HOSPITALS|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicare|MA PART B ONLY IP|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Medicaid|CRIME VICTIMS COMPENSATION|561.20||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Medicaid|MEDICAID|4.88||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Medicaid|LAW ENFORCEMENT OTHER|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Medicaid|MEDICAID HMO|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Medicaid|SUPERIOR HEALTHPLAN CHIP|561.20||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|561.20||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Aetna Value Network|AETNA VALUE NETWORK|||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Aetna|AETNA PPO|561.20||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|4.88||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Aetna|BOON CHAPMAN|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|Medicaid|SMITH COUNTY JAIL|4.88||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Aetna|AETNA QHP HMO|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|Aetna|AETNA OTHER|524.60||||||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicare|HEALTHSPRING MA|4.88||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|ChampVA|CHAMPVA CENTER|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Blue Cross PPO Specialty|BCBSTX OTHER|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Brinson Benefits|THE HEALTH PLAN SMITH CO|524.60||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Tricare|TRICARE FOR LIFE|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|Humana Medicare Advantage|HUMANA MA|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Cigna|CIGNA|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Cigna|CIGNA|561.20||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Cigna|CIGNA OTHER|524.60||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicaid|MEDICAID SUPERIOR|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Managed Medicaid|MEDICAID AMERIGROUP|561.20||||4.88||| 87040|EAP|0300|CULTURE BLOOD|United Healthcare|TML GROUP BENEFITS|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|Multiplan|WEB TPA|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|4.88||||561.20||| 87040|EAP|0300|CULTURE BLOOD|United Medicare Advantage|UHC AARP WELLMED HMO MA|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|United Medicare Advantage|UHC AARP MCR HMO MA|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Access Direct Platinum|HEALTHFIRST TPA UMR|4.88||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.88||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Access Direct Platinum|HEALTHFIRST TPA|561.20||||524.60||| 87040|EAP|0300|CULTURE BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Veterans Affairs|VETERANS ADMINISTRATION|561.20||||561.20||| 87040|EAP|0300|CULTURE BLOOD|Workers Compensation|ZURICH COMPANY|561.20||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Workers Compensation|WORKERS COMPENSATION OTHER|561.20||||4.88||| 87040|EAP|0300|CULTURE BLOOD|Workers Compensation|TEXAS MUTUAL INSURANCE|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Workers Compensation|UT EMPLOYEE INJURY|561.20||||||| 87040|EAP|0300|CULTURE BLOOD|Workers Compensation|BROOKSHIRES WORKERS COMP|4.88||||||| 87040|EAP|0300|CULTURE BLOOD|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|4.88||||||| 87045|EAP|0300|CULTURE STOOL|Veterans Affairs|VETERANS ADMINISTRATION|512.90||||||| 87045|EAP|0300|CULTURE STOOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|512.90||||512.90||| 87045|EAP|0300|CULTURE STOOL|Access Direct Platinum|HEALTHFIRST TPA|4.46||||||| 87045|EAP|0300|CULTURE STOOL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.46||||4.46||| 87045|EAP|0300|CULTURE STOOL|United Medicare Advantage|UHC MEDICARE GOLD MA|4.46||||4.46||| 87045|EAP|0300|CULTURE STOOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|512.90||||512.90||| 87045|EAP|0300|CULTURE STOOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.46||||||| 87045|EAP|0300|CULTURE STOOL|Managed Medicaid|MEDICAID SUPERIOR|512.90||||4.46||| 87045|EAP|0300|CULTURE STOOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.46||||512.90||| 87045|EAP|0300|CULTURE STOOL|Managed Medicaid|MEDICAID AMERIGROUP|512.90||||4.46||| 87045|EAP|0300|CULTURE STOOL|Cigna|CIGNA|512.90||||||| 87045|EAP|0300|CULTURE STOOL|Cigna|CIGNA OTHER|4.46||||4.46||| 87045|EAP|0300|CULTURE STOOL|Humana Medicare Advantage|HUMANA MA|4.46||||4.46||| 87045|EAP|0300|CULTURE STOOL|United Medicare Advantage|UHC AARP MCR HMO MA|512.90||||512.90||| 87045|EAP|0300|CULTURE STOOL|Blue Cross PPO Specialty|BCBSTX PPO|4.46||||4.46||| 87045|EAP|0300|CULTURE STOOL|Blue Cross HMO Specialty|BCBSTX HMO|4.46||||||| 87045|EAP|0300|CULTURE STOOL|Aenta Medicare Advantage|AETNA MEDICARE MA|479.45||||479.45||| 87045|EAP|0300|CULTURE STOOL|Aetna|AETNA PPO|4.46||||||| 87045|EAP|0300|CULTURE STOOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|512.90||||4.46||| 87045|EAP|0300|CULTURE STOOL|Medicaid|MEDICAID|512.90||||||| 87045|EAP|0300|CULTURE STOOL|Medicaid|SMITH COUNTY JAIL|4.46||||||| 87045|EAP|0300|CULTURE STOOL|Medicaid|COUNTY INDIGENT HEALTH OTHER|512.90||||||| 87045|EAP|0300|CULTURE STOOL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.46||||512.90||| 87045|EAP|0300|CULTURE STOOL|Managed Medicare|HEALTHSPRING MA|479.45||||||| 87045|EAP|0300|CULTURE STOOL|UTMB|UTMB CORRECTIONAL MANAGED CARE|512.90||||||| 87045|EAP|0300|CULTURE STOOL|Tricare|TRICARE EAST REGION|512.90||||4.46||| 87045|EAP|0300|CULTURE STOOL|United Healthcare|UNITED HEALTHCARE OTHER|512.90||||||| 87045|EAP|0300|CULTURE STOOL|United Healthcare|GOLDEN RULE|||||4.46||| 87045|EAP|0300|CULTURE STOOL|Medicare|MEDICARE ACUTE|512.90||||4.46||| 87045|EAP|0300|CULTURE STOOL|NON CONTRACTED|COMMERCIAL OTHER 1|512.90||||||| 87045|EAP|0300|CULTURE STOOL|Rusk State Hospital|RUSK STATE HOSP|512.90||||||| 87046|EAP|0300|CULTURE CAMPYLOBACTER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||159.75||| 87070|EAP|0300|CULTURE RESPIRATORY|NON CONTRACTED|COMMERCIAL OTHER 1|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|PHCS|HUMANA INSURANCE|468.05||||||| 87070|EAP|0300|CULTURE WOUND|PHCS|HUMANA|4.07||||468.05||| 87070|EAP|0300|CULTURE WOUND|NON CONTRACTED|COMMERCIAL OTHER 1|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|PHCS|GROUP AND PENSION|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Medicare|MEDICARE PART B ONLY IP|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Medicare|MEDICARE ACUTE|4.07||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Medicare|MEDICARE ACUTE|468.05||||468.05||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|Medicare|MEDICARE ACUTE|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|United Healthcare|UNITED HEALTHCARE OTHER|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|United Healthcare|UNITED HEALTHCARE|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|United Healthcare|TML GROUP BENEFITS|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|United Healthcare|GEHA|4.07||||||| 87070|EAP|0300|CULTURE RESPIRATORY|United Healthcare|UNITED HEALTHCARE|468.05||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|United Healthcare|TML GROUP BENEFITS|468.05||||4.07||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|United Healthcare|UNITED HEALTHCARE OTHER|4.07||||4.07||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|United Healthcare|UNITED HEALTHCARE|468.05||||437.53||| 87070|EAP|0300|CULTURE WOUND|Tricare|TRICARE EAST REGION|437.53||||468.05||| 87070|EAP|0300|CULTURE WOUND|UTMB|UTMB CORRECTIONAL MANAGED CARE|468.05||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|UTMB|UTMB CORRECTIONAL MANAGED CARE|468.05||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicare|BCBS MEDICARE PPO MA|468.05||||468.05||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||4.07||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.07||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicare|WELLCARE CHOICE MA|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Managed Medicare|BCBS MEDICARE PPO MA|4.07||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicare|HEALTHSPRING MA|468.05||||4.07||| 87070|EAP|0300|CULTURE WOUND|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||468.05||| 87070|EAP|0300|CULTURE WOUND|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||468.05||| 87070|EAP|0300|CULTURE WOUND|Managed Medicare|HEALTHSPRING MA|468.05||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicare|ETMC AFFILIATE HOSPITALS|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|Medicaid|LAW ENFORCEMENT OTHER|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Medicaid|CRIME VICTIMS COMPENSATION|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Medicaid|COUNTY INDIGENT HEALTH OTHER|437.53||||||| 87070|EAP|0300|CULTURE RESPIRATORY|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.07||||||| 87070|EAP|0300|CULTURE THROAT|Medicaid|MEDICAID HMO|468.05||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Medicaid|SMITH COUNTY JAIL|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|Medicaid|SMITH COUNTY JAIL|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Medicaid|MEDICAID HMO|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|Medicaid|MEDICAID|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|Medicaid|MOLINA HEALTHCARE OF TEXAS|468.05||||4.07||| 87070|EAP|0300|CULTURE WOUND|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||437.53||| 87070|EAP|0300|CULTURE RESPIRATORY|Medicaid|CRIME VICTIMS COMPENSATION|468.05||||||| 87070|EAP|0300|CULTURE RESPIRATORY|Medicaid|MEDICAID|4.07||||468.05||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|United Medicare Advantage|UHC AARP MCR HMO MA|468.05||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|United Medicare Advantage|UHC MEDICARE GOLD MA|4.07||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|United Medicare Advantage|UHC AARP MCR HMO MA|468.05||||468.05||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|468.05||||437.53||| 87070|EAP|0300|CULTURE WOUND|United Medicare Advantage|UHC AARP WELLMED HMO MA|468.05||||4.07||| 87070|EAP|0300|CULTURE WOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|United Medicare Advantage|UHC AARP MCR HMO MA|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|468.05||||437.53||| 87070|EAP|0300|CULTURE RESPIRATORY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|Access Direct Platinum|HEALTHFIRST TPA UMR|437.53||||4.07||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|United Medicare Advantage|UHC MEDICARE GOLD MA|4.07||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|468.05||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.07||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|468.05||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Access Direct Platinum|HEALTHFIRST TPA|437.53||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Access Direct Platinum|HEALTHFIRST TPA UMR|4.07||||4.07||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|Access Direct Platinum|HEALTHFIRST TPA|4.07||||468.05||| 87070|EAP|0300|CULTURE WOUND|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|468.05||||||| 87070|EAP|0300|CULTURE RESPIRATORY|Access Direct Platinum|HEALTHFIRST TPA|4.07||||468.05||| 87070|EAP|0300|CULTURE WOUND|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Workers Compensation|WORKERS COMPENSATION OTHER|468.05||||4.07||| 87070|EAP|0300|CULTURE WOUND|Workers Compensation|TEXAS MUTUAL INSURANCE|468.05||||468.05||| 87070|EAP|0300|CULTURE THROAT|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.07||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Workers Compensation|UT EMPLOYEE INJURY|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Veterans Affairs|VETERANS ADMINISTRATION|468.05||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Veterans Affairs|VETERANS ADMINISTRATION|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|Workers Compensation|BROOKSHIRES WORKERS COMP|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Workers Compensation|TEXAS MUTUAL INSURANCE|437.53||||468.05||| 87070|EAP|0300|CULTURE WOUND|Humana Medicare Advantage|HUMANA MA|4.07||||468.05||| 87070|EAP|0300|CULTURE WOUND|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.07||||||| 87070|EAP|0300|CULTURE RESPIRATORY|Humana Medicare Advantage|HUMANA MA|4.07||||4.07||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|Humana Medicare Advantage|HUMANA MA|468.05||||4.07||| 87070|EAP|0300|CULTURE WOUND|Cigna|CIGNA|468.05||||437.53||| 87070|EAP|0300|CULTURE WOUND|Cigna|CIGNA OTHER|468.05||||||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||4.07||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|Cigna|CIGNA|468.05||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Cigna|CIGNA|468.05||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|468.05||||4.07||| 87070|EAP|0300|CULTURE GENITAL|Managed Medicaid|MEDICAID SUPERIOR|468.05||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicare|HEALTHSPRING MA|4.07||||468.05||| 87070|EAP|0300|CULTURE WOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.07||||4.07||| 87070|EAP|0300|CULTURE THROAT|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Managed Medicare|OTHER INSTITUTIONS|||||4.07||| 87070|EAP|0300|CULTURE WOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|468.05||||4.07||| 87070|EAP|0300|CULTURE WOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|Managed Medicaid|MEDICAID SUPERIOR|4.07||||468.05||| 87070|EAP|0300|CULTURE WOUND|Managed Medicaid|MEDICAID AMERIGROUP|4.07||||468.05||| 87070|EAP|0300|CULTURE WOUND|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|468.05||||||| 87070|EAP|0300|CULTURE THROAT|Managed Medicaid|MEDICAID SUPERIOR|4.07||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|United Healthcare|UNITED HEALTHCARE OTHER|4.07||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|468.05||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Managed Medicaid|MEDICAID AMERIGROUP|468.05||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Blue Cross HMO Specialty|BCBSTX HMO|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|Blue Cross HMO Specialty|BCBSTX HMO|468.05||||468.05||| 87070|EAP|0300|CULTURE WOUND|United Healthcare|UNITED HEALTHCARE|468.05||||4.07||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|Blue Cross HMO Specialty|BCBSTX HMO|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|ChampVA|CHAMPVA CENTER|468.05||||||| 87070|EAP|0300|CULTURE RESPIRATORY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Blue Cross PPO Specialty|BCBSTX PPO|468.05||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Medicare|MEDICARE PART B ONLY IP|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Brinson Benefits|THE HEALTH PLAN SMITH CO|4.07||||||| 87070|EAP|0300|CULTURE RESPIRATORY|Blue Cross PPO Specialty|BCBSTX OTHER|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Blue Cross PPO Specialty|BCBSTX OTHER|4.07||||||| 87070|EAP|0300|CULTURE BRONCHIAL BRUSH|Blue Cross PPO Specialty|BCBSTX PPO|4.07||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Blue Cross PPO Specialty|BCBSTX PPO|468.05||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Aetna|BOON CHAPMAN|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Aetna|AETNA QHP HMO|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Aetna|AETNA PPO|4.07||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Rusk State Hospital|RUSK STATE HOSP|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Aetna|AETNA PPO|468.05||||4.07||| 87070|EAP|0300|CULTURE RESPIRATORY|Aetna|AETNA QHP HMO|468.05||||||| 87070|EAP|0300|CULTURE RESPIRATORY|Aenta Medicare Advantage|AETNA MEDICARE MA|4.07||||468.05||| 87070|EAP|0300|CULTURE WOUND|Aenta Medicare Advantage|AETNA MEDICARE MA|4.07||||4.07||| 87070|EAP|0300|CULTURE WOUND|Aetna|BOON CHAPMAN|468.05||||||| 87070|EAP|0300|CULTURE WOUND|Aetna|AETNA OTHER|4.07||||||| 87070|EAP|0300|CULTURE WOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|468.05||||468.05||| 87070|EAP|0300|CULTURE RESPIRATORY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|468.05||||437.53||| 87070|EAP|0300|CULTURE WOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.07||||468.05||| 87071|EAP|0300|CULTURE CATH TIP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|479.45||||512.90||| 87071|EAP|0300|CULTURE CATH TIP|Blue Cross PPO Specialty|BCBSTX PPO|479.45||||||| 87071|EAP|0300|CULTURE CATH TIP|Blue Cross HMO Specialty|BCBSTX HMO|512.90||||||| 87071|EAP|0300|CULTURE CATH TIP|Managed Medicaid|MEDICAID SUPERIOR|512.90||||||| 87071|EAP|0300|CULTURE CATH TIP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|479.45||||||| 87071|EAP|0300|CULTURE, TRACHEAL|Managed Medicaid|MEDICAID SUPERIOR|512.90||||||| 87071|EAP|0300|CULTURE, QUANTITATED WOUN|Humana Medicare Advantage|HUMANA MA|512.90||||512.90||| 87071|EAP|0300|CULTURE CATH TIP|Humana Medicare Advantage|HUMANA MA|512.90||||512.90||| 87071|EAP|0300|CULTURE CATH TIP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.46||||||| 87071|EAP|0300|CULTURE, QUANTITATED WOUN|Workers Compensation|WORKERS COMPENSATION OTHER|512.90||||||| 87071|EAP|0300|CULTURE CATH TIP|Veterans Affairs|VETERANS ADMINISTRATION|479.45||||||| 87071|EAP|0300|CULTURE CATH TIP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|512.90||||||| 87071|EAP|0300|CULTURE CATH TIP|United Medicare Advantage|UHC MEDICARE GOLD MA|512.90||||||| 87071|EAP|0300|CULTURE CATH TIP|United Medicare Advantage|UHC AARP MCR HMO MA|512.90||||||| 87071|EAP|0300|CULTURE CATH TIP|Medicaid|MEDICAID HMO|512.90||||||| 87071|EAP|0300|CULTURE CATH TIP|Medicaid|MEDICAID|4.46||||||| 87071|EAP|0300|CULTURE, QUANTITATED WOUN|Managed Medicare|HEALTHSPRING MA|4.46||||512.90||| 87071|EAP|0300|CULTURE CATH TIP|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||4.46||| 87071|EAP|0300|CULTURE CATH TIP|Tricare|TRICARE EAST REGION|512.90||||||| 87071|EAP|0300|CULTURE, QUANTITATED WOUN|United Healthcare|TML GROUP BENEFITS|4.46||||||| 87071|EAP|0300|CULTURE CATH TIP|United Healthcare|TML GROUP BENEFITS|512.90||||||| 87071|EAP|0300|CULTURE CATH TIP|Medicare|MEDICARE ACUTE|512.90||||||| 87071|EAP|0300|CULTURE CATH TIP|NON CONTRACTED|COMMERCIAL OTHER 1|4.46||||||| 87075|EAP|0300|CULTURE ANAEROBIC|PHCS|HUMANA|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|PHCS|HUMANA INSURANCE|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|PHCS|GROUP AND PENSION|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicare|MEDICARE PART B ONLY IP|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|United Healthcare|UNITED HEALTHCARE OTHER|4.47||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|United Healthcare|UNITED HEALTHCARE|514.05||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|United Healthcare|UNITED HEALTHCARE|4.47||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|United Healthcare|TML GROUP BENEFITS|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|United Healthcare|GEHA|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.47||||480.53||| 87075|EAP|0300|CULTURE ANAEROBIC|Tricare|TRICARE EAST REGION|480.53||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicare|HEALTHSPRING MA|514.05||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicare|OTHER INSTITUTIONS|||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid|MEDICAID HMO|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid|SMITH COUNTY JAIL|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid|MOLINA HEALTHCARE OF TEXAS|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid|MEDICAID|4.47||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid|LAW ENFORCEMENT OTHER|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid|COUNTY INDIGENT HEALTH OTHER|480.53||||||| 87075|EAP|0300|CULTURE ANAEROBIC|United Medicare Advantage|UHC AARP MCR HMO MA|514.05||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.47||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|United Medicare Advantage|UHC AARP WELLMED HMO MA|514.05||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|United Medicare Advantage|UHC MEDICARE GOLD MA|514.05||||480.53||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicaid|CRIME VICTIMS COMPENSATION|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Access Direct Platinum|HEALTHFIRST TPA|514.05||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.47||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|514.05||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|Access Direct Platinum|HEALTHFIRST TPA UMR|480.53||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||480.53||| 87075|EAP|0300|CULTURE ANAEROBIC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Workers Compensation|BROOKSHIRES WORKERS COMP|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Veterans Affairs|VETERANS ADMINISTRATION|514.05||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicare|BCBS MEDICARE PPO MA|4.47||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Workers Compensation|WORKERS COMPENSATION OTHER|514.05||||480.53||| 87075|EAP|0300|CULTURE ANAEROBIC|Workers Compensation|TEXAS MUTUAL INSURANCE|||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Cigna|CIGNA OTHER|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Cigna|CIGNA|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Cigna|CIGNA|514.05||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Humana Medicare Advantage|HUMANA MA|4.47||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Medicare|MEDICARE ACUTE|4.47||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|514.05||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.47||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|NON CONTRACTED|COMMERCIAL OTHER 1|514.05||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicaid|MEDICAID AMERIGROUP|4.47||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Managed Medicaid|MEDICAID SUPERIOR|4.47||||514.05||| 87075|EAP|0300|CULTURE ANAEROBIC|Blue Cross HMO Specialty|BCBSTX HMO|514.05||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|ChampVA|CHAMPVA CENTER|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Brinson Benefits|THE HEALTH PLAN SMITH CO|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Blue Cross PPO Specialty|BCBSTX OTHER|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Blue Cross PPO Specialty|BCBSTX PPO|514.05||||480.53||| 87075|EAP|0300|CULTURE ANAEROBIC|Aetna|AETNA OTHER|4.47||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Aetna|AETNA PPO|514.05||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|Aenta Medicare Advantage|AETNA MEDICARE MA|4.47||||4.47||| 87075|EAP|0300|CULTURE ANAEROBIC|Aetna|BOON CHAPMAN|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Aetna|AETNA QHP HMO|514.05||||||| 87075|EAP|0300|CULTURE ANAEROBIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.47||||514.05||| 87076|EAP|0300|ANAEROBE ID|Aetna|BOON CHAPMAN|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Aenta Medicare Advantage|AETNA MEDICARE MA|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Aetna|AETNA PPO|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|ChampVA|CHAMPVA CENTER|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Blue Cross HMO Specialty|BCBSTX HMO|440.45||||3.83||| 87076|EAP|0300|ANAEROBE ID|Managed Medicaid|MEDICAID AMERIGROUP|440.45||||3.83||| 87076|EAP|0300|ANAEROBE ID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.83||||411.73||| 87076|EAP|0300|ANAEROBE ID|Managed Medicaid|MEDICAID SUPERIOR|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|Humana Medicare Advantage|HUMANA MA|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|Cigna|CIGNA|440.45||||3.83||| 87076|EAP|0300|ANAEROBE ID|Veterans Affairs|VETERANS ADMINISTRATION|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Workers Compensation|WORKERS COMPENSATION OTHER|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Access Direct Platinum|HEALTHFIRST TPA|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|440.45||||3.83||| 87076|EAP|0300|ANAEROBE ID|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.83||||||| 87076|EAP|0300|ANAEROBE ID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.83||||440.45||| 87076|EAP|0300|ANAEROBE ID|United Medicare Advantage|UHC AARP MCR HMO MA|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|United Medicare Advantage|UHC AARP WELLMED HMO MA|440.45||||3.83||| 87076|EAP|0300|ANAEROBE ID|Access Direct Platinum|HEALTHFIRST TPA UMR|3.83||||||| 87076|EAP|0300|ANAEROBE ID|United Medicare Advantage|UHC MEDICARE GOLD MA|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|Medicaid|LAW ENFORCEMENT OTHER|440.45||||||| 87076|EAP|0300|ANAEROBE ID|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.83||| 87076|EAP|0300|ANAEROBE ID|Medicaid|SMITH COUNTY JAIL|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Cigna|CIGNA OTHER|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Medicaid|MEDICAID|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|Medicaid|CRIME VICTIMS COMPENSATION|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Blue Cross PPO Specialty|BCBSTX PPO|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Managed Medicare|HEALTHSPRING MA|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Managed Medicare|OTHER INSTITUTIONS|||||3.83||| 87076|EAP|0300|ANAEROBE ID|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||3.83||| 87076|EAP|0300|ANAEROBE ID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|Managed Medicare|BCBS MEDICARE PPO MA|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.83||||440.45||| 87076|EAP|0300|ANAEROBE ID|Tricare|TRICARE EAST REGION|3.83||||||| 87076|EAP|0300|ANAEROBE ID|United Healthcare|UNITED HEALTHCARE OTHER|3.83||||||| 87076|EAP|0300|ANAEROBE ID|United Healthcare|UNITED HEALTHCARE|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|United Healthcare|UNITED HEALTHCARE|3.83||||||| 87076|EAP|0300|ANAEROBE ID|United Healthcare|TML GROUP BENEFITS|3.83||||||| 87076|EAP|0300|ANAEROBE ID|United Healthcare|GEHA|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Medicare|MEDICARE PART B ONLY IP|3.83||||||| 87076|EAP|0300|ANAEROBE ID|Medicare|MEDICARE ACUTE|3.83||||3.83||| 87076|EAP|0300|ANAEROBE ID|NON CONTRACTED|COMMERCIAL OTHER 1|3.83||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Rusk State Hospital|RUSK STATE HOSP|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|PHCS|GROUP AND PENSION|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|PHCS|HUMANA|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|NON CONTRACTED|COMMERCIAL OTHER 1|1.31||||150.65||| 87077|EAP|0300|TDH CHARGES FOR SENSITIVI|Medicare|MEDICARE ACUTE|1.54||||150.65||| 87077|EAP|0300|GRAM POSITIVE RODS|Medicare|MEDICARE ACUTE|2.10||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicare|UTSW MC KIDNEY PROGRAM|||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicare|MEDICARE PART B ONLY IP|150.65||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicare|MEDICARE ACUTE|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Multiplan|NALC|||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Multiplan|WEB TPA|1.31||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Healthcare|UNITED HEALTHCARE OTHER|1.31||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Healthcare|UNITED HEALTHCARE|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Healthcare|TML GROUP BENEFITS|150.65||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Healthcare|GOLDEN RULE|||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Healthcare|GEHA|1.31||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Tricare|TRICARE FOR LIFE|||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Tricare|TRICARE EAST REGION|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|UTMB|UTMB CORRECTIONAL MANAGED CARE|150.65||||140.83||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicare|HEALTHSPRING MA|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.31||||140.83||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicare|BCBS MEDICARE PPO MA|1.31||||140.83||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicare|OTHER INSTITUTIONS|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.31||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|MOLINA HEALTHCARE OF TEXAS|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|MEDICAID HMO|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|LAW ENFORCEMENT OTHER|150.65||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|COUNTY INDIGENT HEALTH OTHER|140.83||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|MEDICAID|1.31||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|BH TEXAS CHILDRENS MEDICAID|150.65||||||| 87077|EAP|0300|GRAM POSITIVE RODS|Medicaid|MEDICAID|2.10||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|SUPERIOR HEALTHPLAN CHIP|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|SMITH COUNTY JAIL|1.31||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Medicare Advantage|UHC MEDICARE GOLD MA|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Medicare Advantage|UHC AARP WELLMED HMO MA|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Medicare Advantage|UHC AARP MCR HMO MA|150.65||||150.65||| 87077|EAP|0300|CULTURE AEROBIC IDENTIFY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|150.65||||43.12||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|CRIME VICTIMS COMPENSATION|150.65||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.31||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Access Direct Platinum|HEALTHFIRST TPA UMR|1.31||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Access Direct Platinum|HEALTHFIRST TPA|1.31||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.31||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.31||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Workers Compensation|TEXAS MUTUAL INSURANCE|1.31||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Veterans Affairs|VETERANS ADMINISTRATION|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicare|WELLCARE CHOICE MA|150.65||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Healthcare|AARP|1.31||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Workers Compensation|WORKERS COMPENSATION OTHER|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Workers Compensation|ZURICH COMPANY|||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Workers Compensation|BROOKSHIRES WORKERS COMP|1.31||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.31||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|United Healthcare|UNITED HEALTHCARE|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Cigna Behavioral Health|BH CIGNA|1.31||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Cigna|CIGNA|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Cigna|CIGNA OTHER|150.65||||140.83||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Magellan Behavioral Health|BH MAGELLAN|1.31||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Humana Medicare Advantage|HUMANA MA|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicaid|MEDICAID AMERIGROUP|1.31||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Managed Medicaid|MEDICAID SUPERIOR|1.31||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Blue Cross HMO Specialty|BCBSTX HMO|150.65||||150.65||| 87077|EAP|0300|TDH 802 CHARGES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.68||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|PHCS|HUMANA INSURANCE|150.65||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Blue Cross PPO Specialty|BCBSTX PPO|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Blue Cross PPO Specialty|BCBSTX OTHER|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|ChampVA|CHAMPVA CENTER|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Aetna|AETNA OTHER|150.65||||||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Aetna|AETNA QHP HMO|150.65||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Aenta Medicare Advantage|AETNA MEDICARE MA|1.31||||150.65||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Aetna|AETNA PPO|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Aetna|BOON CHAPMAN|150.65||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.12||||1.31||| 87077|EAP|0300|DEFINITIVE ID AEROBIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|150.65||||1.31||| 87077|EAP|0300|GRAM POSITIVE RODS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.10||||1.31||| 87081|EAP|0300|CULTURE MRSA|Aetna Value Network|AETNA VALUE NETWORK|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Aenta Medicare Advantage|AETNA MEDICARE MA|1.64||||188.60||| 87081|EAP|0300|CULTURE MRSA|Aetna|BOON CHAPMAN|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Aetna|AETNA OTHER|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|137.81||||1.64||| 87081|EAP|0300|CULTURE MRSA|Blue Cross PPO Specialty|BCBSTX PPO|1.64||||188.60||| 87081|EAP|0300|CULTURE MRSA|Blue Cross PPO Specialty|BCBSTX OTHER|||||188.60||| 87081|EAP|0300|CULTURE BETA STREP SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|1.64||||3.14||| 87081|EAP|0300|CULTURE MRSA|Blue Cross HMO Specialty|BCBSTX HMO|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|188.60||||188.60||| 87081|EAP|0300|CULTURE MRSA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|188.60||||188.60||| 87081|EAP|0300|CULTURE BETA STREP SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|||||3.14||| 87081|EAP|0300|CULTURE MRSA|Managed Medicaid|MEDICAID SUPERIOR|3.14||||188.60||| 87081|EAP|0300|CULTURE MRSA|Managed Medicaid|MEDICAID AMERIGROUP|||||188.60||| 87081|EAP|0300|CULTURE VRE|Humana Medicare Advantage|HUMANA MA|3.14||||188.60||| 87081|EAP|0300|CULTURE MRSA|Cigna|CIGNA|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Cigna|CIGNA OTHER|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Cigna|CIGNA|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Workers Compensation|UT EMPLOYEE INJURY|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Veterans Affairs|VETERANS ADMINISTRATION|1.64||||1.64||| 87081|EAP|0300|CULTURE MRSA|Workers Compensation|WORKERS COMPENSATION OTHER|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||176.30||| 87081|EAP|0300|CULTURE MRSA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.64||||188.60||| 87081|EAP|0300|CULTURE MRSA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|361.10||||1.64||| 87081|EAP|0300|CULTURE MRSA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.64||||1.64||| 87081|EAP|0300|CULTURE MRSA|Access Direct Platinum|HEALTHFIRST TPA|||||1.64||| 87081|EAP|0300|CULTURE MRSA|United Medicare Advantage|UHC MEDICARE GOLD MA|188.60||||1.64||| 87081|EAP|0300|CULTURE MRSA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.64||||1.64||| 87081|EAP|0300|CULTURE MRSA|United Medicare Advantage|UHC AARP MCR HMO MA|188.60||||188.60||| 87081|EAP|0300|CULTURE MRSA|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Medicaid|MEDICAID HMO|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Humana Medicare Advantage|HUMANA MA|188.60||||188.60||| 87081|EAP|0300|CULTURE GC|Medicaid|MEDICAID HMO|||||3.14||| 87081|EAP|0300|CULTURE BETA STREP SCREEN|Medicaid|MEDICAID|3.45||||361.10||| 87081|EAP|0300|CULTURE GC|Managed Medicaid|MEDICAID SUPERIOR|3.14||||3.14||| 87081|EAP|0300|CULTURE MRSA|Medicaid|MEDICAID|188.60||||188.60||| 87081|EAP|0300|CULTURE MRSA|Managed Medicare|HEALTHSPRING MA|176.30||||188.60||| 87081|EAP|0300|CULTURE MRSA|Managed Medicare|OTHER INSTITUTIONS|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.64||||1.64||| 87081|EAP|0300|CULTURE MRSA|Managed Medicare|BCBS MEDICARE PPO MA|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Tricare|TRICARE FOR LIFE|||||188.60||| 87081|EAP|0300|CULTURE MRSA|ChampVA|CHAMPVA CENTER|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Tricare|TRICARE SOUTH PHYSICIAN|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Tricare|TRICARE EAST REGION|||||188.60||| 87081|EAP|0300|CULTURE MRSA|United Healthcare|UNITED HEALTHCARE ERS|||||1.64||| 87081|EAP|0300|CULTURE MRSA|United Healthcare|UNITED HEALTHCARE OTHER|1.64||||188.60||| 87081|EAP|0300|CULTURE MRSA|Aetna|AETNA PPO|||||1.64||| 87081|EAP|0300|CULTURE MRSA|United Healthcare|UNITED HEALTHCARE|188.60||||188.60||| 87081|EAP|0300|CULTURE MRSA|United Healthcare|UNITED HEALTHCARE|||||1.64||| 87081|EAP|0300|CULTURE MRSA|United Healthcare|TML GROUP BENEFITS|||||1.64||| 87081|EAP|0300|CULTURE MRSA|United Healthcare|GOLDEN RULE|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|188.60||||188.60||| 87081|EAP|0300|CULTURE MRSA|United Healthcare|GEHA|||||188.60||| 87081|EAP|0300|CULTURE MRSA|United Healthcare|AARP|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Medicare|MEDICARE PART B ONLY IP|176.30||||||| 87081|EAP|0300|CULTURE MRSA|Multiplan|NALC|||||188.60||| 87081|EAP|0300|CULTURE MRSA|Medicare|MEDICARE ACUTE|188.60||||188.60||| 87081|EAP|0300|CULTURE MRSA|NON CONTRACTED|COMMERCIAL OTHER 1|3.14||||1.64||| 87081|EAP|0300|CULTURE MRSA|NON CONTRACTED|COMMERCIAL OTHER 1|176.30||||1.64||| 87081|EAP|0300|CULTURE MRSA|Rusk State Hospital|RUSK STATE HOSP|1.64||||1.64||| 87081|EAP|0300|CULTURE MRSA|PHCS|GROUP AND PENSION|||||1.64||| 87081|EAP|0300|CULTURE MRSA|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.64||| 87086|EAP|0300|CULTURE URINE|NON CONTRACTED|COMMUNITY HEALTH CENTER|1.92||||||| 87086|EAP|0300|CULTURE URINE|Optum Behavioral Health|BH OPTUM UHC|1.92||||||| 87086|EAP|0300|CULTURE URINE|NON CONTRACTED|COMMERCIAL OTHER 1|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Rusk State Hospital|RUSK STATE HOSP|220.80||||||| 87086|EAP|0300|CULTURE URINE|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.92||| 87086|EAP|0300|CULTURE URINE|PHCS|GROUP AND PENSION|||||220.80||| 87086|EAP|0300|CULTURE URINE|PHCS|HUMANA|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|PHCS|MULTIPLAN PHCS|||||220.80||| 87086|EAP|0300|CULTURE URINE|Multiplan|NALC|||||220.80||| 87086|EAP|0300|CULTURE URINE|Medicare|UTSW MC KIDNEY PROGRAM|||||220.80||| 87086|EAP|0300|CULTURE URINE|Medicare|MEDICARE PART B ONLY IP|1.92||||||| 87086|EAP|0300|CULTURE URINE|Medicare|MEDICARE ACUTE|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||1.92||| 87086|EAP|0300|CULTURE URINE|United Healthcare|UNITED HEALTHCARE OTHER|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|United Healthcare|UNITED HEALTHCARE|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|United Healthcare|TML GROUP BENEFITS|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|United Healthcare|GOLDEN RULE|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|United Healthcare|GEHA|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Tricare|TRICARE FOR LIFE|220.80||||206.40||| 87086|EAP|0300|CULTURE URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.92||||220.80||| 87086|EAP|0300|CULTURE URINE|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.92||||||| 87086|EAP|0300|CULTURE URINE|Managed Medicare|OTHER INSTITUTIONS|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|Managed Medicare|WELLCARE CHOICE MA|220.80||||||| 87086|EAP|0300|CULTURE URINE|Managed Medicare|HEALTHSPRING MA|1.92||||220.80||| 87086|EAP|0300|CULTURE URINE|Managed Medicare|BCBS MEDICARE PPO MA|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|Managed Medicare|UNIVERSAL HEALTHCARE MA|||||206.40||| 87086|EAP|0300|CULTURE URINE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.92||||220.80||| 87086|EAP|0300|CULTURE URINE|Medicaid|SMITH COUNTY JAIL|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.92||||220.80||| 87086|EAP|0300|CULTURE URINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.92||||220.80||| 87086|EAP|0300|CULTURE URINE|Medicaid|CRIME VICTIMS COMPENSATION|220.80||||||| 87086|EAP|0300|CULTURE URINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|Medicaid|BH TEXAS CHILDRENS MEDICAID|220.80||||||| 87086|EAP|0300|CULTURE URINE|Medicaid|MEDICAID|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|Medicaid|SUPERIOR HEALTHPLAN CHIP|220.80||||206.40||| 87086|EAP|0300|CULTURE URINE|Medicaid|MEDICAID HMO|206.40||||220.80||| 87086|EAP|0300|CULTURE URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|United Medicare Advantage|UHC AARP WELLMED HMO MA|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|United Medicare Advantage|UHC AARP MCR HMO MA|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.92||| 87086|EAP|0300|CULTURE URINE|Access Direct Platinum|ANDREWS CENTER|1.92||||||| 87086|EAP|0300|CULTURE URINE|Access Direct Platinum|HEALTHFIRST TPA UMR|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|Access Direct Platinum|HEALTHFIRST TPA|206.40||||220.80||| 87086|EAP|0300|CULTURE URINE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.92||||||| 87086|EAP|0300|CULTURE URINE|Tricare|TRICARE EAST REGION|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|Veterans Affairs|VETERANS ADMINISTRATION|1.92||||220.80||| 87086|EAP|0300|CULTURE URINE|Workers Compensation|WORKERS COMPENSATION OTHER|220.80||||206.40||| 87086|EAP|0300|CULTURE URINE|Workers Compensation|BROOKSHIRES WORKERS COMP|1.92||||||| 87086|EAP|0300|CULTURE URINE|Workers Compensation|TEXAS MUTUAL INSURANCE|1.92||||||| 87086|EAP|0300|CULTURE URINE|United Healthcare|UNITED HEALTHCARE|220.80||||206.40||| 87086|EAP|0300|CULTURE URINE|Workers Compensation|ZURICH COMPANY|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Cigna|CIGNA|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Cigna|CIGNA OTHER|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Cigna Behavioral Health|BH CIGNA|1.92||||||| 87086|EAP|0300|CULTURE URINE|Cigna|CIGNA|220.80||||206.40||| 87086|EAP|0300|CULTURE URINE|Magellan Behavioral Health|BH MAGELLAN|1.92||||||| 87086|EAP|0300|CULTURE URINE|Humana Medicare Advantage|HUMANA MA|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||220.80||| 87086|EAP|0300|CULTURE URINE|Multiplan|WEB TPA|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|PHCS|HUMANA INSURANCE|206.40||||||| 87086|EAP|0300|CULTURE URINE|Managed Medicaid|MEDICAID AMERIGROUP|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Managed Medicaid|MEDICAID SUPERIOR|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|NON CONTRACTED|COMMERCIAL OTHER 2|220.80||||||| 87086|EAP|0300|CULTURE URINE|Blue Cross HMO Specialty|BCBSTX HMO|1.92||||220.80||| 87086|EAP|0300|CULTURE URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Brinson Benefits|THE HEALTH PLAN SMITH CO|206.40||||1.92||| 87086|EAP|0300|CULTURE URINE|ChampVA|CHAMPVA CENTER|1.92||||1.92||| 87086|EAP|0300|CULTURE URINE|Blue Cross PPO Specialty|BCBSTX PPO|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|Blue Cross PPO Specialty|BCBSTX OTHER|220.80||||220.80||| 87086|EAP|0300|CULTURE URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.92||||220.80||| 87086|EAP|0300|CULTURE URINE|Aetna|AETNA OTHER|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Aetna|BOON CHAPMAN|206.40||||1.92||| 87086|EAP|0300|CULTURE URINE|Aetna|AETNA PPO|220.80||||1.92||| 87086|EAP|0300|CULTURE URINE|Aetna|AETNA QHP HMO|1.92||||220.80||| 87086|EAP|0300|CULTURE URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|220.80||||220.80||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Aetna|AETNA PPO|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Aetna|AETNA OTHER|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Aetna|BOON CHAPMAN|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Blue Cross PPO Specialty|BCBSTX OTHER|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Blue Cross PPO Specialty|BCBSTX PPO|440.45||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Blue Cross HMO Specialty|BCBSTX HMO|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Managed Medicaid|MEDICAID SUPERIOR|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|440.45||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Cigna|CIGNA|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Cigna|CIGNA OTHER|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Veterans Affairs|VETERANS ADMINISTRATION|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.83||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Access Direct Platinum|HEALTHFIRST TPA|440.45||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Medicare Advantage|UHC AARP MCR HMO MA|440.45||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|440.45||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|440.45||||||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Medicaid|MEDICAID|||||3.83||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.83||||3.83||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Humana Medicare Advantage|HUMANA MA|440.45||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Managed Medicaid|MEDICAID AMERIGROUP|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Managed Medicare|UNIVERSAL HEALTHCARE MA|||||411.73||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Managed Medicare|HEALTHSPRING MA|3.83||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Managed Medicare|BCBS MEDICARE PPO MA|440.45||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Managed Medicare|OTHER INSTITUTIONS|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|ChampVA|CHAMPVA CENTER|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Tricare|TRICARE FOR LIFE|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Tricare|TRICARE EAST REGION|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||3.83||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Healthcare|UNITED HEALTHCARE OTHER|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Healthcare|UNITED HEALTHCARE|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Healthcare|TML GROUP BENEFITS|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Healthcare|GEHA|||||3.83||| 87088|EAP|0300|PRESUMPTIVE ID URINE|United Healthcare|AARP|||||3.83||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Aetna Value Network|AETNA VALUE NETWORK|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Multiplan|WEB TPA|||||3.83||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Multiplan|PACIFICARE|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Medicare|UTSW MC KIDNEY PROGRAM|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Medicare|MEDICARE ACUTE|440.45||||440.45||| 87088|EAP|0300||Medicare|MEDICARE ACUTE|440.45||||28.46||| 87088|EAP|0300|PRESUMPTIVE ID URINE|NON CONTRACTED|COMMERCIAL OTHER 2|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|NON CONTRACTED|COMMERCIAL OTHER 1|||||440.45||| 87088|EAP|0300|PRESUMPTIVE ID URINE|PHCS|HUMANA|||||3.83||| 87088|EAP|0300|PRESUMPTIVE ID URINE|Rusk State Hospital|RUSK STATE HOSP|440.45||||||| 87088|EAP|0300|PRESUMPTIVE ID URINE|PHCS|HUMANA INSURANCE|||||440.45||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|106,393.62|31727.1|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|114,533.14|11738.47|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|85,366.80|11526.06|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|United Healthcare|UNITED HEALTHCARE|78,638.32|22089.53|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|United Healthcare|UNITED HEALTHCARE OTHER|239,299.56|42506.225|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|United Healthcare|UNITED HEALTHCARE|63,545.45|22089.53|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|127,102.25|11494.29|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Medicaid|MEDICAID|84,990.60|17791.06|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Medicaid|SMITH COUNTY INDIGENT HEALTH|236,543.72|17791.06|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Medicare|MEDICARE ACUTE|92,142.87|11524.98|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|90,830.23|11524.1|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Access Direct Platinum|HEALTHFIRST TPA|58,044.21|15229.4|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|142,886.79|14778.2|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Medicare|MEDICARE PART B ONLY IP|69,059.47|11496.82|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|49,094.80|14709.18|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|98,122.43|11503.7|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Cigna|CIGNA|152,842.80|22323.39|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Cigna|CIGNA|86,799.27|19204.23|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Cigna|CIGNA OTHER|44,435.12|19204.23|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Humana Medicare Advantage|HUMANA MA|78,274.75|11528.62|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|102,661.12|11738.47|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|96,124.47|11856.25|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicaid|MEDICAID SUPERIOR|599.59|11856.25|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicaid|MEDICAID AMERIGROUP|98,460.55|11856.25|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|110,433.40|28287.79|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicare|WELLCARE CHOICE MA|303,989.01|11738.47|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|97,473.45|11524.1|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicare|HEALTHSPRING MA|118,093.06|11524.98|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicare|BCBS MEDICARE PPO MA|54,633.50|11496.82|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Blue Cross PPO Specialty|BCBSTX OTHER|73,838.57|12604.96|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|104,686.71|12604.96|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Aetna|AETNA PPO|52,946.06|21673.34|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Aetna|AETNA OTHER|32,183.87|24080.87|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|107,807.70|214.32|42506.225|214.32|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|955.06|10715.14|42506.225|214.32|||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|457.70||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Aetna|BOON CHAPMAN|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Aetna|AETNA OTHER|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Aetna|AETNA PPO|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Blue Cross PPO Specialty|BCBSTX OTHER|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Blue Cross PPO Specialty|BCBSTX PPO|457.70||||427.85||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Blue Cross HMO Specialty|BCBSTX HMO|3.98||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Managed Medicaid|MEDICAID AMERIGROUP|457.70||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|457.70||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Managed Medicaid|MEDICAID SUPERIOR|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Humana Medicare Advantage|HUMANA MA|3.98||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Cigna|CIGNA|3.98||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Cigna|CIGNA|457.70||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Veterans Affairs|VETERANS ADMINISTRATION|457.70||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Workers Compensation|WORKERS COMPENSATION OTHER|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|457.70||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Access Direct Platinum|HEALTHFIRST TPA UMR|457.70||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.98||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Access Direct Platinum|HEALTHFIRST TPA|3.98||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|457.70||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|United Medicare Advantage|UHC AARP WELLMED HMO MA|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|United Medicare Advantage|UHC AARP MCR HMO MA|457.70||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|ChampVA|CHAMPVA CENTER|427.85||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|United Medicare Advantage|UHC MEDICARE GOLD MA|3.98||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Medicaid|SMITH COUNTY JAIL|3.98||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Medicaid|MOLINA HEALTHCARE OF TEXAS|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Medicaid|MEDICAID HMO|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Medicaid|MEDICAID|3.98||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Medicaid|CRIME VICTIMS COMPENSATION|427.85||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.98||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.98||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Managed Medicare|HEALTHSPRING MA|3.98||||457.70||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Managed Medicare|BCBS MEDICARE PPO MA|3.98||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Aetna|AETNA QHP HMO|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|UTMB|UTMB CORRECTIONAL MANAGED CARE|427.85||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Tricare|TRICARE EAST REGION|427.85||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|United Healthcare|UNITED HEALTHCARE OTHER|3.98||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|United Healthcare|UNITED HEALTHCARE|457.70||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|United Healthcare|UNITED HEALTHCARE|3.98||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|United Healthcare|TML GROUP BENEFITS|3.98||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|United Healthcare|GEHA|3.98||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|NON CONTRACTED|COMMERCIAL OTHER 1|457.70||||427.85||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Aenta Medicare Advantage|AETNA MEDICARE MA|427.85||||3.98||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Rusk State Hospital|RUSK STATE HOSP|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|PHCS|GROUP AND PENSION|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|PHCS|HUMANA|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Medicare|MEDICARE PART B ONLY IP|457.70||||||| 87102|EAP|0300|CULTURE FUNGUS OTHER SOUR|Medicare|MEDICARE ACUTE|3.98||||457.70||| 87103|EAP|0300|CULTURE FUNGUS-BLOOD|Medicare|MEDICARE ACUTE|489.90||||||| 87103|EAP|0300|CULTURE FUNGUS-BLOOD|Medicaid|MEDICAID|489.90||||||| 87103|EAP|0300|CULTURE FUNGUS-BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|489.90||||||| 87103|EAP|0300|CULTURE FUNGUS-BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|489.90||||||| 87103|EAP|0300|CULTURE FUNGUS-BLOOD|Veterans Affairs|VETERANS ADMINISTRATION|489.90||||||| 87103|EAP|0300|CULTURE FUNGUS-BLOOD|Humana Medicare Advantage|HUMANA MA|489.90||||||| 87103|EAP|0300|CULTURE FUNGUS-BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.26||||||| 87103|EAP|0300|CULTURE FUNGUS-BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|489.90||||||| 87103|EAP|0300|CULTURE FUNGUS-BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|489.90||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Aenta Medicare Advantage|AETNA MEDICARE MA|434.70||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Aetna|BOON CHAPMAN|434.70||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Aetna|AETNA PPO|3.78||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Aetna|AETNA OTHER|434.70||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Blue Cross HMO Specialty|BCBSTX HMO|3.78||||406.35||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Blue Cross PPO Specialty|BCBSTX PPO|434.70||||406.35||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Blue Cross PPO Specialty|BCBSTX OTHER|434.70||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|434.70||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Managed Medicaid|MEDICAID SUPERIOR|434.70||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.78||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Cigna|CIGNA OTHER|434.70||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Cigna|CIGNA|434.70||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Humana Medicare Advantage|HUMANA MA|3.78||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.78||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Access Direct Platinum|HEALTHFIRST TPA|406.35||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|434.70||||434.70||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Access Direct Platinum|HEALTHFIRST TPA UMR|434.70||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Cigna|CIGNA|3.78||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Workers Compensation|WORKERS COMPENSATION OTHER|434.70||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Veterans Affairs|VETERANS ADMINISTRATION|434.70||||434.70||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|United Medicare Advantage|UHC MEDICARE GOLD MA|434.70||||434.70||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|United Medicare Advantage|UHC AARP MCR HMO MA|434.70||||434.70||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Managed Medicaid|MEDICAID AMERIGROUP|434.70||||434.70||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|434.70||||434.70||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.78||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||406.35||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Managed Medicare|BCBS MEDICARE PPO MA|3.78||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|434.70||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Managed Medicare|HEALTHSPRING MA|434.70||||434.70||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Medicaid|SMITH COUNTY JAIL|3.78||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.78||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Medicaid|MEDICAID|3.78||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|United Healthcare|UNITED HEALTHCARE OTHER|3.78||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|United Healthcare|TML GROUP BENEFITS|3.78||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|United Healthcare|UNITED HEALTHCARE|434.70||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|United Healthcare|UNITED HEALTHCARE|3.78||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Tricare|TRICARE EAST REGION|3.78||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|UTMB|UTMB CORRECTIONAL MANAGED CARE|434.70||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|NON CONTRACTED|COMMERCIAL OTHER 1|434.70||||3.78||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Rusk State Hospital|RUSK STATE HOSP|434.70||||||| 87116|EAP|0306|CULTURE TUBERCLE, ACID FA|Medicare|MEDICARE ACUTE|3.78||||434.70||| 87143|EAP|0300|TDH CHARGES FOR SENSITIVI|Blue Cross PPO Specialty|BCBSTX PPO|1.54||||||| 87147|EAP|0300|SALMONELLA TYPE|Medicare|MEDICARE ACUTE|0.14||||||| 87147|EAP|0300|AGGLUTINATION TYPING 1|Medicare|MEDICARE ACUTE|2.44||||||| 87147|EAP|0300|AGGLUTINATION TYPING 1|Tricare|TRICARE EAST REGION|2.44||||||| 87147|EAP|0300|AGGLUTINATION TYPING 2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.44||||||| 87147|EAP|0300|AGGLUTINATION TYPING 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.44||||||| 87147|EAP|0300|AGGLUTINATION TYPING 2|United Medicare Advantage|UHC MEDICARE GOLD MA|2.44||||||| 87147|EAP|0300|AGGLUTINATION TYPING 1|United Medicare Advantage|UHC MEDICARE GOLD MA|2.44||||||| 87147|EAP|0300|AGGLUTINATION TYPING 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.44||| 87147|EAP|0300|MRSA WORKUP|Humana Medicare Advantage|HUMANA MA|2.44||||2.44||| 87147|EAP|0300|AGGLUTINATION TYPING 2|Managed Medicaid|MEDICAID SUPERIOR|||||280.60||| 87147|EAP|0300|SALMONELLA TYPE|Managed Medicaid|MEDICAID AMERIGROUP|0.14||||0.14||| 87147|EAP|0300|SALMONELLA TYPE|Blue Cross PPO Specialty|BCBSTX PPO|0.14||||||| 87147|EAP|0300|SHIGELLA TYPE|Blue Cross PPO Specialty|BCBSTX PPO|0.28||||||| 87153|EAP|0300|DNA/RNA SEQUENCING|United Medicare Advantage|UHC MEDICARE GOLD MA|582.54||||||| 87177|EAP|0300|OVA AND PARASITE|Medicaid|MEDICAID|4.14||||||| 87177|EAP|0300|OVA AND PARASITE|Medicare|MEDICARE ACUTE|476.10||||||| 87177|EAP|0300|OVA AND PARASITE|Aenta Medicare Advantage|AETNA MEDICARE MA|4.14||||||| 87177|EAP|0300|OVA AND PARASITE|United Medicare Advantage|UHC MEDICARE GOLD MA|4.14||||||| 87177|EAP|0300|OVA AND PARASITE|United Medicare Advantage|UHC AARP MCR HMO MA|||||476.10||| 87181|EAP|0300|ANTIBIOTIC SENSITIVITY 1|NON CONTRACTED|COMMERCIAL OTHER 1|1.01||||||| 87181|EAP|0300|ANTIBIOTIC SENSITIVITY 1|Medicare|MEDICARE ACUTE|108.58||||||| 87181|EAP|0300|ANTIBIOTIC SENSITIVITY 1|Managed Medicare|HEALTHSPRING MA|116.15||||||| 87181|EAP|0300|ANTIBIOTIC SENSITIVITY 1|Medicaid|MEDICAID|1.01||||||| 87184|EAP|0300|PLATE SENSITIVITY 1|Veterans Affairs|VETERANS ADMINISTRATION|3.26||||||| 87184|EAP|0300|PLATE SENSITIVITY 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.26||||||| 87184|EAP|0300|PLATE SENSITIVITY 1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|United Medicare Advantage|UHC MEDICARE GOLD MA|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|United Medicare Advantage|UHC AARP MCR HMO MA|374.90||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Managed Medicaid|MEDICAID SUPERIOR|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Cigna|CIGNA|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|ChampVA|CHAMPVA CENTER|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Humana Medicare Advantage|HUMANA MA|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Blue Cross HMO Specialty|BCBSTX HMO|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Blue Cross PPO Specialty|BCBSTX PPO|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Blue Cross PPO Specialty|BCBSTX OTHER|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Aenta Medicare Advantage|AETNA MEDICARE MA|374.90||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Aetna|AETNA PPO|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|374.90||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Aetna|AETNA OTHER|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Medicaid|MEDICAID|3.26||||||| 87184|EAP|0300|PLATE SENSITIVITY 1|Managed Medicare|BCBS MEDICARE PPO MA|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Managed Medicare|HEALTHSPRING MA|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Managed Medicare|UNIVERSAL HEALTHCARE MA|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|United Healthcare|UNITED HEALTHCARE OTHER|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|United Healthcare|UNITED HEALTHCARE|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|United Healthcare|TML GROUP BENEFITS|3.26||||||| 87184|EAP|0300|PLATE SENSITIVITY 1|Tricare|TRICARE EAST REGION|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Multiplan|WEB TPA|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|Medicare|MEDICARE ACUTE|3.26||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|PHCS|HUMANA|||||3.26||| 87184|EAP|0300|PLATE SENSITIVITY 1|NON CONTRACTED|COMMERCIAL OTHER 1|3.26||||3.26||| 87186|EAP|0300|SENSITIVITY|Medicaid|MEDICAID HMO|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Medicaid|MEDICAID|1.78||||204.70||| 87186|EAP|0300|SENSITIVITY|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.78||||1.78||| 87186|EAP|0300|SENSITIVITY|Medicaid|CRIME VICTIMS COMPENSATION|204.70||||||| 87186|EAP|0300|SENSITIVITY|Aenta Medicare Advantage|AETNA MEDICARE MA|1.78||||204.70||| 87186|EAP|0300|SENSITIVITY|Aetna|BOON CHAPMAN|204.70||||1.78||| 87186|EAP|0300|SENSITIVITY|Aetna|AETNA PPO|204.70||||1.78||| 87186|EAP|0300|SENSITIVITY|Aetna|AETNA OTHER|204.70||||||| 87186|EAP|0300|SENSITIVITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|204.70||||1.78||| 87186|EAP|0300|SENSITIVITY|Blue Cross PPO Specialty|BCBSTX OTHER|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Blue Cross PPO Specialty|BCBSTX PPO|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Blue Cross HMO Specialty|BCBSTX HMO|1.78||||204.70||| 87186|EAP|0300|SENSITIVITY TO BACTEROIDS|Humana Medicare Advantage|HUMANA MA|204.70||||177.01||| 87186|EAP|0300|SENSITIVITY|Humana Medicare Advantage|HUMANA MA|321.84||||1.78||| 87186|EAP|0300|SENSITIVITY|ChampVA|CHAMPVA CENTER|204.70||||1.78||| 87186|EAP|0300|SENSITIVITY|Cigna Behavioral Health|BH CIGNA|1.78||||||| 87186|EAP|0300|SENSITIVITY|Cigna|CIGNA OTHER|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Cigna|CIGNA|204.70||||1.78||| 87186|EAP|0300|SENSITIVITY|Cigna|CIGNA|191.35||||191.35||| 87186|EAP|0300|SENSITIVITY|Magellan Behavioral Health|BH MAGELLAN|1.78||||||| 87186|EAP|0300|SENSITIVITY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Managed Medicaid|MEDICAID SUPERIOR|1.78||||204.70||| 87186|EAP|0300|SENSITIVITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.41||||204.70||| 87186|EAP|0300|SENSITIVITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Managed Medicaid|MEDICAID AMERIGROUP|191.35||||1.78||| 87186|EAP|0300|SENSITIVITY|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|204.70||||204.70||| 87186|EAP|0300|YEAST SUSPECTIBILITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|321.84||||204.70||| 87186|EAP|0300|SENSITIVITY|United Medicare Advantage|UHC MEDICARE GOLD MA|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Aetna|AETNA QHP HMO|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Medicaid|BH TEXAS CHILDRENS MEDICAID|204.70||||||| 87186|EAP|0300|SENSITIVITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|United Medicare Advantage|UHC AARP WELLMED HMO MA|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|United Medicare Advantage|UHC AARP MCR HMO MA|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Access Direct Platinum|HEALTHFIRST TPA UMR|1.78||||1.78||| 87186|EAP|0300|SENSITIVITY|Medicaid|MOLINA HEALTHCARE OF TEXAS|191.35||||204.70||| 87186|EAP|0300|SENSITIVITY|Access Direct Platinum|HEALTHFIRST TPA|204.70||||191.35||| 87186|EAP|0300|SENSITIVITY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.78||||1.78||| 87186|EAP|0300|SENSITIVITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.78||||||| 87186|EAP|0300|SENSITIVITY|Veterans Affairs|VETERANS ADMINISTRATION|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Workers Compensation|TEXAS MUTUAL INSURANCE|1.78||||204.70||| 87186|EAP|0300|SENSITIVITY|Workers Compensation|BROOKSHIRES WORKERS COMP|1.78||||||| 87186|EAP|0300|SENSITIVITY|Workers Compensation|WORKERS COMPENSATION OTHER|204.70||||1.78||| 87186|EAP|0300|SENSITIVITY|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.78||||||| 87186|EAP|0300|SENSITIVITY|United Healthcare|UNITED HEALTHCARE|204.70||||1.78||| 87186|EAP|0300|SENSITIVITY|Tricare|TRICARE EAST REGION|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||191.35||| 87186|EAP|0300|SENSITIVITY|Medicaid|SUPERIOR HEALTHPLAN CHIP|204.70||||191.35||| 87186|EAP|0300|SENSITIVITY|Medicaid|SMITH COUNTY JAIL|1.78||||1.78||| 87186|EAP|0300|SENSITIVITY|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.78||||||| 87186|EAP|0300|SENSITIVITY|United Healthcare|UNITED HEALTHCARE|5.41||||1.78||| 87186|EAP|0300|SENSITIVITY|United Healthcare|GOLDEN RULE|||||1.78||| 87186|EAP|0300|SENSITIVITY|United Healthcare|UNITED HEALTHCARE|204.70||||191.35||| 87186|EAP|0300|SENSITIVITY|Multiplan|NALC|||||204.70||| 87186|EAP|0300|SENSITIVITY TO BACTEROIDS|Medicare|MEDICARE ACUTE|177.01||||204.70||| 87186|EAP|0300|SENSITIVITY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.78||||191.35||| 87186|EAP|0300|SENSITIVITY|NON CONTRACTED|COMMERCIAL OTHER 1|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Rusk State Hospital|RUSK STATE HOSP|204.70||||||| 87186|EAP|0300|COLISTIN|Medicare|MEDICARE ACUTE|273.24||||204.70||| 87186|EAP|0300|SENSITIVITY|PHCS|GROUP AND PENSION|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.78||||||| 87186|EAP|0300|SENSITIVITY|United Healthcare|UNITED HEALTHCARE OTHER|1.78||||1.78||| 87186|EAP|0300|SENSITIVITY|Medicare|MEDICARE ACUTE|3.08||||204.70||| 87186|EAP|0300|SENSITIVITY|Managed Medicare|WELLCARE CHOICE MA|204.70||||||| 87186|EAP|0300|SENSITIVITY|Medicare|MEDICARE ACUTE|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|PHCS|HUMANA INSURANCE|204.70||||||| 87186|EAP|0300|SENSITIVITY|UTMB|UTMB CORRECTIONAL MANAGED CARE|204.70||||191.35||| 87186|EAP|0300|SENSITIVITY|Managed Medicare|HEALTHSPRING MA|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||204.70||| 87186|EAP|0300|SENSITIVITY|PHCS|HUMANA|204.70||||204.70||| 87186|EAP|0300|SENSITIVITY|Medicare|MEDICARE PART B ONLY IP|191.35||||||| 87186|EAP|0300|SENSITIVITY|Medicare|UTSW MC KIDNEY PROGRAM|||||1.78||| 87186|EAP|0300|SENSITIVITY|United Healthcare|TML GROUP BENEFITS|204.70||||||| 87186|EAP|0300|BACT FRAGILIS|Medicare|MEDICARE ACUTE|5.41||||204.70||| 87186|EAP|0300|SENSITIVITY|United Healthcare|GEHA|1.78||||||| 87186|EAP|0300|SENSITIVITY|Managed Medicare|OTHER INSTITUTIONS|204.70||||1.78||| 87186|EAP|0300|SENSITIVITY|Managed Medicare|BCBS MEDICARE PPO MA|1.78||||1.78||| 87186|EAP|0300|SENSITIVITY|Multiplan|WEB TPA|||||204.70||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA|115,376.55|9012.7|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|59,349.39|7104.72|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|73,131.37|6986.06|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|35,616.99|7149.19|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|73,611.17|7104.72|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|82,519.50|6986.94|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|39,466.10|7378.78|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|48,558.56|5072.97|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Humana Medicare Advantage|HUMANA MA|50,460.87|6963.78|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|47,537.95|8272.015|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|33,232.51|25691.855|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|34,155.85|6968.97|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29,910.68|6311.39|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Medicaid|SUPERIOR HEALTHPLAN CHIP|47,867.08|4770.21|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Medicaid|MEDICAID|96,782.60|17791.06|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|31,934.16|9255.22|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|61,670.47|6982.18|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|48,490.80|12301.15|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|57,438.50|9107.51|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|United Medicare Advantage|UHC AARP MCR HMO MA|54,460.13|7104.72|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|37,787.50|5900.49|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Medicare|MEDICARE PART B ONLY IP|39,057.36|3703.005|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Managed Medicare|HEALTHSPRING MA|45,856.28|6986.06|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|52,528.02|125.02|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|43,814.10|4640.74|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103,668.10|7378.78|25691.855|125.02|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Medicare|MEDICARE ACUTE|56,409.10|6986.94|25691.855|125.02|||| 87205|EAP|0300|GRAM STAIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|231.15||||231.15||| 87205|EAP|0300|GRAM STAIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|231.15||||||| 87205|EAP|0300|GRAM STAIN|United Healthcare|UNITED HEALTHCARE OTHER|231.15||||2.01||| 87205|EAP|0300|GRAM STAIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.01||| 87205|EAP|0300|GRAM STAIN|United Healthcare|UNITED HEALTHCARE|2.01||||2.01||| 87205|EAP|0300|GRAM STAIN|Managed Medicare|HEALTHSPRING MA|231.15||||231.15||| 87205|EAP|0300|GRAM STAIN|Medicaid|SMITH COUNTY JAIL|||||2.01||| 87205|EAP|0300|GRAM STAIN|NON CONTRACTED|COMMERCIAL OTHER 2|231.15||||||| 87205|EAP|0300|GRAM STAIN|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.01||| 87205|EAP|0300|GRAM STAIN|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2.01||| 87205|EAP|0300|GRAM STAIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.01||||||| 87205|EAP|0300|GRAM STAIN|Blue Cross PPO Specialty|BCBSTX PPO|2.01||||2.01||| 87205|EAP|0300|SMEAR BACTERIA|Managed Medicaid|MEDICAID SUPERIOR|231.15||||||| 87205|EAP|0300|GRAM STAIN|United Healthcare|UNITED HEALTHCARE|||||2.01||| 87205|EAP|0300|GRAM STAIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||216.08||| 87205|EAP|0300|GRAM STAIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|216.08||||231.15||| 87205|EAP|0300|GRAM STAIN|Cigna|CIGNA|||||2.01||| 87205|EAP|0300|GRAM STAIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|231.15||||||| 87205|EAP|0300|GRAM STAIN|Access Direct Platinum|HEALTHFIRST TPA|2.01||||||| 87205|EAP|0300|GRAM STAIN|Medicare|MEDICARE ACUTE|231.15||||231.15||| 87205|EAP|0300|GRAM STAIN|Medicaid|MEDICAID|2.01||||||| 87205|EAP|0300|GRAM STAIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.01||||||| 87205|EAP|0300|GRAM STAIN|Humana Medicare Advantage|HUMANA MA|231.15||||2.01||| 87205|EAP|0300|GRAM STAIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.01||||2.01||| 87205|EAP|0300|GRAM STAIN|Blue Cross HMO Specialty|BCBSTX HMO|||||216.08||| 87205|EAP|0300|GRAM STAIN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.01||| 87205|EAP|0300|GRAM STAIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.01||||2.01||| 87205|EAP|0300|GRAM STAIN|Aenta Medicare Advantage|AETNA MEDICARE MA|2.01||||2.01||| 87205|EAP|0300|GRAM STAIN|United Medicare Advantage|UHC MEDICARE GOLD MA|231.15||||231.15||| 87205|EAP|0300|GRAM STAIN|Veterans Affairs|VETERANS ADMINISTRATION|231.15||||231.15||| 87205|EAP|0300|GRAM STAIN|Managed Medicaid|MEDICAID AMERIGROUP|||||231.15||| 87205|EAP|0300|GRAM STAIN|United Medicare Advantage|UHC AARP MCR HMO MA|231.15||||231.15||| 87206|EAP|0306|SMEAR ACID FAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|152.95||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|United Medicare Advantage|UHC AARP MCR HMO MA|152.95||||152.95||| 87206|EAP|0306|SMEAR ACID FAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|152.95||||152.95||| 87206|EAP|0306|SMEAR ACID FAST|Cigna|CIGNA|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Cigna|CIGNA|152.95||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Humana Medicare Advantage|HUMANA MA|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Cigna|CIGNA OTHER|152.95||||||| 87206|EAP|0306|SMEAR ACID FAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|152.95||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|United Healthcare|UNITED HEALTHCARE|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|NON CONTRACTED|COMMERCIAL OTHER 1|152.95||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Medicare|MEDICARE ACUTE|1.33||||152.95||| 87206|EAP|0306|SMEAR ACID FAST|Blue Cross PPO Specialty|BCBSTX OTHER|152.95||||||| 87206|EAP|0306|SMEAR ACID FAST|United Medicare Advantage|UHC MEDICARE GOLD MA|1.33||||152.95||| 87206|EAP|0306|SMEAR ACID FAST|Veterans Affairs|VETERANS ADMINISTRATION|152.95||||152.95||| 87206|EAP|0306|SMEAR ACID FAST|Aetna|AETNA PPO|1.33||||||| 87206|EAP|0306|SMEAR ACID FAST|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.33||||||| 87206|EAP|0306|SMEAR ACID FAST|Medicaid|SMITH COUNTY JAIL|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Blue Cross PPO Specialty|BCBSTX PPO|152.95||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Workers Compensation|WORKERS COMPENSATION OTHER|152.95||||||| 87206|EAP|0306|SMEAR ACID FAST|United Healthcare|UNITED HEALTHCARE|152.95||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Aenta Medicare Advantage|AETNA MEDICARE MA|152.95||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|United Healthcare|UNITED HEALTHCARE OTHER|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Blue Cross HMO Specialty|BCBSTX HMO|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Managed Medicaid|MEDICAID AMERIGROUP|152.95||||152.95||| 87206|EAP|0306|SMEAR ACID FAST|United Healthcare|TML GROUP BENEFITS|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|UTMB|UTMB CORRECTIONAL MANAGED CARE|152.95||||||| 87206|EAP|0306|SMEAR ACID FAST|Tricare|TRICARE EAST REGION|1.33||||||| 87206|EAP|0306|SMEAR ACID FAST|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Managed Medicare|HEALTHSPRING MA|152.95||||152.95||| 87206|EAP|0306|SMEAR ACID FAST|Rusk State Hospital|RUSK STATE HOSP|152.95||||||| 87206|EAP|0306|SMEAR ACID FAST|Medicaid|MEDICAID|1.33||||||| 87206|EAP|0306|SMEAR ACID FAST|Access Direct Platinum|HEALTHFIRST TPA|142.98||||||| 87206|EAP|0306|SMEAR ACID FAST|Access Direct Platinum|HEALTHFIRST TPA UMR|152.95||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.33||||1.33||| 87206|EAP|0306|SMEAR ACID FAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|152.95||||152.95||| 87207|EAP|0300|SMEAR MALARIA|Medicare|MEDICARE ACUTE|2.83||||||| 87207|EAP|0300|SMEAR MALARIA|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.83||| 87209|EAP|0300|SMEAR COMPLEX STAIN|United Medicare Advantage|UHC MEDICARE GOLD MA|1.42||||||| 87209|EAP|0300|SMEAR COMPLEX STAIN|Aenta Medicare Advantage|AETNA MEDICARE MA|1.42||||||| 87209|EAP|0300|SMEAR COMPLEX STAIN|United Medicare Advantage|UHC AARP MCR HMO MA|||||163.30||| 87209|EAP|0300|SMEAR COMPLEX STAIN|Medicare|MEDICARE ACUTE|163.30||||||| 87209|EAP|0300|SMEAR COMPLEX STAIN|Medicaid|MEDICAID|1.42||||||| 87210|EAP|0300|SMEAR INDIA INK|Medicare|MEDICARE ACUTE|216.08||||231.15||| 87210|EAP|0300|SMEAR WET MOUNT|United Healthcare|UNITED HEALTHCARE|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Medicare|MEDICARE ACUTE|231.15||||216.08||| 87210|EAP|0300|SMEAR WET MOUNT|Tricare|TRICARE EAST REGION|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Humana Medicare Advantage|HUMANA MA|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Cigna|CIGNA|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Access Direct Platinum|HEALTHFIRST TPA|||||231.15||| 87210|EAP|0300|SMEAR WET MOUNT|Medicaid|SMITH COUNTY JAIL|231.15||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Medicaid|MEDICAID|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||231.15||| 87210|EAP|0300|SMEAR WET MOUNT|NON CONTRACTED|COMMERCIAL OTHER 1|||||216.08||| 87210|EAP|0300|SMEAR WET MOUNT|United Healthcare|UNITED HEALTHCARE OTHER|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|United Medicare Advantage|UHC AARP MCR HMO MA|231.15||||231.15||| 87210|EAP|0300|SMEAR WET MOUNT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Tricare|TRICARE FOR LIFE|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Medicaid|MEDICAID HMO|||||216.08||| 87210|EAP|0300|SMEAR WET MOUNT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Managed Medicaid|MEDICAID SUPERIOR|231.15||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Blue Cross PPO Specialty|BCBSTX PPO|231.15||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Managed Medicaid|MEDICAID AMERIGROUP|2.01||||2.01||| 87210|EAP|0300|SMEAR WET MOUNT|Blue Cross HMO Specialty|BCBSTX HMO|||||231.15||| 87210|EAP|0300|SMEAR WET MOUNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||216.08||| 87210|EAP|0300|SMEAR WET MOUNT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||231.15||| 87220|EAP|0300|KOH PREP HAIR SKIN NAILS|Managed Medicaid|MEDICAID SUPERIOR|||||231.15||| 87252|EAP|0300|CULTURE VIRUS|Aetna|AETNA PPO|||||1,194.56||| 87252|EAP|0300|CULTURE VIRUS|Medicaid|MEDICAID|1,038.75||||||| 87252|EAP|0300|CULTURE VIRUS|Medicaid|COUNTY INDIGENT HEALTH OTHER|1,038.75||||||| 87255|EAP|0300|HERPES CULTURE SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|3.15||||362.25||| 87255|EAP|0300|HERPES CULTURE SCREEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|362.25||||||| 87255|EAP|0300|HERPES CULTURE SCREEN|Managed Medicare|BCBS MEDICARE PPO MA|3.15||||||| 87255|EAP|0300|HERPES CULTURE SCREEN|Medicaid|MEDICAID|||||362.25||| 87255|EAP|0300|HERPES CULTURE SCREEN|Tricare|TRICARE FOR LIFE|||||3.15||| 87260|EAP|0300|ADENOVIRUS ANTIGEN|Aetna|AETNA OTHER|549.99||||||| 87260|EAP|0300|ADENOVIRUS ANTIGEN|Medicare|MEDICARE ACUTE|478.25||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|478.25||||549.99||| 87278|EAP|0300|LEGIONELLA SMEAR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|549.99||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|United Medicare Advantage|UHC MEDICARE GOLD MA|478.25||||549.99||| 87278|EAP|0300|LEGIONELLA SMEAR|Aenta Medicare Advantage|AETNA MEDICARE MA|549.99||||549.99||| 87278|EAP|0300|LEGIONELLA SMEAR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Cigna|CIGNA|478.25||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Cigna|CIGNA|549.99||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Veterans Affairs|VETERANS ADMINISTRATION|549.99||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Blue Cross PPO Specialty|BCBSTX OTHER|549.99||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|549.99||||549.99||| 87278|EAP|0300|LEGIONELLA SMEAR|Managed Medicaid|MEDICAID SUPERIOR|549.99||||||| 87278|EAP|0300|LEGIONELLA SMEAR|United Medicare Advantage|UHC AARP MCR HMO MA|549.99||||514.12||| 87278|EAP|0300|LEGIONELLA SMEAR|Aetna|AETNA PPO|478.25||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Blue Cross HMO Specialty|BCBSTX HMO|478.25||||549.99||| 87278|EAP|0300|LEGIONELLA SMEAR|Blue Cross PPO Specialty|BCBSTX PPO|514.12||||549.99||| 87278|EAP|0300|LEGIONELLA SMEAR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|549.99||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Medicaid|MEDICAID|478.25||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Aetna|BOON CHAPMAN|549.99||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|478.25||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Humana Medicare Advantage|HUMANA MA|478.25||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Access Direct Platinum|HEALTHFIRST TPA|478.25||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|549.99||||||| 87278|EAP|0300|LEGIONELLA SMEAR|United Healthcare|UNITED HEALTHCARE|549.99||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Managed Medicare|HEALTHSPRING MA|478.25||||514.12||| 87278|EAP|0300|LEGIONELLA SMEAR|UTMB|UTMB CORRECTIONAL MANAGED CARE|549.99||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Managed Medicare|BCBS MEDICARE PPO MA|478.25||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|NON CONTRACTED|COMMERCIAL OTHER 1|478.25||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Medicare|MEDICARE ACUTE|549.99||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|United Healthcare|TML GROUP BENEFITS|||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|United Healthcare|UNITED HEALTHCARE OTHER|478.25||||478.25||| 87278|EAP|0300|LEGIONELLA SMEAR|Aetna|AETNA QHP HMO|549.99||||||| 87278|EAP|0300|LEGIONELLA SMEAR|Managed Medicaid|MEDICAID AMERIGROUP|||||549.99||| 87278|EAP|0300|LEGIONELLA SMEAR|Medicaid|SMITH COUNTY JAIL|||||478.25||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Medicare|MEDICARE ACUTE|653.20||||610.60||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.68||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Managed Medicare|BCBS MEDICARE PPO MA|5.68||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|610.60||||653.20||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Blue Cross PPO Specialty|BCBSTX PPO|5.68||||653.20||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Managed Medicare|HEALTHSPRING MA|5.68||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|United Healthcare|UNITED HEALTHCARE|||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|NON CONTRACTED|COMMERCIAL OTHER 1|5.68||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|United Healthcare|UNITED HEALTHCARE OTHER|610.60||||610.60||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Managed Medicaid|MEDICAID AMERIGROUP|||||653.20||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Blue Cross HMO Specialty|BCBSTX HMO|5.68||||653.20||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|653.20||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|United Healthcare|UNITED HEALTHCARE|610.60||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|UTMB|UTMB CORRECTIONAL MANAGED CARE|653.20||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|653.20||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Aetna|AETNA PPO|5.68||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Aenta Medicare Advantage|AETNA MEDICARE MA|610.60||||653.20||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Humana Medicare Advantage|HUMANA MA|653.20||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Cigna|CIGNA|5.68||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|United Healthcare|TML GROUP BENEFITS|||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Veterans Affairs|VETERANS ADMINISTRATION|653.20||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|653.20||||653.20||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|United Medicare Advantage|UHC AARP MCR HMO MA|653.20||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|653.20||||610.60||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Access Direct Platinum|HEALTHFIRST TPA|5.68||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Aetna|BOON CHAPMAN|653.20||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|United Medicare Advantage|UHC MEDICARE GOLD MA|5.68||||610.60||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Medicaid|SMITH COUNTY JAIL|||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Cigna|CIGNA|653.20||||5.68||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Medicaid|MEDICAID|5.68||||||| 87299|EAP|0300|PNEUMOCYSTIS CARINII DFA|Managed Medicaid|MEDICAID SUPERIOR|653.20||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Medicaid|MEDICAID|5.68||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.68||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|NON CONTRACTED|COMMERCIAL OTHER 1|5.68||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|United Healthcare|TML GROUP BENEFITS|||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Aetna|AETNA OTHER|653.20||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Medicare|MEDICARE ACUTE|653.20||||653.20||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Managed Medicare|BCBS MEDICARE PPO MA|5.68||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Managed Medicare|HEALTHSPRING MA|5.68||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|United Healthcare|UNITED HEALTHCARE OTHER|5.68||||610.60||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|653.20||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|United Healthcare|UNITED HEALTHCARE|653.20||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|653.20||||610.60||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|United Medicare Advantage|UHC AARP MCR HMO MA|653.20||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Medicaid|SMITH COUNTY JAIL|||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|653.20||||653.20||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.68||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|United Medicare Advantage|UHC MEDICARE GOLD MA|653.20||||610.60||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Veterans Affairs|VETERANS ADMINISTRATION|653.20||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|653.20||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Humana Medicare Advantage|HUMANA MA|5.68||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.68||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Cigna|CIGNA|5.68||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Managed Medicaid|MEDICAID AMERIGROUP|653.20||||653.20||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Blue Cross HMO Specialty|BCBSTX HMO|5.68||||653.20||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|653.20||||653.20||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|653.20||||653.20||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Cigna|CIGNA|653.20||||5.68||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Aenta Medicare Advantage|AETNA MEDICARE MA|610.60||||653.20||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Aetna|BOON CHAPMAN|653.20||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Blue Cross PPO Specialty|BCBSTX OTHER|653.20||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA|5.68||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Aetna|AETNA QHP HMO|653.20||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|653.20||||||| 87300|EAP|0300|RESPIRATORY VIRAL ANTIGEN|Aetna|AETNA PPO|5.68||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|Medicaid|MEDICAID|461.72||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|Medicare|MEDICARE ACUTE|429.50||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|Managed Medicare|HEALTHSPRING MA|493.93||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|Aenta Medicare Advantage|AETNA MEDICARE MA|429.50||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|UTMB|UTMB CORRECTIONAL MANAGED CARE|493.93||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|Blue Cross PPO Specialty|BCBSTX PPO|429.50||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|Veterans Affairs|VETERANS ADMINISTRATION|493.93||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|NON CONTRACTED|COMMERCIAL OTHER 1|429.50||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|493.93||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|United Medicare Advantage|UHC MEDICARE GOLD MA|429.50||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|461.72||||||| 87305|EAP|0300|ASPERGILLUS GALACTOMANNAN|United Medicare Advantage|UHC AARP MCR HMO MA|493.93||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|United Medicare Advantage|UHC AARP MCR HMO MA|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|United Medicare Advantage|UHC MEDICARE GOLD MA|33.50||||33.50||| 87328|EAP|0300|AG CRYPTOSPORIDIUM STOOL|United Medicare Advantage|UHC AARP MCR HMO MA|460.75||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Cigna|CIGNA OTHER|||||33.50||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.50||||||| 87328|EAP|0300|AG CRYPTOSPORIDIUM STOOL|Humana Medicare Advantage|HUMANA MA|460.75||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Managed Medicaid|MEDICAID SUPERIOR|33.50||||||| 87328|EAP|0300|AG CRYPTOSPORIDIUM STOOL|Cigna|CIGNA|460.75||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Cigna|CIGNA|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|460.75||||33.50||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|33.50||||33.50||| 87328|EAP|0300|AG CRYPTOSPORIDIUM STOOL|Blue Cross PPO Specialty|BCBSTX PPO|460.75||||460.75||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|33.50||||33.50||| 87328|EAP|0300|AG CRYPTOSPORIDIUM STOOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|460.75||||||| 87328|EAP|0300|AG CRYPTOSPORIDIUM STOOL|Medicaid|MEDICAID|460.75||||||| 87328|EAP|0300|AG CRYPTOSPORIDIUM STOOL|United Medicare Advantage|UHC MEDICARE GOLD MA|460.75||||460.75||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|33.50||||||| 87328|EAP|0300|AG CRYPTOSPORIDIUM STOOL|Medicare|MEDICARE ACUTE|460.75||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Rusk State Hospital|RUSK STATE HOSP|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|NON CONTRACTED|COMMERCIAL OTHER 1|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Managed Medicare|HEALTHSPRING MA|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|United Healthcare|UNITED HEALTHCARE OTHER|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Medicare|MEDICARE ACUTE|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Medicaid|MEDICAID|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.50||||33.50||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Blue Cross PPO Specialty|BCBSTX PPO|33.50||||460.75||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Blue Cross HMO Specialty|BCBSTX HMO|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Humana Medicare Advantage|HUMANA MA|33.50||||||| 87328|EAP|0300|IAAD IA CRYPTOSPORIDIUM|Managed Medicaid|MEDICAID AMERIGROUP|33.50||||33.50||| 87329|EAP|0300|IAAD IA GIARDIA|UTMB|UTMB CORRECTIONAL MANAGED CARE|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Rusk State Hospital|RUSK STATE HOSP|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|NON CONTRACTED|COMMERCIAL OTHER 1|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|United Healthcare|UNITED HEALTHCARE OTHER|33.50||||||| 87329|EAP|0300|AG GIARDIA|Medicare|MEDICARE ACUTE|460.75||||||| 87329|EAP|0300|IAAD IA GIARDIA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|33.50||||33.50||| 87329|EAP|0300|IAAD IA GIARDIA|Managed Medicare|HEALTHSPRING MA|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Medicare|MEDICARE ACUTE|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Medicaid|COUNTY INDIGENT HEALTH OTHER|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Blue Cross HMO Specialty|BCBSTX HMO|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Medicaid|MEDICAID|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.50||||33.50||| 87329|EAP|0300|IAAD IA GIARDIA|United Medicare Advantage|UHC MEDICARE GOLD MA|33.50||||33.50||| 87329|EAP|0300|IAAD IA GIARDIA|Cigna|CIGNA OTHER|||||33.50||| 87329|EAP|0300|IAAD IA GIARDIA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|United Medicare Advantage|UHC AARP MCR HMO MA|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Cigna|CIGNA|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|33.50||||33.50||| 87329|EAP|0300|IAAD IA GIARDIA|Humana Medicare Advantage|HUMANA MA|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Managed Medicaid|MEDICAID SUPERIOR|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|Managed Medicaid|MEDICAID AMERIGROUP|33.50||||33.50||| 87329|EAP|0300|AG GIARDIA|Humana Medicare Advantage|HUMANA MA|460.75||||||| 87329|EAP|0300|IAAD IA GIARDIA|Blue Cross PPO Specialty|BCBSTX PPO|33.50||||||| 87329|EAP|0300|IAAD IA GIARDIA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33.50||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|United Medicare Advantage|UHC MEDICARE GOLD MA|0.33||||0.33||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37.95||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Humana Medicare Advantage|HUMANA MA|0.33||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.33||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35.48||||37.95||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Managed Medicaid|MEDICAID AMERIGROUP|37.95||||0.33||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Managed Medicare|HEALTHSPRING MA|0.33||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Managed Medicaid|MEDICAID SUPERIOR|37.95||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|United Medicare Advantage|UHC AARP MCR HMO MA|37.95||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Rusk State Hospital|RUSK STATE HOSP|37.95||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Medicare|MEDICARE ACUTE|0.33||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|NON CONTRACTED|COMMERCIAL OTHER 1|37.95||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Medicaid|MEDICAID|0.33||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|37.95||||37.95||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|UTMB|UTMB CORRECTIONAL MANAGED CARE|37.95||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Blue Cross PPO Specialty|BCBSTX PPO|37.95||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.33||||37.95||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.33||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.33||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Cigna|CIGNA OTHER|||||0.33||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|United Healthcare|UNITED HEALTHCARE OTHER|37.95||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Cigna|CIGNA|37.95||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.33||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Blue Cross HMO Specialty|BCBSTX HMO|0.33||||||| 87337|EAP|0300|IAAD IA ENTAMOEBA HISTOLY|Medicaid|COUNTY INDIGENT HEALTH OTHER|37.95||||||| 87338|EAP|0300|STOOL FOR HPYLORI|Blue Cross PPO Specialty|BCBSTX PPO|1.29||||||| 87338|EAP|0300|STOOL FOR HPYLORI|United Healthcare|UNITED HEALTHCARE|||||148.35||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST TPA|577.28||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Veterans Affairs|VETERANS ADMINISTRATION|5.37||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|617.55||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|United Medicare Advantage|UHC AARP MCR HMO MA|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|617.55||||617.55||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.37||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Workers Compensation|WORKERS COMPENSATION OTHER|617.55||||577.28||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST TPA UMR|5.37||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|United Medicare Advantage|UHC MEDICARE GOLD MA|617.55||||577.28||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID AMERIGROUP|5.37||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Cigna|CIGNA OTHER|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|617.55||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|ChampVA|CHAMPVA CENTER|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|577.28||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Cigna|CIGNA|577.28||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Aenta Medicare Advantage|AETNA MEDICARE MA|5.37||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Aetna|AETNA PPO|617.55||||577.28||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Humana Medicare Advantage|HUMANA MA|617.55||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|617.55||||617.55||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Aetna|AETNA OTHER|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Cigna|CIGNA|617.55||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Blue Cross HMO Specialty|BCBSTX HMO|617.55||||617.55||| 87340|EAP|0300|HEPATITIS B SURFACE AG|United Healthcare|UNITED HEALTHCARE OTHER|617.55||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID SUPERIOR|5.37||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Managed Medicare|BCBS MEDICARE PPO MA|5.37||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Aetna Value Network|AETNA VALUE NETWORK|577.28||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Blue Cross PPO Specialty|BCBSTX OTHER|5.37||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Managed Medicare|WELLCARE CHOICE MA|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Tricare|TRICARE EAST REGION|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Medicaid|MOLINA HEALTHCARE OF TEXAS|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Medicaid|MEDICAID|5.37||||617.55||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Medicaid|MEDICAID HMO|577.28||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Managed Medicare|HEALTHSPRING MA|5.37||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Medicaid|LAW ENFORCEMENT OTHER|||||617.55||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.37||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|617.55||||577.28||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Blue Cross PPO Specialty|BCBSTX PPO|617.55||||617.55||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Tricare|TRICARE FOR LIFE|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Medicare|MEDICARE PART B ONLY IP|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|PHCS|HUMANA|||||617.55||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Medicare|UTSW MC KIDNEY PROGRAM|||||617.55||| 87340|EAP|0300|HEPATITIS B SURFACE AG|NON CONTRACTED|COMMERCIAL OTHER 1|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|PHCS|HUMANA INSURANCE|5.37||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.37||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.37||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Rusk State Hospital|RUSK STATE HOSP|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|UTMB|UTMB CORRECTIONAL MANAGED CARE|617.55||||617.55||| 87340|EAP|0300|HEPATITIS B SURFACE AG|PHCS|GROUP AND PENSION|577.28||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|United Healthcare|UNITED HEALTHCARE|617.55||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|Medicare|MEDICARE ACUTE|617.55||||5.37||| 87340|EAP|0300|HEPATITIS B SURFACE AG|United Healthcare|TML GROUP BENEFITS|617.55||||||| 87340|EAP|0300|HEPATITIS B SURFACE AG|United Healthcare|UNITED HEALTHCARE|5.37||||617.55||| 87350|EAP|0300|HEPATITIS BE AG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.90||||||| 87350|EAP|0300|HEPATITIS BE AG|United Medicare Advantage|UHC AARP MCR HMO MA|6.90||||||| 87350|EAP|0300|HEPATITIS BE AG|Blue Cross PPO Specialty|BCBSTX PPO|6.00||||||| 87350|EAP|0300|HEPATITIS BE AG|Medicare|MEDICARE ACUTE|6.00||||||| 87350|EAP|0300|HEPATITIS BE AG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.00||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|NON CONTRACTED|COMMERCIAL OTHER 1|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|United Medicare Advantage|UHC AARP MCR HMO MA|549.99||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Humana Medicare Advantage|HUMANA MA|478.25||||478.25||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Managed Medicaid|MEDICAID SUPERIOR|549.99||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Managed Medicare|HEALTHSPRING MA|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Veterans Affairs|VETERANS ADMINISTRATION|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|549.99||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Blue Cross HMO Specialty|BCBSTX HMO|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Medicaid|MEDICAID|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Aetna|AETNA PPO|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Medicare|MEDICARE ACUTE|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|United Healthcare|UNITED HEALTHCARE OTHER|478.25||||||| 87385|EAP|0300|HISTOPLASMA AG,URINE|Blue Cross PPO Specialty|BCBSTX PPO|478.25||||||| 87389|EAP|0300|HIV-ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|819.95||||7.13||| 87389|EAP|0300|HIV-ANTIBODY|United Healthcare|UNITED HEALTHCARE|819.95||||7.13||| 87389|EAP|0300|HIV-ANTIBODY|PHCS|HUMANA|7.13||||819.95||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicare|HEALTHSPRING MA|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicare|WELLCARE CHOICE MA|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicare|BCBS MEDICARE PPO MA|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Medicare|MEDICARE ACUTE|819.95||||7.13||| 87389|EAP|0300|HIV-ANTIBODY|Medicare|UTSW MC KIDNEY PROGRAM|||||7.13||| 87389|EAP|0300|HIV-ANTIBODY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|766.48||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Medicaid|MEDICAID|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Medicaid|SMITH COUNTY JAIL|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|United Healthcare|UNITED HEALTHCARE|819.95||||819.95||| 87389|EAP|0300|HIV-ANTIBODY|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|819.95||||819.95||| 87389|EAP|0300|HIV-ANTIBODY|Cigna|CIGNA|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|United Medicare Advantage|UHC MEDICARE GOLD MA|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|819.95||||7.13||| 87389|EAP|0300|HIV-ANTIBODY|United Healthcare|UNITED HEALTHCARE OTHER|766.48||||||| 87389|EAP|0300|HIV-ANTIBODY|UTMB|UTMB CORRECTIONAL MANAGED CARE|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||7.13||| 87389|EAP|0300|HIV-ANTIBODY|Tricare|TRICARE EAST REGION|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|819.95||||766.48||| 87389|EAP|0300|HIV-ANTIBODY|United Medicare Advantage|UHC AARP MCR HMO MA|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Aenta Medicare Advantage|AETNA MEDICARE MA|7.13||||7.13||| 87389|EAP|0300|HIV-ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UMR|766.48||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicare|ETMC AFFILIATE HOSPITALS|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Humana Medicare Advantage|HUMANA MA|819.95||||7.13||| 87389|EAP|0300|HIV-ANTIBODY|ChampVA|CHAMPVA CENTER|||||819.95||| 87389|EAP|0300|HIV-ANTIBODY|Cigna|CIGNA OTHER|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|819.95||||7.13||| 87389|EAP|0300|HIV-ANTIBODY|Veterans Affairs|VETERANS ADMINISTRATION|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Workers Compensation|WORKERS COMPENSATION OTHER|||||819.95||| 87389|EAP|0300|HIV-ANTIBODY|Aetna|AETNA PPO|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Rusk State Hospital|RUSK STATE HOSP|819.95||||||| 87389|EAP|0300|HIV-ANTIBODY|Aetna|AETNA OTHER|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Access Direct Platinum|ANDREWS CENTER|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|7.13||||||| 87389|EAP|0300|HIV-ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|819.95||||819.95||| 87425|EAP|0300|ROTAVIRUS ANTIGEN|NON CONTRACTED|COMMERCIAL OTHER 1|653.20||||||| 87425|EAP|0300|ROTAVIRUS ANTIGEN|Medicare|MEDICARE ACUTE|653.20||||||| 87425|EAP|0300|ROTAVIRUS ANTIGEN|Managed Medicare|HEALTHSPRING MA|5.68||||||| 87425|EAP|0300|ROTAVIRUS ANTIGEN|Blue Cross HMO Specialty|BCBSTX HMO|5.68||||||| 87425|EAP|0300|ROTAVIRUS ANTIGEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|653.20||||||| 87425|EAP|0300|ROTAVIRUS ANTIGEN|Managed Medicaid|MEDICAID AMERIGROUP|653.20||||653.20||| 87425|EAP|0300|ROTAVIRUS ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||653.20||| 87425|EAP|0300|ROTAVIRUS ANTIGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|610.60||||||| 87427|EAP|0300|SHIGA-LIKE TOXIN|Blue Cross PPO Specialty|BCBSTX PPO|0.30||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|NON CONTRACTED|COMMERCIAL OTHER 1|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Managed Medicaid|MEDICAID AMERIGROUP|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Managed Medicaid|MEDICAID SUPERIOR|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Medicaid|MEDICAID|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Managed Medicare|HEALTHSPRING MA|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Veterans Affairs|VETERANS ADMINISTRATION|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Access Direct Platinum|HEALTHFIRST TPA|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Humana Medicare Advantage|HUMANA MA|478.25||||478.25||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|United Medicare Advantage|UHC AARP MCR HMO MA|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Cigna|CIGNA OTHER|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Managed Medicare|BCBS MEDICARE PPO MA|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|United Healthcare|UNITED HEALTHCARE OTHER|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Aetna|AETNA PPO|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Blue Cross HMO Specialty|BCBSTX HMO|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Tricare|TRICARE EAST REGION|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Medicare|MEDICARE ACUTE|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Blue Cross PPO Specialty|BCBSTX PPO|478.25||||478.25||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Brinson Benefits|THE HEALTH PLAN SMITH CO|478.25||||||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Blue Cross PPO Specialty|BCBSTX OTHER|478.25||||||| 87476|EAP|0300|LYME DIS DNA AMP PROBE|United Healthcare|UNITED HEALTHCARE OTHER|78.85||||||| 87476|EAP|0300|LYME DIS DNA AMP PROBE|Aenta Medicare Advantage|AETNA MEDICARE MA|78.85||||||| 87476|EAP|0300|LYME DIS DNA AMP PROBE|Medicare|MEDICARE ACUTE|78.85||||||| 87486|EAP|0300|CHYLMD PNEUM DNA AMP PROB|Medicaid|MEDICAID|1.05||||||| 87486|EAP|0300|CHYLMD PNEUM DNA AMP PROB|Managed Medicare|BCBS MEDICARE PPO MA|1.05||||||| 87486|EAP|0300|CHYLMD PNEUM DNA AMP PROB|United Healthcare|UNITED HEALTHCARE OTHER|1.05||||||| 87486|EAP|0300|CHYLMD PNEUM DNA AMP PROB|Medicare|MEDICARE ACUTE|1.05||||||| 87486|EAP|0300|CHYLMD PNEUM DNA AMP PROB|Humana Medicare Advantage|HUMANA MA|1.05||||||| 87486|EAP|0300|CHYLMD PNEUM DNA AMP PROB|Blue Cross PPO Specialty|BCBSTX PPO|1.05||||||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Veterans Affairs|VETERANS ADMINISTRATION|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Access Direct Platinum|HEALTHFIRST TPA|||||1,744.73||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Access Direct Platinum|HEALTHFIRST TPA|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Access Direct Platinum|ANDREWS CENTER|16.23||||||| 87491|EAP|0300|IADNA NEISSERIA GONORRHOE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.84||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Blue Cross PPO Specialty|BCBSTX PPO|1,866.45||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Blue Cross PPO Specialty|BCBSTX PPO|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Managed Medicaid|MEDICAID AMERIGROUP|16.23||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1,744.73||||||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Managed Medicaid|MEDICAID SUPERIOR|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Managed Medicaid|MEDICAID SUPERIOR|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Managed Medicaid|MEDICAID AMERIGROUP|16.23||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,744.73||||16.23||| 87491|EAP|0300|IADNA NEISSERIA GONORRHOE|Cigna|CIGNA|||||5.84||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Cigna|CIGNA|||||16.23||| 87491|EAP|0300|IADNA NEISSERIA GONORRHOE|Managed Medicaid|MEDICAID AMERIGROUP|16.23||||5.84||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,744.73||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Humana Medicare Advantage|HUMANA MA|||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Humana Medicare Advantage|HUMANA MA|||||1,744.73||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|United Healthcare|GEHA|||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Cigna|CIGNA|||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Tricare|TRICARE FOR LIFE|||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|United Healthcare|UNITED HEALTHCARE|1,866.45||||16.23||| 87491|EAP|0300|IADNA NEISSERIA GONORRHOE|United Healthcare|UNITED HEALTHCARE|||||5.84||| 87491|EAP|0300|IADNA NEISSERIA GONORRHOE|Managed Medicaid|MEDICAID SUPERIOR|1,866.45||||5.84||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|United Healthcare|UNITED HEALTHCARE|||||16.23||| 87491|EAP|0300|IADNA NEISSERIA GONORRHOE|Blue Cross PPO Specialty|BCBSTX PPO|1,866.45||||5.84||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Blue Cross HMO Specialty|BCBSTX HMO|||||1,744.73||| 87491|EAP|0300|IADNA NEISSERIA GONORRHOE|Blue Cross HMO Specialty|BCBSTX HMO|||||5.84||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Blue Cross HMO Specialty|BCBSTX HMO|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|United Healthcare|UNITED HEALTHCARE OTHER|16.23||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|United Healthcare|UNITED HEALTHCARE|||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|United Healthcare|UNITED HEALTHCARE OTHER|16.23||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|NON CONTRACTED|COMMERCIAL OTHER 1|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|NON CONTRACTED|COMMERCIAL OTHER 1|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Multiplan|WEB TPA|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,744.73||| 87491|EAP|0300|IADNA NEISSERIA GONORRHOE|Medicare|MEDICARE ACUTE|1,744.73||||5.84||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Medicare|MEDICARE ACUTE|1,866.45||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.23||||1,866.45||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.23||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Medicare|MEDICARE ACUTE|1,744.73||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Tricare|TRICARE EAST REGION|||||16.23||| 87491|EAP|0300|CHYLMD TRACH DNA AMP PROB|Medicaid|MEDICAID HMO|||||194.50||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Medicaid|SMITH COUNTY JAIL|16.23||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Managed Medicare|HEALTHSPRING MA|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Medicaid|MEDICAID HMO|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Medicaid|MEDICAID|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA AMPLIFIED DNA|Medicaid|SMITH COUNTY JAIL|16.23||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Medicaid|MEDICAID BCBSTX|||||1,866.45||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Medicaid|MEDICAID|1,866.45||||16.23||| 87491|EAP|0300|CHLAMYDIA DNA BY TMA|Medicaid|MEDICAID HMO|||||1,866.45||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|United Healthcare|UNITED HEALTHCARE OTHER|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Managed Medicare|HEALTHSPRING MA|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Medicaid|MEDICAID|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Medicare|MEDICARE ACUTE|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Rusk State Hospital|RUSK STATE HOSP|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Humana Medicare Advantage|HUMANA MA|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|United Healthcare|GOLDEN RULE|||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Tricare|TRICARE EAST REGION|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Cigna|CIGNA|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|ChampVA|CHAMPVA CENTER|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Medicare|MEDICARE PART B ONLY IP|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Managed Medicaid|MEDICAID AMERIGROUP|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Blue Cross PPO Specialty|BCBSTX OTHER|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Managed Medicare|BCBS MEDICARE PPO MA|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Aetna|AETNA PPO|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Aenta Medicare Advantage|AETNA MEDICARE MA|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Blue Cross HMO Specialty|BCBSTX HMO|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Aetna|AETNA OTHER|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Medicaid|SMITH COUNTY JAIL|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Blue Cross PPO Specialty|BCBSTX PPO|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Access Direct Platinum|HEALTHFIRST TPA|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Managed Medicaid|MEDICAID SUPERIOR|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|NON CONTRACTED|COMMERCIAL OTHER 1|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|Veterans Affairs|VETERANS ADMINISTRATION|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.05||||||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.05||||1.05||| 87493|EAP|0300|CLOSTRIDIUM DIFFICILE PCR|United Medicare Advantage|UHC AARP MCR HMO MA|1.05||||1.05||| 87497|EAP|0300|CMV DNA BY PCR QN|United Medicare Advantage|UHC MEDICARE GOLD MA|1,130.75||||||| 87497|EAP|0300|CMV DNA BY PCR QN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,130.75||||||| 87497|EAP|0300|CMV DNA BY PCR QN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,130.75||||||| 87497|EAP|0300|CMV DNA BY PCR QN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,130.75||| 87497|EAP|0300|CMV DNA BY PCR QN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,130.75||||||| 87497|EAP|0300|CMV DNA BY PCR QN|Blue Cross PPO Specialty|BCBSTX PPO|1,130.75||||1,130.75||| 87497|EAP|0300|CMV DNA BY PCR QN|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,130.75||| 87497|EAP|0300|CMV DNA BY PCR QN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,130.75||||||| 87497|EAP|0300|CMV DNA BY PCR QN|Humana Medicare Advantage|HUMANA MA|1,130.75||||1,130.75||| 87497|EAP|0300|CMV DNA BY PCR QN|United Healthcare|UNITED HEALTHCARE OTHER|1,130.75||||||| 87497|EAP|0300|CMV DNA BY PCR QN|Medicaid|SMITH COUNTY JAIL|1,130.75||||||| 87497|EAP|0300|CMV DNA BY PCR QN|Blue Cross HMO Specialty|BCBSTX HMO|1,130.75||||1,130.75||| 87497|EAP|0300|CMV DNA BY PCR QN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,130.75||||||| 87497|EAP|0300|CMV ON CSF|Managed Medicare|HEALTHSPRING MA|378.67||||||| 87497|EAP|0300|CMV DNA BY PCR QN|Medicare|MEDICARE ACUTE|1,130.75||||1,130.75||| 87497|EAP|0300|CMV DNA BY PCR QN|United Healthcare|UNITED HEALTHCARE|1,130.75||||1,130.75||| 87497|EAP|0300|CMV DNA BY PCR QN|Tricare|TRICARE FOR LIFE|1,130.75||||||| 87498|EAP|0300|ENTEROVIRUS PCR|Medicare|MEDICARE ACUTE|1,367.75||||||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Cigna|CIGNA|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Brinson Benefits|THE HEALTH PLAN SMITH CO|4.69||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Aetna|AETNA QHP HMO|539.35||||||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Aetna Value Network|AETNA VALUE NETWORK|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Aenta Medicare Advantage|AETNA MEDICARE MA|4.69||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.69||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Aetna|AETNA PPO|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Blue Cross PPO Specialty|BCBSTX PPO|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Blue Cross PPO Specialty|BCBSTX OTHER|4.69||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Blue Cross HMO Specialty|BCBSTX HMO|4.69||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Veterans Affairs|VETERANS ADMINISTRATION|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Cigna|CIGNA OTHER|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicaid|MEDICAID SUPERIOR|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Workers Compensation|WORKERS COMPENSATION OTHER|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|539.35||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|United Medicare Advantage|UHC AARP MCR HMO MA|539.35||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Access Direct Platinum|ANDREWS CENTER|4.69||||||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|United Medicare Advantage|UHC AARP WELLMED HMO MA|539.35||||||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|United Medicare Advantage|UHC MEDICARE GOLD MA|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Aetna|AETNA OTHER|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicare|WELLCARE CHOICE MA|539.35||||||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicare|BCBS MEDICARE PPO MA|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicare|HEALTHSPRING MA|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|SMITH COUNTY JAIL|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Workers Compensation|UT EMPLOYEE INJURY|539.35||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|MEDICAID CSHCN|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.69||||||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|MEDICAID HMO|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicare|OTHER INSTITUTIONS|||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|ChampVA|CHAMPVA CENTER|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Humana Medicare Advantage|HUMANA MA|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Managed Medicaid|MEDICAID AMERIGROUP|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|MEDICAID|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|LAW ENFORCEMENT OTHER|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|United Healthcare|UNITED HEALTHCARE|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|BH TEXAS CHILDRENS MEDICAID|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|MEDICAID BCBSTX|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|United Healthcare|UNITED HEALTHCARE|539.35||||504.18||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|United Healthcare|UNITED HEALTHCARE OTHER|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|United Healthcare|GEHA|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Tricare|TRICARE EAST REGION|539.35||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Tricare|TRICARE FOR LIFE|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|PHCS|HUMANA|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.69||||||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Rusk State Hospital|RUSK STATE HOSP|539.35||||||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|NON CONTRACTED|COMMERCIAL OTHER 1|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|United Healthcare|TML GROUP BENEFITS|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|UTMB|UTMB CORRECTIONAL MANAGED CARE|539.35||||539.35||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicare|MEDICARE ACUTE|4.69||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Multiplan|WEB TPA|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Multiplan|NALC|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Medicare|MEDICARE PART B ONLY IP|4.69||||||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|NON CONTRACTED|COMMERCIAL OTHER 2|||||4.69||| 87502|EAP|0300|INFLUENZA DNA AMP PROBE|Optum Behavioral Health|BH OPTUM UHC|4.69||||||| 87517|EAP|0300|HEPATITIS B VIRUS DNA PCR|Medicaid|SMITH COUNTY JAIL|1,130.75||||||| 87517|EAP|0300|HEPATITIS B VIRUS DNA PCR|Medicare|MEDICARE ACUTE|1,300.36||||1,130.75||| 87517|EAP|0300|HEPATITIS B VIRUS DNA PCR|Medicare|UTSW MC KIDNEY PROGRAM|||||1,130.75||| 87517|EAP|0300|HEPATITIS B VIRUS DNA PCR|Medicaid|MEDICAID|1,130.75||||||| 87517|EAP|0300|HEPATITIS B VIRUS DNA PCR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,130.75||||||| 87517|EAP|0300|HEPATITIS B VIRUS DNA PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,130.75||| 87517|EAP|0300|HEPATITIS B VIRUS DNA PCR|Blue Cross PPO Specialty|BCBSTX PPO|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,130.75||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|United Medicare Advantage|UHC MEDICARE GOLD MA|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Managed Medicaid|MEDICAID SUPERIOR|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Managed Medicaid|MEDICAID AMERIGROUP|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Cigna|CIGNA OTHER|||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|Blue Cross HMO Specialty|BCBSTX HMO|||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|Blue Cross PPO Specialty|BCBSTX PPO|1,130.75||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|United Medicare Advantage|UHC AARP MCR HMO MA|1,130.75||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Managed Medicare|HEALTHSPRING MA|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Workers Compensation|WORKERS COMPENSATION OTHER|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Humana Medicare Advantage|HUMANA MA|1,130.75||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|Aetna|AETNA OTHER|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Medicaid|MEDICAID|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Medicare|MEDICARE ACUTE|1,130.75||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|PHCS|HUMANA|||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|United Healthcare|UNITED HEALTHCARE|1,130.75||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|Medicaid|COUNTY INDIGENT HEALTH OTHER|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|Medicare|UTSW MC KIDNEY PROGRAM|||||1,130.75||| 87522|EAP|0300|HCV RNA BY PCR QN|Medicaid|SMITH COUNTY JAIL|1,130.75||||||| 87522|EAP|0300|HCV RNA BY PCR QN|United Healthcare|UNITED HEALTHCARE|1,130.75||||||| 87529|EAP|0300|HSV BY PCR|PHCS|HUMANA|1,367.75||||||| 87529|EAP|0300|HSV BY PCR|Managed Medicare|HEALTHSPRING MA|1,572.91||||1,367.75||| 87529|EAP|0300|HSV BY PCR|United Healthcare|UNITED HEALTHCARE|1,367.75||||||| 87529|EAP|0300|HSV BY PCR|Medicaid|COUNTY INDIGENT HEALTH OTHER|1,572.91||||||| 87529|EAP|0300|HSV BY PCR|Managed Medicare|BCBS MEDICARE PPO MA|1,367.75||||||| 87529|EAP|0300|HSV BY PCR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,572.91||||||| 87529|EAP|0300|HSV BY PCR|Tricare|TRICARE FOR LIFE|1,572.91||||||| 87529|EAP|0300|HSV BY PCR|Medicare|MEDICARE ACUTE|1,572.91||||1,470.33||| 87529|EAP|0300|HSV BY PCR|United Medicare Advantage|UHC AARP MCR HMO MA|1,572.91||||||| 87529|EAP|0300|HSV BY PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|1,470.33||||||| 87529|EAP|0300|HSV BY PCR|Medicaid|SMITH COUNTY JAIL|1,470.33||||||| 87529|EAP|0300|HSV BY PCR|United Healthcare|UNITED HEALTHCARE OTHER|1,572.91||||||| 87529|EAP|0300|HSV BY PCR|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,470.33||||||| 87529|EAP|0300|HSV BY PCR|Medicaid|MEDICAID|1,367.75||||||| 87529|EAP|0300|HSV BY PCR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,367.75||||||| 87529|EAP|0300|HSV BY PCR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,367.75||||1,367.75||| 87529|EAP|0300|HSV BY PCR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,572.91||||||| 87529|EAP|0300|HSV BY PCR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,367.75||||||| 87529|EAP|0300|HSV BY PCR|Veterans Affairs|VETERANS ADMINISTRATION|1,470.33||||||| 87529|EAP|0300|HSV BY PCR|Blue Cross PPO Specialty|BCBSTX PPO|1,470.33||||1,470.33||| 87529|EAP|0300|HSV BY PCR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,572.91||||1,367.75||| 87529|EAP|0300|HSV BY PCR|Blue Cross HMO Specialty|BCBSTX HMO|1,572.91||||||| 87529|EAP|0300|HSV BY PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,367.75||||1,367.75||| 87529|EAP|0300|HSV BY PCR|Aenta Medicare Advantage|AETNA MEDICARE MA|1,572.91||||||| 87529|EAP|0300|HSV BY PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,367.75||||1,572.91||| 87529|EAP|0300|HSV BY PCR|Managed Medicaid|MEDICAID AMERIGROUP|1,572.91||||1,572.91||| 87529|EAP|0300|HSV BY PCR|Managed Medicaid|MEDICAID SUPERIOR|1,367.75||||||| 87529|EAP|0300|HSV BY PCR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,367.75||||||| 87529|EAP|0300|HSV BY PCR|Humana Medicare Advantage|HUMANA MA|1,572.91||||1,572.91||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|Managed Medicaid|MEDICAID AMERIGROUP|2,352.90||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.46||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.46||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|Humana Medicare Advantage|HUMANA MA|20.46||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,352.90||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|20.46||||||| 87536|EAP|0300|HIV-1 QUANT&REVRSE TRNSCR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.70||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|United Medicare Advantage|UHC AARP MCR HMO MA|2,352.90||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|Medicaid|MEDICAID|2,352.90||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|Tricare|TRICARE FOR LIFE|2,352.90||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|UTMB|UTMB CORRECTIONAL MANAGED CARE|20.46||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|Medicare|MEDICARE ACUTE|2,352.90||||||| 87536|EAP|0300|HIV-1 RNA QUANTITATION BY|United Healthcare|UNITED HEALTHCARE OTHER|2,352.90||||||| 87556|EAP|0300|MYCOBACTERIUM TB PCR|Medicare|MEDICARE ACUTE|466.10||||||| 87556|EAP|0300|MYCOBACTERIUM TB PCR|Humana Medicare Advantage|HUMANA MA|||||466.10||| 87556|EAP|0300|MYCOBACTERIUM TB PCR|Managed Medicare|HEALTHSPRING MA|466.10||||466.10||| 87556|EAP|0300|MYCOBACTERIUM TB PCR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|435.70||||||| 87556|EAP|0300|MYCOBACTERIUM TB PCR|Medicaid|SMITH COUNTY JAIL|466.10||||||| 87581|EAP|0300|M.PNEUMON DNA AMP PROBE|Managed Medicare|BCBS MEDICARE PPO MA|1.05||||||| 87581|EAP|0300|M.PNEUMON DNA AMP PROBE|Humana Medicare Advantage|HUMANA MA|1.05||||||| 87581|EAP|0300|M.PNEUMON DNA AMP PROBE|Blue Cross PPO Specialty|BCBSTX PPO|1.05||||||| 87581|EAP|0300|M.PNEUMON DNA AMP PROBE|Medicaid|MEDICAID|1.05||||||| 87581|EAP|0300|M.PNEUMON DNA AMP PROBE|United Healthcare|UNITED HEALTHCARE OTHER|1.05||||||| 87581|EAP|0300|M.PNEUMON DNA AMP PROBE|Medicare|MEDICARE ACUTE|1.05||||||| 87591|EAP|0300|IADNA CHLAMYDIA TRACHOMAT|Medicare|MEDICARE ACUTE|1,256.25||||5.84||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Tricare|TRICARE EAST REGION|||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|NON CONTRACTED|COMMERCIAL OTHER 1|1,866.45||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Multiplan|WEB TPA|||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Medicare|MEDICARE ACUTE|16.23||||1,744.73||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|United Healthcare|UNITED HEALTHCARE|1,744.73||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|United Healthcare|UNITED HEALTHCARE|||||16.23||| 87591|EAP|0300|N.GONORRHOEAE DNA AMP PRO|Medicaid|MEDICAID HMO|||||194.50||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,256.25||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Medicaid|SMITH COUNTY JAIL|16.23||||||| 87591|EAP|0300|MYCOPLASMA PNEUMONIAE PCR|Managed Medicare|HEALTHSPRING MA|1,256.25||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|United Healthcare|UNITED HEALTHCARE OTHER|16.23||||1,866.45||| 87591|EAP|0300|MYCOPLASMA PNEUMONIAE PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|1,256.25||||||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Medicaid|MEDICAID HMO|||||1,744.73||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Veterans Affairs|VETERANS ADMINISTRATION|||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.23||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,866.45||| 87591|EAP|0300|IADNA CHLAMYDIA TRACHOMAT|United Healthcare|UNITED HEALTHCARE|||||5.84||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|United Healthcare|GEHA|||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Access Direct Platinum|HEALTHFIRST TPA|||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Managed Medicare|HEALTHSPRING MA|1,866.45||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Medicaid|MEDICAID BCBSTX|||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Medicaid|MEDICAID|1,866.45||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Access Direct Platinum|ANDREWS CENTER|16.23||||||| 87591|EAP|0300|IADNA CHLAMYDIA TRACHOMAT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.84||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.23||| 87591|EAP|0300|IADNA CHLAMYDIA TRACHOMAT|Managed Medicaid|MEDICAID SUPERIOR|1,866.45||||5.84||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Managed Medicaid|MEDICAID SUPERIOR|1,866.45||||1,866.45||| 87591|EAP|0300|IADNA CHLAMYDIA TRACHOMAT|Managed Medicaid|MEDICAID AMERIGROUP|16.23||||5.84||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,744.73||||1,744.73||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Managed Medicaid|MEDICAID AMERIGROUP|16.23||||1,866.45||| 87591|EAP|0300|IADNA CHLAMYDIA TRACHOMAT|Cigna|CIGNA|||||5.84||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Tricare|TRICARE FOR LIFE|||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1,866.45||||||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Cigna|CIGNA|||||16.23||| 87591|EAP|0300|MYCOPLASMA PNEUMONIAE PCR|Humana Medicare Advantage|HUMANA MA|1,256.25||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Humana Medicare Advantage|HUMANA MA|1,866.45||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Blue Cross HMO Specialty|BCBSTX HMO|||||1,744.73||| 87591|EAP|0300|IADNA CHLAMYDIA TRACHOMAT|Blue Cross HMO Specialty|BCBSTX HMO|||||5.84||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,866.45||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Blue Cross PPO Specialty|BCBSTX PPO|1,744.73||||16.23||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,866.45||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,866.45||| 87591|EAP|0300|IADNA CHLAMYDIA TRACHOMAT|Blue Cross PPO Specialty|BCBSTX PPO|1,256.25||||5.84||| 87591|EAP|0300|GONORRHEA (GC) BYTMA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,744.73||| 87633|EAP|0300|RESP VIRUS 12-25 TARGETS|Humana Medicare Advantage|HUMANA MA|12.50||||||| 87633|EAP|0300|RESP VIRUS 12-25 TARGETS|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||||| 87633|EAP|0300|RESP VIRUS 12-25 TARGETS|United Healthcare|UNITED HEALTHCARE OTHER|12.50||||||| 87633|EAP|0300|RESP VIRUS 12-25 TARGETS|Medicare|MEDICARE ACUTE|12.50||||||| 87633|EAP|0300|RESP VIRUS 12-25 TARGETS|Managed Medicare|BCBS MEDICARE PPO MA|12.50||||||| 87633|EAP|0300|RESP VIRUS 12-25 TARGETS|Medicaid|MEDICAID|12.50||||||| 87640|EAP|0300|STAPH A DNA AMP PROBE|Medicare|MEDICARE ACUTE|63.25||||||| 87640|EAP|0300|STAPH A DNA AMP PROBE|Blue Cross PPO Specialty|BCBSTX PPO|63.25||||||| 87640|EAP|0300|STAPH A DNA AMP PROBE|Humana Medicare Advantage|HUMANA MA|63.25||||||| 87640|EAP|0300|STAPH A DNA AMP PROBE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.13||||||| 87640|EAP|0300|STAPH A DNA AMP PROBE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|63.25||||||| 87640|EAP|0300|STAPH A DNA AMP PROBE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63.25||||||| 87640|EAP|0300|STAPH A DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA|0.55||||||| 87641|EAP|0300|MR-STAPH DNA AMP PROBE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63.25||||||| 87641|EAP|0300|MR-STAPH DNA AMP PROBE|Blue Cross PPO Specialty|BCBSTX PPO|63.25||||||| 87641|EAP|0300|MR-STAPH DNA AMP PROBE|Humana Medicare Advantage|HUMANA MA|63.25||||||| 87641|EAP|0300|MR-STAPH DNA AMP PROBE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.13||||||| 87641|EAP|0300|MR-STAPH DNA AMP PROBE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|63.25||||||| 87641|EAP|0300|MR-STAPH DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA|0.55||||||| 87641|EAP|0300|MR-STAPH DNA AMP PROBE|Medicare|MEDICARE ACUTE|63.25||||||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid|SMITH COUNTY JAIL|268.60||||||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.08||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid|MEDICAID HMO|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid|MEDICAID BCBSTX|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid|LAW ENFORCEMENT OTHER|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||239.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicare|OTHER INSTITUTIONS|||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Tricare|TRICARE FOR LIFE|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicare|BCBS MEDICARE PPO MA|||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid|MEDICAID|329.20||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicare|HEALTHSPRING MA|329.20||||239.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||284.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|United Healthcare|TML GROUP BENEFITS|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|United Healthcare|GEHA|329.20||||||| 87651|EAP|0300|STREP A DNA AMP PROBE|PHCS|HUMANA|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Multiplan|NALC|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicare|MEDICARE ACUTE|329.20||||239.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Veterans Affairs|VETERANS ADMINISTRATION|329.20||||284.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|United Healthcare|UNITED HEALTHCARE OTHER|||||239.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|United Healthcare|UNITED HEALTHCARE|2.08||||223.60||| 87651|EAP|0300|STREP A DNA AMP PROBE|United Healthcare|UNITED HEALTHCARE|329.20||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|223.60||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|NON CONTRACTED|COMMERCIAL OTHER 1|329.20||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|329.20||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicaid|MEDICAID SUPERIOR|284.20||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|268.60||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA|329.20||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicare|MEDICARE PART B ONLY IP|284.20||||||| 87651|EAP|0300|STREP A DNA AMP PROBE|United Medicare Advantage|UHC MEDICARE GOLD MA|329.20||||239.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|UTMB|UTMB CORRECTIONAL MANAGED CARE|329.20||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Tricare|TRICARE EAST REGION|239.20||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.08||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|United Medicare Advantage|UHC AARP MCR HMO MA|329.20||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicare|WELLCARE CHOICE MA|329.20||||||| 87651|EAP|0300|STREP A DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.08||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.08||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.08||||||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicaid|MEDICAID AMERIGROUP|329.20||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.08||||||| 87651|EAP|0300|STREP A DNA AMP PROBE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|329.20||||239.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Cigna|CIGNA|268.60||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Cigna|CIGNA|||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Humana Medicare Advantage|HUMANA MA|329.20||||239.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Aenta Medicare Advantage|AETNA MEDICARE MA|268.60||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Cigna|CIGNA OTHER|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Aetna|AETNA PPO|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Aetna|AETNA OTHER|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||239.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Aetna Value Network|AETNA VALUE NETWORK|||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Blue Cross PPO Specialty|BCBSTX OTHER|||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|329.20||||329.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Blue Cross HMO Specialty|BCBSTX HMO|329.20||||239.20||| 87651|EAP|0300|STREP A DNA AMP PROBE|Blue Cross PPO Specialty|BCBSTX PPO|329.20||||2.08||| 87651|EAP|0300|STREP A DNA AMP PROBE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|329.20||||2.08||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,248.25||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Blue Cross HMO Specialty|BCBSTX HMO|357.50||||1,248.25||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Blue Cross HMO Specialty|BCBSTX HMO|1,248.25||||1,248.25||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.81||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,248.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Aenta Medicare Advantage|AETNA MEDICARE MA|1,248.25||||||| 87798|EAP|0300|DETECT AGENT NOS DNA AMP|Aenta Medicare Advantage|AETNA MEDICARE MA|78.85||||||| 87798|EAP|0300|VARICELLA ZOSTER SWAB|Humana Medicare Advantage|HUMANA MA|425.25||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Humana Medicare Advantage|HUMANA MA|1,703.15||||||| 87798|EAP|0300|PARVOVIRUS PCR|Humana Medicare Advantage|HUMANA MA|1,248.25||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Managed Medicaid|MEDICAID AMERIGROUP|1,703.15||||||| 87798|EAP|0300|EBV BY PCR PARAFIN BLOCK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|842.98||||||| 87798|EAP|0300|PARVOVIRUS PCR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,248.25||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|United Medicare Advantage|UHC AARP MCR HMO MA|1,703.15||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|United Medicare Advantage|UHC MEDICARE GOLD MA|14.81||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.81||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,248.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|United Medicare Advantage|UHC AARP MCR HMO MA|1,248.25||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,703.15||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,248.25||||14.81||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|14.81||||1,248.25||| 87798|EAP|0300|DETECT AGENT NOS DNA AMP|Medicare|MEDICARE ACUTE|78.85||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,248.25||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Veterans Affairs|VETERANS ADMINISTRATION|1,703.15||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|14.81||||14.81||| 87798|EAP|0300|VARICELLA ZOSTER PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|1,248.25||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Medicare|MEDICARE ACUTE|1,703.15||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,248.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Medicare|MEDICARE ACUTE|1,248.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Veterans Affairs|VETERANS ADMINISTRATION|1,248.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|PHCS|HUMANA|1,248.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Managed Medicaid|MEDICAID AMERIGROUP|1,248.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,248.25||||1,248.25||| 87798|EAP|0300|PARVOVIRUS PCR|Medicare|MEDICARE ACUTE|1,248.25||||||| 87798|EAP|0300|JC VIRUS BY PCR|Medicare|MEDICARE ACUTE|14.81||||||| 87798|EAP|0300|VARICELLA ZOSTER SWAB|Medicare|MEDICARE ACUTE|425.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Humana Medicare Advantage|HUMANA MA|1,248.25||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|PHCS|HUMANA|14.81||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|United Healthcare|UNITED HEALTHCARE OTHER|1,703.15||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Tricare|TRICARE FOR LIFE|1,703.15||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Tricare|TRICARE FOR LIFE|1,248.25||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Aenta Medicare Advantage|AETNA MEDICARE MA|1,703.15||||||| 87798|EAP|0300|JC VIRUS PCR CSF DNA QN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|329.33||||||| 87798|EAP|0300|PARVOVIRUS PCR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,248.25||||||| 87798|EAP|0300|PARVOVIRUS PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,248.25||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Medicaid|SMITH COUNTY JAIL|14.81||||||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Medicaid|MEDICAID|14.81||||||| 87798|EAP|0300|VARICELLA ZOSTER SWAB|Medicaid|COUNTY INDIGENT HEALTH OTHER|425.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Medicaid|SMITH COUNTY JAIL|1,248.25||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,248.25||||1,248.25||| 87798|EAP|0300|T WHIPPLE DNA BY PCR|Managed Medicare|HEALTHSPRING MA|1,248.25||||5.70||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Managed Medicare|HEALTHSPRING MA|1,248.25||||1,248.25||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Medicaid|MEDICAID|1,248.25||||||| 87798|EAP|0300|TOXOPLASMA PCR|Medicare|MEDICARE ACUTE|217.60||||||| 87798|EAP|0300|VARICELLA ZOSTER PCR|United Healthcare|UNITED HEALTHCARE|14.81||||1,248.25||| 87798|EAP|0300|VARICELLA ZOSTER PCR|United Healthcare|UNITED HEALTHCARE OTHER|1,248.25||||||| 87798|EAP|0300|DETECT AGENT NOS DNA AMP|United Healthcare|UNITED HEALTHCARE OTHER|78.85||||||| 87798|EAP|0300|VARICELLA ZOSTER SWAB|Blue Cross PPO Specialty|BCBSTX PPO|425.25||||1,248.25||| 87798|EAP|0300|VARICELLA ZOSTER PCR|Blue Cross PPO Specialty|BCBSTX PPO|1,248.25||||1,248.25||| 87798|EAP|0300|TOXOPLASMA PCR|Blue Cross PPO Specialty|BCBSTX PPO|217.60||||1,248.25||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Blue Cross PPO Specialty|BCBSTX PPO|1,703.15||||1,248.25||| 87798|EAP|0300|WEST NILE VIRUS BY PCR, P|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,703.15||||1,248.25||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,392.50||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|United Healthcare|UNITED HEALTHCARE|||||1,392.50||| 87799|EAP|0300|CMV BY PCR|Medicaid|MEDICAID|5.09||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Managed Medicare|ETMC AFFILIATE HOSPITALS|1,392.50||||||| 87799|EAP|0300|CMV BY PCR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.09||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Managed Medicare|HEALTHSPRING MA|1,392.50||||||| 87799|EAP|0300|CMV BY PCR|Tricare|TRICARE FOR LIFE|5.09||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Tricare|TRICARE FOR LIFE|1,392.50||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,392.50||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|United Healthcare|UNITED HEALTHCARE OTHER|1,392.50||||5.09||| 87799|EAP|0300|CMV BY PCR|United Healthcare|UNITED HEALTHCARE|||||5.09||| 87799|EAP|0300|CMV BY PCR|United Healthcare|UNITED HEALTHCARE OTHER|5.09||||5.09||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|United Healthcare|UNITED HEALTHCARE|1,392.50||||||| 87799|EAP|0300|CMV BY PCR|NON CONTRACTED|COMMERCIAL OTHER 1|5.09||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Medicare|UTSW MC KIDNEY PROGRAM|||||1,392.50||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Medicare|MEDICARE ACUTE|1,392.50||||1,392.50||| 87799|EAP|0300|CMV BY PCR|Medicare|UTSW MC KIDNEY PROGRAM|||||5.09||| 87799|EAP|0300|CMV BY PCR|Medicare|MEDICARE ACUTE|5.09||||5.09||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Veterans Affairs|VETERANS ADMINISTRATION|1,392.50||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,392.50||||||| 87799|EAP|0300|CMV BY PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|5.09||||5.09||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,392.50||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|1,392.50||||5.09||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|United Medicare Advantage|UHC AARP MCR HMO MA|1,392.50||||||| 87799|EAP|0300|CMV BY PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.09||||||| 87799|EAP|0300|CMV BY PCR|Managed Medicare|HEALTHSPRING MA|5.09||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Managed Medicaid|MEDICAID AMERIGROUP|1,392.50||||||| 87799|EAP|0300|CMV BY PCR|Managed Medicaid|MEDICAID AMERIGROUP|5.09||||||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Humana Medicare Advantage|HUMANA MA|1,392.50||||1,392.50||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Humana Medicare Advantage|HUMANA MA|5.09||||1,392.50||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.09||||1,392.50||| 87799|EAP|0300|CMV BY PCR|Blue Cross HMO Specialty|BCBSTX HMO|5.09||||5.09||| 87799|EAP|0300|CMV BY PCR|Blue Cross PPO Specialty|BCBSTX PPO|5.09||||5.09||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,392.50||||1,392.50||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Blue Cross PPO Specialty|BCBSTX PPO|1,392.50||||1,392.50||| 87799|EAP|0300|CMV BY PCR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,392.50||||5.09||| 87799|EAP|0300|EPSTEIN BARR VIRUS PCR|Blue Cross HMO Specialty|BCBSTX HMO|1,392.50||||5.09||| 87801|EAP|0300|BORDETELLA PERTUSSIS PCR|Managed Medicaid|MEDICAID AMERIGROUP|2,040.10||||17.74||| 87801|EAP|0300|BORDETELLA PERTUSSIS PCR|Tricare|TRICARE EAST REGION|2,040.10||||||| 87801|EAP|0300|BORDETELLA PERTUSSIS PCR|Veterans Affairs|VETERANS ADMINISTRATION|17.74||||||| 87801|EAP|0300|PARAFIN BLOCK FOR HISTOPL|Managed Medicaid|MEDICAID AMERIGROUP|2,040.10||||420.04||| 87801|EAP|0300|BORDETELLA PERTUSSIS PCR|Blue Cross PPO Specialty|BCBSTX PPO|2,040.10||||2,040.10||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Managed Medicare|HEALTHSPRING MA|256.45||||||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Medicaid|MEDICAID HMO|||||239.73||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Medicare|MEDICARE ACUTE|256.45||||256.45||| 87807|EAP|0300|RSV ASSAY W/OPTIC|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|United Healthcare|UNITED HEALTHCARE OTHER|||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|United Healthcare|UNITED HEALTHCARE|256.45||||||| 87807|EAP|0300|RSV ASSAY W/OPTIC|United Healthcare|UNITED HEALTHCARE|||||256.45||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Tricare|TRICARE EAST REGION|2.23||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||256.45||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Humana Medicare Advantage|HUMANA MA|256.45||||256.45||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Aetna|AETNA PPO|||||239.73||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Blue Cross PPO Specialty|BCBSTX PPO|2.23||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Medicaid|MEDICAID|2.23||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Blue Cross HMO Specialty|BCBSTX HMO|||||256.45||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||239.73||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Managed Medicaid|MEDICAID AMERIGROUP|239.73||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||256.45||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Managed Medicaid|MEDICAID SUPERIOR|239.73||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Access Direct Platinum|HEALTHFIRST TPA|||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.23||| 87807|EAP|0300|RSV ASSAY W/OPTIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||256.45||| 87807|EAP|0300|RSV ASSAY W/OPTIC|United Medicare Advantage|UHC AARP MCR HMO MA|256.45||||||| 87807|EAP|0300|RSV ASSAY W/OPTIC|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||256.45||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|514.12||||549.99||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Blue Cross HMO Specialty|BCBSTX HMO|514.12||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|478.25||||478.25||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Cigna|CIGNA|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Humana Medicare Advantage|HUMANA MA|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Access Direct Platinum|HEALTHFIRST TPA|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|United Medicare Advantage|UHC MEDICARE GOLD MA|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|United Medicare Advantage|UHC AARP MCR HMO MA|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Tricare|TRICARE EAST REGION|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Veterans Affairs|VETERANS ADMINISTRATION|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|United Healthcare|UNITED HEALTHCARE OTHER|478.25||||478.25||| 87899|EAP|0300|OVA AND PARASITE SCREEN|United Healthcare|TML GROUP BENEFITS|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|United Healthcare|GEHA|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|NON CONTRACTED|COMMERCIAL OTHER 1|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Cigna|CIGNA OTHER|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Rusk State Hospital|RUSK STATE HOSP|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Medicare|MEDICARE PART B ONLY IP|549.99||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Medicare|MEDICARE ACUTE|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Aenta Medicare Advantage|AETNA MEDICARE MA|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Medicaid|MEDICAID|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Aetna|AETNA PPO|514.12||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Managed Medicare|HEALTHSPRING MA|478.25||||478.25||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|478.25||||||| 87899|EAP|0300|OVA AND PARASITE SCREEN|Managed Medicare|BCBS MEDICARE PPO MA|478.25||||||| 87901|EAP|0300|HIV-1 GENOTYPE|Medicare|MEDICARE ACUTE|5,277.35||||||| 87901|EAP|0300|HIV-1 GENOTYPE|NON CONTRACTED|COMMERCIAL OTHER 1|||||45.89||| 87901|EAP|0300|HIV-1 GENOTYPE|UTMB|UTMB CORRECTIONAL MANAGED CARE|45.89||||||| 87901|EAP|0300|HIV-1 GENOTYPE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|45.89||||||| 87902|EAP|0300|HCV GENOTYPE|United Medicare Advantage|UHC MEDICARE GOLD MA|1,958.50||||||| 87902|EAP|0300|HCV GENOTYPE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,958.50||||||| 87902|EAP|0300|HCV GENOTYPE|Humana Medicare Advantage|HUMANA MA|1,958.50||||||| 87902|EAP|0300|HCV GENOTYPE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,958.50||||||| 87902|EAP|0300|HCV GENOTYPE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,958.50||||||| 87902|EAP|0300|HCV GENOTYPE|Medicaid|MEDICAID|1,958.50||||||| 87902|EAP|0300|HCV GENOTYPE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,958.50||||||| 87902|EAP|0300|HCV GENOTYPE|Medicare|UTSW MC KIDNEY PROGRAM|||||1,958.50||| 87906|EAP|0300|GENOTYPE DNA/RNA HIV 8790|Medicare|MEDICARE ACUTE|989.71||||||| 87906|EAP|0300|GENOTYPE DNA/RNA HIV 8790|UTMB|UTMB CORRECTIONAL MANAGED CARE|860.62||||||| 88|DRG||CONCUSSION W MCC|Blue Cross PPO Specialty|BCBSTX PPO|76,234.50|9242.44|9242.44|9242.44|||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Humana Medicare Advantage|HUMANA MA|88,482.52||||||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29,536.39||||||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Blue Cross HMO Specialty|BCBSTX HMO|95,798.20||||||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Blue Cross PPO Specialty|BCBSTX PPO|227.98||||||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Medicare|MEDICARE ACUTE|70,764.45|6020.31|10142.27|4274.53|||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|United Medicare Advantage|UHC AARP MCR HMO MA|51,775.14|6087.89|10142.27|4274.53|||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|67,393.55|5971.55|10142.27|4274.53|||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|United Healthcare|UNITED HEALTHCARE|71,672.67|10142.27|10142.27|4274.53|||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Tricare|TRICARE EAST REGION|18,884.25|4274.53|10142.27|4274.53|||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Access Direct Platinum|ANDREWS CENTER|19,032.50|7421.78|10142.27|4274.53|||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Access Direct Platinum|HEALTHFIRST TPA|33,168.30|7421.78|10142.27|4274.53|||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Managed Medicaid|MEDICAID AMERIGROUP|43,105.50|5774.7|10142.27|4274.53|||| 880|DRG||ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,604.70|5219.59|10142.27|4274.53|||| 881|DRG||DEPRESSIVE NEUROSES|Access Direct Platinum|HEALTHFIRST TPA UMR|65.47|7478.95|7478.95|41.67|||| 881|DRG||DEPRESSIVE NEUROSES|Access Direct Platinum|ANDREWS CENTER|19,684.50|7055.08|7478.95|41.67|||| 881|DRG||DEPRESSIVE NEUROSES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|66.73|7055.08|7478.95|41.67|||| 881|DRG||DEPRESSIVE NEUROSES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20,133.25|2561.87|7478.95|41.67|||| 881|DRG||DEPRESSIVE NEUROSES|Blue Cross PPO Specialty|BCBSTX PPO|20,800.12|41.67|7478.95|41.67|||| 881|DRG||DEPRESSIVE NEUROSES|Humana Medicare Advantage|HUMANA MA|17,909.96||||||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Medicare|MEDICARE ACUTE|200.75||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Managed Medicare|HEALTHSPRING MA|200.75||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|200.75||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|United Medicare Advantage|UHC AARP MCR HMO MA|200.75||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|United Medicare Advantage|UHC MEDICARE GOLD MA|200.75||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Managed Medicaid|MEDICAID AMERIGROUP|||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Aenta Medicare Advantage|AETNA MEDICARE MA|||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Humana Medicare Advantage|HUMANA MA|200.75||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|200.75||||200.75||| 88104|EAP|0311|CYTOPATH - FLUIDS WASHING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|200.75||||200.75||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Aenta Medicare Advantage|AETNA MEDICARE MA|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|ChampVA|CHAMPVA CENTER|2.40||||||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Humana Medicare Advantage|HUMANA MA|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Managed Medicaid|MEDICAID SUPERIOR|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Managed Medicaid|MEDICAID AMERIGROUP|||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|United Medicare Advantage|UHC AARP MCR HMO MA|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Medicaid|MEDICAID|2.40||||||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Managed Medicare|HEALTHSPRING MA|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Managed Medicare|BCBS MEDICARE PPO MA|2.40||||||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Tricare|TRICARE FOR LIFE|2.40||||||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|United Healthcare|UNITED HEALTHCARE|2.40||||||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|PHCS|HUMANA|2.40||||||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Medicare|MEDICARE ACUTE|2.40||||2.40||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Veterans Affairs|VETERANS ADMINISTRATION|2.40||||||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Medicare|MEDICARE PART B ONLY IP|2.40||||||| 88112|EAP|0311|CYTOPATH-SEL CELL ENHANCE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.40||||2.40||| 88162|EAP|0311|RENAL BIOPSY|Medicare|MEDICARE ACUTE|450.50||||450.50||| 88162|EAP|0311|RENAL BIOPSY|NON CONTRACTED|COMMERCIAL OTHER 1|||||450.50||| 88162|EAP|0311|RENAL BIOPSY|Tricare|TRICARE EAST REGION|||||450.50||| 88162|EAP|0311|RENAL BIOPSY|United Medicare Advantage|UHC MEDICARE GOLD MA|450.50||||||| 88162|EAP|0311|RENAL BIOPSY|Medicaid|MEDICAID|450.50||||||| 88162|EAP|0311|MUSCLE BIOPSY|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||450.50||| 88162|EAP|0311|RENAL BIOPSY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||450.50||| 88162|EAP|0311|RENAL BIOPSY|Workers Compensation|WORKERS COMPENSATION OTHER|||||450.50||| 88162|EAP|0311|RENAL BIOPSY|Medicaid|SMITH COUNTY JAIL|450.50||||||| 88162|EAP|0311|RENAL BIOPSY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|450.50||||||| 88162|EAP|0311|RENAL BIOPSY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||450.50||| 88162|EAP|0311|MUSCLE BIOPSY|UTMB|UTMB CORRECTIONAL MANAGED CARE|450.50||||||| 88162|EAP|0311|RENAL BIOPSY|Humana Medicare Advantage|HUMANA MA|||||450.50||| 88162|EAP|0311|RENAL BIOPSY|Cigna|CIGNA|||||450.50||| 88162|EAP|0311|RENAL BIOPSY|Blue Cross PPO Specialty|BCBSTX PPO|450.50||||450.50||| 88162|EAP|0311|NERVE BIOPSY|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||450.50||| 88162|EAP|0311|RENAL BIOPSY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|450.50||||||| 88162|EAP|0311|RENAL BIOPSY|Blue Cross HMO Specialty|BCBSTX HMO|450.50||||||| 88162|EAP|0311|RENAL BIOPSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|450.50||||450.50||| 88172|EAP|0311|FNA DETER ADEQ|Aenta Medicare Advantage|AETNA MEDICARE MA|235.75||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|Humana Medicare Advantage|HUMANA MA|235.75||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|Managed Medicaid|MEDICAID AMERIGROUP|||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|235.75||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|235.75||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|235.75||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|Managed Medicare|HEALTHSPRING MA|235.75||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|Medicare|MEDICARE ACUTE|235.75||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|United Medicare Advantage|UHC AARP MCR HMO MA|235.75||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|United Medicare Advantage|UHC MEDICARE GOLD MA|235.75||||235.75||| 88172|EAP|0311|FNA DETER ADEQ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|235.75||||235.75||| 88173|EAP|0311|FNA INTERP/REPORT|Medicare|MEDICARE ACUTE|318.25||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|318.25||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|United Medicare Advantage|UHC MEDICARE GOLD MA|318.25||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|Managed Medicaid|MEDICAID AMERIGROUP|||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|318.25||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|Humana Medicare Advantage|HUMANA MA|318.25||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|318.25||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|United Medicare Advantage|UHC AARP MCR HMO MA|318.25||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|Managed Medicare|HEALTHSPRING MA|318.25||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|Aenta Medicare Advantage|AETNA MEDICARE MA|318.25||||318.25||| 88173|EAP|0311|FNA INTERP/REPORT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|318.25||||318.25||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|Aenta Medicare Advantage|AETNA MEDICARE MA|||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|Humana Medicare Advantage|HUMANA MA|154.75||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|Managed Medicaid|MEDICAID AMERIGROUP|||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|154.75||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|Managed Medicaid|MEDICAID UNITED HEALTHCARE|154.75||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|United Medicare Advantage|UHC MEDICARE GOLD MA|154.75||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|United Medicare Advantage|UHC AARP MCR HMO MA|||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|154.75||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|Managed Medicare|HEALTHSPRING MA|154.75||||154.75||| 88177|EAP|0311|CYTOPATH FNA EVALUATION -|Medicare|MEDICARE ACUTE|154.75||||154.75||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|United Healthcare|UNITED HEALTHCARE OTHER|228.70||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|United Healthcare|UNITED HEALTHCARE OTHER|1.00||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|United Healthcare|UNITED HEALTHCARE|1.00||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Tricare|TRICARE EAST REGION|228.70||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Tricare|TRICARE FOR LIFE|228.70||||||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Medicare|UTSW MC KIDNEY PROGRAM|||||228.70||| 88184|EAP|0300|FLOW CYTOMETRY/BLOOD|Medicare|MEDICARE ACUTE|11.99||||11.99||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|Medicare|MEDICARE ACUTE|1.00||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Medicare|MEDICARE ACUTE|228.70||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Medicaid|MEDICAID|1.00||||228.70||| 88184|EAP|0300|FLOW CYTOMETRY/BLOOD|Managed Medicare|WELLCARE CHOICE MA|11.99||||||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.00||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.00||||||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|Managed Medicare|BCBS MEDICARE PPO MA|||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||1.00||| 88184|EAP|0300|FLOW CYTOMETRY/BLOOD|Managed Medicare|HEALTHSPRING MA|11.99||||||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|United Medicare Advantage|UHC MEDICARE GOLD MA|228.70||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|228.70||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|United Medicare Advantage|UHC AARP MCR HMO MA|228.70||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Managed Medicare|HEALTHSPRING MA|1.00||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.00||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|Managed Medicare|HEALTHSPRING MA|1.00||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|228.70||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|United Medicare Advantage|UHC AARP MCR HMO MA|228.70||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|228.70||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.00||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Managed Medicaid|MEDICAID SUPERIOR|228.70||||||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|228.70||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Managed Medicaid|MEDICAID AMERIGROUP|||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.00||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|ChampVA|CHAMPVA CENTER|228.70||||||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Humana Medicare Advantage|HUMANA MA|228.70||||228.70||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|Humana Medicare Advantage|HUMANA MA|1.00||||1.00||| 88184|EAP|0300|FLOW CYTOMETRY/BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||11.99||| 88184|EAP|0311|FLOW CYTOMETRY CS 1 MARKE|Aenta Medicare Advantage|AETNA MEDICARE MA|228.70||||1.00||| 88184|EAP|0311|FLOW CYTOMETRY/TC 1 MARKE|Aenta Medicare Advantage|AETNA MEDICARE MA|228.70||||228.70||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.42||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Humana Medicare Advantage|HUMANA MA|0.42||||0.42||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Humana Medicare Advantage|HUMANA MA|1.44||||1.44||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|ChampVA|CHAMPVA CENTER|1.44||||||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.44||||1.44||| 88185|EAP|0310|FLOW OVER 24 PANEL MARKER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.77||||||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.44||||1.44||| 88185|EAP|0300|FLOWCYTOMETRY/TC ADD-ON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.56||||||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Managed Medicaid|MEDICAID AMERIGROUP|||||1.44||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Managed Medicaid|MEDICAID SUPERIOR|1.44||||||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|United Medicare Advantage|UHC AARP MCR HMO MA|1.44||||1.44||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.42||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.42||| 88185|EAP|0310|FLOW OVER 24 PANEL MARKER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.77||| 88185|EAP|0310|FLOW OVER 24 PANEL MARKER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.77||| 88185|EAP|0300|FLOWCYTOMETRY/TC ADD-ON|United Medicare Advantage|UHC MEDICARE GOLD MA|0.56||||0.56||| 88185|EAP|0300|FLOWCYTOMETRY/TC ADD-ON|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.56||| 88185|EAP|0300|FLOWCYTOMETRY/TC ADD-ON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.56||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.42||||||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.42||| 88185|EAP|0310|FLOW OVER 24 PANEL MARKER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.77||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.42||||||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Managed Medicare|WELLCARE CHOICE MA|0.42||||||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|United Medicare Advantage|UHC MEDICARE GOLD MA|1.44||||1.44||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.42||| 88185|EAP|0310|FLOW OVER 24 PANEL MARKER|Managed Medicare|WELLCARE CHOICE MA|0.77||||||| 88185|EAP|0310|FLOW OVER 24 PANEL MARKER|Managed Medicare|HEALTHSPRING MA|0.42||||0.77||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.44||||1.44||| 88185|EAP|0300|FLOWCYTOMETRY/TC ADD-ON|Managed Medicare|BCBS MEDICARE PPO MA|||||0.56||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.44||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.42||||||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.42||||0.42||| 88185|EAP|0300|FLOWCYTOMETRY/TC ADD-ON|Managed Medicare|HEALTHSPRING MA|0.56||||0.56||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.44||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Managed Medicare|HEALTHSPRING MA|||||1.44||| 88185|EAP|0310|FLOW OVER 24 PANEL MARKER|Managed Medicare|BCBS MEDICARE PPO MA|||||0.77||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Medicaid|MEDICAID|||||1.44||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Medicare|MEDICARE ACUTE|0.42||||0.42||| 88185|EAP|0300|FLOWCYTOMETRY/TC ADD-ON|Medicare|MEDICARE ACUTE|0.56||||0.56||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Medicare|UTSW MC KIDNEY PROGRAM|||||1.44||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Tricare|TRICARE FOR LIFE|1.44||||||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Aenta Medicare Advantage|AETNA MEDICARE MA|1.44||||1.44||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Tricare|TRICARE EAST REGION|1.44||||1.44||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|Medicare|MEDICARE ACUTE|1.44||||1.44||| 88185|EAP|0300|FLOWCYTOMETRY/TC ADD-ON|United Healthcare|UNITED HEALTHCARE|0.56||||0.56||| 88185|EAP|0311|FLOW CYTOMETRY / TC ADD-O|United Healthcare|UNITED HEALTHCARE OTHER|1.44||||||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|Medicaid|MEDICAID|0.42||||||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|United Healthcare|UNITED HEALTHCARE OTHER|0.77||||0.42||| 88185|EAP|0310|FLOW OVER 24 PANEL MARKER|Medicare|MEDICARE ACUTE|0.77||||0.77||| 88185|EAP|0310|FLOW OVER 24 PANEL MARKER|United Healthcare|UNITED HEALTHCARE|0.77||||||| 88185|EAP|0310|FLOW PNH PANEL MARKERS|United Healthcare|UNITED HEALTHCARE OTHER|0.42||||0.42||| 88189|EAP|0311|FLOW CYTOMETRY / READ 16|Medicare|MEDICARE ACUTE|294.25||||||| 882|DRG||NEUROSES EXCEPT DEPRESSIVE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|364.74|4472.79|5610.15|27.78|||| 882|DRG||NEUROSES EXCEPT DEPRESSIVE|Managed Medicaid|MEDICAID AMERIGROUP|463.44|4472.79|5610.15|27.78|||| 882|DRG||NEUROSES EXCEPT DEPRESSIVE|Blue Cross PPO Specialty|BCBSTX PPO|13,888.55|27.78|5610.15|27.78|||| 882|DRG||NEUROSES EXCEPT DEPRESSIVE|Aetna|BH AETNA|12,276.50|32.4|5610.15|27.78|||| 882|DRG||NEUROSES EXCEPT DEPRESSIVE|Medicare|MEDICARE ACUTE|21,069.50|5610.15|5610.15|27.78|||| 882|DRG||NEUROSES EXCEPT DEPRESSIVE|Medicaid|MOLINA HEALTHCARE OF TEXAS|25,344.75|2813.08|5610.15|27.78|||| 88230|EAP|0311|TISSUE CULTURE NON NEOPLA|Blue Cross PPO Specialty|BCBSTX PPO|1,692.25||||||| 88230|EAP|0311|TISSUE CULTURE NON NEOPLA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,692.25||||||| 88233|EAP|0310|TISSUE CULTURE SKIN/BIOPS|Blue Cross PPO Specialty|BCBSTX PPO|1,768.75||||||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|United Healthcare|UNITED HEALTHCARE OTHER|0.99||||||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|United Healthcare|UNITED HEALTHCARE|463.10||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|United Healthcare|UNITED HEALTHCARE|0.99||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Medicare|MEDICARE ACUTE|0.99||||0.99||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Managed Medicare|WELLCARE CHOICE MA|463.10||||||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Managed Medicare|HEALTHSPRING MA|463.10||||||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Medicare|MEDICARE ACUTE|463.10||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Managed Medicare|HEALTHSPRING MA|0.99||||||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|463.10||||||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Medicaid|MEDICAID|463.10||||||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|United Healthcare|UNITED HEALTHCARE OTHER|463.10||||||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Veterans Affairs|VETERANS ADMINISTRATION|||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.99||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|463.10||||||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|463.10||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|463.10||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Humana Medicare Advantage|HUMANA MA|||||463.10||| 88237|EAP|0311|TISSUE CULTURE BONE MARRO|Humana Medicare Advantage|HUMANA MA|||||0.99||| 88262|EAP|0311|CHROMOSONE ANALYSIS 15-20|Blue Cross PPO Specialty|BCBSTX PPO|1,724.50||||||| 88262|EAP|0311|CHROMOSONE ANALYSIS 15-20|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,983.18||||||| 88262|EAP|0311|CHROMOSONE ANALYSIS 15-20|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,983.18||| 88262|EAP|0311|CHROMOSONE ANALYSIS 15-20|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,724.50||||||| 88271|EAP|0311|MOLECULAR CYTOGENICS DNA|Medicaid|MEDICAID|1.50||||||| 88271|EAP|0311|MOLECULAR CYTOGENICS DNA|NON CONTRACTED|COMMERCIAL OTHER 1|172.50||||||| 88271|EAP|0311|MOLECULAR CYTOGENICS DNA|Medicare|MEDICARE ACUTE|172.50||||||| 88271|EAP|0311|MOLECULAR CYTOGENICS DNA|United Medicare Advantage|UHC MEDICARE GOLD MA|1.50||||||| 88271|EAP|0311|MOLECULAR CYTOGENICS DNA|Veterans Affairs|VETERANS ADMINISTRATION|1.50||||||| 88271|EAP|0311|MOLECULAR CYTOGENICS DNA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.50||||||| 88271|EAP|0311|MOLECULAR CYTOGENICS DNA|Humana Medicare Advantage|HUMANA MA|1.50||||||| 88275|EAP|0311|MOLECULAR CYTOGENICS 100-|Humana Medicare Advantage|HUMANA MA|135.06||||||| 88275|EAP|0311|MOLECULAR CYTOGENICS 100-|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|135.06||||||| 88275|EAP|0311|MOLECULAR CYTOGENICS 100-|Veterans Affairs|VETERANS ADMINISTRATION|135.06||||||| 88275|EAP|0311|MOLECULAR CYTOGENICS 100-|United Medicare Advantage|UHC MEDICARE GOLD MA|135.06||||||| 88275|EAP|0311|MOLECULAR CYTOGENICS 100-|Medicare|MEDICARE ACUTE|155.32||||||| 88275|EAP|0311|MOLECULAR CYTOGENICS 100-|NON CONTRACTED|COMMERCIAL OTHER 1|155.32||||||| 88275|EAP|0311|MOLECULAR CYTOGENICS 100-|Medicaid|MEDICAID|135.06||||||| 88291|EAP|0311|CYTOGENICS/MOLECULAR INTE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|127.40||||||| 88291|EAP|0311|CYTOGENICS/MOLECULAR INTE|Blue Cross PPO Specialty|BCBSTX PPO|127.40||||||| 883|DRG||DISORDERS OF PERSONALITY & IMPULSE CONTROL|Medicare|MEDICARE ACUTE|9,373.93|8617.45|8617.45|3907.05|||| 883|DRG||DISORDERS OF PERSONALITY & IMPULSE CONTROL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|41,450.75|3907.05|8617.45|3907.05|||| 88300|EAP|0312|LEVEL I GROSS|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| 88300|EAP|0312|LEVEL I GROSS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||||| 88300|EAP|0312|LEVEL I GROSS|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||||| 88300|EAP|0312|LEVEL I GROSS|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||||| 88300|EAP|0312|LEVEL I GROSS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| 88300|EAP|0312|LEVEL I GROSS|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| 88300|EAP|0312|LEVEL I GROSS|Managed Medicare|HEALTHSPRING MA|||||1.27||| 88300|EAP|0312|LEVEL I GROSS|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.27||| 88300|EAP|0312|LEVEL I GROSS|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.27||||||| 88300|EAP|0312|LEVEL I GROSS|Medicaid|MEDICAID HMO|1.27||||||| 88300|EAP|0312|LEVEL I GROSS|Medicaid|MEDICAID|1.27||||||| 88300|EAP|0312|LEVEL I GROSS|Medicare|MEDICARE ACUTE|1.27||||1.27||| 88300|EAP|0312|LEVEL I GROSS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.27||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Medicaid|MEDICAID|213.75||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Managed Medicare|HEALTHSPRING MA|213.75||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Managed Medicare|BCBS MEDICARE PPO MA|||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Medicare|MEDICARE ACUTE|213.75||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Cigna|CIGNA|||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|ChampVA|CHAMPVA CENTER|213.75||||||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Humana Medicare Advantage|HUMANA MA|213.75||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Managed Medicaid|MEDICAID SUPERIOR|213.75||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|213.75||||||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|213.75||||||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Managed Medicaid|MEDICAID AMERIGROUP|213.75||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|213.75||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|United Medicare Advantage|UHC AARP MCR HMO MA|213.75||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|United Medicare Advantage|UHC AARP WELLMED HMO MA|213.75||||||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Multiplan|WEB TPA|||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|United Healthcare|UNITED HEALTHCARE|213.75||||||| 88302|EAP|0312|LEVEL II GROSS & MICRO|United Medicare Advantage|UHC MEDICARE GOLD MA|213.75||||||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Aenta Medicare Advantage|AETNA MEDICARE MA|213.75||||213.75||| 88302|EAP|0312|LEVEL II GROSS & MICRO|Blue Cross PPO Specialty|BCBSTX PPO|||||213.75||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Veterans Affairs|VETERANS ADMINISTRATION|||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|United Medicare Advantage|UHC MEDICARE GOLD MA|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Managed Medicaid|MEDICAID AMERIGROUP|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|ChampVA|CHAMPVA CENTER|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Medicare|MEDICARE ACUTE|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Medicare|MEDICARE PART B ONLY IP|2.86||||||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Tricare|TRICARE SOUTH PHYSICIAN|||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Tricare|TRICARE FOR LIFE|||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Tricare|TRICARE EAST REGION|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|United Healthcare|UNITED HEALTHCARE OTHER|2.86||||||| 88304|EAP|0312|LEVEL III GROSS & MICRO|United Medicare Advantage|UHC AARP MCR HMO MA|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|United Healthcare|UNITED HEALTHCARE|2.86||||||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Aenta Medicare Advantage|AETNA MEDICARE MA|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Managed Medicare|BCBS MEDICARE PPO MA|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Managed Medicaid|MEDICAID SUPERIOR|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Managed Medicare|HEALTHSPRING MA|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Humana Medicare Advantage|HUMANA MA|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|Medicaid|MEDICAID|2.86||||2.86||| 88304|EAP|0312|LEVEL III GROSS & MICRO|NON CONTRACTED|COMMERCIAL OTHER 1|2.86||||2.86||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|Medicaid|MEDICAID|0.58||||||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Medicaid|MEDICAID|376.25||||376.25||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|Managed Medicare|HEALTHSPRING MA|0.58||||||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Medicaid|MEDICAID HMO|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicare|OTHER INSTITUTIONS|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Medicaid|SMITH COUNTY JAIL|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicare|HEALTHSPRING MA|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|United Healthcare|UNITED HEALTHCARE OTHER|376.25||||||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|United Healthcare|UNITED HEALTHCARE|376.25||||||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Tricare|TRICARE FOR LIFE|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Tricare|TRICARE EAST REGION|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Medicare|UTSW MC KIDNEY PROGRAM|||||376.25||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|Medicare|MEDICARE ACUTE|0.58||||0.58||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Blue Cross PPO Specialty|BCBSTX PPO|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|PHCS|HUMANA|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Aenta Medicare Advantage|AETNA MEDICARE MA|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|ChampVA|CHAMPVA CENTER|376.25||||376.25||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|Humana Medicare Advantage|HUMANA MA|||||0.58||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Humana Medicare Advantage|HUMANA MA|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|376.25||||376.25||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.58||||||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|PHCS|HUMANA INSURANCE|376.25||||||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.58||||0.58||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicare|BCBS MEDICARE PPO MA|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Medicare|MEDICARE PART B ONLY IP|376.25||||||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicaid|MEDICAID SUPERIOR|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Managed Medicaid|MEDICAID AMERIGROUP|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Tricare|TRICARE SOUTH PHYSICIAN|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Medicare|MEDICARE ACUTE|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|United Medicare Advantage|UHC AARP WELLMED HMO MA|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|United Medicare Advantage|UHC AARP MCR HMO MA|376.25||||376.25||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|United Medicare Advantage|UHC MEDICARE GOLD MA|376.25||||376.25||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.58||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Veterans Affairs|VETERANS ADMINISTRATION|376.25||||376.25||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.58||||||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.58||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||376.25||| 88305|EAP|0310|SURGICAL PATH/GROSS MICRO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.58||| 88305|EAP|0312|LEVEL IV GROSS & MICRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||376.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Workers Compensation|WORKERS COMPENSATION OTHER|567.25||||||| 88307|EAP|0312|LEVEL V GROSS & MICRO|United Medicare Advantage|UHC AARP MCR HMO MA|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Access Direct Platinum|HEALTHFIRST TPA|567.25||||||| 88307|EAP|0312|LEVEL V GROSS & MICRO|United Medicare Advantage|UHC MEDICARE GOLD MA|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|ChampVA|CHAMPVA CENTER|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Aenta Medicare Advantage|AETNA MEDICARE MA|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Blue Cross PPO Specialty|BCBSTX PPO|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Medicare|MEDICARE PART B ONLY IP|567.25||||||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Medicare|MEDICARE ACUTE|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Tricare|TRICARE EAST REGION|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|United Medicare Advantage|UHC AARP WELLMED HMO MA|567.25||||||| 88307|EAP|0312|LEVEL V GROSS & MICRO|United Healthcare|UNITED HEALTHCARE|567.25||||||| 88307|EAP|0312|LEVEL V GROSS & MICRO|United Healthcare|UNITED HEALTHCARE OTHER|567.25||||||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Veterans Affairs|VETERANS ADMINISTRATION|567.25||||||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicare|HEALTHSPRING MA|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicaid|MEDICAID AMERIGROUP|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicare|BCBS MEDICARE PPO MA|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicaid|MEDICAID SUPERIOR|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|567.25||||||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Medicaid|MEDICAID|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Medicaid|MEDICAID HMO|||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Humana Medicare Advantage|HUMANA MA|567.25||||567.25||| 88307|EAP|0312|LEVEL V GROSS & MICRO|Medicaid|MOLINA HEALTHCARE OF TEXAS|567.25||||||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Managed Medicare|BCBS MEDICARE PPO MA|764.50||||764.50||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Medicaid|MEDICAID|||||764.50||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Managed Medicare|HEALTHSPRING MA|764.50||||764.50||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|764.50||||||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|United Healthcare|UNITED HEALTHCARE OTHER|764.50||||||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Medicare|MEDICARE PART B ONLY IP|764.50||||||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Medicare|MEDICARE ACUTE|764.50||||764.50||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Aenta Medicare Advantage|AETNA MEDICARE MA|764.50||||||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|ChampVA|CHAMPVA CENTER|764.50||||||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Humana Medicare Advantage|HUMANA MA|764.50||||764.50||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|764.50||||764.50||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Managed Medicaid|MEDICAID SUPERIOR|||||764.50||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|764.50||||764.50||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|Managed Medicaid|MEDICAID AMERIGROUP|764.50||||||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|United Medicare Advantage|UHC MEDICARE GOLD MA|764.50||||||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|United Medicare Advantage|UHC AARP MCR HMO MA|764.50||||764.50||| 88309|EAP|0312|LEVEL VI GROSS & MICRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|764.50||||||| 88311|EAP|0310|DECALIFICATION PROCEDURE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.06||| 88311|EAP|0310|DECALIFICATION PROCEDURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.06||| 88311|EAP|0310|DECALIFICATION PROCEDURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.06||||0.06||| 88311|EAP|0312|DECAL|Humana Medicare Advantage|HUMANA MA|1.12||||1.12||| 88311|EAP|0310|DECALIFICATION PROCEDURE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.06||| 88311|EAP|0312|DECAL|NON CONTRACTED|COMMERCIAL OTHER 1|1.12||||||| 88311|EAP|0310|DECALIFICATION PROCEDURE|Medicare|MEDICARE ACUTE|0.06||||0.06||| 88311|EAP|0312|DECAL|Tricare|TRICARE EAST REGION|1.12||||||| 88311|EAP|0312|DECAL|United Healthcare|UNITED HEALTHCARE OTHER|1.12||||||| 88311|EAP|0310|DECALIFICATION PROCEDURE|Managed Medicare|HEALTHSPRING MA|0.06||||||| 88311|EAP|0312|DECAL|Medicare|UTSW MC KIDNEY PROGRAM|||||1.12||| 88311|EAP|0312|DECAL|Managed Medicare|BCBS MEDICARE PPO MA|1.12||||||| 88311|EAP|0312|DECAL|Medicare|MEDICARE ACUTE|1.12||||1.12||| 88311|EAP|0312|DECAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.12||| 88311|EAP|0312|DECAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.12||||1.12||| 88311|EAP|0312|DECAL|Managed Medicare|HEALTHSPRING MA|1.12||||1.12||| 88311|EAP|0312|DECAL|PHCS|HUMANA INSURANCE|1.12||||||| 88311|EAP|0312|DECAL|Aenta Medicare Advantage|AETNA MEDICARE MA|1.12||||1.12||| 88311|EAP|0310|DECALIFICATION PROCEDURE|Medicaid|MEDICAID|0.06||||||| 88311|EAP|0312|DECAL|Medicaid|MEDICAID|1.12||||1.12||| 88311|EAP|0310|DECALIFICATION PROCEDURE|Humana Medicare Advantage|HUMANA MA|||||0.06||| 88311|EAP|0312|DECAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.12||||1.12||| 88311|EAP|0310|DECALIFICATION PROCEDURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.06||||||| 88311|EAP|0312|DECAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.12||||1.12||| 88311|EAP|0312|DECAL|Managed Medicaid|MEDICAID SUPERIOR|1.12||||1.12||| 88311|EAP|0312|DECAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.12||||1.12||| 88311|EAP|0312|DECAL|United Medicare Advantage|UHC AARP MCR HMO MA|1.12||||1.12||| 88311|EAP|0310|DECALIFICATION PROCEDURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.06||||||| 88311|EAP|0312|DECAL|Workers Compensation|WORKERS COMPENSATION OTHER|1.12||||||| 88311|EAP|0312|DECAL|United Medicare Advantage|UHC MEDICARE GOLD MA|1.12||||1.12||| 88311|EAP|0312|DECAL|Veterans Affairs|VETERANS ADMINISTRATION|1.12||||||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Managed Medicare|HEALTHSPRING MA|207.75||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Medicare|MEDICARE ACUTE|207.75||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Aenta Medicare Advantage|AETNA MEDICARE MA|207.75||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Humana Medicare Advantage|HUMANA MA|207.75||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|207.75||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|207.75||||207.75||| 88312|EAP|0310|SPECIAL TISSUE STAIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|67.43||||||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|207.75||||||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Managed Medicaid|MEDICAID AMERIGROUP|207.75||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|Managed Medicaid|MEDICAID SUPERIOR|||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|United Medicare Advantage|UHC MEDICARE GOLD MA|207.75||||207.75||| 88312|EAP|0310|SPECIAL TISSUE STAIN|Medicare|MEDICARE ACUTE|67.43||||||| 88312|EAP|0312|SPECIAL STAIN GRP 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|207.75||||207.75||| 88312|EAP|0312|SPECIAL STAIN GRP 1|United Medicare Advantage|UHC AARP MCR HMO MA|207.75||||||| 88313|EAP|0310|TISSUE STAIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.55||| 88313|EAP|0312|SPECIAL STAIN GRP 2|United Medicare Advantage|UHC AARP MCR HMO MA|202.75||||202.75||| 88313|EAP|0312|SPECIAL STAIN GRP 2|United Medicare Advantage|UHC MEDICARE GOLD MA|202.75||||202.75||| 88313|EAP|0310|TISSUE STAIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.55||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|202.75||||202.75||| 88313|EAP|0310|TISSUE STAIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.55||||||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Managed Medicaid|MEDICAID SUPERIOR|||||202.75||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|202.75||||202.75||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Managed Medicaid|MEDICAID AMERIGROUP|||||202.75||| 88313|EAP|0310|TISSUE STAIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.55||||0.55||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Humana Medicare Advantage|HUMANA MA|202.75||||202.75||| 88313|EAP|0310|TISSUE STAIN|Humana Medicare Advantage|HUMANA MA|||||0.55||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Blue Cross PPO Specialty|BCBSTX PPO|||||202.75||| 88313|EAP|0312|SPECIAL STAIN GRP 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|202.75||||202.75||| 88313|EAP|0310|TISSUE STAIN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.55||| 88313|EAP|0312|SPECIAL STAIN GRP 2|ChampVA|CHAMPVA CENTER|202.75||||||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Aenta Medicare Advantage|AETNA MEDICARE MA|202.75||||||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Tricare|TRICARE EAST REGION|202.75||||||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Medicare|UTSW MC KIDNEY PROGRAM|||||202.75||| 88313|EAP|0310|TISSUE STAIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.55||||||| 88313|EAP|0310|TISSUE STAIN|Medicare|MEDICARE ACUTE|0.55||||0.55||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Medicare|MEDICARE ACUTE|202.75||||202.75||| 88313|EAP|0310|TISSUE STAIN|Medicaid|MEDICAID|0.55||||||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Medicaid|MEDICAID|||||202.75||| 88313|EAP|0310|TISSUE STAIN|Managed Medicare|HEALTHSPRING MA|0.55||||||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||202.75||| 88313|EAP|0310|TISSUE STAIN|Managed Medicare|WELLCARE CHOICE MA|0.55||||||| 88313|EAP|0312|SPECIAL STAIN GRP 2|Managed Medicare|HEALTHSPRING MA|202.75||||202.75||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Medicare|MEDICARE PART B ONLY IP|0.50||||||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Medicare|MEDICARE ACUTE|0.50||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|United Healthcare|UNITED HEALTHCARE OTHER|||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.50||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|United Healthcare|UNITED HEALTHCARE|||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Tricare|TRICARE EAST REGION|0.50||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Aenta Medicare Advantage|AETNA MEDICARE MA|0.50||||||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Humana Medicare Advantage|HUMANA MA|0.50||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Cigna|CIGNA|||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.50||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.50||| 88323|EAP|0310|CONSULT AND REPORT MICROS|Veterans Affairs|VETERANS ADMINISTRATION|0.50||||0.50||| 88331|EAP|0312|FROZEN SECTION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|Managed Medicaid|MEDICAID AMERIGROUP|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|Aenta Medicare Advantage|AETNA MEDICARE MA|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|Tricare|TRICARE EAST REGION|||||3.37||| 88331|EAP|0312|FROZEN SECTION|Medicare|MEDICARE ACUTE|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|Medicare|MEDICARE PART B ONLY IP|3.37||||||| 88331|EAP|0312|FROZEN SECTION|Blue Cross PPO Specialty|BCBSTX PPO|||||3.37||| 88331|EAP|0312|FROZEN SECTION|Medicaid|MEDICAID|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|Managed Medicare|BCBS MEDICARE PPO MA|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|Managed Medicare|HEALTHSPRING MA|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|United Medicare Advantage|UHC AARP MCR HMO MA|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||3.37||| 88331|EAP|0312|FROZEN SECTION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.37||| 88331|EAP|0312|FROZEN SECTION|United Medicare Advantage|UHC MEDICARE GOLD MA|3.37||||3.37||| 88331|EAP|0312|FROZEN SECTION|Veterans Affairs|VETERANS ADMINISTRATION|||||3.37||| 88331|EAP|0312|FROZEN SECTION|Humana Medicare Advantage|HUMANA MA|3.37||||3.37||| 88332|EAP|0312|ADDITIONAL SECTION|Medicare|MEDICARE ACUTE|121.25||||121.25||| 88332|EAP|0312|ADDITIONAL SECTION|Managed Medicare|HEALTHSPRING MA|||||121.25||| 88332|EAP|0312|ADDITIONAL SECTION|Medicaid|MEDICAID|||||121.25||| 88332|EAP|0312|ADDITIONAL SECTION|Aenta Medicare Advantage|AETNA MEDICARE MA|||||121.25||| 88332|EAP|0312|ADDITIONAL SECTION|Humana Medicare Advantage|HUMANA MA|||||121.25||| 88332|EAP|0312|ADDITIONAL SECTION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||121.25||| 88332|EAP|0312|ADDITIONAL SECTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||121.25||| 88332|EAP|0312|ADDITIONAL SECTION|Managed Medicaid|MEDICAID AMERIGROUP|||||121.25||| 88332|EAP|0312|ADDITIONAL SECTION|United Medicare Advantage|UHC MEDICARE GOLD MA|121.25||||||| 88332|EAP|0312|ADDITIONAL SECTION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|121.25||||||| 88332|EAP|0312|ADDITIONAL SECTION|United Medicare Advantage|UHC AARP MCR HMO MA|121.25||||||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|United Medicare Advantage|UHC MEDICARE GOLD MA|190.25||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|190.25||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicaid|MEDICAID AMERIGROUP|||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|Humana Medicare Advantage|HUMANA MA|190.25||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|190.25||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|Medicare|MEDICARE ACUTE|190.25||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicare|HEALTHSPRING MA|190.25||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|190.25||||190.25||| 88333|EAP|0311|CONSULT SURGERY CYTOLOGY|United Medicare Advantage|UHC AARP MCR HMO MA|190.25||||190.25||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|88.50||||||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicare|BCBS MEDICARE PPO MA|||||88.50||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicare|HEALTHSPRING MA|88.50||||88.50||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|Medicare|MEDICARE ACUTE|88.50||||88.50||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|United Medicare Advantage|UHC AARP MCR HMO MA|88.50||||||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||88.50||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|88.50||||88.50||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|Humana Medicare Advantage|HUMANA MA|88.50||||88.50||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|Managed Medicaid|MEDICAID AMERIGROUP|||||88.50||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||88.50||| 88334|EAP|0311|CONSULT SURGERY CYTOLOGY|United Medicare Advantage|UHC MEDICARE GOLD MA|88.50||||88.50||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.52||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Veterans Affairs|VETERANS ADMINISTRATION|0.52||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.52||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.52||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Cigna|CIGNA|||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|United Healthcare|UNITED HEALTHCARE|||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Medicare|MEDICARE ACUTE|0.52||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|United Healthcare|UNITED HEALTHCARE OTHER|||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Medicare|MEDICARE PART B ONLY IP|0.52||||||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Medicaid|MEDICAID|0.52||||||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.52||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Tricare|TRICARE EAST REGION|0.52||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Managed Medicare|HEALTHSPRING MA|0.52||||||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Managed Medicare|WELLCARE CHOICE MA|0.52||||||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Humana Medicare Advantage|HUMANA MA|0.52||||0.52||| 88341|EAP|0310|IHC QUALITATIVE ADDT'L SI|Aenta Medicare Advantage|AETNA MEDICARE MA|0.52||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Managed Medicare|WELLCARE CHOICE MA|0.52||||||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.52||||0.52||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicare|BCBS MEDICARE PPO MA|321.75||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicare|HEALTHSPRING MA|321.75||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicare|OTHER INSTITUTIONS|||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Medicaid|MEDICAID|0.52||||||| 88342|EAP|0312|IMMUNOSTAIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Medicaid|MEDICAID|321.75||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Medicare|UTSW MC KIDNEY PROGRAM|||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Medicare|MEDICARE PART B ONLY IP|0.52||||||| 88342|EAP|0312|IMMUNOSTAIN|Medicare|MEDICARE ACUTE|321.75||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Tricare|TRICARE EAST REGION|0.52||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|United Healthcare|UNITED HEALTHCARE|||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.52||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Humana Medicare Advantage|HUMANA MA|0.52||||0.52||| 88342|EAP|0312|IMMUNOSTAIN|Humana Medicare Advantage|HUMANA MA|321.75||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Cigna|CIGNA|||||0.52||| 88342|EAP|0312|IMMUNOSTAIN|ChampVA|CHAMPVA CENTER|321.75||||||| 88342|EAP|0312|IMMUNOSTAIN|Aenta Medicare Advantage|AETNA MEDICARE MA|321.75||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|321.75||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicaid|MEDICAID SUPERIOR|||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|321.75||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicaid|MEDICAID AMERIGROUP|||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||0.52||| 88342|EAP|0312|IMMUNOSTAIN|Tricare|TRICARE EAST REGION|321.75||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.52||||0.52||| 88342|EAP|0312|IMMUNOSTAIN|Medicare|MEDICARE PART B ONLY IP|321.75||||||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.52||||0.52||| 88342|EAP|0312|IMMUNOSTAIN|United Medicare Advantage|UHC MEDICARE GOLD MA|321.75||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|321.75||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|United Medicare Advantage|UHC AARP MCR HMO MA|321.75||||321.75||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Veterans Affairs|VETERANS ADMINISTRATION|0.52||||0.52||| 88342|EAP|0312|IMMUNOSTAIN|Veterans Affairs|VETERANS ADMINISTRATION|321.75||||||| 88342|EAP|0312|IMMUNOSTAIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|321.75||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.52||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.52||| 88342|EAP|0312|IMMUNOSTAIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||321.75||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Medicare|MEDICARE ACUTE|0.52||||0.52||| 88342|EAP|0310|IHC PER SPECIMEN, INITIAL|Managed Medicare|HEALTHSPRING MA|0.52||||||| 88360|EAP|0312|MORPHOMETRIC ANALYS TUMOR|Humana Medicare Advantage|HUMANA MA|3.39||||3.39||| 88360|EAP|0312|TUMOR IMMUOHISTOCHEM/MANU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||59.44||| 88360|EAP|0312|TUMOR IMMUOHISTOCHEM/MANU|Veterans Affairs|VETERANS ADMINISTRATION|||||59.44||| 88360|EAP|0312|TUMOR IMMUOHISTOCHEM/MANU|United Medicare Advantage|UHC MEDICARE GOLD MA|3.39||||59.44||| 88360|EAP|0312|TUMOR IMMUOHISTOCHEM/MANU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.39||||59.44||| 88360|EAP|0312|MORPHOMETRIC ANALYS TUMOR|United Medicare Advantage|UHC MEDICARE GOLD MA|3.39||||3.39||| 88360|EAP|0312|MORPHOMETRIC ANALYS TUMOR|United Medicare Advantage|UHC AARP MCR HMO MA|||||3.39||| 88360|EAP|0312|MORPHOMETRIC ANALYS TUMOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.39||||3.39||| 88360|EAP|0312|MORPHOMETRIC ANALYS TUMOR|Aenta Medicare Advantage|AETNA MEDICARE MA|59.44||||3.39||| 88360|EAP|0312|TUMOR IMMUOHISTOCHEM/MANU|United Healthcare|UNITED HEALTHCARE OTHER|||||59.44||| 88360|EAP|0312|TUMOR IMMUOHISTOCHEM/MANU|Tricare|TRICARE EAST REGION|59.44||||||| 88360|EAP|0312|TUMOR IMMUOHISTOCHEM/MANU|Medicare|MEDICARE ACUTE|59.44||||59.44||| 88360|EAP|0312|MORPHOMETRIC ANALYS TUMOR|Medicare|MEDICARE ACUTE|3.39||||3.39||| 88360|EAP|0312|TUMOR IMMUOHISTOCHEM/MANU|Medicaid|MEDICAID|59.44||||||| 88360|EAP|0312|MORPHOMETRIC ANALYS TUMOR|Medicaid|MEDICAID|3.39||||||| 88360|EAP|0312|MORPHOMETRIC ANALYS TUMOR|Managed Medicare|HEALTHSPRING MA|||||3.39||| 88360|EAP|0312|MORPHOMETRIC ANALYS TUMOR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.39||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Medicaid|MEDICAID|1.00||||||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Medicare|MEDICARE ACUTE|1.00||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Tricare|TRICARE FOR LIFE|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Tricare|TRICARE EAST REGION|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|United Healthcare|UNITED HEALTHCARE|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|United Medicare Advantage|UHC AARP MCR HMO MA|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Humana Medicare Advantage|HUMANA MA|1.00||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Cigna|CIGNA|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Managed Medicare|HEALTHSPRING MA|||||1.00||| 88361|EAP|0312|TUMOR IMMUNOHISTOCHEM/COM|Managed Medicare|BCBS MEDICARE PPO MA|||||1.00||| 88364|EAP|0310|IN SITU HYBRIDIZATION-EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|90.80||||||| 88364|EAP|0310|IN SITU HYBRIDIZATION-EA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||90.80||| 88364|EAP|0310|IN SITU HYBRIDIZATION-EA|Humana Medicare Advantage|HUMANA MA|||||90.80||| 88364|EAP|0310|IN SITU HYBRIDIZATION-EA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||90.80||| 88364|EAP|0310|IN SITU HYBRIDIZATION-EA|Tricare|TRICARE EAST REGION|||||90.80||| 88364|EAP|0310|IN SITU HYBRIDIZATION-EA|Medicare|MEDICARE PART B ONLY IP|90.80||||||| 88364|EAP|0310|IN SITU HYBRIDIZATION-EA|Medicare|MEDICARE ACUTE|90.80||||90.80||| 88364|EAP|0310|IN SITU HYBRIDIZATION-EA|Managed Medicare|WELLCARE CHOICE MA|90.80||||||| 88364|EAP|0310|IN SITU HYBRIDIZATION-EA|Managed Medicare|HEALTHSPRING MA|90.80||||||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Veterans Affairs|VETERANS ADMINISTRATION|||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Managed Medicare|WELLCARE CHOICE MA|0.90||||||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Managed Medicare|HEALTHSPRING MA|0.90||||||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Medicare|MEDICARE ACUTE|0.90||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.90||||||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Medicare|MEDICARE PART B ONLY IP|0.90||||||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|United Healthcare|UNITED HEALTHCARE|||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|United Healthcare|UNITED HEALTHCARE OTHER|||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Tricare|TRICARE EAST REGION|0.90||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Aenta Medicare Advantage|AETNA MEDICARE MA|0.90||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Humana Medicare Advantage|HUMANA MA|0.90||||0.90||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.90||||||| 88365|EAP|0310|IN SITU HYBRIDIZATION, IN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.90||| 88367|EAP|0312|FISH AUTO TC (SINGLE PROB|Medicare|MEDICARE ACUTE|2.98||||||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Humana Medicare Advantage|HUMANA MA|327.54||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|United Medicare Advantage|UHC AARP MCR HMO MA|||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Medicaid|MEDICAID|327.54||||||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|United Healthcare|UNITED HEALTHCARE OTHER|327.54||||||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Medicare|MEDICARE ACUTE|327.54||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|PHCS|HUMANA INSURANCE|327.54||||||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|United Healthcare|UNITED HEALTHCARE|327.54||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Tricare|TRICARE FOR LIFE|||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Tricare|TRICARE EAST REGION|327.54||||||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|327.54||||||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Managed Medicare|HEALTHSPRING MA|||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|United Medicare Advantage|UHC MEDICARE GOLD MA|327.54||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||327.54||| 88374|EAP|0312|M/PHMTRC ALYS ISHQUANT/SE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|327.54||||327.54||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|Medicare|MEDICARE ACUTE|264.24||||264.24||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|United Healthcare|UNITED HEALTHCARE OTHER|||||264.24||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|United Healthcare|UNITED HEALTHCARE|||||264.24||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|Managed Medicare|HEALTHSPRING MA|||||264.24||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||264.24||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||264.24||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||264.24||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|Aenta Medicare Advantage|AETNA MEDICARE MA|264.24||||||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||264.24||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|Humana Medicare Advantage|HUMANA MA|264.24||||264.24||| 88377|EAP|0312|M/PHMTRC ANYS ISHQUANT/SE|United Medicare Advantage|UHC AARP MCR HMO MA|||||264.24||| 884|DRG||ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY|United Medicare Advantage|UHC AARP MCR HMO MA|34,973.33|6544.75|9338.66|460.52|||| 884|DRG||ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY|Blue Cross PPO Specialty|BCBSTX OTHER|50,336.62||||||| 884|DRG||ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY|Managed Medicare|BCBS MEDICARE PPO MA|71,402.87|9173.86|9338.66|460.52|||| 884|DRG||ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY|Humana Medicare Advantage|HUMANA MA|65,524.96|9338.66|9338.66|460.52|||| 884|DRG||ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY|Medicare|MEDICARE PART B ONLY IP|19,815.01|460.52|9338.66|460.52|||| 884|DRG||ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY|Medicare|MEDICARE ACUTE|44,335.56|9160.22|9338.66|460.52|||| 884|DRG||ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY|United Healthcare|UNITED HEALTHCARE OTHER|72,397.70|9180.05|9338.66|460.52|||| 884|DRG||ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|52,549.76|9338.66|9338.66|460.52|||| 885|DRG||PSYCHOSES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|48,991.50||||||| 885|DRG||PSYCHOSES|United Medicare Advantage|UHC MEDICARE GOLD MA|40,066.80||||||| 885|DRG||PSYCHOSES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|302.61||||||| 885|DRG||PSYCHOSES|Humana Medicare Advantage|HUMANA MA|307.87||||||| 885|DRG||PSYCHOSES|Tricare|TRICARE EAST REGION|33,115.68|2756.62|55377.25|28.95|||| 885|DRG||PSYCHOSES|Texas Workforce Commission|DIS DETER SERV (DDS)|328,178.52|16404.95|55377.25|28.95|||| 885|DRG||PSYCHOSES|PHCS|HUMANA INSURANCE|31,227.25|20661.8|55377.25|28.95|||| 885|DRG||PSYCHOSES|Multiplan|WEB TPA|46,862.68|34678.38|55377.25|28.95|||| 885|DRG||PSYCHOSES|NON CONTRACTED|COMMUNITY HEALTH CENTER|55,377.25|55377.25|55377.25|28.95|||| 885|DRG||PSYCHOSES|United Medicare Advantage|UHC AARP MCR HMO MA|44,455.99|4291.765|55377.25|28.95|||| 885|DRG||PSYCHOSES|Medicaid|MEDICAID HMO|38,405.88|2425.655|55377.25|28.95|||| 885|DRG||PSYCHOSES|Medicaid|MEDICAID|43,952.50|2394.05|55377.25|28.95|||| 885|DRG||PSYCHOSES|Medicare|MEDICARE PART B ONLY IP|20,884.34|1006.72|55377.25|28.95|||| 885|DRG||PSYCHOSES|Medicare|MEDICARE ACUTE|46,992.50|7952.38|55377.25|28.95|||| 885|DRG||PSYCHOSES|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|31,321.25|2314.52|55377.25|28.95|||| 885|DRG||PSYCHOSES|Veterans Affairs|VETERANS ADMINISTRATION|41,072.25|7952.38|55377.25|28.95|||| 885|DRG||PSYCHOSES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|45,104.38|10240.4|55377.25|28.95|||| 885|DRG||PSYCHOSES|Medicaid|MOLINA HEALTHCARE OF TEXAS|28,445.75|2314.52|55377.25|28.95|||| 885|DRG||PSYCHOSES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|39,354.38|10105.85|55377.25|28.95|||| 885|DRG||PSYCHOSES|Access Direct Platinum|HEALTHFIRST TPA|30,720.75|10105.85|55377.25|28.95|||| 885|DRG||PSYCHOSES|Medicaid|BH TEXAS CHILDRENS MEDICAID|38,016.48|2457.26|55377.25|28.95|||| 885|DRG||PSYCHOSES|Access Direct Platinum|HEALTHFIRST TPA UMR|69,072.75|10240.4|55377.25|28.95|||| 885|DRG||PSYCHOSES|United Healthcare|UNITED HEALTHCARE OTHER|26,067.12|28.95|55377.25|28.95|||| 885|DRG||PSYCHOSES|Access Direct Platinum|ANDREWS CENTER|37,596.19|10105.85|55377.25|28.95|||| 885|DRG||PSYCHOSES|Aenta Medicare Advantage|AETNA MEDICARE MA|53,822.12|7925.1|55377.25|28.95|||| 885|DRG||PSYCHOSES|Aetna|BH AETNA|42,282.33|95.2|55377.25|28.95|||| 885|DRG||PSYCHOSES|NON CONTRACTED|COMMERCIAL OTHER 1|38,822.25|26586.5|55377.25|28.95|||| 885|DRG||PSYCHOSES|Brinson Benefits|THE HEALTH PLAN SMITH CO|25,702.25|25702.25|55377.25|28.95|||| 885|DRG||PSYCHOSES|Medicaid|SUPERIOR HEALTHPLAN CHIP|36,749.25|2314.52|55377.25|28.95|||| 885|DRG||PSYCHOSES|Blue Cross PPO Specialty|BCBSTX OTHER|64,932.98|736.27|55377.25|28.95|||| 885|DRG||PSYCHOSES|Blue Cross PPO Specialty|BCBSTX PPO|35,063.12|78.35|55377.25|28.95|||| 885|DRG||PSYCHOSES|Optum Behavioral Health|BH OPTUM UHC|341.67|48.25|55377.25|28.95|||| 885|DRG||PSYCHOSES|Magellan Behavioral Health|BH MAGELLAN|37,040.25|40|55377.25|28.95|||| 885|DRG||PSYCHOSES|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|39,033.25|3806.54|55377.25|28.95|||| 885|DRG||PSYCHOSES|Managed Medicaid|MEDICAID SUPERIOR|943.99|4801.15|55377.25|28.95|||| 885|DRG||PSYCHOSES|Cigna Behavioral Health|BH CIGNA|32,161.50|40|55377.25|28.95|||| 885|DRG||PSYCHOSES|Managed Medicare|JACKSONVILLE ACCESS|26,909.12|7953.26|55377.25|28.95|||| 885|DRG||PSYCHOSES|Cigna|CIGNA|30,715.25|3680.08|55377.25|28.95|||| 885|DRG||PSYCHOSES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47,126.10|3994.23|55377.25|28.95|||| 885|DRG||PSYCHOSES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|50,288.65|7953.26|55377.25|28.95|||| 885|DRG||PSYCHOSES|Managed Medicaid|MEDICAID AMERIGROUP|37,700.94|3806.54|55377.25|28.95|||| 885|DRG||PSYCHOSES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40,211.87|3994.23|55377.25|28.95|||| 885|DRG||PSYCHOSES|Managed Medicare|HEALTHSPRING MA|56,094.31|7953.26|55377.25|28.95|||| 89|DRG||CONCUSSION W CC|Workers Compensation|TRAVELERS INSURANCE COMPANY|71,553.88|9575.46|9575.46|6696.12|||| 89|DRG||CONCUSSION W CC|Medicare|MEDICARE ACUTE|45,724.95|6696.12|9575.46|6696.12|||| 89050|EAP|0300|CELL COUNT W/O DIFF, BODY|Medicare|MEDICARE ACUTE|279.45||||279.45||| 89050|EAP|0300|CELL COUNT W/O DIFF, BODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.43||||||| 89050|EAP|0300|CELL COUNT W/O DIFF, BODY|United Medicare Advantage|UHC AARP MCR HMO MA|279.45||||||| 89050|EAP|0300|CELL COUNT W/O DIFF, BODY|Blue Cross PPO Specialty|BCBSTX PPO|2.43||||||| 89050|EAP|0300|CELL COUNT W/O DIFF, BODY|Veterans Affairs|VETERANS ADMINISTRATION|||||2.43||| 89050|EAP|0300|CELL COUNT W/O DIFF, BODY|Humana Medicare Advantage|HUMANA MA|279.45||||||| 89050|EAP|0300|CELL COUNT W/O DIFF, BODY|United Healthcare|UNITED HEALTHCARE|2.43||||||| 89050|EAP|0300|CELL COUNT W/O DIFF, BODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|279.45||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Access Direct Platinum|HEALTHFIRST TPA UMR|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Access Direct Platinum|HEALTHFIRST TPA|2.43||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Veterans Affairs|VETERANS ADMINISTRATION|279.45||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|United Medicare Advantage|UHC AARP MCR HMO MA|279.45||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|United Medicare Advantage|UHC MEDICARE GOLD MA|2.43||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|279.45||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Aenta Medicare Advantage|AETNA MEDICARE MA|279.45||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Aetna|AETNA QHP HMO|279.45||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Aetna|AETNA OTHER|279.45||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|279.45||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Blue Cross HMO Specialty|BCBSTX HMO|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Blue Cross PPO Specialty|BCBSTX PPO|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|279.45||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|ChampVA|CHAMPVA CENTER|2.43||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Cigna|CIGNA OTHER|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Cigna|CIGNA|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Humana Medicare Advantage|HUMANA MA|279.45||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Cigna|CIGNA|261.23||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicaid|MEDICAID SUPERIOR|279.45||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|279.45||||261.23||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicaid|MEDICAID AMERIGROUP|2.43||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Blue Cross PPO Specialty|BCBSTX OTHER|279.45||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Aetna|AETNA PPO|2.43||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||261.23||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicare|BCBS MEDICARE PPO MA|261.23||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||261.23||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicare|WELLCARE CHOICE MA|279.45||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Medicaid|SMITH COUNTY JAIL|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.43||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Medicaid|MEDICAID HMO|||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|279.45||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicare|HEALTHSPRING MA|2.43||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Medicaid|MEDICAID|2.43||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|PHCS|HUMANA|261.23||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|NON CONTRACTED|COMMERCIAL OTHER 1|261.23||||261.23||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Medicare|MEDICARE PART B ONLY IP|279.45||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.43||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Medicare|MEDICARE ACUTE|279.45||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Tricare|TRICARE EAST REGION|279.45||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|279.45||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.43||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|Tricare|TRICARE FOR LIFE|279.45||||||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|United Healthcare|UNITED HEALTHCARE|279.45||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|United Healthcare|TML GROUP BENEFITS|||||279.45||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|United Healthcare|UNITED HEALTHCARE|2.43||||2.43||| 89051|EAP|0300|CELL COUNT WITH DIFF, BOD|United Healthcare|UNITED HEALTHCARE OTHER|279.45||||261.23||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.99||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|United Healthcare|UNITED HEALTHCARE OTHER|0.99||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|United Healthcare|GOLDEN RULE|||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Tricare|TRICARE EAST REGION|113.85||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Medicare|MEDICARE ACUTE|0.99||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|NON CONTRACTED|COMMERCIAL OTHER 1|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Medicaid|SMITH COUNTY JAIL|0.99||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Medicaid|COUNTY INDIGENT HEALTH OTHER|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Managed Medicare|BCBS MEDICARE PPO MA|||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.99||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Managed Medicaid|MEDICAID SUPERIOR|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.99||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Managed Medicaid|MEDICAID AMERIGROUP|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Cigna|CIGNA OTHER|0.99||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|106.43||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Blue Cross HMO Specialty|BCBSTX HMO|106.43||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Aenta Medicare Advantage|AETNA MEDICARE MA|113.85||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Blue Cross PPO Specialty|BCBSTX PPO|113.85||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|United Medicare Advantage|UHC MEDICARE GOLD MA|0.99||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|United Medicare Advantage|UHC AARP MCR HMO MA|113.85||||113.85||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Veterans Affairs|VETERANS ADMINISTRATION|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Humana Medicare Advantage|HUMANA MA|0.99||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Access Direct Platinum|HEALTHFIRST TPA|0.99||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.99||||0.99||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Cigna|CIGNA|113.85||||||| 89055|EAP|0300|LEUKOCYTE ASSESSMENT FECA|Managed Medicare|HEALTHSPRING MA|0.99||||||| 89060|EAP|0300|BODY FLUID CRYSTALS|Veterans Affairs|VETERANS ADMINISTRATION|422.05||||3.67||| 89060|EAP|0300|BODY FLUID CRYSTALS|United Medicare Advantage|UHC AARP MCR HMO MA|422.05||||||| 89060|EAP|0300|BODY FLUID CRYSTALS|United Medicare Advantage|UHC MEDICARE GOLD MA|3.67||||||| 89060|EAP|0300|BODY FLUID CRYSTALS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|422.05||||||| 89060|EAP|0300|BODY FLUID CRYSTALS|Blue Cross PPO Specialty|BCBSTX PPO|422.05||||||| 89060|EAP|0300|BODY FLUID CRYSTALS|Managed Medicare|HEALTHSPRING MA|3.67||||||| 89060|EAP|0300|BODY FLUID CRYSTALS|United Healthcare|UNITED HEALTHCARE|3.67||||||| 89060|EAP|0300|BODY FLUID CRYSTALS|Medicare|MEDICARE ACUTE|394.53||||422.05||| 89060|EAP|0300|BODY FLUID CRYSTALS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.67||||||| 89060|EAP|0300|BODY FLUID CRYSTALS|Humana Medicare Advantage|HUMANA MA|422.05||||3.67||| 895|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY|Blue Cross PPO Specialty|BCBSTX PPO|141.63||||||| 895|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY|NON CONTRACTED|COMMERCIAL OTHER 1|58,947.92|27657.3|27657.3|1923.11|||| 895|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY|Medicare|MEDICARE ACUTE|39,757.98|10211.31|27657.3|1923.11|||| 895|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY|Medicaid|MEDICAID|438.32|1923.11|27657.3|1923.11|||| 895|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY|Managed Medicare|JACKSONVILLE ACCESS|66,502.75|10210.43|27657.3|1923.11|||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|73,860.33||||||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|Blue Cross PPO Specialty|BCBSTX PPO|73,544.15||||||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|55,866.06|7303.7|27047.11|107.17|||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|Medicare|MEDICARE ACUTE|56,401.75|107.17|27047.11|107.17|||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43,933.30|27047.11|27047.11|107.17|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|19,994.34||||||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43,225.20||||||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|30,180.80|30180.8|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|United Healthcare|UNITED HEALTHCARE|81,562.22|9726.82|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|38,881.25||||||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Medicare|MEDICARE ACUTE|31,675.61|5886.05|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|26,301.50|5793.46|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Medicaid|MEDICAID|37,340.80|5855.98|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|49,345.85|7489.41|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|112,316.40|7496.38|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Access Direct Platinum|ANDREWS CENTER|26,239.50|7496.38|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|20,296.65|5765.3|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Humana Medicare Advantage|HUMANA MA|56,310.06|5886.05|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36,913.50|4980.64|30180.8|4980.64|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Aetna|AETNA PPO|73,845.77|9543.56|30180.8|4980.64|||| 9|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| 9|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| 9|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||1.75||| 9|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| 9|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| 9|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| 90|DRG||CONCUSSION W/O CC/MCC|Medicare|MEDICARE ACUTE|45,993.53|5924.34|5938.86|457.53|||| 90|DRG||CONCUSSION W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|339.67|457.53|5938.86|457.53|||| 90|DRG||CONCUSSION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63,120.45|5938.86|5938.86|457.53|||| 901|DRG||WOUND DEBRIDEMENTS FOR INJURIES W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|421,611.22|48354.955|115122.09|48354.955|||| 901|DRG||WOUND DEBRIDEMENTS FOR INJURIES W MCC|Aetna|AETNA PPO|295,184.84|115122.09|115122.09|48354.955|||| 902|DRG||WOUND DEBRIDEMENTS FOR INJURIES W CC|Medicaid|SUPERIOR HEALTHPLAN CHIP|49,454.34|4250.84|20239.4|35.72|||| 902|DRG||WOUND DEBRIDEMENTS FOR INJURIES W CC|Managed Medicare|HEALTHSPRING MA|61,578.12|12077.01|20239.4|35.72|||| 902|DRG||WOUND DEBRIDEMENTS FOR INJURIES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|66,662.80|4012.88|20239.4|35.72|||| 902|DRG||WOUND DEBRIDEMENTS FOR INJURIES W CC|Cigna|CIGNA|82,259.14|20239.4|20239.4|35.72|||| 902|DRG||WOUND DEBRIDEMENTS FOR INJURIES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30,597.37|35.72|20239.4|35.72|||| 902|DRG||WOUND DEBRIDEMENTS FOR INJURIES W CC|Workers Compensation|WORKERS COMPENSATION OTHER|136,611.83|17592.06|20239.4|35.72|||| 903|DRG||WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC|Medicare|MEDICARE ACUTE|62,321.05|7533.32|10778.65|463.75|||| 903|DRG||WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|18,427.55|463.75|10778.65|463.75|||| 903|DRG||WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|46,351.07|10778.65|10778.65|463.75|||| 903|DRG||WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|85,962.70|7902.88|10778.65|463.75|||| 90371|ERX|0636|HEP B IMMUNE GLOB 110 UNI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|456.40||||||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|NON CONTRACTED|COMMERCIAL OTHER 1|||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Tricare|TRICARE EAST REGION|203.75||||||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|United Healthcare|UNITED HEALTHCARE OTHER|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|United Healthcare|UNITED HEALTHCARE|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Medicaid|MEDICAID|||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Multiplan|WEB TPA|||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Access Direct Platinum|HEALTHFIRST TPA UMR|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Access Direct Platinum|HEALTHFIRST TPA|203.75||||||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Managed Medicaid|MEDICAID SUPERIOR|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Managed Medicaid|MEDICAID AMERIGROUP|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|203.75||||||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Blue Cross PPO Specialty|BCBSTX PPO|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Blue Cross HMO Specialty|BCBSTX HMO|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Aetna|AETNA PPO|203.75||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Aetna|AETNA OTHER|||||203.75||| 90384|EAP|0636|RH IMMUNE GLOBULIN IM FUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|203.75||||203.75||| 904|DRG||SKIN GRAFTS FOR INJURIES W CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|133,915.99|21904.54|30175.53|21904.54|||| 904|DRG||SKIN GRAFTS FOR INJURIES W CC/MCC|Workers Compensation|BROOKSHIRES WORKERS COMP|60,967.46|30175.53|30175.53|21904.54|||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Managed Medicare|HEALTHSPRING MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Managed Medicare|BCBS MEDICARE PPO MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Managed Medicare|HEALTHSPRING MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Medicaid|CRIME VICTIMS COMPENSATION|0.69||||||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Medicaid|MEDICAID|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Medicaid|SMITH COUNTY JAIL|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Medicaid|CRIME VICTIMS COMPENSATION|0.69||||||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Medicaid|SMITH COUNTY JAIL|||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|United Healthcare|UNITED HEALTHCARE OTHER|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|United Healthcare|UNITED HEALTHCARE ERS|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|United Healthcare|UNITED HEALTHCARE OTHER|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|United Healthcare|UNITED HEALTHCARE|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|United Healthcare|TML GROUP BENEFITS|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|United Healthcare|UNITED HEALTHCARE|0.69||||0.69||| 90471|EAP|0771|ADMIN RABIES VACCINE|Tricare|TRICARE EAST REGION|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Tricare|TRICARE EAST REGION|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.69||||0.69||| 90471|EAP|0771|ADMIN VACCINE-DIPH TETANU|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.69||||0.70||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Medicare|MEDICARE ACUTE|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Medicare|MEDICARE PART B ONLY IP|0.69||||||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Medicare|MEDICARE ACUTE|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|PHCS|HUMANA|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|PHCS|HUMANA|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|PHCS|GROUP AND PENSION|0.69||||||| 90471|EAP|0771|ADMIN MMR VACCINE|PHCS|GROUP AND PENSION|0.69||||||| 90471|EAP|0771|ADMIN TETANUS VACCINE|NON CONTRACTED|COMMERCIAL OTHER 1|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|NON CONTRACTED|COMMERCIAL OTHER 2|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|NON CONTRACTED|COMMERCIAL OTHER 1|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|United Medicare Advantage|UHC AARP MCR HMO MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|United Medicare Advantage|UHC AARP MCR HMO MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|United Medicare Advantage|UHC MEDICARE GOLD MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Access Direct Platinum|HEALTHFIRST TPA|0.69||||||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Access Direct Platinum|HEALTHFIRST TPA UMR|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Access Direct Platinum|HEALTHFIRST TPA|0.69||||||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.69||||0.69||| 90471|EAP|0771|ADMIN MMR VACCINE|Access Direct Platinum|HEALTHFIRST TPA|0.69||||||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Workers Compensation|BROOKSHIRES WORKERS COMP|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||0.69||| 90471|EAP|0771|ADMIN VACCINE-DIPH TETANU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.69||||0.70||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Workers Compensation|TEXAS MUTUAL INSURANCE|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Workers Compensation|WORKERS COMP PHYSICIAN|||||0.69||| 90471|EAP|0771|ADMIN VACCINE-DIPH TETANU|Workers Compensation|WORKERS COMPENSATION OTHER|0.69||||0.70||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Workers Compensation|UT EMPLOYEE INJURY|||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Workers Compensation|WORKERS COMPENSATION OTHER|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Workers Compensation|TEXAS MUTUAL INSURANCE|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Workers Compensation|WORKERS COMPENSATION OTHER|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Workers Compensation|UT EMPLOYEE INJURY|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|NON CONTRACTED|COMMERCIAL OTHER 2|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Medicare|MEDICARE PART B ONLY IP|0.69||||||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Veterans Affairs|VETERANS ADMINISTRATION|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Veterans Affairs|VETERANS ADMINISTRATION|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Tricare|TRICARE EAST REGION|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Cigna|CIGNA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Cigna|CIGNA OTHER|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Cigna|CIGNA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Humana Medicare Advantage|HUMANA MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|United Healthcare|AARP|||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Humana Medicare Advantage|HUMANA MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.69||||0.69||| 90471|EAP|0771|ADMIN VACCINE-DIPH TETANU|Managed Medicaid|MEDICAID SUPERIOR|0.70||||0.70||| 90471|EAP|0771|ADMIN VACCINE-DIPH TETANU|Managed Medicaid|MEDICAID SUPERIOR|0.69||||0.70||| 90471|EAP|0771|ADMIN VACCINE-DIPH TETANU|Managed Medicaid|MEDICAID AMERIGROUP|0.69||||0.70||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Managed Medicaid|MEDICAID SUPERIOR|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Managed Medicaid|MEDICAID AMERIGROUP|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Medicaid|MEDICAID HMO|0.69||||||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.69||||||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Medicaid|MEDICAID|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Managed Medicaid|MEDICAID AMERIGROUP|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Managed Medicare|BCBS MEDICARE PPO MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Managed Medicaid|MEDICAID SUPERIOR|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Aenta Medicare Advantage|AETNA MEDICARE MA|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Aetna Value Network|AETNA VALUE NETWORK|0.69||||||| 90471|EAP|0771|ADMIN VACCINE-DIPH TETANU|Aetna|AETNA OTHER|||||0.70||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Aetna|AETNA PPO|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Aetna|AETNA OTHER|||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Aetna|AETNA PPO|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Aetna|AETNA OTHER|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Blue Cross PPO Specialty|BCBSTX PPO|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Blue Cross PPO Specialty|BCBSTX PPO|0.69||||0.69||| 90471|EAP|0771|ADMIN TET-DIPH-PERTUSS VA|Blue Cross HMO Specialty|BCBSTX HMO|0.69||||0.69||| 90471|EAP|0771|ADMIN TETANUS VACCINE|Blue Cross HMO Specialty|BCBSTX HMO|0.69||||0.69||| 905|DRG||SKIN GRAFTS FOR INJURIES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|24,806.85|12012.87|12012.87|12012.87|||| 906|DRG||HAND PROCEDURES FOR INJURIES|PHCS|HUMANA|114,543.31|11035.85|29595.3|5745.175|||| 906|DRG||HAND PROCEDURES FOR INJURIES|NON CONTRACTED|COMMERCIAL OTHER 1|69,592.77|29595.3|29595.3|5745.175|||| 906|DRG||HAND PROCEDURES FOR INJURIES|United Medicare Advantage|UHC AARP MCR HMO MA|46,287.86|5745.175|29595.3|5745.175|||| 906|DRG||HAND PROCEDURES FOR INJURIES|Workers Compensation|TEXAS MUTUAL INSURANCE|44,238.66|15781.26|29595.3|5745.175|||| 906|DRG||HAND PROCEDURES FOR INJURIES|Workers Compensation|BROOKSHIRES WORKERS COMP|149,443.40|15781.26|29595.3|5745.175|||| 906|DRG||HAND PROCEDURES FOR INJURIES|Workers Compensation|WORKERS COMPENSATION OTHER|40,409.09|15781.26|29595.3|5745.175|||| 906|DRG||HAND PROCEDURES FOR INJURIES|Veterans Affairs|VETERANS ADMINISTRATION|103,749.31|10843.29|29595.3|5745.175|||| 906|DRG||HAND PROCEDURES FOR INJURIES|Blue Cross HMO Specialty|BCBSTX HMO|55,844.77|10638.95|29595.3|5745.175|||| 90648|ERX|0636|CS HAEMOPHILUS B CONJ 0.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|291.50||||||| 90648|ERX|0636|CS HAEMOPHILUS B CONJ 0.5|Humana Medicare Advantage|HUMANA MA|291.50||||||| 90648|ERX|0636|CS HAEMOPHILUS B CONJ 0.5|Blue Cross PPO Specialty|BCBSTX PPO|291.50||||||| 90675|ERX|0636|CS RABIES VACCINE, PCEC 2|Tricare|TRICARE EAST REGION|||||1,688.87||| 90686|ERX|0636|CS INFLUENZA VACCINE|United Medicare Advantage|UHC MEDICARE GOLD MA|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|United Medicare Advantage|UHC AARP MCR HMO MA|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|158.25||||129.30||| 90686|ERX|0636|CS INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Access Direct Platinum|ANDREWS CENTER|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Veterans Affairs|VETERANS ADMINISTRATION|158.25||||100.35||| 90686|ERX|0636|CS INFLUENZA VACCINE|Workers Compensation|TEXAS MUTUAL INSURANCE|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Workers Compensation|WORKERS COMPENSATION OTHER|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Aenta Medicare Advantage|AETNA MEDICARE MA|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Aetna|BH AETNA|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Aetna|AETNA QHP HMO|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Aetna|AETNA PPO|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Aetna|AETNA OTHER|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Blue Cross HMO Specialty|BCBSTX HMO|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Blue Cross PPO Specialty|BCBSTX OTHER|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Blue Cross PPO Specialty|BCBSTX PPO|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Cigna Behavioral Health|BH CIGNA|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Cigna|CIGNA|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|ChampVA|CHAMPVA CENTER|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Humana Medicare Advantage|HUMANA MA|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Magellan Behavioral Health|BH MAGELLAN|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicaid|MEDICAID SUPERIOR|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Cigna|CIGNA OTHER|129.30||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Brinson Benefits|THE HEALTH PLAN SMITH CO|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicaid|MEDICAID AMERIGROUP|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|SUPERIOR HEALTHPLAN CHIP|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Aetna|BOON CHAPMAN|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|158.25||||100.35||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|MEDICAID HMO|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|LAW ENFORCEMENT OTHER|100.35||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|SMITH COUNTY JAIL|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|MEDICAID|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|CRIME VICTIMS COMPENSATION|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicaid|BH TEXAS CHILDRENS MEDICAID|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicare|HEALTHSPRING MA|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicare|OTHER INSTITUTIONS|100.35||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA UMR|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|United Medicare Advantage|UHC AARP WELLMED HMO MA|100.35||||100.35||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicare|BCBS MEDICARE PPO MA|158.25||||100.35||| 90686|ERX|0636|CS INFLUENZA VACCINE|Managed Medicare|ETMC AFFILIATE HOSPITALS|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicare|MEDICARE PART B ONLY IP|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|Medicare|MEDICARE ACUTE|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Optum Behavioral Health|BH OPTUM UHC|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|NON CONTRACTED|COMMUNITY HEALTH CENTER|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|PHCS|GROUP AND PENSION|158.25||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|NON CONTRACTED|COMMERCIAL OTHER 1|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Rusk State Hospital|RUSK STATE HOSP|100.35||||||| 90686|ERX|0636|CS INFLUENZA VACCINE|United Healthcare|UNITED HEALTHCARE OTHER|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|United Healthcare|UNITED HEALTHCARE|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|United Healthcare|TML GROUP BENEFITS|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|Tricare|TRICARE EAST REGION|158.25||||158.25||| 90686|ERX|0636|CS INFLUENZA VACCINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|158.25||||||| 907|DRG||OTHER O.R. PROCEDURES FOR INJURIES W MCC|Medicare|MEDICARE ACUTE|136,268.45|23148.07|50649.7|204.12|||| 907|DRG||OTHER O.R. PROCEDURES FOR INJURIES W MCC|Managed Medicare|HEALTHSPRING MA|91,999.92|23683.72|50649.7|204.12|||| 907|DRG||OTHER O.R. PROCEDURES FOR INJURIES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|76,067.10|23175.35|50649.7|204.12|||| 907|DRG||OTHER O.R. PROCEDURES FOR INJURIES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|307,224.56|50649.7|50649.7|204.12|||| 907|DRG||OTHER O.R. PROCEDURES FOR INJURIES W MCC|Humana Medicare Advantage|HUMANA MA|377,884.88|23153.05|50649.7|204.12|||| 907|DRG||OTHER O.R. PROCEDURES FOR INJURIES W MCC|Blue Cross PPO Specialty|BCBSTX PPO|104,184.91|25901.775|50649.7|204.12|||| 907|DRG||OTHER O.R. PROCEDURES FOR INJURIES W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110,912.75|204.12|50649.7|204.12|||| 907|DRG||OTHER O.R. PROCEDURES FOR INJURIES W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|244,920.15|46345.3|50649.7|204.12|||| 90700|ERX|0636|TET-DIPH-PERTUS(ACEL)(PED|Managed Medicaid|MEDICAID SUPERIOR|142.05||||||| 90700|ERX|0636|TET-DIPH-PERTUS(ACEL)(PED|Managed Medicaid|MEDICAID AMERIGROUP|||||142.05||| 90700|ERX|0636|TET-DIPH-PERTUS(ACEL)(PED|Medicare|MEDICARE ACUTE|142.05||||||| 90702|ERX|0636|TETANUS-DIPTHE TOX(PEDI)P|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||310.90||| 90702|ERX|0636|TETANUS-DIPTHE TOX(PEDI)P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||310.90||| 90702|ERX|0636|TETANUS-DIPTHE TOX(PEDI)P|Workers Compensation|WORKERS COMPENSATION OTHER|||||310.90||| 90702|ERX|0636|TETANUS-DIPTHE TOX(PEDI)P|Aetna|AETNA OTHER|||||310.90||| 90702|ERX|0636|TETANUS-DIPTHE TOX(PEDI)P|Managed Medicaid|MEDICAID SUPERIOR|310.90||||310.90||| 90702|ERX|0636|TETANUS-DIPTHE TOX(PEDI)P|Managed Medicaid|MEDICAID AMERIGROUP|||||310.90||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Managed Medicaid|MEDICAID SUPERIOR|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Cigna|CIGNA|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Managed Medicaid|MEDICAID AMERIGROUP|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Blue Cross PPO Specialty|BCBSTX PPO|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Blue Cross HMO Specialty|BCBSTX HMO|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Aetna|AETNA PPO|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Access Direct Platinum|HEALTHFIRST TPA UMR|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|Access Direct Platinum|HEALTHFIRST TPA|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|PHCS|GROUP AND PENSION|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|NON CONTRACTED|COMMERCIAL OTHER 1|5.92||||||| 90707|ERX|0636|CS MEASLES,MUMP&RUBELLA V|United Healthcare|UNITED HEALTHCARE OTHER|5.92||||||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Managed Medicare|BCBS MEDICARE PPO MA|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Managed Medicare|HEALTHSPRING MA|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Medicaid|CRIME VICTIMS COMPENSATION|195.84||||||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Medicaid|MEDICAID HMO|195.84||||||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Medicaid|MEDICAID|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Tricare|TRICARE EAST REGION|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|United Healthcare|UNITED HEALTHCARE ERS|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|United Healthcare|UNITED HEALTHCARE OTHER|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|United Healthcare|UNITED HEALTHCARE|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|United Healthcare|AARP|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|United Healthcare|TML GROUP BENEFITS|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Medicare|MEDICARE ACUTE|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Medicare|MEDICARE PART B ONLY IP|195.84||||||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|NON CONTRACTED|COMMERCIAL OTHER 2|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|NON CONTRACTED|COMMERCIAL OTHER 1|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|PHCS|HUMANA|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|United Medicare Advantage|UHC AARP MCR HMO MA|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Workers Compensation|TEXAS MUTUAL INSURANCE|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|United Medicare Advantage|UHC MEDICARE GOLD MA|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Veterans Affairs|VETERANS ADMINISTRATION|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Workers Compensation|WORKERS COMPENSATION OTHER|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Workers Compensation|TRAVELERS INSURANCE COMPANY|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Workers Compensation|UT EMPLOYEE INJURY|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Access Direct Platinum|HEALTHFIRST TPA|195.84||||||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Aenta Medicare Advantage|AETNA MEDICARE MA|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|United Healthcare|UNITED HEALTHCARE|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|UTMB|UTMB CORRECTIONAL MANAGED CARE|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Medicaid|SMITH COUNTY JAIL|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Aetna|AETNA PPO|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Aetna|AETNA OTHER|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Blue Cross HMO Specialty|BCBSTX HMO|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Blue Cross PPO Specialty|BCBSTX OTHER|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Blue Cross PPO Specialty|BCBSTX PPO|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Managed Medicaid|MEDICAID SUPERIOR|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|195.84||||||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Managed Medicaid|MEDICAID AMERIGROUP|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Humana Medicare Advantage|HUMANA MA|195.84||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Cigna|CIGNA OTHER|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Cigna|CIGNA|||||195.84||| 90714|ERX|0636|TETANUS-DIPTHE TOX (ADULT|Cigna|CIGNA|195.84||||||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Cigna|CIGNA|238.05||||||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Cigna|CIGNA|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Humana Medicare Advantage|HUMANA MA|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicaid|MEDICAID SUPERIOR|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicaid|MEDICAID AMERIGROUP|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Blue Cross PPO Specialty|BCBSTX PPO|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Blue Cross HMO Specialty|BCBSTX HMO|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Aetna Value Network|AETNA VALUE NETWORK|238.05||||||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Aetna|AETNA PPO|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Aetna|AETNA OTHER|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Access Direct Platinum|HEALTHFIRST TPA|238.05||||||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Veterans Affairs|VETERANS ADMINISTRATION|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Workers Compensation|WORKERS COMPENSATION OTHER|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Workers Compensation|TEXAS MUTUAL INSURANCE|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Workers Compensation|UT EMPLOYEE INJURY|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Workers Compensation|WORKERS COMP PHYSICIAN|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Workers Compensation|BROOKSHIRES WORKERS COMP|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Aenta Medicare Advantage|AETNA MEDICARE MA|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|United Medicare Advantage|UHC MEDICARE GOLD MA|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|United Medicare Advantage|UHC AARP MCR HMO MA|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|PHCS|HUMANA|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|PHCS|GROUP AND PENSION|238.05||||||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|NON CONTRACTED|COMMERCIAL OTHER 2|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|NON CONTRACTED|COMMERCIAL OTHER 1|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Medicare|MEDICARE ACUTE|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Medicare|MEDICARE PART B ONLY IP|238.05||||||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|United Healthcare|UNITED HEALTHCARE|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|United Healthcare|UNITED HEALTHCARE OTHER|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|United Healthcare|UNITED HEALTHCARE|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|United Healthcare|TML GROUP BENEFITS|238.05||||||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|UTMB|UTMB CORRECTIONAL MANAGED CARE|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Tricare|TRICARE EAST REGION|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Medicaid|SMITH COUNTY JAIL|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Medicaid|CRIME VICTIMS COMPENSATION|238.05||||||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Medicaid|MEDICAID|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicare|HEALTHSPRING MA|238.05||||238.05||| 90715|ERX|0636|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicare|BCBS MEDICARE PPO MA|238.05||||238.05||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicare|BCBS MEDICARE PPO MA|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicare|WELLCARE CHOICE MA|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicare|HEALTHSPRING MA|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicare|ETMC AFFILIATE HOSPITALS|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Medicaid|MEDICAID HMO|||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Medicaid|COUNTY INDIGENT HEALTH OTHER|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Medicaid|LAW ENFORCEMENT OTHER|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Medicaid|MOLINA HEALTHCARE OF TEXAS|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Medicaid|SMITH COUNTY JAIL|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Medicaid|MEDICAID|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Medicaid|CRIME VICTIMS COMPENSATION|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|UTMB|UTMB CORRECTIONAL MANAGED CARE|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|United Healthcare|UNITED HEALTHCARE OTHER|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|United Healthcare|UNITED HEALTHCARE|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|United Healthcare|UNITED HEALTHCARE|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Medicare|MEDICARE PART B ONLY IP|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Medicare|MEDICARE ACUTE|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Rusk State Hospital|RUSK STATE HOSP|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|United Medicare Advantage|UHC MEDICARE GOLD MA|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|United Medicare Advantage|UHC AARP MCR HMO MA|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Veterans Affairs|VETERANS ADMINISTRATION|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Workers Compensation|GALLAGHER BASSETT|||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|NON CONTRACTED|COMMERCIAL OTHER 1|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Workers Compensation|TEXAS MUTUAL INSURANCE|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Workers Compensation|UT EMPLOYEE INJURY|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|United Healthcare|TML GROUP BENEFITS|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Workers Compensation|WORKERS COMPENSATION OTHER|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Tricare|TRICARE EAST REGION|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Access Direct Platinum|HEALTHFIRST TPA UMR|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Access Direct Platinum|HEALTHFIRST TPA|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Aenta Medicare Advantage|AETNA MEDICARE MA|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Aetna|BOON CHAPMAN|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Aetna|BH AETNA|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Aetna|AETNA PPO|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Aetna|AETNA OTHER|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Blue Cross HMO Specialty|BCBSTX HMO|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Blue Cross PPO Specialty|BCBSTX OTHER|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicare|OTHER INSTITUTIONS|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Blue Cross PPO Specialty|BCBSTX PPO|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Brinson Benefits|THE HEALTH PLAN SMITH CO|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicaid|MEDICAID SUPERIOR|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicaid|MEDICAID AMERIGROUP|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Humana Medicare Advantage|HUMANA MA|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Cigna|CIGNA|413.75||||413.75||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Cigna|CIGNA|413.75||||||| 90732|ERX|0636|CS PNEUMOCOCCAL VACC 25MC|Cigna|CIGNA OTHER|413.75||||||| 90734|ERX|0636|CS MENINGOCOCCAL VACC (ME|Humana Medicare Advantage|HUMANA MA|6.42||||||| 90734|ERX|0636|CS MENINGOCOCCAL VACC (ME|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.42||||||| 90734|ERX|0636|CS MENINGOCOCCAL VACC (ME|Blue Cross PPO Specialty|BCBSTX PPO|6.42||||||| 90734|ERX|0636|CS MENINGOCOCCAL VACC (ME|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.42||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|PHCS|HUMANA INSURANCE|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|PHCS|GROUP AND PENSION|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|NON CONTRACTED|COMMERCIAL OTHER 1|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|United Healthcare|UNITED HEALTHCARE OTHER|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|United Healthcare|UNITED HEALTHCARE|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|United Healthcare|TML GROUP BENEFITS|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Medicaid|SUPERIOR HEALTHPLAN CHIP|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Medicaid|MOLINA HEALTHCARE OF TEXAS|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Medicaid|MEDICAID HMO|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Medicaid|MEDICAID|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Access Direct Platinum|HEALTHFIRST TPA UMR|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Tricare|TRICARE EAST REGION|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Multiplan|WEB TPA|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Access Direct Platinum|HEALTHFIRST TPA|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Aetna Value Network|AETNA VALUE NETWORK|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Aetna|AETNA PPO|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Aetna|AETNA OTHER|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Blue Cross HMO Specialty|BCBSTX HMO|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Blue Cross PPO Specialty|BCBSTX PPO|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Blue Cross PPO Specialty|BCBSTX OTHER|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Managed Medicaid|MEDICAID SUPERIOR|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Managed Medicaid|MEDICAID AMERIGROUP|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Cigna|CIGNA OTHER|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|ChampVA|CHAMPVA CENTER|272.50||||||| 90744|ERX|0636|CS HEPATITIS B VACC(PF) 0|Cigna|CIGNA|272.50||||||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Managed Medicaid|MEDICAID AMERIGROUP|226,928.03|20696.25|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|87,988.92|12108.5|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Humana Medicare Advantage|HUMANA MA|75,835.65|12841.15|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Blue Cross PPO Specialty|BCBSTX PPO|93,693.10|13531.11|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Blue Cross HMO Specialty|BCBSTX HMO|39,172.54|107.16|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Veterans Affairs|VETERANS ADMINISTRATION|45,401.55|12604.89|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Workers Compensation|TEXAS MUTUAL INSURANCE|50,468.64|18023.73|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|47,809.02|16150.21|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Medicaid|CRIME VICTIMS COMPENSATION|216,037.40|10815.71|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Medicare|MEDICARE ACUTE|104,460.96|12841.15|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|United Healthcare|UNITED HEALTHCARE OTHER|116,423.75|24418.85|24418.85|107.16|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|95,513.40|15147.53|24418.85|107.16|||| 90832|EAP|0900|OP-MCR PSYTH PT & OR FAM|Medicare|MEDICARE ACUTE|||||3.23||| 90832|EAP|0906|CDIOP PSYCHOTH W PT & OR|Medicare|MEDICARE ACUTE|||||3.23||| 90832|EAP|0905|IOP PSYCHOTHERAPY W PT &|Tricare|TRICARE FOR LIFE|||||3.23||| 90832|EAP|0905|IOP PSYCHOTHERAPY W PT &|Aetna|BH AETNA|||||355.30||| 90832|EAP|0906|CDIOP PSYCHOTH W PT & OR|Aetna|BH AETNA|||||3.23||| 90832|EAP|0906|CDIOP PSYCHOTH W PT & OR|Blue Cross PPO Specialty|BCBSTX PPO|||||387.60||| 90832|EAP|0905|IOP PSYCHOTHERAPY W PT &|Blue Cross PPO Specialty|BCBSTX PPO|||||387.60||| 90832|EAP|0905|IOP PSYCHOTHERAPY W PT &|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.23||| 90832|EAP|0905|IOP PSYCHOTHERAPY W PT &|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||3.23||| 90832|EAP|0905|IOP PSYCHOTHERAPY W PT &|Cigna Behavioral Health|BH CIGNA|||||3.23||| 90832|EAP|0906|CDIOP PSYCHOTH W PT & OR|Cigna Behavioral Health|BH CIGNA|||||3.23||| 90834|EAP|0905|IOP PSYCHOTHERAPY W PT &|Magellan Behavioral Health|BH MAGELLAN|||||4.02||| 90834|EAP|0905|IOP PSYCHOTHERAPY W PT &|Cigna Behavioral Health|BH CIGNA|||||4.02||| 90834|EAP|0905|IOP PSYCHOTHERAPY W PT &|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.02||| 90834|EAP|0905|IOP PSYCHOTHERAPY W PT &|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||4.02||| 90834|EAP|0905|IOP PSYCHOTHERAPY W PT &|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||482.40||| 90834|EAP|0906|CDIOP PSYCHOTH W PT & OR|Blue Cross PPO Specialty|BCBSTX PPO|||||4.02||| 90834|EAP|0905|IOP PSYCHOTHERAPY W PT &|Blue Cross PPO Specialty|BCBSTX PPO|||||4.02||| 90834|EAP|0900|OP-MCR PSYTH PT & OR FAM|Medicare|MEDICARE ACUTE|||||4.02||| 90837|EAP|0905|IOP PSYCHOTHERAPY W PT &|Medicaid|BH TEXAS CHILDRENS MEDICAID|626.40||||5.22||| 90837|EAP|0900|OP-MCR PSYTH PT & OR FAM|Medicare|MEDICARE ACUTE|||||736.80||| 90837|EAP|0906|CDIOP PSYCHOTHERAP W PT &|Aetna|BH AETNA|||||5.22||| 90837|EAP|0905|IOP PSYCHOTHERAPY W PT &|Blue Cross PPO Specialty|BCBSTX PPO|||||574.20||| 90837|EAP|0906|CDIOP PSYCHOTHERAP W PT &|Blue Cross PPO Specialty|BCBSTX PPO|||||5.22||| 90837|EAP|0905|IOP PSYCHOTHERAPY W PT &|Blue Cross PPO Specialty|BCBSTX PPO|||||5.22||| 90837|EAP|0905|IOP PSYCHOTHERAPY W PT &|Managed Medicaid|MEDICAID AMERIGROUP|||||5.22||| 90837|EAP|0905|IOP PSYCHOTHERAPY W PT &|Cigna Behavioral Health|BH CIGNA|||||5.22||| 90837|EAP|0906|CDIOP PSYCHOTHERAP W PT &|Magellan Behavioral Health|BH MAGELLAN|||||626.40||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.22||| 90853|EAP|0905|OP MCR GRP THR OTH THN MU|Access Direct Platinum|HEALTHFIRST TPA UMR|||||626.40||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||626.40||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||626.40||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.22||| 90853|EAP|0905|OP MCR GRP THR OTH THN MU|Humana Medicare Advantage|HUMANA MA|5.22||||626.40||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Humana Medicare Advantage|HUMANA MA|5.22||||626.40||| 90853|EAP|0905|OP MCR GRP THR OTH THN MU|Magellan Behavioral Health|BH MAGELLAN|||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Magellan Behavioral Health|BH MAGELLAN|||||626.40||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Cigna Behavioral Health|BH CIGNA|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Cigna Behavioral Health|BH CIGNA|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Cigna|CIGNA OTHER|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Magellan Behavioral Health|BH MAGELLAN|||||626.40||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Managed Medicaid|MEDICAID AMERIGROUP|5.22||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Managed Medicaid|MEDICAID AMERIGROUP|||||626.40||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Magellan Behavioral Health|BH MAGELLAN|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Blue Cross PPO Specialty|BCBSTX PPO|||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Blue Cross PPO Specialty|BCBSTX PPO|||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Aetna|BH AETNA|||||5.22||| 90853|EAP|0905|OP MCR GRP THR OTH THN MU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Aetna|BH AETNA|||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|United Healthcare|UNITED HEALTHCARE|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Tricare|TRICARE FOR LIFE|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Optum Behavioral Health|BH OPTUM UHC|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|PHCS|HUMANA INSURANCE|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|NON CONTRACTED|COMMERCIAL OTHER 1|||||626.40||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Optum Behavioral Health|BH OPTUM UHC|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Multiplan|WEB TPA|||||5.22||| 90853|EAP|0905|OP MCR GRP THR OTH THN MU|Medicare|MEDICARE ACUTE|5.22||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Medicare|MEDICARE ACUTE|5.22||||5.22||| 90853|EAP|0906|CDIOP GRP PSYCH OTH/TH MU|Medicare|MEDICARE ACUTE|5.22||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Managed Medicare|HEALTHSPRING MA|||||626.40||| 90853|EAP|0905|OP MCR GRP THR OTH THN MU|Managed Medicare|HEALTHSPRING MA|||||626.40||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.22||| 90853|EAP|0905|IOP GRP THPY OTH MULT FAM|Medicaid|BH TEXAS CHILDRENS MEDICAID|626.40||||5.22||| 909|DRG||OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC|Medicare|MEDICARE ACUTE|60,620.12|8670.23|10960.56|68.04|||| 909|DRG||OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58,978.10|68.04|10960.56|68.04|||| 909|DRG||OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|29,451.05|8999.47|10960.56|68.04|||| 909|DRG||OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|46,848.60|8513.06|10960.56|68.04|||| 909|DRG||OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|43,158.80|8736.61|10960.56|68.04|||| 909|DRG||OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|48,812.26|10960.56|10960.56|68.04|||| 90935|EAP|0820|ART KID DIAL ACUTE|United Medicare Advantage|UHC AARP MCR HMO MA|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|United Medicare Advantage|UHC MEDICARE GOLD MA|3,046.35||||3,046.35||| 90935|EAP|0820|ART KID DIAL ACUTE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.49||||2,847.68||| 90935|EAP|0820|ART KID DIAL ACUTE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Access Direct Platinum|HEALTHFIRST TPA UMR|26.49||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,046.35||||3,046.35||| 90935|EAP|0820|ART KID DIAL ACUTE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,046.35||||3,046.35||| 90935|EAP|0820|ART KID DIAL ACUTE|Managed Medicaid|MEDICAID AMERIGROUP|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Blue Cross PPO Specialty|BCBSTX PPO|3,046.35||||3,046.35||| 90935|EAP|0820|ART KID DIAL ACUTE|Blue Cross HMO Specialty|BCBSTX HMO|26.49||||26.49||| 90935|EAP|0820|ART KID DIAL ACUTE|Aenta Medicare Advantage|AETNA MEDICARE MA|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Aetna|AETNA QHP HMO|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Aetna|AETNA PPO|26.49||||26.49||| 90935|EAP|0820|ART KID DIAL ACUTE|Aetna|AETNA OTHER|26.49||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Humana Medicare Advantage|HUMANA MA|26.49||||26.49||| 90935|EAP|0820|ART KID DIAL ACUTE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,046.35||||3,046.35||| 90935|EAP|0820|ART KID DIAL ACUTE|Medicare|MEDICARE PART B ONLY IP|26.49||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Access Direct Platinum|HEALTHFIRST TPA|2,847.68||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Medicare|MEDICARE ACUTE|3,046.35||||3,046.35||| 90935|EAP|0820|ART KID DIAL ACUTE|PHCS|HUMANA|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Veterans Affairs|VETERANS ADMINISTRATION|26.49||||26.49||| 90935|EAP|0820|ART KID DIAL ACUTE|PHCS|GROUP AND PENSION|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|NON CONTRACTED|COMMERCIAL OTHER 1|26.49||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Rusk State Hospital|RUSK STATE HOSP|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Tricare|TRICARE EAST REGION|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|UTMB|UTMB CORRECTIONAL MANAGED CARE|26.49||||||| 90935|EAP|0820|ART KID DIAL ACUTE|United Healthcare|UNITED HEALTHCARE OTHER|3,046.35||||3,046.35||| 90935|EAP|0820|ART KID DIAL ACUTE|United Healthcare|UNITED HEALTHCARE|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Managed Medicare|BCBS MEDICARE PPO MA|26.49||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Managed Medicare|HEALTHSPRING MA|26.49||||2,847.68||| 90935|EAP|0820|ART KID DIAL ACUTE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.49||||26.49||| 90935|EAP|0820|ART KID DIAL ACUTE|Managed Medicare|ETMC SPECIALTY HOSPITAL|26.49||||3,046.35||| 90935|EAP|0820|ART KID DIAL ACUTE|Medicaid|MEDICAID|26.49||||3,046.35||| 90935|EAP|0820|ART KID DIAL ACUTE|Medicaid|COUNTY INDIGENT HEALTH OTHER|3,046.35||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Medicaid|SMITH COUNTY INDIGENT HEALTH|26.49||||||| 90935|EAP|0820|ART KID DIAL ACUTE|Medicaid|LAW ENFORCEMENT OTHER|||||3,046.35||| 90945|EAP|0800|CRRT TREATMENT|Medicaid|COUNTY INDIGENT HEALTH OTHER|2,954.10||||||| 90945|EAP|0800|CRRT TREATMENT|Medicaid|MEDICAID|27.48||||||| 90945|EAP|0800|CRRT TREATMENT|Managed Medicare|BCBS MEDICARE PPO MA|27.48||||||| 90945|EAP|0800|CRRT TREATMENT|Managed Medicare|HEALTHSPRING MA|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|PHCS|HUMANA|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|Medicare|MEDICARE ACUTE|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|Aenta Medicare Advantage|AETNA MEDICARE MA|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|Blue Cross HMO Specialty|BCBSTX HMO|27.48||||||| 90945|EAP|0800|CRRT TREATMENT|Blue Cross PPO Specialty|BCBSTX PPO|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|Humana Medicare Advantage|HUMANA MA|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|Veterans Affairs|VETERANS ADMINISTRATION|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|United Medicare Advantage|UHC MEDICARE GOLD MA|3,160.20||||||| 90945|EAP|0800|CRRT TREATMENT|United Medicare Advantage|UHC AARP MCR HMO MA|3,160.20||||||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|Managed Medicare|BCBS MEDICARE PPO MA|66,146.27|9852.96|14776.4|232.18|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|Managed Medicare|HEALTHSPRING MA|38,416.67|9872.19|14776.4|232.18|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|Humana Medicare Advantage|HUMANA MA|90,649.51|9846.61|14776.4|232.18|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47,394.25|9464.09|14776.4|232.18|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|211,392.76|14776.4|14776.4|232.18|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|87,291.68|232.18|14776.4|232.18|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|44,965.76|9872.19|14776.4|232.18|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|273,838.67|10069.74|14776.4|232.18|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|1,432.42|9880.99|14776.4|232.18|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|Medicare|MEDICARE ACUTE|67,994.80|9871.75|14776.4|232.18|||| 91035|EAP|0750|ESOPH ACID REFLUX TEST MU|Medicare|MEDICARE ACUTE|||||4,747.20||| 91035|EAP|0750|ESOPH ACID REFLUX TEST MU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,437.60||| 91035|EAP|0750|ESOPH ACID REFLUX TEST MU|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4,747.20||| 91035|EAP|0750|ESOPH ACID REFLUX TEST MU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,747.20||| 91035|EAP|0750|ESOPH ACID REFLUX TEST MU|Blue Cross HMO Specialty|BCBSTX HMO|||||4,747.20||| 91037|EAP|0750|ESOPH IMPED FUNCTION TEST|Humana Medicare Advantage|HUMANA MA|||||684.03||| 91037|EAP|0750|ESOPH IMPED FUNCTION TEST|Blue Cross PPO Specialty|BCBSTX PPO|||||684.03||| 91037|EAP|0750|ESOPH IMPED FUNCTION TEST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||684.03||| 91037|EAP|0750|ESOPH IMPED FUNCTION TEST|Managed Medicare|HEALTHSPRING MA|||||684.03||| 91037|EAP|0750|ESOPH IMPED FUNCTION TEST|Medicare|MEDICARE ACUTE|||||684.03||| 91110|EAP|0750|GI TRACT IMAGING|Tricare|TRICARE EAST REGION|||||41.56||| 91110|EAP|0750|GI TRACT IMAGING|UTMB|UTMB CORRECTIONAL MANAGED CARE|4,363.80||||||| 91110|EAP|0750|GI TRACT IMAGING|United Healthcare|UNITED HEALTHCARE OTHER|41.56||||41.56||| 91110|EAP|0750|GI TRACT IMAGING|Medicare|MEDICARE ACUTE|4,363.80||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|41.56||||41.56||| 91110|EAP|0750|GI TRACT IMAGING|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||41.56||| 91110|EAP|0750|GI TRACT IMAGING|Managed Medicare|HEALTHSPRING MA|4,259.90||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||41.56||| 91110|EAP|0750|GI TRACT IMAGING|Managed Medicare|BCBS MEDICARE PPO MA|||||41.56||| 91110|EAP|0750|GI TRACT IMAGING|United Healthcare|UNITED HEALTHCARE|41.56||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Access Direct Platinum|HEALTHFIRST TPA|||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,259.90||||41.56||| 91110|EAP|0750|GI TRACT IMAGING|United Medicare Advantage|UHC AARP WELLMED HMO MA|4,363.80||||||| 91110|EAP|0750|GI TRACT IMAGING|United Medicare Advantage|UHC AARP MCR HMO MA|||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41.56||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Aenta Medicare Advantage|AETNA MEDICARE MA|41.56||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Blue Cross HMO Specialty|BCBSTX HMO|||||41.56||| 91110|EAP|0750|GI TRACT IMAGING|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Blue Cross PPO Specialty|BCBSTX PPO|||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Managed Medicaid|MEDICAID SUPERIOR|41.56||||||| 91110|EAP|0750|GI TRACT IMAGING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Cigna|CIGNA|||||4,363.80||| 91110|EAP|0750|GI TRACT IMAGING|Humana Medicare Advantage|HUMANA MA|4,363.80||||4,363.80||| 915|DRG||ALLERGIC REACTIONS W MCC|Managed Medicaid|MEDICAID AMERIGROUP|174,620.35|17475.86|17483.74|178.6|||| 915|DRG||ALLERGIC REACTIONS W MCC|Cigna|CIGNA|100,588.65|17483.74|17483.74|178.6|||| 915|DRG||ALLERGIC REACTIONS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|71,211.95|11386.15|17483.74|178.6|||| 915|DRG||ALLERGIC REACTIONS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|65,928.95|178.6|17483.74|178.6|||| 915|DRG||ALLERGIC REACTIONS W MCC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|53,863.42|13612.55|17483.74|178.6|||| 915|DRG||ALLERGIC REACTIONS W MCC|Medicare|MEDICARE ACUTE|271,257.85|10607.5|17483.74|178.6|||| 916|DRG||ALLERGIC REACTIONS W/O MCC|Medicaid|MEDICAID|13,141.60|1729.29|4132.105|1729.29|||| 916|DRG||ALLERGIC REACTIONS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|13,823.90|4132.105|4132.105|1729.29|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Veterans Affairs|VETERANS ADMINISTRATION|56,450.42|9313.04|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|141,209.72|9479.87|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|104,712.97|2325.1|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Managed Medicare|HEALTHSPRING MA|361,745.86|13392.79|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Humana Medicare Advantage|HUMANA MA|170,288.23|9479.87|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|96,920.81|12044.275|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Managed Medicaid|MEDICAID SUPERIOR|55,286.05|7452.01|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97,491.55|12977.78|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|621.71|8864.27|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Aetna|AETNA PPO|56,343.06|16992.14|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|135,851.37|142.88|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|362,460.20|10887.93|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|46,309.40|10006.42|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|56,716.03|56716.025|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|55,989.41|9312.16|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|109,146.90|9382.375|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|45,007.68|9313.04|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|United Healthcare|UNITED HEALTHCARE OTHER|400.65|17318.44|56716.025|142.88|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Medicare|MEDICARE ACUTE|62,529.68|9284.88|56716.025|142.88|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Medicaid|MEDICAID HMO|32,119.50|1484.28|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Medicare|MEDICARE PART B ONLY IP|9,651.60|660.56|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|25,316.20|9279.42|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|United Healthcare|UNITED HEALTHCARE|7,926.10|7926.1|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|85.65|5544.98|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Medicare|MEDICARE ACUTE|23,803.55|5586.02|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|57,627.07|9313.04|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|40,931.10|5674.25|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|38,240.50|38240.5|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|22,946.91|5287.37|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20,537.25|68.04|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|39,071.75|4494.66|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Aetna|AETNA PPO|23,890.85|10115.95|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|17,587.95|2478.01|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38,542.40|3014.49|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Cigna|CIGNA|7,788.80|7788.8|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11,352.90|7232.85|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|27,550.52|7832.52|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|16,209.90|5674.25|38240.5|68.04|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|16,549.16|5674.25|38240.5|68.04|||| 919|DRG||COMPLICATIONS OF TREATMENT W MCC|Managed Medicare|BCBS MEDICARE PPO MA|231,712.50|11271.84|21604.25|123.87|||| 919|DRG||COMPLICATIONS OF TREATMENT W MCC|Humana Medicare Advantage|HUMANA MA|164,002.07|11408.605|21604.25|123.87|||| 919|DRG||COMPLICATIONS OF TREATMENT W MCC|Cigna|CIGNA OTHER|22,345.90|18782.34|21604.25|123.87|||| 919|DRG||COMPLICATIONS OF TREATMENT W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39,388.75|9895.4|21604.25|123.87|||| 919|DRG||COMPLICATIONS OF TREATMENT W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|85,354.31|142.88|21604.25|123.87|||| 919|DRG||COMPLICATIONS OF TREATMENT W MCC|Blue Cross PPO Specialty|BCBSTX PPO|42,981.30|123.87|21604.25|123.87|||| 919|DRG||COMPLICATIONS OF TREATMENT W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|201,980.59|11530.82|21604.25|123.87|||| 919|DRG||COMPLICATIONS OF TREATMENT W MCC|United Healthcare|UNITED HEALTHCARE|55,210.32|21604.25|21604.25|123.87|||| 919|DRG||COMPLICATIONS OF TREATMENT W MCC|Medicare|MEDICARE ACUTE|101,838.24|11299.12|21604.25|123.87|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Medicare|MEDICARE ACUTE|43,036.75|6584.4|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|United Healthcare|TML GROUP BENEFITS|37,482.67|11434.76|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|43,659.12|6568.52|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|78,044.56|6694.58|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Veterans Affairs|VETERANS ADMINISTRATION|48,375.25|6585.28|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Medicaid|SMITH COUNTY JAIL|114,299.92|5952.26|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|62,710.80|8502.38|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|94,883.92|9036.44|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Blue Cross PPO Specialty|BCBSTX PPO|15,750.55|6405.01|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Aetna|AETNA PPO|30,754.87|12221.16|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Blue Cross HMO Specialty|BCBSTX HMO|62,451.65|5444.73|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|52,922.96|9464.09|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|101,985.75|9464.09|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Humana Medicare Advantage|HUMANA MA|125,197.40|6584.4|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|78,591.25|6584.4|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Managed Medicare|BCBS MEDICARE PPO MA|51,343.31|6560.69|12221.16|5444.73|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|Managed Medicare|HEALTHSPRING MA|42,773.40|6694.58|12221.16|5444.73|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Managed Medicare|HEALTHSPRING MA|33,368.35|6926.54|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44,314.95|6849.63|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62,916.41|107.16|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Blue Cross HMO Specialty|BCBSTX HMO|68,814.53|5789.89|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Aetna|AETNA PPO|32,536.55|12744.88|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Brinson Benefits|THE HEALTH PLAN SMITH CO|32,571.25|32571.25|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Blue Cross PPO Specialty|BCBSTX PPO|50,385.61|6811.05|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Veterans Affairs|VETERANS ADMINISTRATION|116,358.17|6926.54|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|NON CONTRACTED|COMMERCIAL OTHER 1|32,062.50|32062.5|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|83,414.03|6926.54|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|United Medicare Advantage|UHC AARP MCR HMO MA|101,635.76|6926.54|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Medicare|MEDICARE ACUTE|31,128.13|6812.01|32571.25|107.16|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Medicaid|MEDICAID|53,397.55|6223.52|32571.25|107.16|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|38,089.90|1001.7|7106.27|1001.7|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Medicare|MEDICARE ACUTE|66,111.33|5045.35|7106.27|1001.7|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|50,278.30|5060.95|7106.27|1001.7|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|44,044.45|6693.25|7106.27|1001.7|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|31,164.15|4797.81|7106.27|1001.7|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Cigna|CIGNA|23,903.80|7106.27|7106.27|1001.7|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|163.90|5045.09|7106.27|1001.7|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29,762.10|6849.63|7106.27|1001.7|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|14,992.85|5045.35|7106.27|1001.7|||| 922|DRG||OTHER INJURY, POISONING & TOXIC EFFECT DIAG W MCC|Managed Medicare|HEALTHSPRING MA|63,419.16|10266.54|10266.54|9945.98|||| 922|DRG||OTHER INJURY, POISONING & TOXIC EFFECT DIAG W MCC|Managed Medicaid|MEDICAID AMERIGROUP|29,174.92|9945.98|10266.54|9945.98|||| 922|DRG||OTHER INJURY, POISONING & TOXIC EFFECT DIAG W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|107,093.80|10147.68|10266.54|9945.98|||| 923|DRG||OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O MCC|Medicare|MEDICARE ACUTE|45,663.07|6067.985|6067.985|6067.985|||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|United Medicare Advantage|UHC MEDICARE GOLD MA|3.91||||3.91||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|United Medicare Advantage|UHC AARP MCR HMO MA|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Workers Compensation|WORKERS COMPENSATION OTHER|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Access Direct Platinum|HEALTHFIRST TPA UMR|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Access Direct Platinum|HEALTHFIRST TPA|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Aetna|AETNA PPO|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Aenta Medicare Advantage|AETNA MEDICARE MA|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.91||||3.91||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Blue Cross PPO Specialty|BCBSTX PPO|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Blue Cross HMO Specialty|BCBSTX HMO|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Cigna|CIGNA|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Veterans Affairs|VETERANS ADMINISTRATION|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Humana Medicare Advantage|HUMANA MA|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Managed Medicaid|MEDICAID SUPERIOR|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|NON CONTRACTED|COMMERCIAL OTHER 1|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Medicare|MEDICARE ACUTE|3.91||||3.91||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|United Healthcare|UNITED HEALTHCARE OTHER|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Tricare|TRICARE EAST REGION|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Managed Medicare|BCBS MEDICARE PPO MA|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Managed Medicare|HEALTHSPRING MA|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.91||||||| 92507|EAP|0440|SPEECH/LANGUAGE/VOICE IND|Medicaid|MEDICAID|3.91||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Medicaid|SMITH COUNTY INDIGENT HEALTH|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Medicaid|MEDICAID|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Managed Medicare|HEALTHSPRING MA|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Managed Medicare|ETMC AFFILIATE HOSPITALS|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Tricare|TRICARE EAST REGION|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|United Healthcare|UNITED HEALTHCARE OTHER|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|United Healthcare|UNITED HEALTHCARE|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|United Healthcare|GEHA|||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Medicare|MEDICARE PART B ONLY IP|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Medicare|MEDICARE ACUTE|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|PHCS|HUMANA INSURANCE|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Managed Medicaid|MEDICAID SUPERIOR|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|NON CONTRACTED|COMMERCIAL OTHER 1|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Managed Medicaid|MEDICAID AMERIGROUP|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Humana Medicare Advantage|HUMANA MA|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|ChampVA|CHAMPVA CENTER|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Cigna|CIGNA|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Blue Cross HMO Specialty|BCBSTX HMO|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Blue Cross PPO Specialty|BCBSTX PPO|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Blue Cross PPO Specialty|BCBSTX OTHER|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Aetna|AETNA QHP HMO|||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Aetna|AETNA OTHER|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Aetna|AETNA PPO|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Managed Medicare|BCBS MEDICARE PPO MA|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Aenta Medicare Advantage|AETNA MEDICARE MA|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Access Direct Platinum|HEALTHFIRST TPA UMR|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Access Direct Platinum|HEALTHFIRST TPA|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Workers Compensation|WORKERS COMPENSATION OTHER|9.92||||||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|Veterans Affairs|VETERANS ADMINISTRATION|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|United Medicare Advantage|UHC MEDICARE GOLD MA|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.92||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||9.92||| 92523|EAP|0440|SPEECH EVAL LANGUATE COMP|United Medicare Advantage|UHC AARP MCR HMO MA|9.92||||9.92||| 92524|EAP|0440|SPEECH EVAL OF VOICE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.29||||||| 92524|EAP|0440|SPEECH EVAL OF VOICE|United Medicare Advantage|UHC AARP MCR HMO MA|5.29||||||| 92524|EAP|0440|SPEECH EVAL OF VOICE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.29||||||| 92524|EAP|0440|SPEECH EVAL OF VOICE|Humana Medicare Advantage|HUMANA MA|5.29||||||| 92524|EAP|0440|SPEECH EVAL OF VOICE|Medicare|MEDICARE ACUTE|5.29||||||| 92524|EAP|0440|SPEECH EVAL OF VOICE|Managed Medicare|HEALTHSPRING MA|5.29||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Medicaid|SMITH COUNTY JAIL|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Medicaid|CRIME VICTIMS COMPENSATION|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Managed Medicare|BCBS MEDICARE PPO MA|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||3.05||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Managed Medicare|HEALTHSPRING MA|3.05||||3.05||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|United Healthcare|UNITED HEALTHCARE OTHER|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|United Healthcare|UNITED HEALTHCARE|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|United Healthcare|TML GROUP BENEFITS|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|PHCS|HUMANA|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Rusk State Hospital|RUSK STATE HOSP|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|NON CONTRACTED|COMMERCIAL OTHER 1|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Tricare|TRICARE EAST REGION|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Medicare|MEDICARE PART B ONLY IP|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Medicare|MEDICARE ACUTE|3.05||||3.05||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.05||||3.05||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Managed Medicaid|MEDICAID SUPERIOR|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Cigna|CIGNA|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Humana Medicare Advantage|HUMANA MA|3.05||||3.05||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Blue Cross PPO Specialty|BCBSTX PPO|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Managed Medicare|WELLCARE CHOICE MA|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Blue Cross PPO Specialty|BCBSTX OTHER|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Blue Cross HMO Specialty|BCBSTX HMO|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Aetna|AETNA OTHER|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Medicaid|MEDICAID|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Aenta Medicare Advantage|AETNA MEDICARE MA|3.05||||3.05||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Aetna|AETNA PPO|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.05||||3.05||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Workers Compensation|WORKERS COMPENSATION OTHER|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Veterans Affairs|VETERANS ADMINISTRATION|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Access Direct Platinum|HEALTHFIRST TPA UMR|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|Access Direct Platinum|HEALTHFIRST TPA|3.05||||||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|United Medicare Advantage|UHC AARP MCR HMO MA|3.05||||3.05||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|United Medicare Advantage|UHC MEDICARE GOLD MA|3.05||||3.05||| 92526|EAP|0440|SWALLOWING AND/OR ORAL FU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.05||||3.05||| 92585|EAP|0471|BAER|United Medicare Advantage|UHC MEDICARE GOLD MA|22.61||||||| 92585|EAP|0471|BAER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,487.10||||||| 92585|EAP|0471|BAER|Access Direct Platinum|HEALTHFIRST TPA|2,713.20||||||| 92585|EAP|0471|BAER|Aetna|BOON CHAPMAN|22.61||||||| 92585|EAP|0471|BAER|Blue Cross HMO Specialty|BCBSTX HMO|2,713.20||||||| 92585|EAP|0471|BAER|Blue Cross PPO Specialty|BCBSTX PPO|2,713.20||||||| 92585|EAP|0471|BAER|Humana Medicare Advantage|HUMANA MA|22.61||||||| 92585|EAP|0471|BAER|ChampVA|CHAMPVA CENTER|22.61||||||| 92585|EAP|0471|BAER|Medicare|MEDICARE ACUTE|2,713.20||||||| 92585|EAP|0471|BAER|United Healthcare|UNITED HEALTHCARE OTHER|22.61||||||| 92585|EAP|0471|BAER|United Healthcare|UNITED HEALTHCARE|2,713.20||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Managed Medicare|HEALTHSPRING MA|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Medicaid|CRIME VICTIMS COMPENSATION|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Medicaid|MEDICAID|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|United Healthcare|UNITED HEALTHCARE OTHER|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Medicare|MEDICARE ACUTE|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Humana Medicare Advantage|HUMANA MA|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Blue Cross PPO Specialty|BCBSTX PPO|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Blue Cross PPO Specialty|BCBSTX OTHER|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Aenta Medicare Advantage|AETNA MEDICARE MA|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|Access Direct Platinum|HEALTHFIRST TPA|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|United Medicare Advantage|UHC MEDICARE GOLD MA|6.65||||||| 92597|EAP|0440|ORAL SPEECH DEVICE EVAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.65||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|United Medicare Advantage|UHC MEDICARE GOLD MA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|United Medicare Advantage|UHC AARP MCR HMO MA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Workers Compensation|WORKERS COMPENSATION OTHER|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Veterans Affairs|VETERANS ADMINISTRATION|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Access Direct Platinum|HEALTHFIRST TPA UMR|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Access Direct Platinum|HEALTHFIRST TPA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Aetna|AETNA OTHER|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Aetna|AETNA QHP HMO|||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Aetna|AETNA PPO|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Blue Cross HMO Specialty|BCBSTX HMO|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Blue Cross PPO Specialty|BCBSTX PPO|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Cigna|CIGNA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|ChampVA|CHAMPVA CENTER|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Cigna|CIGNA|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Humana Medicare Advantage|HUMANA MA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Managed Medicaid|MEDICAID SUPERIOR|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Managed Medicaid|MEDICAID AMERIGROUP|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|PHCS|HUMANA INSURANCE|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Rusk State Hospital|RUSK STATE HOSP|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Blue Cross PPO Specialty|BCBSTX OTHER|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Aenta Medicare Advantage|AETNA MEDICARE MA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|NON CONTRACTED|COMMERCIAL OTHER 1|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|PHCS|HUMANA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Medicare|MEDICARE PART B ONLY IP|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Medicare|MEDICARE ACUTE|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Tricare|TRICARE EAST REGION|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|United Healthcare|UNITED HEALTHCARE OTHER|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|United Healthcare|UNITED HEALTHCARE|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|United Healthcare|UNITED HEALTHCARE|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|United Healthcare|TML GROUP BENEFITS|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|United Healthcare|GEHA|||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Medicaid|SMITH COUNTY JAIL|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Medicaid|CRIME VICTIMS COMPENSATION|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Medicaid|MEDICAID|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Managed Medicare|BCBS MEDICARE PPO MA|7.35||||7.35||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Managed Medicare|ETMC AFFILIATE HOSPITALS|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Managed Medicare|WELLCARE CHOICE MA|7.35||||||| 92610|EAP|0444|EVAL ORAL/PHARYNGEAL SWAL|Managed Medicare|HEALTHSPRING MA|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Managed Medicare|BCBS MEDICARE PPO MA|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Managed Medicare|WELLCARE CHOICE MA|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Managed Medicare|HEALTHSPRING MA|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Managed Medicare|ETMC AFFILIATE HOSPITALS|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Medicaid|SMITH COUNTY JAIL|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Medicaid|MEDICAID|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|United Healthcare|UNITED HEALTHCARE OTHER|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|United Healthcare|UNITED HEALTHCARE|||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Tricare|TRICARE EAST REGION|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Medicare|MEDICARE ACUTE|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Multiplan|WEB TPA|||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|NON CONTRACTED|COMMERCIAL OTHER 1|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Medicare|MEDICARE PART B ONLY IP|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Managed Medicaid|MEDICAID SUPERIOR|||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Managed Medicaid|MEDICAID AMERIGROUP|||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|United Healthcare|UNITED HEALTHCARE|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Medicaid|MEDICAID HMO|||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Humana Medicare Advantage|HUMANA MA|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Blue Cross PPO Specialty|BCBSTX PPO|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Blue Cross HMO Specialty|BCBSTX HMO|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Aetna|AETNA PPO|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Aetna|AETNA OTHER|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Aenta Medicare Advantage|AETNA MEDICARE MA|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Access Direct Platinum|HEALTHFIRST TPA|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Workers Compensation|WORKERS COMPENSATION OTHER|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|Veterans Affairs|VETERANS ADMINISTRATION|7.35||||||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|United Medicare Advantage|UHC MEDICARE GOLD MA|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.35||||7.35||| 92611|EAP|0444|MOTION FLUOROSCOPIC EVAL|United Medicare Advantage|UHC AARP MCR HMO MA|7.35||||7.35||| 928|DRG||FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|328,995.46|213847.05|213847.05|213847.05|||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|Medicare|MEDICARE ACUTE|214.34||||21,969.85||| 92920|EAP|0481|PTCA SINGLE VESSEL LC|Medicare|MEDICARE ACUTE|214.34||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Medicare|MEDICARE ACUTE|214.34||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL LC|Tricare|TRICARE EAST REGION|||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL LC|UTMB|UTMB CORRECTIONAL MANAGED CARE|22,505.70||||||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|United Healthcare|UNITED HEALTHCARE OTHER|214.34||||||| 92920|EAP|0481|PTCA SINGLE VESSEL LC|United Healthcare|UNITED HEALTHCARE|||||22,505.70||| 92920|EAP|0481|PTCA-COR SINGLE VESSEL-LM|Medicaid|MEDICAID|22,050.07||||||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Managed Medicare|HEALTHSPRING MA|22,505.70||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Managed Medicare|HEALTHSPRING MA|21,969.85||||214.34||| 92920|EAP|0481|PTCA-COR SINGLE VESSEL-LM|United Medicare Advantage|UHC AARP MCR HMO MA|22,505.70||||22,050.70||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|United Medicare Advantage|UHC MEDICARE GOLD MA|22,505.70||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|22,505.70||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL LC|Managed Medicare|HEALTHSPRING MA|22,505.70||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|United Medicare Advantage|UHC MEDICARE GOLD MA|22,505.70||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|United Medicare Advantage|UHC AARP MCR HMO MA|22,505.70||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL LC|United Medicare Advantage|UHC MEDICARE GOLD MA|22,505.70||||21,969.85||| 92920|EAP|0481|PTCA SINGLE VESSEL LC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21,969.85||||214.34||| 92920|EAP|0481|PTCA-COR SINGLE VESSEL-RI|Veterans Affairs|VETERANS ADMINISTRATION|214.34||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Veterans Affairs|VETERANS ADMINISTRATION|22,505.70||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|214.34||||||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Cigna|CIGNA|22,505.70||||||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|Tricare|TRICARE EAST REGION|||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|Humana Medicare Advantage|HUMANA MA|21,969.85||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL LC|Humana Medicare Advantage|HUMANA MA|214.34||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Humana Medicare Advantage|HUMANA MA|214.34||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|22,505.70||||21,969.85||| 92920|EAP|0481|PTCA-COR SINGLE VESSEL-RI|Medicare|MEDICARE ACUTE|22,050.70||||21,969.85||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Blue Cross HMO Specialty|BCBSTX HMO|214.34||||||| 92920|EAP|0481|PTCA-COR SINGLE VESSEL-LM|Blue Cross PPO Specialty|BCBSTX PPO|22,505.70||||22,050.07||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|Blue Cross PPO Specialty|BCBSTX PPO|21,969.85||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL LC|Blue Cross PPO Specialty|BCBSTX PPO|214.34||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|Aenta Medicare Advantage|AETNA MEDICARE MA|22,505.70||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Aenta Medicare Advantage|AETNA MEDICARE MA|22,505.70||||22,505.70||| 92920|EAP|0481|PTCA SINGLE VESSEL RC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,505.70||||214.34||| 92920|EAP|0481|PTCA SINGLE VESSEL LD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,505.70||||22,505.70||| 92921|EAP|0481|PTCA EA ADDL VESSEL RC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11,252.85||||107.17||| 92921|EAP|0481|PTCA EA ADDL VESSEL LD|Aenta Medicare Advantage|AETNA MEDICARE MA|11,252.85||||||| 92921|EAP|0481|PTCA EA ADDL VESSEL LD|Blue Cross PPO Specialty|BCBSTX PPO|11,252.85||||11,252.85||| 92921|EAP|0481|PTCA EA ADDL VESSEL LD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11,252.85||||107.17||| 92921|EAP|0481|PTCA EA ADDL VESSEL LC|Blue Cross PPO Specialty|BCBSTX PPO|11,252.85||||107.17||| 92921|EAP|0481|PTCA EA ADDL VESSEL LD|Humana Medicare Advantage|HUMANA MA|11,252.85||||11,252.85||| 92921|EAP|0481|PTCA EA ADDL VESSEL LD|Humana Medicare Advantage|HUMANA MA|107.17||||11,252.85||| 92921|EAP|0481|PTCA EA ADDL VESSEL LC|Humana Medicare Advantage|HUMANA MA|107.17||||11,252.85||| 92921|EAP|0481|PTCA EA ADDL VESSEL LD|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10,984.93||| 92921|EAP|0481|PTCA EA ADDL VESSEL LD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11,252.85||||||| 92921|EAP|0481|PTCA EA ADDL VESSEL LC|Medicaid|MEDICAID|11,252.85||||||| 92921|EAP|0481|PTCA EA ADDL VESSEL LD|Medicaid|MEDICAID|11,252.85||||||| 92921|EAP|0481|PTCA EA ADDL VESSEL RC|United Healthcare|UNITED HEALTHCARE|11,252.85||||||| 92921|EAP|0481|PTCA EA ADDL VESSEL LD|Medicare|MEDICARE ACUTE|11,252.85||||107.17||| 92921|EAP|0481|PTCA EA ADDL VESSEL LC|Medicare|MEDICARE ACUTE|107.17||||107.17||| 92921|EAP|0481|PTCA EA ADDL VESSEL RC|Medicare|MEDICARE ACUTE|107.17||||107.17||| 92924|EAP|0481|PTCA/ATHR SINGLE VESSEL R|Medicare|MEDICARE ACUTE|||||22,505.70||| 92924|EAP|0481|PTCRA/LASER CORONARY ATHE|Tricare|TRICARE EAST REGION|||||23,217.50||| 92924|EAP|0481|PTCA/ATHR SINGLE VESSEL R|Managed Medicare|BCBS MEDICARE PPO MA|||||214.34||| 92924|EAP|0481|PTCRA/LASER CORONARY ATHE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||23,217.50||| 92924|EAP|0481|PTCA/ATHR/SINGLE VESSEL L|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,505.70||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Managed Medicaid|MEDICAID UNITED HEALTHCARE|22,505.70||||214.34||| 92928|EAP|0481||Managed Medicaid|MEDICAID AMERIGROUP|||||214.34||| 92928|EAP|0481||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Cigna|CIGNA OTHER|||||214.34||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Cigna|CIGNA|214.34||||22,505.70||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Humana Medicare Advantage|HUMANA MA|22,505.70||||22,505.70||| 92928|EAP|0481||Humana Medicare Advantage|HUMANA MA|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES R|Humana Medicare Advantage|HUMANA MA|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Humana Medicare Advantage|HUMANA MA|214.34||||22,505.70||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Humana Medicare Advantage|HUMANA MA|214.34||||22,505.70||| 92928|EAP|0481||Blue Cross HMO Specialty|BCBSTX HMO|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Blue Cross HMO Specialty|BCBSTX HMO|214.34||||214.34||| 92928|EAP|0481|STENT SINGLE VESSEL DES R|Blue Cross PPO Specialty|BCBSTX PPO|214.34||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Blue Cross PPO Specialty|BCBSTX PPO|22,505.70||||22,505.70||| 92928|EAP|0481||Blue Cross PPO Specialty|BCBSTX PPO|21,969.85||||22,505.70||| 92928|EAP|0481||Blue Cross PPO Specialty|BCBSTX OTHER|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Blue Cross PPO Specialty|BCBSTX OTHER|214.34||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|22,505.70||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Aenta Medicare Advantage|AETNA MEDICARE MA|214.34||||22,505.70||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Aenta Medicare Advantage|AETNA MEDICARE MA|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES R|Aetna|AETNA OTHER|22,505.70||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Aetna|AETNA OTHER|22,505.70||||||| 92928|EAP|0481||Aetna|AETNA PPO|22,505.70||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Aetna|AETNA PPO|22,505.70||||||| 92928|EAP|0481||Aetna|AETNA OTHER|214.34||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|214.34||||214.34||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|214.34||||22,505.70||| 92928|EAP|0481||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|214.34||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|214.34||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Access Direct Platinum|HEALTHFIRST TPA UMR|21,969.85||||22,505.70||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22,505.70||||22,505.70||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Access Direct Platinum|HEALTHFIRST TPA UMR|21,969.85||||22,505.70||| 92928|EAP|0481||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|214.34||||||| 92928|EAP|0481||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|214.34||||||| 92928|EAP|0481||Access Direct Platinum|HEALTHFIRST TPA|214.34||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|22,505.70||||||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Veterans Affairs|VETERANS ADMINISTRATION|22,505.70||||||| 92928|EAP|0481||Veterans Affairs|VETERANS ADMINISTRATION|214.34||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES R|Veterans Affairs|VETERANS ADMINISTRATION|22,505.70||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Veterans Affairs|VETERANS ADMINISTRATION|214.34||||||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1V|Veterans Affairs|VETERANS ADMINISTRATION|22,505.85||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|214.34||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES R|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES R|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21,969.85||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|United Medicare Advantage|UHC MEDICARE GOLD MA|214.34||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|United Medicare Advantage|UHC AARP MCR HMO MA|22,505.70||||22,505.70||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,505.70||||214.34||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|United Medicare Advantage|UHC MEDICARE GOLD MA|22,505.70||||22,505.70||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|214.34||||22,505.70||| 92928|EAP|0481||Aetna|AETNA PPO|214.34||||||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|United Medicare Advantage|UHC AARP MCR HMO MA|22,505.70||||22,505.70||| 92928|EAP|0481||United Medicare Advantage|UHC MEDICARE GOLD MA|214.34||||22,505.70||| 92928|EAP|0481||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|22,505.70||||22,505.70||| 92928|EAP|0481||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21,969.85||||214.34||| 92928|EAP|0481||United Medicare Advantage|UHC AARP MCR HMO MA|22,505.70||||214.34||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Medicaid|COUNTY INDIGENT HEALTH OTHER|214.34||||||| 92928|EAP|0481||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|21,969.85||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Medicaid|MEDICAID|21,969.85||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Medicaid|LAW ENFORCEMENT OTHER|214.34||||||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Medicaid|MEDICAID|22,505.70||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|22,505.70||||||| 92928|EAP|0481||Blue Cross PPO Specialty|BCBSTX PPO|214.34||||214.34||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Managed Medicare|HEALTHSPRING MA|22,505.70||||||| 92928|EAP|0481||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|214.34||||||| 92928|EAP|0481||Managed Medicare|HEALTHSPRING MA|22,505.70||||||| 92928|EAP|0481||Managed Medicare|HEALTHSPRING MA|214.34||||||| 92928|EAP|0481||Blue Cross HMO Specialty|BCBSTX HMO|21,969.85||||214.34||| 92928|EAP|0481||Managed Medicare|BCBS MEDICARE PPO MA|22,505.70||||||| 92928|EAP|0481||Managed Medicare|BCBS MEDICARE PPO MA|214.34||||||| 92928|EAP|0481||United Healthcare|UNITED HEALTHCARE|22,505.70||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|United Healthcare|UNITED HEALTHCARE OTHER|22,505.70||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|United Healthcare|UNITED HEALTHCARE|22,505.70||||22,505.70||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|United Healthcare|UNITED HEALTHCARE|22,505.70||||22,505.70||| 92928|EAP|0481||United Healthcare|UNITED HEALTHCARE OTHER|214.34||||||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|22,505.70||||||| 92928|EAP|0481||Cigna|CIGNA|22,505.70||||22,505.70||| 92928|EAP|0481||Managed Medicaid|MEDICAID UNITED HEALTHCARE|21,969.85||||22,505.70||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Tricare|TRICARE FOR LIFE|22,505.70||||||| 92928|EAP|0481||Tricare|TRICARE EAST REGION|214.34||||||| 92928|EAP|0481||PHCS|HUMANA|214.34||||||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|NON CONTRACTED|COMMERCIAL OTHER 1|22,505.70||||||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|22,505.70||||214.34||| 92928|EAP|0481||NON CONTRACTED|COMMERCIAL OTHER 1|21,969.85||||||| 92928|EAP|0481||NON CONTRACTED|COMMERCIAL OTHER 1|214.34||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|NON CONTRACTED|COMMERCIAL OTHER 1|214.34||||||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Medicare|MEDICARE ACUTE|214.34||||214.34||| 92928|EAP|0481||Medicare|MEDICARE PART B ONLY IP|214.34||||||| 92928|EAP|0481||Medicare|MEDICARE ACUTE|22,505.70||||214.34||| 92928|EAP|0481|STENT SINGLE VESSEL DES R|Medicare|MEDICARE ACUTE|22,505.70||||214.34||| 92928|EAP|0481|STENT SINGLE VESSEL DES L|Medicare|MEDICARE ACUTE|22,505.70||||214.34||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Medicare|MEDICARE ACUTE|21,969.85||||22,505.70||| 92928|EAP|0481|PRQ CARD STENT W/ANGIO 1|Medicare|MEDICARE PART B ONLY IP|22,505.70||||||| 92928|EAP|0481||Medicare|MEDICARE ACUTE|214.34||||22,505.70||| 92929|EAP|0481||Medicare|MEDICARE ACUTE|11,252.85||||10,984.93||| 92929|EAP|0481|STENT ADDL VESSEL LD|Medicare|MEDICARE ACUTE|10,984.93||||11,252.85||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|Medicare|MEDICARE ACUTE|11,252.85||||11,252.85||| 92929|EAP|0481|STENT ADDL VESSEL DES LC|NON CONTRACTED|COMMERCIAL OTHER 1|10,984.93||||||| 92929|EAP|0481|STENT ADDL VESSEL LC|UTMB|UTMB CORRECTIONAL MANAGED CARE|11,252.85||||||| 92929|EAP|0481||United Healthcare|UNITED HEALTHCARE|11,252.85||||||| 92929|EAP|0481|STENT ADDL VESSEL DES LC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||107.17||| 92929|EAP|0481|STENT ADDL VESSEL DES LC|Managed Medicare|HEALTHSPRING MA|11,252.85||||||| 92929|EAP|0481||Managed Medicare|HEALTHSPRING MA|107.17||||||| 92929|EAP|0481||Medicaid|MEDICAID|||||11,252.85||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|United Medicare Advantage|UHC MEDICARE GOLD MA|11,252.85||||||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|United Medicare Advantage|UHC AARP MCR HMO MA|11,252.85||||||| 92929|EAP|0481|STENT ADDL VESSEL DES LC|United Medicare Advantage|UHC AARP MCR HMO MA|11,252.85||||||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|Managed Medicare|HEALTHSPRING MA|10,984.93||||||| 92929|EAP|0481||United Medicare Advantage|UHC MEDICARE GOLD MA|107.17||||||| 92929|EAP|0481||United Medicare Advantage|UHC AARP MCR HMO MA|11,252.85||||||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|NON CONTRACTED|COMMERCIAL OTHER 1|107.17||||||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|Access Direct Platinum|HEALTHFIRST TPA UMR|11,252.85||||||| 92929|EAP|0481||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|107.17||||||| 92929|EAP|0481|PRQ CARD STENT W/ANGIO AD|Medicare|MEDICARE ACUTE|11,252.85||||11,252.85||| 92929|EAP|0481|STENT ADDL VESSEL DES LC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11,252.85||||107.17||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|Aenta Medicare Advantage|AETNA MEDICARE MA|107.17||||||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|Blue Cross PPO Specialty|BCBSTX PPO|107.17||||11,252.85||| 92929|EAP|0481|STENT ADDL VESSEL DES LC|Blue Cross PPO Specialty|BCBSTX PPO|11,252.85||||11,252.85||| 92929|EAP|0481|STENT ADDL VESSEL DES LC|Blue Cross HMO Specialty|BCBSTX HMO|||||107.17||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|Blue Cross HMO Specialty|BCBSTX HMO|||||107.17||| 92929|EAP|0481||Blue Cross HMO Specialty|BCBSTX HMO|||||11,252.85||| 92929|EAP|0481|STENT ADDL VESSEL DES LC|Humana Medicare Advantage|HUMANA MA|11,252.85||||||| 92929|EAP|0481||Humana Medicare Advantage|HUMANA MA|11,252.85||||||| 92929|EAP|0481|STENT ADDL VESSEL DES LC|Cigna|CIGNA|11,252.85||||||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|107.17||||11,252.85||| 92929|EAP|0481|STENT ADDL VESSEL DES LD|Managed Medicaid|MEDICAID AMERIGROUP|||||107.17||| 92933|EAP|0481|PTCA/STENT/ATH RC|Humana Medicare Advantage|HUMANA MA|214.34||||214.34||| 92933|EAP|0481||Blue Cross PPO Specialty|BCBSTX PPO|214.34||||22,505.70||| 92933|EAP|0481||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,505.70||||||| 92933|EAP|0481|PTCA/STENT/ATH LD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22,505.70||| 92933|EAP|0481|PTCA/STENT/ATH LD|United Medicare Advantage|UHC AARP MCR HMO MA|||||214.34||| 92933|EAP|0481|PTCA/STENT/ATH RC|Medicare|MEDICARE ACUTE|214.34||||214.34||| 92933|EAP|0481|PTCA/STENT/ATH DES LM|Medicare|MEDICARE ACUTE|22,505.70||||214.34||| 92933|EAP|0481||Medicare|MEDICARE ACUTE|21,969.85||||214.34||| 92933|EAP|0481|PTCA/STENT/ATH LD|Medicare|MEDICARE ACUTE|22,505.70||||214.34||| 92934|EAP|0481|PTCA/STENT/ATH ADDL VESS|United Medicare Advantage|UHC AARP MCR HMO MA|||||11,252.85||| 92934|EAP|0481|PTCA/STENT/ATH ADDL VESS|Humana Medicare Advantage|HUMANA MA|107.17||||||| 92937|EAP|0481|PTCA/STENT/ATH SVG RC|Managed Medicare|HEALTHSPRING MA|22,505.70||||||| 92937|EAP|0481|PTCA/STENT/ATH SVG LC|Managed Medicare|HEALTHSPRING MA|22,505.70||||||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES RC|Managed Medicare|BCBS MEDICARE PPO MA|22,505.70||||||| 92937|EAP|0481||United Healthcare|UNITED HEALTHCARE|214.34||||||| 92937|EAP|0481|PTCA/STENT/ATH SVG LC|Medicare|MEDICARE ACUTE|21,969.85||||21,969.85||| 92937|EAP|0481|PTCA/STENT/ATH SVG RC|Medicare|MEDICARE ACUTE|22,505.70||||22,505.70||| 92937|EAP|0481|PTCA/STENT/ATH SVG LD|Medicare|MEDICARE ACUTE|214.34||||22,505.70||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES RC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|214.34||||22,505.70||| 92937|EAP|0481||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|214.34||||22,505.70||| 92937|EAP|0481||Blue Cross HMO Specialty|BCBSTX HMO|214.34||||||| 92937|EAP|0481||Managed Medicare|HEALTHSPRING MA|214.34||||||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES LC|Blue Cross PPO Specialty|BCBSTX PPO|214.34||||214.34||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES RC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|22,505.70||||||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES RC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||22,505.70||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES LC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||214.34||| 92937|EAP|0481|PTCA/STENT/ATH SVG RC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||214.34||| 92937|EAP|0481|PTCA/STENT/ATH SVG RC|Humana Medicare Advantage|HUMANA MA|214.34||||214.34||| 92937|EAP|0481|PTCA/STENT/ATH SVG LD|Humana Medicare Advantage|HUMANA MA|214.34||||214.34||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES RC|Humana Medicare Advantage|HUMANA MA|21,969.85||||214.34||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES RC|Veterans Affairs|VETERANS ADMINISTRATION|||||22,505.70||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES RC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|22,505.70||||||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES RC|United Medicare Advantage|UHC AARP MCR HMO MA|22,505.70||||||| 92937|EAP|0481|PTCA/STENT/ATH SVG DES LC|United Medicare Advantage|UHC MEDICARE GOLD MA|214.34||||||| 92937|EAP|0481||United Medicare Advantage|UHC MEDICARE GOLD MA|22,505.70||||||| 92938|EAP|0481||United Medicare Advantage|UHC MEDICARE GOLD MA|107.17||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|NON CONTRACTED|COMMERCIAL OTHER 1|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE LD|Medicare|MEDICARE ACUTE|214.34||||22,505.70||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Medicare|MEDICARE ACUTE|22,505.70||||22,505.70||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE RC|Medicare|MEDICARE ACUTE|214.34||||22,505.70||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Medicare|MEDICARE ACUTE|214.34||||22,505.70||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE LD|UTMB|UTMB CORRECTIONAL MANAGED CARE|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|United Healthcare|TML GROUP BENEFITS|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|United Healthcare|GOLDEN RULE|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|214.34||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE LD|Humana Medicare Advantage|HUMANA MA|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Humana Medicare Advantage|HUMANA MA|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Humana Medicare Advantage|HUMANA MA|214.34||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE LC|UTMB|UTMB CORRECTIONAL MANAGED CARE|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|214.34||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE RC|Blue Cross PPO Specialty|BCBSTX PPO|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Blue Cross PPO Specialty|BCBSTX PPO|214.34||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Blue Cross PPO Specialty|BCBSTX OTHER|214.34||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE LC|Medicare|MEDICARE ACUTE|22,505.70||||22,505.70||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Blue Cross HMO Specialty|BCBSTX HMO|214.34||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Blue Cross HMO Specialty|BCBSTX HMO|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Aetna|AETNA PPO|214.34||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|214.34||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE LC|Veterans Affairs|VETERANS ADMINISTRATION|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Veterans Affairs|VETERANS ADMINISTRATION|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE LD|United Medicare Advantage|UHC AARP MCR HMO MA|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|United Medicare Advantage|UHC MEDICARE GOLD MA|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|22,505.70||||||| 92941|EAP|0481|PTCA/STENT/ATH/ACUTE DES|United Medicare Advantage|UHC AARP MCR HMO MA|22,505.70||||||| 92943|EAP|0481|PTCA/STENT/ATH/CHRONIC DE|Blue Cross PPO Specialty|BCBSTX PPO|||||22,505.70||| 92943|EAP|0481|PTCA/STENT/ATH/CHRONIC DE|Blue Cross PPO Specialty|BCBSTX PPO|||||21,969.85||| 92943|EAP|0481||Blue Cross PPO Specialty|BCBSTX PPO|||||214.34||| 92943|EAP|0481|PTCA/STENT/ATH/CHRONIC DE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,505.70||||||| 92943|EAP|0481|PTCA/STENT/ATH/CHRONIC DE|Humana Medicare Advantage|HUMANA MA|214.34||||||| 92943|EAP|0481|PTCA/STENT/ATH/CHRONIC RC|Managed Medicare|HEALTHSPRING MA|||||22,505.70||| 92943|EAP|0481||Medicare|MEDICARE ACUTE|22,505.70||||||| 92950|EAP|0410|CPR|United Healthcare|UNITED HEALTHCARE OTHER|496.65||||4.73||| 92950|EAP|0410|CPR|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.73||||||| 92950|EAP|0450|CPR|PHCS|HUMANA INSURANCE|||||7.77||| 92950|EAP|0450|CPR|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.40||| 92950|EAP|0410|CPR|Medicare|MEDICARE PART B ONLY IP|4.73||||||| 92950|EAP|0410|CPR|Medicare|MEDICARE ACUTE|4.73||||4.73||| 92950|EAP|0450|CPR|Medicare|MEDICARE PART B ONLY IP|7.40||||||| 92950|EAP|0410|CPR|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.73||||||| 92950|EAP|0410|CPR|Medicaid|MEDICAID|4.73||||||| 92950|EAP|0410|CPR|Medicaid|CRIME VICTIMS COMPENSATION|4.73||||||| 92950|EAP|0450|CPR|Medicaid|MEDICAID|||||7.40||| 92950|EAP|0450|CPR|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.40||||||| 92950|EAP|0410|CPR|Managed Medicare|HEALTHSPRING MA|496.65||||496.65||| 92950|EAP|0450|CPR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.40||| 92950|EAP|0450|CPR|Managed Medicare|HEALTHSPRING MA|7.77||||7.40||| 92950|EAP|0410|CPR|Managed Medicare|BCBS MEDICARE PPO MA|4.73||||4.73||| 92950|EAP|0410|CPR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|484.83||||4.73||| 92950|EAP|0450|CPR|United Medicare Advantage|UHC MEDICARE GOLD MA|7.40||||7.40||| 92950|EAP|0450|CPR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.40||| 92950|EAP|0450|CPR|United Medicare Advantage|UHC AARP MCR HMO MA|758.50||||7.40||| 92950|EAP|0410|CPR|United Medicare Advantage|UHC AARP MCR HMO MA|4.73||||||| 92950|EAP|0410|CPR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|496.65||||4.73||| 92950|EAP|0410|CPR|United Medicare Advantage|UHC MEDICARE GOLD MA|496.65||||496.65||| 92950|EAP|0410|CPR|Workers Compensation|TRAVELERS INSURANCE COMPANY|4.73||||||| 92950|EAP|0450|CPR|Managed Medicare|WELLCARE CHOICE MA|7.77||||||| 92950|EAP|0410|CPR|Workers Compensation|WORKERS COMPENSATION OTHER|496.65||||||| 92950|EAP|0410|CPR|Veterans Affairs|VETERANS ADMINISTRATION|496.65||||||| 92950|EAP|0450|CPR|Veterans Affairs|VETERANS ADMINISTRATION|7.40||||||| 92950|EAP|0450|CPR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.40||| 92950|EAP|0450|CPR|Managed Medicare|BCBS MEDICARE PPO MA|7.77||||7.40||| 92950|EAP|0450|CPR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.40||| 92950|EAP|0450|CPR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.40||| 92950|EAP|0410|CPR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.73||| 92950|EAP|0410|CPR|ChampVA|CHAMPVA CENTER|496.65||||||| 92950|EAP|0450|CPR|Medicare|MEDICARE ACUTE|7.40||||7.40||| 92950|EAP|0450|CPR|Humana Medicare Advantage|HUMANA MA|7.77||||7.40||| 92950|EAP|0410|CPR|Humana Medicare Advantage|HUMANA MA|4.73||||496.65||| 92950|EAP|0450|CPR|Managed Medicaid|MEDICAID SUPERIOR|7.40||||||| 92950|EAP|0450|CPR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.40||||7.40||| 92950|EAP|0410|CPR|NON CONTRACTED|COMMERCIAL OTHER 1|4.73||||496.65||| 92950|EAP|0410|CPR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|484.83||||||| 92950|EAP|0410|CPR|Managed Medicaid|MEDICAID SUPERIOR|||||4.73||| 92950|EAP|0410|CPR|Managed Medicaid|MEDICAID AMERIGROUP|||||496.65||| 92950|EAP|0450|CPR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.40||| 92950|EAP|0450|CPR|United Healthcare|UNITED HEALTHCARE|||||7.40||| 92950|EAP|0450|CPR|Managed Medicaid|MEDICAID AMERIGROUP|||||7.40||| 92950|EAP|0410|CPR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.73||||||| 92950|EAP|0450|CPR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.40||||7.40||| 92950|EAP|0410|CPR|Aetna|AETNA PPO|496.65||||4.73||| 92950|EAP|0410|CPR|Aenta Medicare Advantage|AETNA MEDICARE MA|4.73||||4.73||| 92950|EAP|0410|CPR|Aetna|AETNA QHP HMO|496.65||||||| 92950|EAP|0450|CPR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.40||| 92950|EAP|0410|CPR|Blue Cross HMO Specialty|BCBSTX HMO|4.73||||4.73||| 92950|EAP|0450|CPR|Blue Cross HMO Specialty|BCBSTX HMO|||||7.40||| 92950|EAP|0410|CPR|Blue Cross PPO Specialty|BCBSTX PPO|4.73||||||| 92950|EAP|0450|CPR|Blue Cross PPO Specialty|BCBSTX PPO|7.40||||7.40||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Blue Cross PPO Specialty|BCBSTX PPO|35.30||||35.30||| 92960|EAP|0480|CARDIOVERSION|Blue Cross PPO Specialty|BCBSTX PPO|2,894.10||||2,702.55||| 92960|EAP|0480|CARDIOVERSION|Blue Cross HMO Specialty|BCBSTX HMO|3,794.75||||2,894.10||| 92960|EAP|0480|CARDIOVERSION|Aetna|AETNA PPO|35.30||||25.14||| 92960|EAP|0480|CARDIOVERSION|Aenta Medicare Advantage|AETNA MEDICARE MA|35.30||||2,891.10||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35.30||||2,891.10||| 92960|EAP|0480|CARDIOVERSION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,894.10||||2,891.10||| 92960|EAP|0480|CARDIOVERSION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.14||||2,894.10||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Managed Medicaid|MEDICAID AMERIGROUP|4,059.50||||||| 92960|EAP|0480|CARDIOVERSION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,059.50||||2,894.10||| 92960|EAP|0480|CARDIOVERSION EXTERNAL|Humana Medicare Advantage|HUMANA MA|35.30||||2,891.10||| 92960|EAP|0480|CARDIOVERSION|Humana Medicare Advantage|HUMANA MA|2,891.10||||2,891.10||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Humana Medicare Advantage|HUMANA MA|35.30||||35.30||| 92960|EAP|0480|CARDIOVERSION|Cigna|CIGNA|||||25.14||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Cigna|CIGNA OTHER|4,059.50||||||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Access Direct Platinum|HEALTHFIRST TPA UMR|||||35.30||| 92960|EAP|0480|CARDIOVERSION EXTERNAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||25.14||| 92960|EAP|0480|CARDIOVERSION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,891.10||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Veterans Affairs|VETERANS ADMINISTRATION|35.30||||35.30||| 92960|EAP|0480|CARDIOVERSION EXTERNAL|Veterans Affairs|VETERANS ADMINISTRATION|35.30||||2,891.10||| 92960|EAP|0480|CARDIOVERSION|Veterans Affairs|VETERANS ADMINISTRATION|35.30||||25.14||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|United Medicare Advantage|UHC MEDICARE GOLD MA|21.75||||||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|United Medicare Advantage|UHC MEDICARE GOLD MA|35.30||||35.30||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,059.50||||||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|United Medicare Advantage|UHC AARP MCR HMO MA|4,059.50||||4,059.50||| 92960|EAP|0480|CARDIOVERSION|United Medicare Advantage|UHC MEDICARE GOLD MA|2,891.10||||2,702.55||| 92960|EAP|0480|CARDIOVERSION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,894.10||||||| 92960|EAP|0480|CARDIOVERSION|United Medicare Advantage|UHC AARP MCR HMO MA|4,059.50||||2,892.60||| 92960|EAP|0480|CARDIOVERSION|Cigna|CIGNA|4,059.50||||2,891.10||| 92960|EAP|0480|CARDIOVERSION|Managed Medicare|HEALTHSPRING MA|4,059.50||||2,891.10||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|35.30||||25.14||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,794.75||||2,894.10||| 92960|EAP|0480|CARDIOVERSION|Managed Medicare|BCBS MEDICARE PPO MA|35.30||||2,894.10||| 92960|EAP|0480|CARDIOVERSION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.14||||25.14||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|Managed Medicare|HEALTHSPRING MA|21.75||||||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|21.75||||||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Managed Medicare|HEALTHSPRING MA|4,059.50||||3,794.75||| 92960|EAP|0480|CARDIOVERSION|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||2,892.60||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||21.75||| 92960|EAP|0480|CARDIOVERSION|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2,894.10||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Medicaid|MEDICAID|35.30||||||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|Medicare|MEDICARE ACUTE|2,501.25||||21.75||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Medicare|MEDICARE PART B ONLY IP|4,059.50||||||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|Medicare|MEDICARE ACUTE|4,059.50||||35.30||| 92960|EAP|0480|CARDIOVERSION EXTERNAL|Medicare|MEDICARE ACUTE|2,891.10||||2,891.10||| 92960|EAP|0480|CARDIOVERSION|Medicare|MEDICARE PART B ONLY IP|25.14||||||| 92960|EAP|0480|CARDIOVERSION|Medicare|MEDICARE ACUTE|2,894.10||||25.14||| 92960|EAP|0480|CARDIOVERSION|PHCS|GROUP AND PENSION|4,059.50||||2,891.10||| 92960|EAP|0480|CARDIOVERSION|NON CONTRACTED|COMMERCIAL OTHER 1|2,894.10||||||| 92960|EAP|0480|CARDIOVERSION|Tricare|TRICARE EAST REGION|||||2,891.10||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|United Healthcare|UNITED HEALTHCARE OTHER|4,059.50||||||| 92960|EAP|0480|CARDIOVERSION, ELECTRIC E|United Healthcare|UNITED HEALTHCARE|4,059.50||||||| 92960|EAP|0480|CARDIOVERSION EXTERNAL|United Healthcare|UNITED HEALTHCARE OTHER|2,891.10||||||| 92960|EAP|0480|CARDIOVERSION|United Healthcare|UNITED HEALTHCARE|4,059.50||||2,891.10||| 92977|EAP|0450|THROMBOLYSIS CORONARY INF|Blue Cross HMO Specialty|BCBSTX HMO|846.30||||||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|United Healthcare|UNITED HEALTHCARE|||||23.05||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|United Healthcare|UNITED HEALTHCARE|2,383.86||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Tricare|TRICARE EAST REGION|||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Medicare|MEDICARE PART B ONLY IP|2,462.71||||||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Medicare|MEDICARE ACUTE|23.05||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Medicaid|MEDICAID|2,462.71||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Managed Medicare|HEALTHSPRING MA|23.05||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||23.05||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|United Medicare Advantage|UHC MEDICARE GOLD MA|2,462.71||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,383.86||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|United Medicare Advantage|UHC AARP MCR HMO MA|2,462.71||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Veterans Affairs|VETERANS ADMINISTRATION|23.05||||23.05||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,462.71||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Managed Medicare|BCBS MEDICARE PPO MA|2,383.86||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Access Direct Platinum|HEALTHFIRST TPA UMR|23.05||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|2,462.71||||||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|23.05||||23.05||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Access Direct Platinum|HEALTHFIRST TPA|23.05||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Cigna|CIGNA|||||23.05||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Humana Medicare Advantage|HUMANA MA|2,383.86||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Managed Medicaid|MEDICAID SUPERIOR|||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|United Healthcare|UNITED HEALTHCARE OTHER|||||23.05||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23.05||||23.05||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|23.05||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Aetna|AETNA PPO|||||23.05||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Aenta Medicare Advantage|AETNA MEDICARE MA|2,462.71||||2,383.86||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Blue Cross PPO Specialty|BCBSTX OTHER|||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Blue Cross PPO Specialty|BCBSTX PPO|23.05||||2,462.71||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||23.05||| 92978|EAP|0480|INTRAV DOPPLER INITIAL VE|Blue Cross HMO Specialty|BCBSTX HMO|||||2,383.86||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|Blue Cross HMO Specialty|BCBSTX HMO|||||1,223.34||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|Blue Cross PPO Specialty|BCBSTX PPO|||||1,223.34||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,223.34||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,223.34||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,223.34||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|Managed Medicaid|MEDICAID SUPERIOR|||||1,223.34||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|Humana Medicare Advantage|HUMANA MA|11.45||||1,223.34||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|United Medicare Advantage|UHC AARP MCR HMO MA|11.45||||1,223.34||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|Medicaid|MEDICAID|1,223.34||||||| 92979|EAP|0481|INTRAV DOPPLER ADD VESSEL|Medicare|MEDICARE ACUTE|1,184.17||||1,223.34||| 92986|EAP|0481|PERCUTANEOUS BALLOON VALV|Medicare|MEDICARE ACUTE|214.34||||||| 93|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|132,015.27|5460.93|12940.4|5009.66|||| 93|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|52,181.35|5009.66|12940.4|5009.66|||| 93|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC|Medicare|MEDICARE ACUTE|42,126.06|5460.05|12940.4|5009.66|||| 93|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC|PHCS|HUMANA|71,983.55|12940.4|12940.4|5009.66|||| 93005|EAP|0730|EKG 12 LEAD|Tricare|TRICARE EAST REGION|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Tricare|TRICARE SOUTH PHYSICIAN|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Tricare|TRICARE FOR LIFE|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Healthcare|UNITED HEALTHCARE|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Healthcare|AARP|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Healthcare|UNITED HEALTHCARE OTHER|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Healthcare|TML GROUP BENEFITS|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Healthcare|GOLDEN RULE|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicare|UTSW MC KIDNEY PROGRAM|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Multiplan|PACIFICARE|5.58||||||| 93005|EAP|0730|EKG 12 LEAD|Multiplan|WEB TPA|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicare|MEDICARE PART B ONLY IP|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicare|MEDICARE ACUTE|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|PHCS|HUMANA INSURANCE|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|PHCS|HUMANA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|NON CONTRACTED|COMMUNITY HEALTH CENTER|5.58||||||| 93005|EAP|0730|EKG 12 LEAD|NON CONTRACTED|COMMERCIAL OTHER 4|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|NON CONTRACTED|COMMERCIAL OTHER 2|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Texas Workforce Commission|DIS DETER SERV (DDS)|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Rusk State Hospital|RUSK STATE HOSP|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|PHCS|GROUP AND PENSION|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicare|OTHER INSTITUTIONS|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicare|MA PART B ONLY IP|5.58||||||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicare|ETMC AFFILIATE HOSPITALS|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicare|BCBS MEDICARE PPO MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicare|ETMC REHABILITATION HOSPITAL|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicare|HEALTHSPRING MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|MEDICAID|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|SMITH COUNTY JAIL|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|MEDICAID BCBSTX|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|CRIME VICTIMS COMPENSATION|5.58||||||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|BH TEXAS CHILDRENS MEDICAID|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|MEDICAID HMO|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|LAW ENFORCEMENT OTHER|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Access Direct Platinum|HEALTHFIRST TPA UMR|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Access Direct Platinum|HEALTHFIRST TPA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Medicaid|SUPERIOR HEALTHPLAN CHIP|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Access Direct Platinum|ANDREWS CENTER|5.58||||||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|WORKERS COMPENSATION OTHER|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|ZURICH COMPANY|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|TEXAS MUTUAL INSURANCE|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicare|WELLCARE CHOICE MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|BROOKSHIRES WORKERS COMP|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|UT EMPLOYEE INJURY|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Optum Behavioral Health|BH OPTUM UHC|5.58||||||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|WORKERS COMP PHYSICIAN|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|TRAVELERS INSURANCE COMPANY|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Workers Compensation|GALLAGHER BASSETT|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Veterans Affairs|VETERANS ADMINISTRATION|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Medicare Advantage|UHC MEDICARE GOLD MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|NON CONTRACTED|COMMERCIAL OTHER 1|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Medicare Advantage|UHC AARP MCR HMO MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Aetna|BH AETNA|5.58||||||| 93005|EAP|0730|EKG 12 LEAD|Multiplan|NALC|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Aetna|AETNA QHP HMO|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Aetna|AETNA PPO|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Healthcare|GEHA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Aetna|AETNA OTHER|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Aetna|BOON CHAPMAN|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Aetna Value Network|AETNA VALUE NETWORK|||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|United Healthcare|UNITED HEALTHCARE ERS|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Aenta Medicare Advantage|AETNA MEDICARE MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Blue Cross PPO Specialty|BCBSTX PPO|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Blue Cross PPO Specialty|BCBSTX OTHER|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Blue Cross HMO Specialty|BCBSTX HMO|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|ChampVA|CHAMPVA CENTER|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Cigna|CIGNA OTHER|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Cigna Behavioral Health|BH CIGNA|5.58||||||| 93005|EAP|0730|EKG 12 LEAD|Cigna|CIGNA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Humana Medicare Advantage|HUMANA MA|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Magellan Behavioral Health|BH MAGELLAN|5.58||||||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicaid|MEDICAID SUPERIOR|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicaid|MEDICAID AMERIGROUP|5.58||||5.58||| 93005|EAP|0730|EKG 12 LEAD|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.58||||5.58||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Managed Medicaid|MEDICAID AMERIGROUP|36.21||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|35.48||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Managed Medicaid|MEDICAID SUPERIOR|35.48||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Managed Medicaid|MEDICAID AMERIGROUP|35.48||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35.48||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Humana Medicare Advantage|HUMANA MA|35.48||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Humana Medicare Advantage|HUMANA MA|36.21||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Cigna|CIGNA OTHER|||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Cigna|CIGNA|35.48||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Cigna|CIGNA|35.48||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Blue Cross HMO Specialty|BCBSTX HMO|35.48||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Blue Cross HMO Specialty|BCBSTX HMO|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Blue Cross PPO Specialty|BCBSTX PPO|35.48||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Blue Cross PPO Specialty|BCBSTX OTHER|35.48||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Blue Cross PPO Specialty|BCBSTX PPO|35.48||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Aenta Medicare Advantage|AETNA MEDICARE MA|36.21||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Aenta Medicare Advantage|AETNA MEDICARE MA|35.48||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Aetna|BOON CHAPMAN|||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Aetna|AETNA PPO|35.48||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36.21||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|United Medicare Advantage|UHC MEDICARE GOLD MA|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|United Medicare Advantage|UHC AARP MCR HMO MA|35.48||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|United Medicare Advantage|UHC AARP MCR HMO MA|35.48||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Veterans Affairs|VETERANS ADMINISTRATION|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Access Direct Platinum|HEALTHFIRST TPA|35.48||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35.48||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|35.48||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Access Direct Platinum|HEALTHFIRST TPA UMR|||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|35.48||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Access Direct Platinum|HEALTHFIRST TPA|35.48||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Aetna|AETNA OTHER|35.48||||||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Medicaid|COUNTY INDIGENT HEALTH OTHER|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Medicaid|SMITH COUNTY JAIL|||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Medicaid|MEDICAID|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Blue Cross PPO Specialty|BCBSTX OTHER|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Medicaid|LAW ENFORCEMENT OTHER|35.48||||||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Managed Medicare|HEALTHSPRING MA|35.48||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Managed Medicare|BCBS MEDICARE PPO MA|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Managed Medicare|OTHER INSTITUTIONS|||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Managed Medicare|HEALTHSPRING MA|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|NON CONTRACTED|COMMERCIAL OTHER 1|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Medicare|MEDICARE ACUTE|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Medicare|UTSW MC KIDNEY PROGRAM|||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Medicare|MEDICARE ACUTE|36.21||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Managed Medicaid|MEDICAID SUPERIOR|35.48||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|Medicare|UTSW MC KIDNEY PROGRAM|||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Medicare|MEDICARE PART B ONLY IP|35.48||||||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|United Healthcare|UNITED HEALTHCARE OTHER|||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|United Healthcare|UNITED HEALTHCARE OTHER|||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|United Healthcare|UNITED HEALTHCARE|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|United Healthcare|UNITED HEALTHCARE|||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|United Healthcare|GEHA|||||35.48||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|United Healthcare|UNITED HEALTHCARE|||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|United Healthcare|TML GROUP BENEFITS|||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|United Healthcare|GOLDEN RULE|||||36.21||| 93017|EAP|0482|STRESS TEST W/TREADMILL O|United Healthcare|GEHA|||||36.21||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|UTMB|UTMB CORRECTIONAL MANAGED CARE|35.48||||35.48||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Tricare|TRICARE FOR LIFE|35.48||||||| 93017|EAP|0482|STRESS W TREADMILL/PHARM|Tricare|TRICARE EAST REGION|35.48||||35.48||| 93226|EAP|0510|ECG MONIT/REPRT UP TO 48|Medicare|MEDICARE ACUTE|||||123.40||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27.68||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA UMR|50.53||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|27.68||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA|50.53||||5,225.87||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA UMR|27.68||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Veterans Affairs|VETERANS ADMINISTRATION|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Veterans Affairs|VETERANS ADMINISTRATION|2,862.70||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC MEDICARE GOLD MA|50.53||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,957.39||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC AARP MCR HMO MA|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC AARP MCR HMO MA|2,957.39||||5,398.73||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|United Medicare Advantage|UHC MEDICARE GOLD MA|27.68||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Aenta Medicare Advantage|AETNA MEDICARE MA|2,957.39||||2,957.39||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aenta Medicare Advantage|AETNA MEDICARE MA|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aetna|BOON CHAPMAN|5,398.73||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aetna|AETNA OTHER|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aetna|AETNA PPO|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aetna|AETNA QHP HMO|5,398.73||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross PPO Specialty|BCBSTX OTHER|50.53||||5,225.87||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Blue Cross PPO Specialty|BCBSTX PPO|2,957.39||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross HMO Specialty|BCBSTX HMO|50.53||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Cigna|CIGNA OTHER|5,398.73||||5,225.87||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Cigna|CIGNA|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|ChampVA|CHAMPVA CENTER|5,398.73||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Cigna|CIGNA|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Humana Medicare Advantage|HUMANA MA|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Humana Medicare Advantage|HUMANA MA|27.68||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID AMERIGROUP|2,957.39||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,957.39||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID SUPERIOR|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID AMERIGROUP|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,862.70||||2,957.39||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|BCBS MEDICARE PPO MA|50.53||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|BCBS MEDICARE PPO MA|27.68||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|ETMC AFFILIATE HOSPITALS|50.53||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Cigna|CIGNA|2,862.70||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|HEALTHSPRING MA|50.53||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.68||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|OTHER INSTITUTIONS|||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|HEALTHSPRING MA|27.68||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|WELLCARE CHOICE MA|5,398.73||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|MEDICAID|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|SMITH COUNTY INDIGENT HEALTH|50.53||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|COUNTY INDIGENT HEALTH OTHER|27.68||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross PPO Specialty|BCBSTX PPO|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|LAW ENFORCEMENT OTHER|5,398.73||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|SMITH COUNTY JAIL|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|MOLINA HEALTHCARE OF TEXAS|50.53||||||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.68||||2,957.39||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|MEDICAID|27.68||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|COUNTY INDIGENT HEALTH OTHER|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Tricare|TRICARE EAST REGION|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC AARP WELLMED HMO MA|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Tricare|TRICARE EAST REGION|27.68||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|UTMB|UTMB CORRECTIONAL MANAGED CARE|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Workers Compensation|WORKERS COMPENSATION OTHER|5,225.87||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|UNITED HEALTHCARE OTHER|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|UNITED HEALTHCARE|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|UNITED HEALTHCARE|27.68||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|GOLDEN RULE|5,398.73||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|GEHA|||||5,398.73||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|United Healthcare|UNITED HEALTHCARE OTHER|2,862.70||||2,957.39||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|5,398.73||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|TML GROUP BENEFITS|5,398.73||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|PHCS|HUMANA INSURANCE|50.53||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|PHCS|HUMANA|5,398.73||||5,398.73||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|PHCS|HUMANA|2,957.39||||2,957.39||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|PHCS|GROUP AND PENSION|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Rusk State Hospital|RUSK STATE HOSP|5,398.73||||||| 93306|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Texas Workforce Commission|DIS DETER SERV (DDS)|||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Texas Workforce Commission|DIS DETER SERV (DDS)|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|NON CONTRACTED|COMMERCIAL OTHER 2|5,398.73||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|NON CONTRACTED|COMMERCIAL OTHER 1|5,225.87||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|NON CONTRACTED|COMMERCIAL OTHER 1|2,957.39||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicare|UTSW MC KIDNEY PROGRAM|||||5,398.73||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicare|MEDICARE PART B ONLY IP|5,398.73||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicare|MEDICARE ACUTE|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicare|MEDICARE ACUTE|2,862.70||||50.53||| 93308|EAP|0483|ECHO LTD OR F/U|Medicare|MEDICARE ACUTE|1,243.64||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U|NON CONTRACTED|COMMERCIAL OTHER 1|1,243.64||||||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|United Healthcare|UNITED HEALTHCARE|1,472.28||||||| 93308|EAP|0483|ECHO LTD OR F/U|United Healthcare|UNITED HEALTHCARE OTHER|1,243.64||||||| 93308|EAP|0483|ECHO LTD OR F/U|United Healthcare|UNITED HEALTHCARE|1,203.82||||||| 93308|EAP|0483|ECHO LTD OR F/U|Tricare|TRICARE EAST REGION|11.64||||||| 93308|EAP|0483|ECHO LTD OR F/U|Medicaid|SMITH COUNTY JAIL|11.64||||||| 93308|EAP|0483|ECHO LTD OR F/U|Medicaid|MEDICAID|1,203.82||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.64||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Medicaid|MEDICAID|1,425.14||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U|Medicaid|SMITH COUNTY INDIGENT HEALTH|11.64||||||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Managed Medicare|HEALTHSPRING MA|1,472.28||||1,203.82||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicare|HEALTHSPRING MA|1,243.64||||1,203.82||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicare|BCBS MEDICARE PPO MA|11.64||||1,203.82||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicaid|MEDICAID AMERIGROUP|1,203.82||||||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,243.64||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.78||||1,203.82||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.78||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicaid|MEDICAID SUPERIOR|1,243.64||||||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.64||||1,203.82||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Humana Medicare Advantage|HUMANA MA|13.78||||1,472.28||| 93308|EAP|0483|ECHO LTD OR F/U|Humana Medicare Advantage|HUMANA MA|11.64||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Cigna|CIGNA|||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Blue Cross HMO Specialty|BCBSTX HMO|13.78||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Blue Cross HMO Specialty|BCBSTX HMO|11.64||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.64||||||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicare|OTHER INSTITUTIONS|||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Blue Cross PPO Specialty|BCBSTX PPO|13.78||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Blue Cross PPO Specialty|BCBSTX PPO|1,243.64||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Blue Cross PPO Specialty|BCBSTX OTHER|11.64||||||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Blue Cross PPO Specialty|BCBSTX OTHER|13.78||||||| 93308|EAP|0483|ECHO LTD OR F/U|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,243.64||||||| 93308|EAP|0483|ECHO LTD OR F/U|Aenta Medicare Advantage|AETNA MEDICARE MA|1,243.64||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Aetna|AETNA QHP HMO|1,243.64||||13.78||| 93308|EAP|0483|ECHO LTD OR F/U|Aetna|AETNA OTHER|1,243.64||||||| 93308|EAP|0483|ECHO LTD OR F/U|United Healthcare|UNITED HEALTHCARE|1,243.64||||||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Medicare|MEDICARE ACUTE|1,472.28||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U|Aetna|AETNA PPO|||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,203.82||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,472.28||||1,203.82||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|United Medicare Advantage|UHC MEDICARE GOLD MA|1,425.14||||1,472.28||| 93308|EAP|0483|ECHO LTD OR F/U|United Medicare Advantage|UHC MEDICARE GOLD MA|11.64||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.64||||1,203.82||| 93308|EAP|0483|ECHO LTD OR F/U|United Medicare Advantage|UHC AARP MCR HMO MA|1,243.64||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Veterans Affairs|VETERANS ADMINISTRATION|13.78||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U|Veterans Affairs|VETERANS ADMINISTRATION|11.64||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,243.64||||||| 93308|EAP|0483|ECHO LTD OR F/U|Access Direct Platinum|HEALTHFIRST TPA UMR|11.64||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,243.64||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Access Direct Platinum|HEALTHFIRST TPA|13.78||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,003.51||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|48.38||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Access Direct Platinum|HEALTHFIRST TPA|48.38||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|48.38||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|48.38||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|United Medicare Advantage|UHC MEDICARE GOLD MA|48.38||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,169.02||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|United Medicare Advantage|UHC AARP MCR HMO MA|5,169.02||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|48.38||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Aenta Medicare Advantage|AETNA MEDICARE MA|48.38||||5,003.51||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Aetna|AETNA PPO|48.38||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Blue Cross PPO Specialty|BCBSTX PPO|5,169.02||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Blue Cross PPO Specialty|BCBSTX OTHER|48.38||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,169.02||||5,003.51||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Cigna|CIGNA OTHER|5,003.51||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Cigna|CIGNA|5,169.02||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Cigna|CIGNA|||||5,003.51||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Humana Medicare Advantage|HUMANA MA|5,169.02||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicaid|MEDICAID AMERIGROUP|5,169.02||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Blue Cross HMO Specialty|BCBSTX HMO|5,169.02||||5,003.51||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|48.38||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicaid|MEDICAID SUPERIOR|5,169.02||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,169.02||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicare|OTHER INSTITUTIONS|||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|48.38||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicare|ETMC AFFILIATE HOSPITALS|48.38||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Aetna|AETNA OTHER|5,169.02||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicare|HEALTHSPRING MA|5,169.02||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Managed Medicare|BCBS MEDICARE PPO MA|48.38||||5,003.51||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Veterans Affairs|VETERANS ADMINISTRATION|5,169.02||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|48.38||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Medicaid|MEDICAID HMO|5,169.02||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|48.38||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Medicaid|MEDICAID|48.38||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|48.38||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Tricare|TRICARE EAST REGION|5,169.02||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|United Healthcare|UNITED HEALTHCARE OTHER|5,169.02||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|United Healthcare|UNITED HEALTHCARE|5,169.02||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|PHCS|HUMANA INSURANCE|48.38||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|PHCS|GROUP AND PENSION|5,169.02||||5,169.02||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|NON CONTRACTED|COMMERCIAL OTHER 1|5,003.51||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Medicare|MEDICARE PART B ONLY IP|5,003.51||||||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Medicare|UTSW MC KIDNEY PROGRAM|||||48.38||| 93312|EAP|0483|ECHO TRANSESOPHAGEAL|Medicare|MEDICARE ACUTE|5,169.02||||48.38||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Medicare|MEDICARE ACUTE|1,773.58||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Medicare|MEDICARE PART B ONLY IP|1,716.79||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|PHCS|GROUP AND PENSION|1,773.58||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|PHCS|HUMANA INSURANCE|16.60||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|United Healthcare|UNITED HEALTHCARE OTHER|1,773.58||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|United Healthcare|UNITED HEALTHCARE|1,773.58||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Tricare|TRICARE EAST REGION|1,773.58||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.60||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Medicaid|SMITH COUNTY INDIGENT HEALTH|16.60||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Medicaid|MEDICAID HMO|1,773.58||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Medicaid|MEDICAID|16.60||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.60||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicare|OTHER INSTITUTIONS|||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicare|ETMC AFFILIATE HOSPITALS|16.60||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicare|HEALTHSPRING MA|1,773.58||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicare|BCBS MEDICARE PPO MA|16.60||||1,716.79||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicaid|MEDICAID AMERIGROUP|1,773.58||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicaid|MEDICAID SUPERIOR|1,773.58||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.60||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,773.58||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Humana Medicare Advantage|HUMANA MA|1,773.58||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Cigna|CIGNA OTHER|1,716.79||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Cigna|CIGNA|||||1,716.79||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Medicaid|COUNTY INDIGENT HEALTH OTHER|16.60||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Cigna|CIGNA|1,773.58||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Blue Cross HMO Specialty|BCBSTX HMO|1,773.58||||1,716.79||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Blue Cross PPO Specialty|BCBSTX OTHER|16.60||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Blue Cross PPO Specialty|BCBSTX PPO|1,773.58||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|NON CONTRACTED|COMMERCIAL OTHER 1|1,716.79||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,773.58||||1,716.79||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Aenta Medicare Advantage|AETNA MEDICARE MA|16.60||||1,716.79||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Aetna|AETNA OTHER|1,773.58||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Aetna|AETNA PPO|16.60||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Medicare|UTSW MC KIDNEY PROGRAM|||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.60||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|United Medicare Advantage|UHC MEDICARE GOLD MA|16.60||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,773.58||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|United Medicare Advantage|UHC AARP MCR HMO MA|1,773.58||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Veterans Affairs|VETERANS ADMINISTRATION|1,773.58||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|16.60||||||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,716.79||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.60||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|16.60||||16.60||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Access Direct Platinum|HEALTHFIRST TPA|16.60||||1,773.58||| 93325|EAP|0483|ECHO COLOR FLOW MAPPING|Access Direct Platinum|HEALTHFIRST TPA UMR|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UMR|||||27.68||| 93351|EAP|0483|ECHO STRESS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.60||| 93351|EAP|0483|ECHO STRESS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Veterans Affairs|VETERANS ADMINISTRATION|||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,957.39||| 93351|EAP|0483|ECHO STRESS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,773.58||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,957.39||| 93351|EAP|0483|ECHO STRESS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||16.60||| 93351|EAP|0483|ECHO STRESS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,773.58||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|16.60||||2,957.39||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|27.68||||2,957.39||| 93351|EAP|0483|ECHO STRESS|Blue Cross HMO Specialty|BCBSTX HMO|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||2,957.39||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Cigna|CIGNA|||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Humana Medicare Advantage|HUMANA MA|||||27.68||| 93351|EAP|0483|ECHO STRESS|Humana Medicare Advantage|HUMANA MA|||||1,773.58||| 93351|EAP|0483|ECHO STRESS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,773.58||| 93351|EAP|0483|ECHO STRESS|Managed Medicaid|MEDICAID AMERIGROUP|1,773.58||||||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Managed Medicaid|MEDICAID SUPERIOR|||||2,957.39||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,773.58||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,957.39||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|United Healthcare|TML GROUP BENEFITS|||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|United Healthcare|GEHA|||||27.68||| 93351|EAP|0483|ECHO STRESS|United Healthcare|UNITED HEALTHCARE OTHER|||||16.60||| 93351|EAP|0483|ECHO STRESS|United Healthcare|TML GROUP BENEFITS|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Medicare|MEDICARE ACUTE|2,957.39||||2,957.39||| 93351|EAP|0483|ECHO STRESS|Medicare|MEDICARE ACUTE|2,957.39||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Medicare|UTSW MC KIDNEY PROGRAM|||||2,957.39||| 934|DRG||FULL THICKNESS BURN W/O SKIN GRAFT OR INHAL INJ|Medicare|MEDICARE ACUTE|34,896.17|11421.89|11421.89|11421.89|||| 93451|EAP|0481|RHC ONLY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,521.30||||||| 93451|EAP|0481|RHC ONLY|Humana Medicare Advantage|HUMANA MA|4,413.65||||43.06||| 93451|EAP|0481|RHC ONLY|Blue Cross PPO Specialty|BCBSTX PPO|||||43.06||| 93451|EAP|0481|RHC ONLY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.06||||43.06||| 93451|EAP|0481|RHC ONLY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||43.06||| 93451|EAP|0481|RHC ONLY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||43.06||| 93451|EAP|0481|RHC ONLY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43.06||||||| 93451|EAP|0481|RHC ONLY|NON CONTRACTED|COMMERCIAL OTHER 1|4,521.30||||||| 93451|EAP|0481|RHC ONLY|Medicare|MEDICARE ACUTE|4,521.30||||4,521.30||| 93451|EAP|0481|RHC ONLY|Tricare|TRICARE EAST REGION|||||43.06||| 93451|EAP|0481|RHC ONLY|United Healthcare|UNITED HEALTHCARE OTHER|||||43.06||| 93451|EAP|0481|RHC ONLY|Managed Medicare|HEALTHSPRING MA|43.06||||||| 93451|EAP|0481|RHC ONLY|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||4,521.30||| 93451|EAP|0481|RHC ONLY|Managed Medicare|BCBS MEDICARE PPO MA|||||43.06||| 93452|EAP|0481|LHC W/VGRAM|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||6,876.45||| 93452|EAP|0481|LHC W/VGRAM|Medicare|MEDICARE ACUTE|6,876.45||||6,876.45||| 93452|EAP|0481|LHC W/VGRAM|Humana Medicare Advantage|HUMANA MA|6,876.45||||||| 93453|EAP|0481|LHC/RHC W/VGRAM ONLY|Medicare|MEDICARE ACUTE|16,781.10||||||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Veterans Affairs|VETERANS ADMINISTRATION|6,293.70||||59.94||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||59.94||| 93454|EAP|0481|ANGIO CORONARIES ONLY|United Medicare Advantage|UHC MEDICARE GOLD MA|6,293.70||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|United Medicare Advantage|UHC AARP MCR HMO MA|6,143.85||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Aenta Medicare Advantage|AETNA MEDICARE MA|6,143.85||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Aetna|AETNA OTHER|6,143.85||||6,143.85||| 93454|EAP|0481|ANGIO CORONARIES ONLY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,293.70||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Blue Cross PPO Specialty|BCBSTX PPO|59.94||||6,143.85||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6,293.70||||||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|59.94||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,293.70||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Humana Medicare Advantage|HUMANA MA|59.94||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Medicaid|MEDICAID|59.94||||||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||59.94||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Managed Medicare|HEALTHSPRING MA|6,293.70||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||59.94||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Managed Medicare|BCBS MEDICARE PPO MA|||||6,293.70||| 93454|EAP|0481|ANGIO CORONARIES ONLY|United Healthcare|UNITED HEALTHCARE|||||59.94||| 93454|EAP|0481|ANGIO CORONARIES ONLY|PHCS|GROUP AND PENSION|6,293.70||||||| 93454|EAP|0481|ANGIO CORONARIES ONLY|NON CONTRACTED|COMMERCIAL OTHER 1|59.94||||||| 93454|EAP|0481|ANGIO CORONARIES ONLY|Medicare|MEDICARE ACUTE|6,293.70||||59.94||| 93455|EAP|0481|ANGIO GRAFTS/LIMA ONLY|Medicare|MEDICARE ACUTE|75.26||||7,902.30||| 93455|EAP|0481|ANGIO GRAFTS/LIMA ONLY|Managed Medicare|HEALTHSPRING MA|7,902.30||||7,902.30||| 93455|EAP|0481|ANGIO GRAFTS/LIMA ONLY|Humana Medicare Advantage|HUMANA MA|75.26||||75.26||| 93455|EAP|0481|ANGIO GRAFTS/LIMA ONLY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|75.26||||75.26||| 93455|EAP|0481|ANGIO GRAFTS/LIMA ONLY|United Medicare Advantage|UHC AARP MCR HMO MA|7,902.30||||||| 93456|EAP|0481|RHC W/CORONARIES ONLY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||108.15||| 93456|EAP|0481|RHC W/CORONARIES ONLY|Medicare|MEDICARE ACUTE|108.15||||103.00||| 93457|EAP|0481|RHC W/GRAFTS/LIMA ONLY|Medicare|MEDICARE ACUTE|||||118.32||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Blue Cross HMO Specialty|BCBSTX HMO|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Blue Cross PPO Specialty|BCBSTX OTHER|25,012.05||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|238.21||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25,012.05||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Aenta Medicare Advantage|AETNA MEDICARE MA|24,416.53||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Aetna|AETNA QHP HMO|||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Aetna|AETNA OTHER|24,416.53||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Managed Medicaid|MEDICAID SUPERIOR|25,012.05||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Managed Medicaid|MEDICAID AMERIGROUP|238.21||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Cigna|CIGNA OTHER|25,012.05||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Cigna|CIGNA|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Cigna|CIGNA|238.21||||24,416.53||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Humana Medicare Advantage|HUMANA MA|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|United Medicare Advantage|UHC MEDICARE GOLD MA|238.21||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|United Medicare Advantage|UHC AARP WELLMED HMO MA|25,012.05||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|United Medicare Advantage|UHC AARP MCR HMO MA|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Veterans Affairs|VETERANS ADMINISTRATION|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|238.21||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Access Direct Platinum|HEALTHFIRST TPA|238.21||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|25,012.05||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|238.21||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Access Direct Platinum|HEALTHFIRST TPA UMR|25,012.05||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|238.21||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicaid|SMITH COUNTY INDIGENT HEALTH|238.21||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicaid|MEDICAID|238.21||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicaid|SMITH COUNTY JAIL|||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25,012.05||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicaid|LAW ENFORCEMENT OTHER|238.21||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|238.21||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Managed Medicare|HEALTHSPRING MA|238.21||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Aetna|AETNA PPO|238.21||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Managed Medicare|BCBS MEDICARE PPO MA|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Tricare|TRICARE EAST REGION|238.21||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|UTMB|UTMB CORRECTIONAL MANAGED CARE|25,012.05||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Tricare|TRICARE FOR LIFE|25,012.05||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Blue Cross PPO Specialty|BCBSTX PPO|238.21||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|United Healthcare|TML GROUP BENEFITS|25,012.05||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|United Healthcare|UNITED HEALTHCARE OTHER|25,012.05||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|United Healthcare|UNITED HEALTHCARE|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|United Healthcare|UNITED HEALTHCARE|25,012.05||||24,416.53||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|United Healthcare|GOLDEN RULE|25,012.05||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|PHCS|GROUP AND PENSION|||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|PHCS|HUMANA|24,416.53||||238.21||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|PHCS|HUMANA INSURANCE|238.21||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|NON CONTRACTED|COMMERCIAL OTHER 1|25,012.05||||25,012.05||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicare|UTSW MC KIDNEY PROGRAM|||||24,416.53||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicare|MEDICARE PART B ONLY IP|238.21||||||| 93458|EAP|0481|LHC W/CORONARIES W/VGRAM|Medicare|MEDICARE ACUTE|25,012.05||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Medicare|MEDICARE PART B ONLY IP|24,416.53||||||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Medicare|MEDICARE ACUTE|25,012.05||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|United Healthcare|UNITED HEALTHCARE OTHER|25,012.05||||238.21||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|United Healthcare|UNITED HEALTHCARE|238.21||||238.21||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|United Healthcare|UNITED HEALTHCARE|||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||238.21||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Managed Medicare|HEALTHSPRING MA|238.21||||24,416.53||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Managed Medicare|BCBS MEDICARE PPO MA|25,012.05||||||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Medicaid|MEDICAID|25,012.05||||||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||238.21||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25,012.05||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Veterans Affairs|VETERANS ADMINISTRATION|238.21||||24,416.53||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|UTMB|UTMB CORRECTIONAL MANAGED CARE|25,012.05||||||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|NON CONTRACTED|COMMERCIAL OTHER 1|25,012.05||||||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|United Medicare Advantage|UHC MEDICARE GOLD MA|24,416.53||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25,012.05||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|United Medicare Advantage|UHC AARP MCR HMO MA|25,012.05||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Humana Medicare Advantage|HUMANA MA|238.21||||238.21||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25,012.05||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25,012.05||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Managed Medicaid|MEDICAID AMERIGROUP|||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Aetna|AETNA OTHER|||||24,416.53||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25,012.05||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Blue Cross PPO Specialty|BCBSTX PPO|25,012.05||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Blue Cross PPO Specialty|BCBSTX OTHER|||||25,012.05||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25,012.05||||||| 93459|EAP|0481|LHC W/GRAFTS/LIMA W/LT/VG|Blue Cross HMO Specialty|BCBSTX HMO|238.21||||24,416.53||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Blue Cross PPO Specialty|BCBSTX OTHER|||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Blue Cross PPO Specialty|BCBSTX PPO|22,525.40||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,525.40||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||219.76||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Aetna|AETNA QHP HMO|23,074.80||||||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Managed Medicaid|MEDICAID AMERIGROUP|||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23,074.80||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23,074.80||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Humana Medicare Advantage|HUMANA MA|219.76||||219.76||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|United Medicare Advantage|UHC AARP MCR HMO MA|23,074.80||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|23,074.80||||22,525.40||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Veterans Affairs|VETERANS ADMINISTRATION|22,525.40||||||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|23,074.80||||||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||219.76||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Blue Cross HMO Specialty|BCBSTX HMO|219.76||||219.76||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Medicaid|MEDICAID|219.76||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Managed Medicare|HEALTHSPRING MA|219.76||||219.76||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Managed Medicare|BCBS MEDICARE PPO MA|||||219.76||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Tricare|TRICARE EAST REGION|23,074.80||||||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|United Healthcare|UNITED HEALTHCARE OTHER|||||219.76||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|United Healthcare|UNITED HEALTHCARE|||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|NON CONTRACTED|COMMERCIAL OTHER 2|23,074.80||||||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Medicare|UTSW MC KIDNEY PROGRAM|||||23,074.80||| 93460|EAP|0481|LHC/RHC W/CORONARIES W/VG|Medicare|MEDICARE ACUTE|219.76||||23,074.80||| 93461|EAP|0481|LHC/RHC W/GRAFTS/LIMA W/V|Medicare|MEDICARE ACUTE|24,682.35||||235.07||| 93461|EAP|0481|LHC/RHC W/GRAFTS/LIMA W/V|United Medicare Advantage|UHC AARP MCR HMO MA|||||24,682.35||| 93461|EAP|0481|LHC/RHC W/GRAFTS/LIMA W/V|Humana Medicare Advantage|HUMANA MA|24,682.35||||24,682.35||| 93461|EAP|0481|LHC/RHC W/GRAFTS/LIMA W/V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||235.07||| 93461|EAP|0481|LHC/RHC W/GRAFTS/LIMA W/V|Blue Cross PPO Specialty|BCBSTX PPO|||||24,094.68||| 93462|EAP|0481|L HRT CATH TRNSPTL PUNCTU|Humana Medicare Advantage|HUMANA MA|||||88.35||| 93462|EAP|0481|L HRT CATH TRNSPTL PUNCTU|United Medicare Advantage|UHC AARP MCR HMO MA|9,276.75||||||| 93462|EAP|0481|L HRT CATH TRNSPTL PUNCTU|Medicare|MEDICARE ACUTE|||||9,055.88||| 935|DRG||NON-EXTENSIVE BURNS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46,949.37|15915.13|16998.62|15915.13|||| 935|DRG||NON-EXTENSIVE BURNS|Workers Compensation|WORKERS COMPENSATION OTHER|110,549.55|16998.62|16998.62|15915.13|||| 93567|EAP|0481|AORTOGRAM|United Healthcare|UNITED HEALTHCARE|||||3,028.20||| 93567|EAP|0481|AORTOGRAM|UTMB|UTMB CORRECTIONAL MANAGED CARE|28.84||||||| 93567|EAP|0481|AORTOGRAM|Medicare|MEDICARE PART B ONLY IP|28.84||||||| 93567|EAP|0481|AORTOGRAM|Managed Medicare|HEALTHSPRING MA|||||28.84||| 93567|EAP|0481|AORTOGRAM|Medicare|MEDICARE ACUTE|28.84||||2,956.10||| 93567|EAP|0481|AORTOGRAM|Blue Cross PPO Specialty|BCBSTX PPO|28.84||||3,028.20||| 93567|EAP|0481|AORTOGRAM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,956.10||| 93567|EAP|0481|AORTOGRAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.84||||3,028.20||| 93567|EAP|0481|AORTOGRAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.84||||||| 93567|EAP|0481|AORTOGRAM|Humana Medicare Advantage|HUMANA MA|28.84||||2,956.10||| 93567|EAP|0481|AORTOGRAM|United Medicare Advantage|UHC MEDICARE GOLD MA|3,028.20||||||| 93567|EAP|0481|AORTOGRAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,028.20||||28.84||| 93567|EAP|0481|AORTOGRAM|United Medicare Advantage|UHC AARP MCR HMO MA|3,028.20||||3,028.20||| 93567|EAP|0481|AORTOGRAM|Veterans Affairs|VETERANS ADMINISTRATION|||||2,956.10||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Aetna|AETNA OTHER|||||6,114.57||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Humana Medicare Advantage|HUMANA MA|6,114.57||||57.23||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Cigna|CIGNA|||||57.23||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||6,114.57||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|United Healthcare|UNITED HEALTHCARE OTHER|6,114.57||||||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,114.57||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Veterans Affairs|VETERANS ADMINISTRATION|6,114.57||||57.23||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Medicare|MEDICARE ACUTE|57.23||||57.23||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Blue Cross PPO Specialty|BCBSTX PPO|||||6,114.57||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||57.23||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,114.57||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Aetna|AETNA PPO|||||6,114.57||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,114.57||||||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||57.23||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|United Medicare Advantage|UHC MEDICARE GOLD MA|57.23||||57.23||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||57.23||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|57.23||||||| 93571|EAP|0481|INTRAVASCULAR FLOWIRE|Managed Medicare|HEALTHSPRING MA|57.23||||6,114.57||| 93572|EAP|0481|INTRAVASCULAR FLOWIRE ADD|Humana Medicare Advantage|HUMANA MA|||||11.45||| 93572|EAP|0481|INTRAVASCULAR FLOWIRE ADD|United Medicare Advantage|UHC AARP MCR HMO MA|||||11.45||| 93572|EAP|0481|INTRAVASCULAR FLOWIRE ADD|Blue Cross PPO Specialty|BCBSTX PPO|||||1,223.34||| 93572|EAP|0481|INTRAVASCULAR FLOWIRE ADD|Medicare|MEDICARE ACUTE|11.45||||1,184.17||| 93572|EAP|0481|INTRAVASCULAR FLOWIRE ADD|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,223.34||| 93572|EAP|0481|INTRAVASCULAR FLOWIRE ADD|Veterans Affairs|VETERANS ADMINISTRATION|||||11.45||| 93580|EAP|0481|TRANSCATH CLOSURE CONGEN|Aetna|AETNA PPO|||||130.66||| 93580|EAP|0481|TRANSCATH CLOSURE CONGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||130.66||| 93580|EAP|0481|TRANSCATH CLOSURE CONGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||13,392.65||| 93580|EAP|0481|TRANSCATH CLOSURE CONGEN|Medicare|MEDICARE ACUTE|||||13,719.30||| 93580|EAP|0481|TRANSCATH CLOSURE CONGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||130.66||| 93580|EAP|0481|TRANSCATH CLOSURE CONGEN|Access Direct Platinum|HEALTHFIRST TPA|||||13,719.30||| 93580|EAP|0481|TRANSCATH CLOSURE CONGEN|Managed Medicare|BCBS MEDICARE PPO MA|||||13,719.30||| 93609|EAP|0480|EP INT-ATRIAL & OR INT VE|Medicare|MEDICARE ACUTE|||||71.01||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11,715.90||||11,715.90||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Humana Medicare Advantage|HUMANA MA|11,715.90||||11,715.90||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Managed Medicare|BCBS MEDICARE PPO MA|||||11,436.95||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|111.58||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Aetna|AETNA OTHER|||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11,715.90||||11,715.90||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11,715.90||||11,715.90||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|United Healthcare|UNITED HEALTHCARE OTHER|11,715.90||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Aetna|AETNA PPO|111.58||||||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Managed Medicare|HEALTHSPRING MA|||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|111.58||||||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11,715.90||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Medicare|MEDICARE ACUTE|11,436.95||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|United Healthcare|UNITED HEALTHCARE|11,715.90||||11,715.90||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||11,436.95||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Blue Cross PPO Specialty|BCBSTX PPO|11,715.90||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Blue Cross HMO Specialty|BCBSTX HMO|||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|United Healthcare|UNITED HEALTHCARE|||||11,436.95||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Cigna|CIGNA|||||11,715.90||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Medicare|MEDICARE PART B ONLY IP|111.58||||||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Access Direct Platinum|HEALTHFIRST TPA|||||11,715.90||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||111.58||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|Veterans Affairs|VETERANS ADMINISTRATION|11,715.90||||11,715.90||| 93613|EAP|0480|INTRACARDIAC EP 3D MAPPIN|United Medicare Advantage|UHC AARP MCR HMO MA|11,715.90||||11,715.90||| 93619|EAP|0480|COMP EP STUDY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||159.57||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||19,332.60||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||19,332.60||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Managed Medicaid|MEDICAID AMERIGROUP|||||184.12||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19,332.60||||18,872.30||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||184.12||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Blue Cross HMO Specialty|BCBSTX HMO|||||19,332.60||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Managed Medicare|HEALTHSPRING MA|||||19,332.60||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||184.12||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Medicare|MEDICARE ACUTE|19,332.60||||19,332.60||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Blue Cross PPO Specialty|BCBSTX PPO|184.12||||18,872.30||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Humana Medicare Advantage|HUMANA MA|184.12||||19,332.60||| 93620|EAP|0480|COMP EP W/ARRTH INDUCT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||19,332.60||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Veterans Affairs|VETERANS ADMINISTRATION|||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,793.70||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||66.28||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Blue Cross PPO Specialty|BCBSTX PPO|66.28||||66.28||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Managed Medicare|BCBS MEDICARE PPO MA|||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Blue Cross HMO Specialty|BCBSTX HMO|||||66.28||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Managed Medicare|HEALTHSPRING MA|||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||66.28||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Humana Medicare Advantage|HUMANA MA|6,959.40||||6,793.70||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|United Medicare Advantage|UHC AARP MCR HMO MA|6,959.40||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Cigna|CIGNA|||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6,793.70||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||66.28||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||66.28||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Medicare|MEDICARE ACUTE|6,959.40||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|United Healthcare|UNITED HEALTHCARE|6,959.40||||||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,793.70||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|United Healthcare|UNITED HEALTHCARE|||||66.28||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,793.70||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,959.40||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|Access Direct Platinum|HEALTHFIRST TPA|||||6,959.40||| 93621|EAP|0480|CS/LEFT ATRIAL RECORDING|United Healthcare|UNITED HEALTHCARE OTHER|||||66.28||| 93622|EAP|0480|EP EVAL W/LV PACING & REC|Blue Cross PPO Specialty|BCBSTX PPO|||||9,354.45||| 93622|EAP|0480|EP EVAL W/LV PACING & REC|United Healthcare|UNITED HEALTHCARE|||||89.09||| 93622|EAP|0480|EP EVAL W/LV PACING & REC|United Healthcare|UNITED HEALTHCARE OTHER|||||89.09||| 93622|EAP|0480|EP EVAL W/LV PACING & REC|Humana Medicare Advantage|HUMANA MA|||||9,354.45||| 93622|EAP|0480|EP EVAL W/LV PACING & REC|United Medicare Advantage|UHC AARP MCR HMO MA|9,354.45||||||| 93622|EAP|0480|EP EVAL W/LV PACING & REC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||89.09||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Veterans Affairs|VETERANS ADMINISTRATION|||||16,754.85||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Cigna|CIGNA|||||16,754.85||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||16,754.85||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|159.57||||||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16,754.85||||16,754.85||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Aetna|AETNA OTHER|||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Humana Medicare Advantage|HUMANA MA|16,754.85||||16,754.85||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Managed Medicaid|MEDICAID AMERIGROUP|||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|United Medicare Advantage|UHC AARP MCR HMO MA|16,754.85||||16,754.85||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Blue Cross HMO Specialty|BCBSTX HMO|||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Blue Cross PPO Specialty|BCBSTX PPO|16,754.85||||16,355.93||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Managed Medicare|BCBS MEDICARE PPO MA|16,754.85||||||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Access Direct Platinum|HEALTHFIRST TPA|||||16,754.85||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Medicare|MEDICARE ACUTE|16,355.93||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|United Healthcare|UNITED HEALTHCARE|||||159.57||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Managed Medicare|HEALTHSPRING MA|||||16,754.85||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||16,355.93||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|United Healthcare|UNITED HEALTHCARE|||||16,754.85||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||16,355.93||| 93623|EAP|0480|COMP E-P STIM/PACING/DRUG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16,754.85||||||| 93641|EAP|0480|DFT TESTING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4,659.60||| 93641|EAP|0480|DFT TESTING|Humana Medicare Advantage|HUMANA MA|||||38.83||| 93641|EAP|0480|DFT TESTING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,659.60||||4,659.60||| 93641|EAP|0480|DFT TESTING|Blue Cross PPO Specialty|BCBSTX OTHER|4,659.60||||||| 93641|EAP|0480|DFT TESTING|Medicare|MEDICARE ACUTE|38.83||||4,659.60||| 93641|EAP|0480|DFT TESTING|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.83||||||| 93641|EAP|0480|DFT TESTING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||38.83||| 93641|EAP|0480|DFT TESTING|Managed Medicare|HEALTHSPRING MA|||||38.83||| 93650|EAP|0480|EP AV ABLATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||176.75||| 93650|EAP|0480|EP AV ABLATION|Humana Medicare Advantage|HUMANA MA|18,558.75||||18,558.75||| 93650|EAP|0480|EP AV ABLATION|United Medicare Advantage|UHC MEDICARE GOLD MA|18,116.88||||||| 93650|EAP|0480|EP AV ABLATION|Medicare|MEDICARE ACUTE|18,558.75||||18,558.75||| 93650|EAP|0480|EP AV ABLATION|Blue Cross PPO Specialty|BCBSTX PPO|176.75||||||| 93650|EAP|0480|EP AV ABLATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18,558.75||||18,558.75||| 93650|EAP|0480|EP AV ABLATION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||176.75||| 93650|EAP|0480|EP AV ABLATION|Managed Medicare|HEALTHSPRING MA|18,116.88||||18,558.75||| 93650|EAP|0480|EP AV ABLATION|United Medicare Advantage|UHC AARP MCR HMO MA|18,558.75||||18,558.75||| 93650|EAP|0480|EP AV ABLATION|Managed Medicare|BCBS MEDICARE PPO MA|||||18,558.75||| 93650|EAP|0480|EP AV ABLATION|Veterans Affairs|VETERANS ADMINISTRATION|||||176.75||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Aetna|AETNA OTHER|||||518.41||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||518.41||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Medicare|MEDICARE ACUTE|53,137.03||||518.41||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|United Healthcare|UNITED HEALTHCARE|54,433.05||||||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Blue Cross HMO Specialty|BCBSTX HMO|||||518.41||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Aenta Medicare Advantage|AETNA MEDICARE MA|||||53,137.03||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Blue Cross PPO Specialty|BCBSTX PPO|54,433.05||||53,137.03||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Managed Medicare|BCBS MEDICARE PPO MA|||||54,433.05||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|United Healthcare|UNITED HEALTHCARE|||||518.41||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|54,433.05||||54,433.05||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Access Direct Platinum|HEALTHFIRST TPA|||||54,433.05||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Veterans Affairs|VETERANS ADMINISTRATION|||||54,433.05||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Cigna|CIGNA|||||54,433.05||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||518.41||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Access Direct Platinum|HEALTHFIRST TPA UMR|||||54,433.05||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||54,433.05||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|54,433.05||||54,433.05||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|United Medicare Advantage|UHC AARP MCR HMO MA|54,433.05||||54,433.05||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Humana Medicare Advantage|HUMANA MA|54,433.05||||518.41||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||518.41||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||518.41||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|518.41||||||| 93653|EAP|0480|EP SINGLE ATRIAL FOCAL AB|United Healthcare|UNITED HEALTHCARE OTHER|54,433.05||||518.41||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|Veterans Affairs|VETERANS ADMINISTRATION|561.61||||58,969.05||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||561.61||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|United Medicare Advantage|UHC AARP MCR HMO MA|||||58,969.05||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||561.61||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|United Healthcare|UNITED HEALTHCARE|||||561.61||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|Medicare|MEDICARE ACUTE|58,969.05||||58,969.05||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|Managed Medicare|BCBS MEDICARE PPO MA|58,969.05||||||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|United Healthcare|UNITED HEALTHCARE|||||58,969.05||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|Blue Cross PPO Specialty|BCBSTX PPO|58,969.05||||58,969.05||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|United Healthcare|UNITED HEALTHCARE OTHER|||||561.61||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|Humana Medicare Advantage|HUMANA MA|||||58,969.05||| 93654|EAP|0480|EP SINGLE VENT FOCAL ABL|Aetna|AETNA PPO|||||58,969.05||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|Humana Medicare Advantage|HUMANA MA|38,557.05||||||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||367.21||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|United Healthcare|UNITED HEALTHCARE|||||367.21||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||367.21||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|Veterans Affairs|VETERANS ADMINISTRATION|38,557.05||||||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|United Medicare Advantage|UHC MEDICARE GOLD MA|||||38,557.05||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|United Medicare Advantage|UHC AARP MCR HMO MA|||||38,557.05||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|Managed Medicare|HEALTHSPRING MA|||||367.21||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|Blue Cross PPO Specialty|BCBSTX PPO|38,557.05||||||| 93655|EAP|0480|ADDITIONAL ARRHYHTHMIA (A|Medicare|MEDICARE ACUTE|||||367.21||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Veterans Affairs|VETERANS ADMINISTRATION|58,969.05||||58,969.05||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58,969.05||||||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|58,969.05||||||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|United Medicare Advantage|UHC AARP MCR HMO MA|||||58,969.05||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|561.61||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Medicare|MEDICARE ACUTE|57,565.03||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Managed Medicare|HEALTHSPRING MA|||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Medicare|MEDICARE PART B ONLY IP|561.61||||||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Humana Medicare Advantage|HUMANA MA|57,565.03||||58,969.05||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Blue Cross PPO Specialty|BCBSTX PPO|58,969.05||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Managed Medicare|BCBS MEDICARE PPO MA|||||561.61||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|Aetna|AETNA PPO|561.61||||||| 93656|EAP|0481|PULMONARY VEIN ISOLA ABLA|United Healthcare|UNITED HEALTHCARE|||||58,969.05||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|United Healthcare|UNITED HEALTHCARE|||||38,557.05||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|Humana Medicare Advantage|HUMANA MA|37,639.03||||38,557.05||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||367.21||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|Blue Cross PPO Specialty|BCBSTX PPO|38,557.05||||367.21||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||37,639.03||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|Aetna|AETNA PPO|367.21||||||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|Medicare|MEDICARE ACUTE|37,639.03||||367.21||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|Veterans Affairs|VETERANS ADMINISTRATION|38,557.05||||||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||367.21||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|United Medicare Advantage|UHC AARP MCR HMO MA|||||38,557.05||| 93657|EAP|0480|ADDT'L ABLATION-COMPLETIO|Medicare|MEDICARE PART B ONLY IP|367.21||||||| 93660|EAP|0480|STRESS TILT TABLE TEST|United Medicare Advantage|UHC AARP MCR HMO MA|||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|Access Direct Platinum|HEALTHFIRST TPA UMR|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|Managed Medicaid|MEDICAID AMERIGROUP|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|Blue Cross HMO Specialty|BCBSTX HMO|||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|Managed Medicaid|MEDICAID SUPERIOR|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|Aetna|BOON CHAPMAN|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|Managed Medicare|HEALTHSPRING MA|97.87||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|Cigna|CIGNA|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|Blue Cross PPO Specialty|BCBSTX OTHER|||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|UTMB|UTMB CORRECTIONAL MANAGED CARE|11,744.40||||||| 93660|EAP|0480|STRESS TILT TABLE TEST|United Healthcare|UNITED HEALTHCARE OTHER|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|Blue Cross PPO Specialty|BCBSTX PPO|||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|Humana Medicare Advantage|HUMANA MA|10,765.70||||97.87||| 93660|EAP|0480|STRESS TILT TABLE TEST|Aenta Medicare Advantage|AETNA MEDICARE MA|11,744.40||||10,765.70||| 93660|EAP|0480|STRESS TILT TABLE TEST|Medicare|MEDICARE ACUTE|97.87||||11,744.40||| 93660|EAP|0480|STRESS TILT TABLE TEST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11,744.40||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||69.67||| 93662|EAP|0483|ECHO INTRACARDIAC (ICE)|Access Direct Platinum|HEALTHFIRST TPA|||||94.38||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,360.40||||||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Aetna|AETNA PPO|69.67||||||| 93662|EAP|0483|ECHO INTRACARDIAC (ICE)|Aetna|AETNA PPO|||||78.65||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9,360.40||||||| 93662|EAP|0483|ECHO INTRACARDIAC (ICE)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||78.65||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||69.67||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Aenta Medicare Advantage|AETNA MEDICARE MA|||||69.67||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Access Direct Platinum|HEALTHFIRST TPA UMR|||||69.67||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Veterans Affairs|VETERANS ADMINISTRATION|8,360.40||||9,360.40||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Humana Medicare Advantage|HUMANA MA|8,360.40||||9,360.40||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|United Medicare Advantage|UHC AARP MCR HMO MA|8,360.40||||8,860.40||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Blue Cross PPO Specialty|BCBSTX PPO|9,360.40||||69.67||| 93662|EAP|0483|ECHO INTRACARDIAC (ICE)|Managed Medicare|BCBS MEDICARE PPO MA|||||94.38||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|United Healthcare|UNITED HEALTHCARE|||||8,860.40||| 93662|EAP|0480|IC ULTRASOUND DURING INTE|Medicare|MEDICARE ACUTE|7,663.70||||94.38||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Medicare|MEDICARE PART B ONLY IP|69.67||||||| 93662|EAP|0483|ECHO INTRACARDIAC (ICE)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||94.38||| 93662|EAP|0483|ECHO INTRACARDIAC (ICE)|Blue Cross PPO Specialty|BCBSTX PPO|||||78.65||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||69.67||| 93662|EAP|0483|ECHO INTRACARDIAC (ICE)|Medicare|MEDICARE ACUTE|||||94.38||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Managed Medicare|HEALTHSPRING MA|||||69.67||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|69.67||||69.67||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Managed Medicare|BCBS MEDICARE PPO MA|||||69.67||| 93662|EAP|0480|INTRACARDIAC ECG (ICE)|Medicare|MEDICARE ACUTE|7,663.70||||69.67||| 93724|EAP|0480|ANTI-TACHY PM ANALYSIS|Humana Medicare Advantage|HUMANA MA|3.77||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Medicare|MEDICARE ACUTE|5.82||||201.30||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Managed Medicare|HEALTHSPRING MA|1.83||||201.30||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|NON CONTRACTED|COMMERCIAL OTHER 1|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Managed Medicare|BCBS MEDICARE PPO MA|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|PHCS|GROUP AND PENSION|1.83||||||| 93797|EAP|0943|PULMONARY REHAB CONSULT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.83||||2.67||| 93797|EAP|0943|PULMONARY REHAB CONSULT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|320.40||||2.67||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Medicaid|MEDICAID|201.30||||||| 93797|EAP|0943|PULMONARY REHAB CONSULT|Managed Medicare|HEALTHSPRING MA|293.70||||201.30||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|United Healthcare|UNITED HEALTHCARE|201.30||||219.60||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Medicare|MEDICARE ACUTE|1.83||||201.30||| 93797|EAP|0943|PULMONARY REHAB CONSULT|Medicare|MEDICARE ACUTE|2.67||||201.30||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.83||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Tricare|TRICARE EAST REGION|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|United Healthcare|UNITED HEALTHCARE OTHER|1.83||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Tricare|TRICARE FOR LIFE|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|United Healthcare|TML GROUP BENEFITS|219.60||||||| 93797|EAP|0943|PULMONARY REHAB CONSULT|United Medicare Advantage|UHC MEDICARE GOLD MA|320.40||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|United Medicare Advantage|UHC AARP MCR HMO MA|219.60||||219.60||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|United Healthcare|GOLDEN RULE|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|United Medicare Advantage|UHC MEDICARE GOLD MA|1.83||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||219.60||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Aenta Medicare Advantage|AETNA MEDICARE MA|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Aetna|AETNA PPO|1.83||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|219.60||||1.83||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Veterans Affairs|VETERANS ADMINISTRATION|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Aetna|AETNA OTHER|201.30||||||| 93797|EAP|0943|PULMONARY REHAB CONSULT|Veterans Affairs|VETERANS ADMINISTRATION|2.67||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.83||||||| 93797|EAP|0943|CV REHAB W/O CONT EKG MON|Veterans Affairs|VETERANS ADMINISTRATION|4.85||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|United Healthcare|UNITED HEALTHCARE|201.30||||||| 93797|EAP|0943|PULMONARY REHAB CONSULT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|320.40||||219.60||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.83||||219.60||| 93797|EAP|0943|PULMONARY REHAB CONSULT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|320.40||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Blue Cross HMO Specialty|BCBSTX HMO|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Cigna|CIGNA OTHER|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Managed Medicaid|MEDICAID AMERIGROUP|1.83||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|219.60||||||| 93797|EAP|0943|PULMONARY REHAB CONSULT|Humana Medicare Advantage|HUMANA MA|2.67||||201.30||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Humana Medicare Advantage|HUMANA MA|219.60||||201.30||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Blue Cross PPO Specialty|BCBSTX PPO|1.83||||1.83||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Access Direct Platinum|HEALTHFIRST TPA UMR|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.83||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Cigna|CIGNA|219.60||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Blue Cross PPO Specialty|BCBSTX OTHER|201.30||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.83||||||| 93797|EAP|0943|INDIVIDUAL EXERCI-W/O MON|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|219.60||||||| 93797|EAP|0943|PULMONARY REHAB CONSULT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.67||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Blue Cross PPO Specialty|BCBSTX PPO|6.41||||6.41||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Cigna|CIGNA|293.70||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Cigna|CIGNA|705.10||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Humana Medicare Advantage|HUMANA MA|320.40||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Cigna|CIGNA|320.40||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Cigna|CIGNA OTHER|320.40||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Humana Medicare Advantage|HUMANA MA|769.20||||705.10||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Blue Cross HMO Specialty|BCBSTX HMO|769.20||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.67||||2.67||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Managed Medicaid|MEDICAID AMERIGROUP|6.41||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Blue Cross PPO Specialty|BCBSTX PPO|320.40||||320.40||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Cigna|CIGNA OTHER|769.20||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|769.20||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Cigna|CIGNA|769.20||||320.40||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.41||||6.41||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Blue Cross PPO Specialty|BCBSTX OTHER|320.40||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Access Direct Platinum|HEALTHFIRST TPA|2.67||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.67||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.41||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Aetna|AETNA PPO|2.67||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|United Medicare Advantage|UHC MEDICARE GOLD MA|2.67||||293.70||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Aetna|AETNA OTHER|6.41||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|United Medicare Advantage|UHC AARP MCR HMO MA|320.40||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.67||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Access Direct Platinum|HEALTHFIRST TPA UMR|320.40||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.41||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Aetna|AETNA QHP HMO|769.20||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Aenta Medicare Advantage|AETNA MEDICARE MA|769.20||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Veterans Affairs|VETERANS ADMINISTRATION|320.40||||293.70||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Aenta Medicare Advantage|AETNA MEDICARE MA|2.67||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Aetna|AETNA QHP HMO|320.40||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Veterans Affairs|VETERANS ADMINISTRATION|769.20||||293.70||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Blue Cross PPO Specialty|BCBSTX OTHER|769.20||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Managed Medicaid|MEDICAID AMERIGROUP|2.67||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|769.20||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|320.40||||320.40||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|769.20||||769.20||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|320.40||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Aetna|AETNA OTHER|2.67||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|769.20||||6.41||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|320.40||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|320.40||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|United Healthcare|UNITED HEALTHCARE|320.40||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Medicare|MEDICARE ACUTE|320.40||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Tricare|TRICARE EAST REGION|2.67||||2.67||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.41||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|United Medicare Advantage|UHC AARP MCR HMO MA|769.20||||769.20||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Tricare|TRICARE FOR LIFE|769.20||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Aetna|AETNA PPO|6.41||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Medicare|MEDICARE PART B ONLY IP|2.67||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Medicaid|MEDICAID|293.70||||320.40||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|United Healthcare|GOLDEN RULE|769.20||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.67||||320.40||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|United Healthcare|UNITED HEALTHCARE OTHER|6.41||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Managed Medicare|HEALTHSPRING MA|2.67||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|769.20||||2.67||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Medicaid|COUNTY INDIGENT HEALTH OTHER|6.41||||2.67||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|United Medicare Advantage|UHC MEDICARE GOLD MA|6.41||||705.10||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|United Healthcare|TML GROUP BENEFITS|769.20||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Managed Medicare|BCBS MEDICARE PPO MA|320.40||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.67||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Access Direct Platinum|HEALTHFIRST TPA UMR|769.20||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Medicaid|MEDICAID|769.20||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|NON CONTRACTED|COMMERCIAL OTHER 1|6.41||||320.40||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|PHCS|HUMANA|2.67||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.41||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.41||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.67||||2.67||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|United Medicare Advantage|UHC AARP WELLMED HMO MA|769.20||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Managed Medicare|HEALTHSPRING MA|6.41||||769.20||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|United Healthcare|UNITED HEALTHCARE OTHER|320.40||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Tricare|TRICARE EAST REGION|769.20||||2.67||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.67||||||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Managed Medicare|BCBS MEDICARE PPO MA|769.20||||320.40||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|United Healthcare|UNITED HEALTHCARE|6.41||||769.20||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|Blue Cross HMO Specialty|BCBSTX HMO|293.70||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|769.20||||769.20||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|United Healthcare|UNITED HEALTHCARE|320.40||||769.20||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|United Healthcare|UNITED HEALTHCARE|769.20||||||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|Medicare|MEDICARE ACUTE|705.10||||769.20||| 93798|EAP|0943|INDIVIDUAL EXERCISE RX/30|NON CONTRACTED|COMMERCIAL OTHER 1|320.40||||320.40||| 93798|EAP|0943|CV REHAB W CONT EKG MONIT|PHCS|GROUP AND PENSION|6.41||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|NON CONTRACTED|COMMERCIAL OTHER 1|||||34.06||| 93880|EAP|0921|CAROTID DUPLEX EXAM|PHCS|HUMANA|34.06||||34.06||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||3,639.04||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.19||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Managed Medicare|BCBS MEDICARE PPO MA|||||6.19||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Managed Medicare|BCBS MEDICARE PPO MA|34.06||||3,639.04||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Managed Medicare|HEALTHSPRING MA|||||6.19||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Managed Medicare|HEALTHSPRING MA|34.06||||3,639.04||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Medicare|MEDICARE ACUTE|34.06||||34.06||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3,522.52||||34.06||| 93880|EAP|0921|CAROTID DUPLEX EXAM|United Healthcare|UNITED HEALTHCARE OTHER|34.06||||34.06||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Medicare|MEDICARE PART B ONLY IP|3,639.04||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Tricare|TRICARE EAST REGION|3,639.04||||3,639.04||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Medicare|MEDICARE ACUTE|||||6.19||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.19||| 93880|EAP|0921|CAROTID DUPLEX EXAM|United Healthcare|UNITED HEALTHCARE|34.06||||||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Tricare|TRICARE EAST REGION|||||6.19||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Blue Cross PPO Specialty|BCBSTX OTHER|||||257.93||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Blue Cross PPO Specialty|BCBSTX PPO|||||257.93||| 93880|EAP|0921|CAROTID DUPLEX EXAM|United Healthcare|GEHA|||||34.06||| 93880|EAP|0921|CAROTID DUPLEX EXAM|United Medicare Advantage|UHC AARP WELLMED HMO MA|3,639.04||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Blue Cross PPO Specialty|BCBSTX PPO|34.06||||3,522.52||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|United Medicare Advantage|UHC AARP MCR HMO MA|||||6.19||| 93880|EAP|0921|CAROTID DUPLEX EXAM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,639.04||||34.06||| 93880|EAP|0921|CAROTID DUPLEX EXAM|United Medicare Advantage|UHC AARP MCR HMO MA|3,639.04||||3,639.04||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3,639.04||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,639.04||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Aetna|AETNA PPO|||||257.93||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Aetna|AETNA QHP HMO|3,639.04||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Aetna|AETNA PPO|3,522.52||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Blue Cross HMO Specialty|BCBSTX HMO|3,522.52||||3,639.04||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Aenta Medicare Advantage|AETNA MEDICARE MA|3,639.04||||34.06||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.19||| 93880|EAP|0921|CAROTID DUPLEX EXAM|United Healthcare|UNITED HEALTHCARE|||||3,639.04||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.06||||34.06||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Managed Medicaid|MEDICAID SUPERIOR|3,639.04||||||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Veterans Affairs|VETERANS ADMINISTRATION|||||257.93||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,639.04||||34.06||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.19||| 93880|EAP|0921|CAROTID DUPLEX EXAM|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,639.04||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Managed Medicare|ETMC AFFILIATE HOSPITALS|34.06||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3,639.04||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Aetna|AETNA OTHER|||||3,522.52||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Medicaid|MEDICAID|34.06||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Access Direct Platinum|HEALTHFIRST TPA|3,639.04||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|United Medicare Advantage|UHC MEDICARE GOLD MA|3,639.04||||3,639.04||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|United Healthcare|UNITED HEALTHCARE OTHER|||||257.93||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Blue Cross PPO Specialty|BCBSTX OTHER|34.06||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Managed Medicare|OTHER INSTITUTIONS|||||34.06||| 93880|EAP|0921|CAROTID DUPLEX EXAM|United Healthcare|GOLDEN RULE|3,639.04||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,639.04||||3,639.04||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Veterans Affairs|VETERANS ADMINISTRATION|3,522.52||||3,522.52||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Medicare|UTSW MC KIDNEY PROGRAM|||||3,639.04||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.19||| 93880|EAP|0921|CAROTID DUPLEX EXAM|ChampVA|CHAMPVA CENTER|3,639.04||||||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Humana Medicare Advantage|HUMANA MA|3,639.04||||3,639.04||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|34.06||||3,522.52||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Managed Medicaid|MEDICAID AMERIGROUP|||||3,639.04||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Cigna|CIGNA|3,522.52||||||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Cigna|CIGNA|||||6.19||| 93880|EAP|0402|DUP SCAN XTRC ART COMPL B|Humana Medicare Advantage|HUMANA MA|||||257.93||| 93880|EAP|0921|CAROTID DUPLEX EXAM|Cigna|CIGNA|3,639.04||||3,639.04||| 93882|EAP|0921|CAROTID DUPLEX LIMITED|Medicare|MEDICARE ACUTE|1,573.04||||1,625.07||| 93882|EAP|0921|CAROTID DUPLEX LIMITED|Humana Medicare Advantage|HUMANA MA|1,625.07||||||| 93882|EAP|0402|DUP SCAN XTRC ART UNI/LMT|Medicare|MEDICARE ACUTE|||||213.92||| 93882|EAP|0921|CAROTID DUPLEX LIMITED|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,625.07||||||| 93882|EAP|0921|CAROTID DUPLEX LIMITED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,625.07||| 93882|EAP|0921|CAROTID DUPLEX LIMITED|Aenta Medicare Advantage|AETNA MEDICARE MA|1,625.07||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|UTMB|UTMB CORRECTIONAL MANAGED CARE|37.39||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Medicare|MEDICARE PART B ONLY IP|3,994.83||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,994.83||||3,994.83||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|PHCS|HUMANA|37.39||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|NON CONTRACTED|COMMERCIAL OTHER 1|3,866.92||||3,994.83||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|PHCS|GROUP AND PENSION|3,994.83||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|United Medicare Advantage|UHC MEDICARE GOLD MA|3,994.83||||3,866.92||| 93886|EAP|0402||Medicare|MEDICARE ACUTE|||||3.02||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||37.39||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Veterans Affairs|VETERANS ADMINISTRATION|||||257.92||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.19||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3,866.92||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,994.83||||37.39||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Aenta Medicare Advantage|AETNA MEDICARE MA|3,994.83||||||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Blue Cross PPO Specialty|BCBSTX OTHER|||||257.92||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Access Direct Platinum|HEALTHFIRST TPA|3,994.83||||3,994.83||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Veterans Affairs|VETERANS ADMINISTRATION|3,994.83||||3,994.83||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Medicare|MEDICARE ACUTE|3,994.83||||3,994.83||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Medicare|MEDICARE ACUTE|||||6.19||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|United Medicare Advantage|UHC AARP MCR HMO MA|3,994.83||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|PHCS|HUMANA INSURANCE|37.39||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3,994.83||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Tricare|TRICARE EAST REGION|3,994.83||||||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Blue Cross PPO Specialty|BCBSTX PPO|||||257.92||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Blue Cross PPO Specialty|BCBSTX PPO|3,994.83||||37.39||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,994.83||||37.39||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.19||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Blue Cross PPO Specialty|BCBSTX OTHER|37.39||||||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.19||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Blue Cross HMO Specialty|BCBSTX HMO|3,866.92||||3,994.83||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Aetna|AETNA PPO|||||257.92||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,994.83||||37.39||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|United Medicare Advantage|UHC AARP MCR HMO MA|||||6.19||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Tricare|TRICARE EAST REGION|||||6.19||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Cigna|CIGNA|||||6.19||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,994.83||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Cigna|CIGNA|3,866.92||||3,994.83||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Cigna|CIGNA|3,994.83||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Aetna|AETNA PPO|37.39||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Humana Medicare Advantage|HUMANA MA|3,994.83||||37.39||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Humana Medicare Advantage|HUMANA MA|||||257.92||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Managed Medicaid|MEDICAID AMERIGROUP|3,994.83||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Managed Medicare|BCBS MEDICARE PPO MA|37.39||||3,994.83||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Managed Medicare|HEALTHSPRING MA|37.39||||3,866.92||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.19||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Medicaid|MEDICAID|37.39||||||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Managed Medicare|HEALTHSPRING MA|||||6.19||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|Managed Medicare|BCBS MEDICARE PPO MA|||||6.19||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|37.39||||||| 93886|EAP|0402|TCD STD ICRA ART COMPL ST|United Healthcare|UNITED HEALTHCARE OTHER|||||257.92||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|United Healthcare|UNITED HEALTHCARE|3,994.83||||||| 93886|EAP|0921|TRANSCRANIAL DOPPLER|United Healthcare|UNITED HEALTHCARE|37.39||||||| 93890|EAP|0760|TCD VASOREACTIVITY STUDY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|23.02||||||| 93890|EAP|0402|TCD STD ICRA ART VASOREAC|Cigna|CIGNA|||||6.19||| 93890|EAP|0402|TCD STD ICRA ART VASOREAC|Humana Medicare Advantage|HUMANA MA|||||6.19||| 93890|EAP|0760|TCD VASOREACTIVITY STUDY|Cigna|CIGNA|2,762.40||||||| 93890|EAP|0402|TCD STD ICRA ART VASOREAC|Tricare|TRICARE EAST REGION|||||6.19||| 93890|EAP|0760|TCD VASOREACTIVITY STUDY|Humana Medicare Advantage|HUMANA MA|2,532.20||||||| 93890|EAP|0760|TCD VASOREACTIVITY STUDY|Aetna|AETNA PPO|23.02||||||| 93890|EAP|0760|TCD VASOREACTIVITY STUDY|Medicare|MEDICARE ACUTE|23.02||||2,762.40||| 93890|EAP|0402|TCD STD ICRA ART VASOREAC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||438.46||| 93890|EAP|0402|TCD STD ICRA ART VASOREAC|Medicare|MEDICARE ACUTE|||||6.19||| 93890|EAP|0402|TCD STD ICRA ART VASOREAC|Managed Medicare|HEALTHSPRING MA|||||6.19||| 93890|EAP|0760|TCD VASOREACTIVITY STUDY|Managed Medicare|HEALTHSPRING MA|2,762.40||||||| 93890|EAP|0760|TCD VASOREACTIVITY STUDY|United Healthcare|UNITED HEALTHCARE|2,762.40||||||| 93890|EAP|0760|TCD VASOREACTIVITY STUDY|PHCS|HUMANA|23.02||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|United Healthcare|UNITED HEALTHCARE|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.12||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Medicaid|MEDICAID|27.12||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Managed Medicare|BCBS MEDICARE PPO MA|27.12||||2,871.83||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|United Healthcare|UNITED HEALTHCARE|27.12||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Tricare|TRICARE EAST REGION|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|UTMB|UTMB CORRECTIONAL MANAGED CARE|27.12||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|PHCS|HUMANA INSURANCE|27.12||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|PHCS|HUMANA|27.12||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|PHCS|GROUP AND PENSION|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Managed Medicare|HEALTHSPRING MA|27.12||||2,791.92||| 93892|EAP|0510|TCD,EMBOLI DETECT W/O INJ|Medicare|MEDICARE ACUTE|||||41.67||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,871.83||||2,871.83||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||27.12||| 93892|EAP|0510|TCD,EMBOLI DETECT W/O INJ|Veterans Affairs|VETERANS ADMINISTRATION|||||41.67||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2,791.92||||||| 93892|EAP|0510|TCD,EMBOLI DETECT W/O INJ|United Medicare Advantage|UHC AARP MCR HMO MA|||||3.02||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Blue Cross PPO Specialty|BCBSTX PPO|2,871.83||||27.12||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|United Medicare Advantage|UHC AARP MCR HMO MA|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,871.83||||27.12||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|United Medicare Advantage|UHC MEDICARE GOLD MA|2,871.83||||2,791.92||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Aenta Medicare Advantage|AETNA MEDICARE MA|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Aetna|AETNA PPO|27.12||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Cigna|CIGNA|2,791.92||||2,871.83||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Blue Cross PPO Specialty|BCBSTX OTHER|27.12||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Cigna|CIGNA|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|NON CONTRACTED|COMMERCIAL OTHER 1|2,791.92||||2,871.83||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Access Direct Platinum|HEALTHFIRST TPA|2,871.83||||2,871.83||| 93892|EAP|0510|TCD,EMBOLI DETECT W/O INJ|Humana Medicare Advantage|HUMANA MA|||||41.67||| 93892|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||3.02||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Blue Cross HMO Specialty|BCBSTX HMO|2,791.92||||2,871.83||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Medicare|MEDICARE PART B ONLY IP|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Managed Medicaid|MEDICAID AMERIGROUP|2,871.83||||||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Humana Medicare Advantage|HUMANA MA|2,871.83||||27.12||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Medicare|MEDICARE ACUTE|2,871.83||||2,871.83||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,871.83||||27.12||| 93892|EAP|0761||Medicare|MEDICARE ACUTE|||||3.02||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,871.83||||27.12||| 93892|EAP|0921|TCD EMBOLI DETECT W/O INJ|Veterans Affairs|VETERANS ADMINISTRATION|2,871.83||||2,871.83||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Cigna|CIGNA|1,996.09||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Cigna|CIGNA|18.85||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Managed Medicaid|MEDICAID AMERIGROUP|1,996.09||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,996.09||||18.85||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,996.09||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Veterans Affairs|VETERANS ADMINISTRATION|1,996.09||||1,996.09||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Blue Cross HMO Specialty|BCBSTX HMO|1,940.55||||1,996.09||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|United Medicare Advantage|UHC MEDICARE GOLD MA|1,996.09||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|United Medicare Advantage|UHC AARP MCR HMO MA|1,996.09||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,996.09||||1,996.09||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Humana Medicare Advantage|HUMANA MA|1,996.09||||1,940.55||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||18.85||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Blue Cross PPO Specialty|BCBSTX PPO|1,996.09||||18.85||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.85||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Access Direct Platinum|HEALTHFIRST TPA|1,996.09||||1,996.09||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,996.09||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,996.09||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Blue Cross PPO Specialty|BCBSTX OTHER|18.85||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Managed Medicare|HEALTHSPRING MA|1,996.09||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.85||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Managed Medicare|BCBS MEDICARE PPO MA|18.85||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.85||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Tricare|TRICARE EAST REGION|1,996.09||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|United Healthcare|UNITED HEALTHCARE|18.85||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|PHCS|GROUP AND PENSION|1,996.09||||||| 93893|EAP|0510|TCD,EMBOLI DETECT W/INJ|Medicare|MEDICARE ACUTE|||||20.83||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|United Healthcare|UNITED HEALTHCARE|1,996.09||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|PHCS|HUMANA|18.85||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Medicaid|MEDICAID|1,940.55||||||| 93893|EAP|0921|TCD EMBOLI DETECT W/INJ|Medicare|MEDICARE ACUTE|1,996.09||||1,996.09||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Managed Medicare|HEALTHSPRING MA|||||7.68||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Managed Medicare|BCBS MEDICARE PPO MA|||||6.40||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||7.68||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.68||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Access Direct Platinum|HEALTHFIRST TPA|||||7.68||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Veterans Affairs|VETERANS ADMINISTRATION|||||6.40||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.68||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.68||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Blue Cross HMO Specialty|BCBSTX HMO|||||6.40||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.40||||6.40||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Blue Cross PPO Specialty|BCBSTX OTHER|7.68||||||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Blue Cross PPO Specialty|BCBSTX PPO|||||7.04||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.68||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.40||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Humana Medicare Advantage|HUMANA MA|7.68||||7.68||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.40||||6.40||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|Medicare|MEDICARE ACUTE|6.40||||7.68||| 93922|EAP|0921|U/L XTREMITY ART 2L PHYSI|United Healthcare|UNITED HEALTHCARE OTHER|7.68||||||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|United Healthcare|UNITED HEALTHCARE|||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|35.89||||35.89||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|United Medicare Advantage|UHC AARP MCR HMO MA|3,619.79||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Access Direct Platinum|HEALTHFIRST TPA UMR|3,619.79||||||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Cigna|CIGNA OTHER|||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Cigna|CIGNA|35.89||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Aenta Medicare Advantage|AETNA MEDICARE MA|3,604.40||||3,604.40||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Humana Medicare Advantage|HUMANA MA|3,619.79||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,619.79||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,619.79||||35.89||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Aetna|BOON CHAPMAN|||||35.89||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,619.79||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Aetna|AETNA QHP HMO|3,619.79||||||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Blue Cross PPO Specialty|BCBSTX PPO|3,619.79||||35.89||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Blue Cross HMO Specialty|BCBSTX HMO|35.89||||3,604.40||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||35.89||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|United Medicare Advantage|UHC MEDICARE GOLD MA|3,604.40||||35.89||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Veterans Affairs|VETERANS ADMINISTRATION|3,619.79||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3,619.79||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,619.79||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicaid|MEDICAID AMERIGROUP|3,619.79||||||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicaid|MEDICAID SUPERIOR|35.89||||||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,619.79||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Medicare|UTSW MC KIDNEY PROGRAM|||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicare|OTHER INSTITUTIONS|||||3,604.40||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicare|HEALTHSPRING MA|3,604.40||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|United Healthcare|UNITED HEALTHCARE OTHER|3,619.79||||||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicare|BCBS MEDICARE PPO MA|35.89||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Medicaid|MEDICAID|35.89||||||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Medicare|MEDICARE ACUTE|35.89||||3,619.79||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Tricare|TRICARE EAST REGION|3,619.79||||||| 93925|EAP|0921|ARTERIAL DUPLEX LOWER EXT|UTMB|UTMB CORRECTIONAL MANAGED CARE|35.89||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicare|HEALTHSPRING MA|2,006.06||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,006.06||||19.89||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Medicaid|SMITH COUNTY JAIL|19.89||||||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|19.89||||||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Managed Medicare|BCBS MEDICARE PPO MA|||||2,006.06||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Managed Medicare|HEALTHSPRING MA|1,594.50||||1,997.53||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicare|BCBS MEDICARE PPO MA|19.89||||||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Tricare|TRICARE FOR LIFE|2,006.06||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,006.06||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Medicare|MEDICARE ACUTE|2,006.06||||19.89||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|PHCS|HUMANA INSURANCE|2,006.06||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Workers Compensation|ZURICH COMPANY|||||19.89||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|19.89||||||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Veterans Affairs|VETERANS ADMINISTRATION|19.89||||19.89||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|United Medicare Advantage|UHC MEDICARE GOLD MA|19.89||||2,006.06||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Blue Cross HMO Specialty|BCBSTX HMO|19.89||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|United Medicare Advantage|UHC MEDICARE GOLD MA|19.89||||19.89||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Aenta Medicare Advantage|AETNA MEDICARE MA|19.89||||19.89||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Blue Cross PPO Specialty|BCBSTX OTHER|2,006.06||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Tricare|TRICARE EAST REGION|19.89||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,997.53||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|United Medicare Advantage|UHC AARP MCR HMO MA|2,006.06||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Aetna|AETNA PPO|2,006.06||||19.89||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.89||||19.89||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Humana Medicare Advantage|HUMANA MA|19.89||||1,997.53||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,006.06||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Humana Medicare Advantage|HUMANA MA|2,006.06||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Cigna|CIGNA|2,006.06||||||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,006.06||||19.89||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Cigna|CIGNA|||||2,006.06||| 93926|EAP|0921|ARTERIAL GRAFTS LOWER EXT|Cigna|CIGNA|19.89||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicaid|MEDICAID AMERIGROUP|19.89||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Cigna|CIGNA|19.89||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicaid|MEDICAID SUPERIOR|19.89||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,006.06||||||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Blue Cross PPO Specialty|BCBSTX PPO|2,006.06||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Blue Cross PPO Specialty|BCBSTX PPO|19.89||||19.89||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Blue Cross HMO Specialty|BCBSTX HMO|19.89||||2,006.06||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|United Medicare Advantage|UHC AARP MCR HMO MA|2,006.06||||||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,006.06||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.89||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Medicaid|MEDICAID|19.89||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Veterans Affairs|VETERANS ADMINISTRATION|2,006.06||||2,006.06||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||19.89||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Workers Compensation|WORKERS COMPENSATION OTHER|||||2,006.06||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Access Direct Platinum|HEALTHFIRST TPA UMR|19.89||||||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,997.53||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|NON CONTRACTED|COMMERCIAL OTHER 1|19.89||||19.89||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|Medicare|MEDICARE ACUTE|19.89||||2,006.06||| 93926|EAP|0920|PSEUDO ANEURYSM RULE OUT|United Healthcare|UNITED HEALTHCARE OTHER|||||19.89||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|Managed Medicare|WELLCARE CHOICE MA|2,006.06||||||| 93926|EAP|0921|ARTERIAL DUPLEX LOWER EXT|United Healthcare|UNITED HEALTHCARE|2,006.06||||||| 93930|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Humana Medicare Advantage|HUMANA MA|39.87||||||| 93930|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|39.87||||||| 93930|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,021.20||||||| 93930|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Blue Cross PPO Specialty|BCBSTX PPO|||||39.87||| 93930|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Veterans Affairs|VETERANS ADMINISTRATION|39.87||||||| 93930|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Medicare|MEDICARE ACUTE|4,021.20||||||| 93931|EAP|0921|ARTERIAL GRAFTS UPPER EXT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,997.53||||||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Blue Cross PPO Specialty|BCBSTX PPO|1,997.53||||19.89||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Veterans Affairs|VETERANS ADMINISTRATION|19.89||||||| 93931|EAP|0921|ARTERIAL GRAFTS UPPER EXT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.89||||19.89||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Managed Medicare|HEALTHSPRING MA|2,006.06||||19.89||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,006.06||||||| 93931|EAP|0921|ARTERIAL GRAFTS UPPER EXT|Managed Medicare|OTHER INSTITUTIONS|||||2,006.06||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|United Medicare Advantage|UHC MEDICARE GOLD MA|1,997.53||||19.89||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|United Healthcare|UNITED HEALTHCARE OTHER|19.89||||||| 93931|EAP|0921|ARTERIAL GRAFTS UPPER EXT|Blue Cross PPO Specialty|BCBSTX PPO|19.89||||19.89||| 93931|EAP|0921|ARTERIAL GRAFTS UPPER EXT|Humana Medicare Advantage|HUMANA MA|2,006.06||||1,997.53||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||19.89||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19.89||||||| 93931|EAP|0921|ARTERIAL GRAFTS UPPER EXT|Medicare|MEDICARE ACUTE|1,997.53||||2,006.06||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Humana Medicare Advantage|HUMANA MA|1,997.53||||2,006.06||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Medicare|MEDICARE ACUTE|19.89||||19.89||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.89||||2,006.06||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.89||||||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,006.06||| 93931|EAP|0921|ARTERIAL DUPLEX UPPER EXT|Cigna|CIGNA|2,006.06||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Cigna|CIGNA|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Humana Medicare Advantage|HUMANA MA|48.89||||4,909.97||| 93970|EAP|0921|VEIN MAPPING BILATERAL|Cigna|CIGNA|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||4,909.97||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Aenta Medicare Advantage|AETNA MEDICARE MA|4,930.94||||4,909.97||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Aetna|AETNA OTHER|||||48.89||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Blue Cross HMO Specialty|BCBSTX HMO|4,930.94||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Blue Cross PPO Specialty|BCBSTX PPO|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Aetna|AETNA PPO|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Blue Cross PPO Specialty|BCBSTX OTHER|4,930.94||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Blue Cross PPO Specialty|BCBSTX PPO|48.89||||4,930.94||| 93970|EAP|0921|VEIN MAPPING BILATERAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4,909.97||||||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Blue Cross PPO Specialty|BCBSTX PPO|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Cigna|CIGNA OTHER|||||4,930.94||| 93970|EAP|0921|VEIN MAPPING BILATERAL|Blue Cross PPO Specialty|BCBSTX OTHER|4,930.94||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Access Direct Platinum|HEALTHFIRST TPA|4,930.94||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Veterans Affairs|VETERANS ADMINISTRATION|48.89||||4,909.97||| 93970|EAP|0921|VEIN MAPPING BILATERAL|Veterans Affairs|VETERANS ADMINISTRATION|4,930.94||||48.89||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,909.97||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|United Medicare Advantage|UHC MEDICARE GOLD MA|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|United Medicare Advantage|UHC AARP WELLMED HMO MA|4,930.94||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|PHCS|GROUP AND PENSION|||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|United Healthcare|TML GROUP BENEFITS|4,930.94||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Rusk State Hospital|RUSK STATE HOSP|4,930.94||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|United Medicare Advantage|UHC MEDICARE GOLD MA|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|NON CONTRACTED|COMMERCIAL OTHER 1|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Medicare|MEDICARE ACUTE|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicare|MEDICARE PART B ONLY IP|4,909.97||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Access Direct Platinum|HEALTHFIRST TPA UMR|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Humana Medicare Advantage|HUMANA MA|4,930.94||||4,909.97||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicare|MEDICARE PART B ONLY IP|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicare|MEDICARE ACUTE|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4,930.94||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Managed Medicaid|MEDICAID SUPERIOR|4,909.97||||48.89||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|United Healthcare|UNITED HEALTHCARE OTHER|4,930.94||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|United Healthcare|UNITED HEALTHCARE OTHER|4,930.94||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|United Healthcare|UNITED HEALTHCARE|4,930.94||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|United Healthcare|UNITED HEALTHCARE|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|United Healthcare|UNITED HEALTHCARE|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Managed Medicaid|MEDICAID AMERIGROUP|48.89||||4,909.97||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Managed Medicaid|MEDICAID UNITED HEALTHCARE|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Aenta Medicare Advantage|AETNA MEDICARE MA|48.89||||4,909.97||| 93970|EAP|0921|VEIN MAPPING BILATERAL|Medicare|MEDICARE ACUTE|48.89||||4,930.94||| 93970|EAP|0921|VEIN MAPPING BILATERAL|United Healthcare|UNITED HEALTHCARE OTHER|4,930.94||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Tricare|TRICARE EAST REGION|48.89||||4,930.94||| 93970|EAP|0921|VEIN MAPPING BILATERAL|Tricare|TRICARE EAST REGION|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|UTMB|UTMB CORRECTIONAL MANAGED CARE|4,909.97||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|UTMB|UTMB CORRECTIONAL MANAGED CARE|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicaid|MEDICAID|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicaid|MEDICAID|4,909.97||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicaid|SMITH COUNTY INDIGENT HEALTH|4,909.97||||||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Managed Medicare|BCBS MEDICARE PPO MA|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Managed Medicare|OTHER INSTITUTIONS|4,930.94||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicaid|CRIME VICTIMS COMPENSATION|4,909.97||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Cigna|CIGNA|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Humana Medicare Advantage|HUMANA MA|48.89||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Managed Medicare|ETMC AFFILIATE HOSPITALS|48.89||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicaid|MOLINA HEALTHCARE OF TEXAS|48.89||||||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Medicaid|COUNTY INDIGENT HEALTH OTHER|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|United Medicare Advantage|UHC AARP MCR HMO MA|4,930.94||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Managed Medicare|HEALTHSPRING MA|48.89||||4,909.97||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||4,930.94||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Managed Medicare|HEALTHSPRING MA|4,930.94||||48.89||| 93970|EAP|0921|VENOUS DUPLEX LOWER EXT B|Managed Medicare|BCBS MEDICARE PPO MA|48.89||||48.89||| 93970|EAP|0921|VENOUS DUPLEX UPPER EXT B|Medicaid|CRIME VICTIMS COMPENSATION|4,930.94||||||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Medicaid|MEDICAID|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Managed Medicare|BCBS MEDICARE PPO MA|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Managed Medicare|HEALTHSPRING MA|2,973.29||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Medicaid|SMITH COUNTY JAIL|29.48||||||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,960.65||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Medicaid|SMITH COUNTY JAIL|29.48||||||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Medicaid|COUNTY INDIGENT HEALTH OTHER|29.48||||||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Medicaid|MEDICAID|29.48||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Tricare|TRICARE EAST REGION|29.48||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,960.65||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|UTMB|UTMB CORRECTIONAL MANAGED CARE|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|United Healthcare|UNITED HEALTHCARE OTHER|2,973.29||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|United Healthcare|UNITED HEALTHCARE|2,960.65||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|United Healthcare|AARP|29.48||||||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|United Healthcare|UNITED HEALTHCARE|||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Medicare|MEDICARE ACUTE|2,973.29||||2,973.29||| 93971|EAP|0921|VEIN MAPPING UNILATERAL|Medicare|MEDICARE ACUTE|29.48||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Medicare|MEDICARE ACUTE|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|NON CONTRACTED|COMMERCIAL OTHER 2|2,973.29||||||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Rusk State Hospital|RUSK STATE HOSP|||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,973.29||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,960.65||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|NON CONTRACTED|COMMERCIAL OTHER 1|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|United Medicare Advantage|UHC MEDICARE GOLD MA|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|United Medicare Advantage|UHC AARP MCR HMO MA|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Workers Compensation|WORKERS COMPENSATION OTHER|2,973.29||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Workers Compensation|ZURICH COMPANY|||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|2,973.29||||||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Access Direct Platinum|HEALTHFIRST TPA|29.48||||2,960.65||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Veterans Affairs|VETERANS ADMINISTRATION|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2,973.29||||||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Blue Cross PPO Specialty|BCBSTX OTHER|||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Blue Cross PPO Specialty|BCBSTX PPO|2,973.29||||2,960.65||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Blue Cross HMO Specialty|BCBSTX HMO|29.48||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Brinson Benefits|THE HEALTH PLAN SMITH CO|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|United Medicare Advantage|UHC AARP MCR HMO MA|29.48||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Aetna|AETNA PPO|29.48||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Aenta Medicare Advantage|AETNA MEDICARE MA|2,960.65||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Blue Cross HMO Specialty|BCBSTX HMO|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|United Medicare Advantage|UHC MEDICARE GOLD MA|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|United Healthcare|UNITED HEALTHCARE ERS|||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Aenta Medicare Advantage|AETNA MEDICARE MA|29.48||||2,960.65||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Blue Cross PPO Specialty|BCBSTX PPO|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.38||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|United Healthcare|UNITED HEALTHCARE OTHER|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Access Direct Platinum|HEALTHFIRST TPA UMR|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Managed Medicaid|MEDICAID AMERIGROUP|2,960.65||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Aetna|AETNA PPO|29.48||||2,960.65||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Managed Medicaid|MEDICAID SUPERIOR|29.48||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Aetna|AETNA QHP HMO|2,973.29||||||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,973.29||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Managed Medicare|BCBS MEDICARE PPO MA|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29.48||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Managed Medicare|HEALTHSPRING MA|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Managed Medicaid|MEDICAID AMERIGROUP|2,960.65||||2,960.65||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Cigna|CIGNA|2,973.29||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|ChampVA|CHAMPVA CENTER|||||2,960.65||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Workers Compensation|WORKERS COMPENSATION OTHER|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Cigna|CIGNA|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Humana Medicare Advantage|HUMANA MA|29.48||||29.48||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Aetna|BOON CHAPMAN|29.48||||||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Veterans Affairs|VETERANS ADMINISTRATION|2,973.29||||2,973.29||| 93971|EAP|0921|VENOUS DUPLEX LOWER EXT U|Humana Medicare Advantage|HUMANA MA|29.48||||2,960.65||| 93971|EAP|0921|VENOUS DUPLEX UPPER EXT U|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,960.65||||29.48||| 93971|EAP|0921|VEIN MAPPING UNILATERAL|Humana Medicare Advantage|HUMANA MA|29.48||||29.48||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.63||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Cigna|CIGNA|1,374.69||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Aetna|AETNA OTHER|1,368.85||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Managed Medicaid|MEDICAID SUPERIOR|1,368.85||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Aenta Medicare Advantage|AETNA MEDICARE MA|||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,374.69||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Aetna|AETNA PPO|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Managed Medicaid|MEDICAID AMERIGROUP|1,374.69||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Humana Medicare Advantage|HUMANA MA|13.63||||1,368.85||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Cigna|CIGNA|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Blue Cross HMO Specialty|BCBSTX HMO|1,368.85||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,368.85||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Blue Cross PPO Specialty|BCBSTX OTHER|13.63||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,374.69||||1,368.85||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.63||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Access Direct Platinum|HEALTHFIRST TPA|||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Veterans Affairs|VETERANS ADMINISTRATION|13.63||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Medicare|UTSW MC KIDNEY PROGRAM|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,368.85||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|PHCS|GROUP AND PENSION|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|United Medicare Advantage|UHC AARP MCR HMO MA|1,374.69||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|PHCS|HUMANA|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|1,374.69||||||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Blue Cross PPO Specialty|BCBSTX PPO|13.63||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Medicare|MEDICARE ACUTE|13.63||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|United Medicare Advantage|UHC MEDICARE GOLD MA|13.63||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|NON CONTRACTED|COMMERCIAL OTHER 1|13.63||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Medicare|MEDICARE PART B ONLY IP|13.63||||||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|PHCS|MULTIPLAN PHCS|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Medicaid|SMITH COUNTY JAIL|13.63||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,368.85||||||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Medicaid|COUNTY INDIGENT HEALTH OTHER|13.63||||||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Cigna|CIGNA OTHER|||||1,368.85||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,374.69||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Managed Medicare|OTHER INSTITUTIONS|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Medicaid|MEDICAID HMO|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Managed Medicare|HEALTHSPRING MA|1,368.85||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Managed Medicare|BCBS MEDICARE PPO MA|1,368.85||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|United Healthcare|TML GROUP BENEFITS|||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Tricare|TRICARE EAST REGION|||||13.63||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|United Healthcare|UNITED HEALTHCARE|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Tricare|TRICARE FOR LIFE|||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|United Healthcare|UNITED HEALTHCARE|1,374.69||||1,374.69||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|United Healthcare|UNITED HEALTHCARE OTHER|13.63||||1,368.85||| 93975|EAP|0921|US ARTERIAL DOP & VENUS D|Medicaid|MEDICAID|13.63||||1,374.69||| 93976|EAP|0921|US VASCULAR STUDY LIMITED|Managed Medicare|HEALTHSPRING MA|8.78||||||| 93980|EAP|0402|PENILE VASCULAR STUDY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|United Medicare Advantage|UHC AARP MCR HMO MA|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|Blue Cross PPO Specialty|BCBSTX OTHER|||||3.03||| 93980|EAP|0402|PENILE VASCULAR STUDY|Blue Cross PPO Specialty|BCBSTX PPO|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|Cigna|CIGNA OTHER|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|Cigna|CIGNA|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|Humana Medicare Advantage|HUMANA MA|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|Medicare|MEDICARE ACUTE|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|United Healthcare|UNITED HEALTHCARE|||||3.03||| 93980|EAP|0402|PENILE VASCULAR STUDY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||126.25||| 93980|EAP|0402|PENILE VASCULAR STUDY|Managed Medicare|HEALTHSPRING MA|||||214.63||| 94|DRG||BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W MCC|Blue Cross HMO Specialty|BCBSTX HMO|480,461.37|21228.84|21228.84|20926.79|||| 94|DRG||BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W MCC|Medicare|MEDICARE ACUTE|393,129.65|20926.79|21228.84|20926.79|||| 940|DRG||O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W CC|Medicare|MEDICARE ACUTE|96,342.05|20887.88|20887.88|20887.88|||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Veterans Affairs|VETERANS ADMINISTRATION|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Access Direct Platinum|HEALTHFIRST TPA UMR|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Access Direct Platinum|HEALTHFIRST TPA|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Workers Compensation|TEXAS MUTUAL INSURANCE|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|United Medicare Advantage|UHC AARP MCR HMO MA|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|United Medicare Advantage|UHC MEDICARE GOLD MA|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Humana Medicare Advantage|HUMANA MA|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Cigna|CIGNA OTHER|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Cigna|CIGNA|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|ChampVA|CHAMPVA CENTER|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Blue Cross HMO Specialty|BCBSTX HMO|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Managed Medicaid|MEDICAID SUPERIOR|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Blue Cross PPO Specialty|BCBSTX OTHER|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Managed Medicaid|MEDICAID AMERIGROUP|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Blue Cross PPO Specialty|BCBSTX PPO|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Managed Medicaid|MEDICAID UNITED HEALTHCARE|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Aetna|AETNA OTHER|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Aetna|AETNA PPO|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Aetna|AETNA QHP HMO|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Aetna|BOON CHAPMAN|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|PHCS|GROUP AND PENSION|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|NON CONTRACTED|COMMERCIAL OTHER 1|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Rusk State Hospital|RUSK STATE HOSP|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Aenta Medicare Advantage|AETNA MEDICARE MA|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|PHCS|HUMANA|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Workers Compensation|WORKERS COMPENSATION OTHER|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|United Medicare Advantage|UHC AARP WELLMED HMO MA|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Medicare|MEDICARE ACUTE|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|NON CONTRACTED|COMMERCIAL OTHER 2|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|United Healthcare|UNITED HEALTHCARE OTHER|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Managed Medicare|WELLCARE CHOICE MA|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|UTMB|UTMB CORRECTIONAL MANAGED CARE|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Tricare|TRICARE EAST REGION|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Managed Medicare|BCBS MEDICARE PPO MA|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Managed Medicare|HEALTHSPRING MA|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Medicaid|SMITH COUNTY INDIGENT HEALTH|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Medicaid|MEDICAID|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|106.34||||106.34||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Medicaid|MOLINA HEALTHCARE OF TEXAS|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Medicaid|CRIME VICTIMS COMPENSATION|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|Medicaid|COUNTY INDIGENT HEALTH OTHER|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|United Healthcare|TML GROUP BENEFITS|106.34||||||| 94002|EAP|0410|VENTILATOR ASSIST/MGMNT F|United Healthcare|UNITED HEALTHCARE|106.34||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|United Medicare Advantage|UHC AARP MCR HMO MA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|United Medicare Advantage|UHC MEDICARE GOLD MA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Humana Medicare Advantage|HUMANA MA|88.62||||88.62||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|United Medicare Advantage|UHC AARP WELLMED HMO MA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Access Direct Platinum|HEALTHFIRST TPA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Veterans Affairs|VETERANS ADMINISTRATION|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Workers Compensation|WORKERS COMPENSATION OTHER|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Workers Compensation|TEXAS MUTUAL INSURANCE|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Access Direct Platinum|HEALTHFIRST TPA UMR|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Medicaid|COUNTY INDIGENT HEALTH OTHER|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Medicaid|SMITH COUNTY INDIGENT HEALTH|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Medicaid|MOLINA HEALTHCARE OF TEXAS|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Medicaid|CRIME VICTIMS COMPENSATION|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Medicaid|MEDICAID|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Managed Medicare|WELLCARE CHOICE MA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Managed Medicare|HEALTHSPRING MA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|United Healthcare|UNITED HEALTHCARE OTHER|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|United Healthcare|TML GROUP BENEFITS|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Tricare|TRICARE EAST REGION|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|UTMB|UTMB CORRECTIONAL MANAGED CARE|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|United Healthcare|UNITED HEALTHCARE|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Medicare|MEDICARE ACUTE|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|PHCS|HUMANA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|NON CONTRACTED|COMMERCIAL OTHER 2|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|NON CONTRACTED|COMMERCIAL OTHER 1|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Managed Medicare|BCBS MEDICARE PPO MA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Rusk State Hospital|RUSK STATE HOSP|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Aetna|AETNA OTHER|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Aenta Medicare Advantage|AETNA MEDICARE MA|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Aetna|AETNA QHP HMO|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Aetna|BOON CHAPMAN|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Aetna|AETNA PPO|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Blue Cross PPO Specialty|BCBSTX PPO|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Blue Cross PPO Specialty|BCBSTX OTHER|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Blue Cross HMO Specialty|BCBSTX HMO|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Managed Medicaid|MEDICAID SUPERIOR|88.62||||||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|88.62||||88.62||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Managed Medicaid|MEDICAID AMERIGROUP|88.62||||88.62||| 94003|EAP|0410|VENTILATOR ASSIST/MGMNT S|Cigna|CIGNA|88.62||||||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Veterans Affairs|VETERANS ADMINISTRATION|570.90||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Veterans Affairs|VETERANS ADMINISTRATION|570.90||||622.80||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Access Direct Platinum|HEALTHFIRST TPA|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||570.90||| 94010|EAP|0460|PFT SPIROMETRY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||622.80||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Medicare Advantage|UHC MEDICARE GOLD MA|5.19||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|622.80||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Medicare Advantage|UHC AARP MCR HMO MA|622.80||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|United Medicare Advantage|UHC MEDICARE GOLD MA|5.19||||5.19||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Humana Medicare Advantage|HUMANA MA|3.65||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Cigna|CIGNA OTHER|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Cigna|CIGNA|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Cigna|CIGNA|||||622.80||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicaid|MEDICAID AMERIGROUP|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|622.80||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicaid|MEDICAID SUPERIOR|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Blue Cross HMO Specialty|BCBSTX HMO|||||622.80||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Blue Cross PPO Specialty|BCBSTX PPO|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Managed Medicaid|MEDICAID AMERIGROUP|||||5.19||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Blue Cross PPO Specialty|BCBSTX OTHER|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Blue Cross PPO Specialty|BCBSTX PPO|||||622.80||| 94010|EAP|0460|PFT SPIROMETRY|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||622.80||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|ChampVA|CHAMPVA CENTER|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Aetna|AETNA OTHER|||||258.54||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Aetna|BOON CHAPMAN|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Aetna|AETNA PPO|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.19||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Blue Cross HMO Specialty|BCBSTX HMO|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|PHCS|HUMANA|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|PHCS|HUMANA INSURANCE|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Texas Workforce Commission|DIS DETER SERV (DDS)|||||622.80||| 94010|EAP|0460|PFT SPIROMETRY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.19||||5.19||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|NON CONTRACTED|COMMERCIAL OTHER 1|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicare|MEDICARE ACUTE|152.08||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Humana Medicare Advantage|HUMANA MA|622.80||||5.19||| 94010|EAP|0460|PFT SPIROMETRY|Medicare|UTSW MC KIDNEY PROGRAM|||||622.80||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.19||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Medicare|MEDICARE ACUTE|622.80||||622.80||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||3.65||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Aetna Value Network|AETNA VALUE NETWORK|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Tricare|TRICARE EAST REGION|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Healthcare|UNITED HEALTHCARE OTHER|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||622.80||| 94010|EAP|0460|PFT SPIROMETRY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||622.80||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Healthcare|UNITED HEALTHCARE|||||258.54||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Healthcare|UNITED HEALTHCARE|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Healthcare|GOLDEN RULE|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Healthcare|GEHA|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|United Healthcare|UNITED HEALTHCARE|||||622.80||| 94010|EAP|0460|PFT SPIROMETRY|Managed Medicare|HEALTHSPRING MA|622.80||||5.19||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicare|BCBS MEDICARE PPO MA|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Workers Compensation|WORKERS COMPENSATION OTHER|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicaid|MEDICAID|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicaid|SMITH COUNTY JAIL|||||3.65||| 94010|EAP|0460|PFT SPIROMETRY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||622.80||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicare|HEALTHSPRING MA|152.08||||152.08||| 94010|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||152.08||| 94010|EAP|0460|PFT SPIROMETRY|Managed Medicare|BCBS MEDICARE PPO MA|||||5.19||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicaid|MEDICAID|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicare|HEALTHSPRING MA|14.11||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicare|BCBS MEDICARE PPO MA|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|14.11||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||14.11||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Healthcare|UNITED HEALTHCARE OTHER|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Healthcare|UNITED HEALTHCARE|||||258.54||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Healthcare|UNITED HEALTHCARE|||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|United Healthcare|UNITED HEALTHCARE OTHER|||||14.11||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Tricare|TRICARE EAST REGION|14.11||||258.54||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicare|MEDICARE ACUTE|258.54||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Medicare|MEDICARE ACUTE|14.11||||1,693.20||| 94060|EAP|0460|PFT BRONCHDIL RESPONSE|Medicare|UTSW MC KIDNEY PROGRAM|||||4.53||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|PHCS|HUMANA INSURANCE|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|NON CONTRACTED|COMMERCIAL OTHER 1|||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,693.20||||1,693.20||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Aenta Medicare Advantage|AETNA MEDICARE MA|1,552.10||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Blue Cross PPO Specialty|BCBSTX PPO|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Blue Cross PPO Specialty|BCBSTX OTHER|||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,552.10||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Aetna|AETNA PPO|||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,693.20||||||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Blue Cross HMO Specialty|BCBSTX HMO|||||14.11||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Blue Cross HMO Specialty|BCBSTX HMO|||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Medicare|UTSW MC KIDNEY PROGRAM|||||1,693.20||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.53||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1,693.20||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,693.20||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,693.20||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicaid|MEDICAID SUPERIOR|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,693.20||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Healthcare|GEHA|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Managed Medicaid|MEDICAID AMERIGROUP|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Cigna|CIGNA|||||258.54||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Cigna|CIGNA|||||3.65||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Humana Medicare Advantage|HUMANA MA|1,552.10||||1,693.20||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,693.20||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Humana Medicare Advantage|HUMANA MA|1,552.10||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|United Medicare Advantage|UHC AARP MCR HMO MA|||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,693.20||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,693.20||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||152.08||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,693.20||| 94060|EAP|0460|SPMTRY W/VC EXPIRATORY FL|Veterans Affairs|VETERANS ADMINISTRATION|152.08||||152.08||| 94060|EAP|0460|PFT PRE/POST BD COMPLETE|Veterans Affairs|VETERANS ADMINISTRATION|1,693.20||||14.11||| 941|DRG||O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|151,727.98|35.72|22851.77|35.72|||| 941|DRG||O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|142,621.10|22851.77|22851.77|35.72|||| 94150|EAP|0460|VITAL CAPACITY|Managed Medicare|HEALTHSPRING MA|1.82||||||| 94150|EAP|0460|VITAL CAPACITY|Medicaid|MEDICAID|1.82||||||| 94150|EAP|0460|VITAL CAPACITY|NON CONTRACTED|COMMERCIAL OTHER 1|1.82||||||| 94150|EAP|0460|VITAL CAPACITY|Medicare|MEDICARE ACUTE|1.82||||||| 94150|EAP|0460|VITAL CAPACITY|United Healthcare|UNITED HEALTHCARE OTHER|200.20||||||| 94150|EAP|0460|VITAL CAPACITY|United Healthcare|UNITED HEALTHCARE|1.82||||||| 94150|EAP|0460|VITAL CAPACITY|Veterans Affairs|VETERANS ADMINISTRATION|218.40||||||| 94150|EAP|0460|VITAL CAPACITY|United Medicare Advantage|UHC MEDICARE GOLD MA|1.82||||||| 94150|EAP|0460|VITAL CAPACITY|Humana Medicare Advantage|HUMANA MA|1.82||||||| 94150|EAP|0460|VITAL CAPACITY|Blue Cross HMO Specialty|BCBSTX HMO|1.82||||||| 94150|EAP|0460|VITAL CAPACITY|Blue Cross PPO Specialty|BCBSTX PPO|218.40||||||| 94375|EAP|0460|RESPIRATORY FLOW VOLUME L|Medicare|MEDICARE ACUTE|||||282.08||| 94375|EAP|0460|RESPIRATORY FLOW VOLUME L|Aenta Medicare Advantage|AETNA MEDICARE MA|||||282.08||| 94453|EAP|0000|HIGH ALTITUDE SIMULATJ W/|Medicare|MEDICARE ACUTE|||||1.23||| 94618|EAP|0460|PULMONARY STRESS TESTING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|United Medicare Advantage|UHC AARP MCR HMO MA|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|Access Direct Platinum|HEALTHFIRST TPA UMR|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|Veterans Affairs|VETERANS ADMINISTRATION|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TEST/SIM|Humana Medicare Advantage|HUMANA MA|||||1.06||| 94618|EAP|0460|PULMONARY STRESS TESTING|Humana Medicare Advantage|HUMANA MA|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|Blue Cross PPO Specialty|BCBSTX PPO|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|Blue Cross PPO Specialty|BCBSTX OTHER|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|Blue Cross HMO Specialty|BCBSTX HMO|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|Aenta Medicare Advantage|AETNA MEDICARE MA|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|United Healthcare|GEHA|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TESTING|NON CONTRACTED|COMMERCIAL OTHER 1|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TEST/SIM|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.06||| 94618|EAP|0460|PULMONARY STRESS TEST/SIM|Medicare|UTSW MC KIDNEY PROGRAM|||||116.60||| 94618|EAP|0460|PULMONARY STRESS TESTING|Managed Medicare|HEALTHSPRING MA|||||119.17||| 94618|EAP|0460|PULMONARY STRESS TEST/SIM|Managed Medicare|BCBS MEDICARE PPO MA|||||1.06||| 94618|EAP|0460|PULMONARY STRESS TEST/SIM|Medicare|MEDICARE ACUTE|1.06||||1.06||| 94618|EAP|0460|PULMONARY STRESS TESTING|Medicare|MEDICARE ACUTE|1.06||||119.17||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Medicaid|MEDICAID|||||6.36||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Managed Medicare|HEALTHSPRING MA|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Medicare|MEDICARE ACUTE|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|United Healthcare|UNITED HEALTHCARE OTHER|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|United Healthcare|UNITED HEALTHCARE|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|United Healthcare|UNITED HEALTHCARE|5.30||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Aenta Medicare Advantage|AETNA MEDICARE MA|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|NON CONTRACTED|COMMERCIAL OTHER 1|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.30||||6.36||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Blue Cross HMO Specialty|BCBSTX HMO|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Blue Cross PPO Specialty|BCBSTX PPO|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.30||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Humana Medicare Advantage|HUMANA MA|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Access Direct Platinum|HEALTHFIRST TPA UMR|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.30||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|United Medicare Advantage|UHC MEDICARE GOLD MA|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.30||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|United Medicare Advantage|UHC AARP MCR HMO MA|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Veterans Affairs|VETERANS ADMINISTRATION|6.36||||||| 94621|EAP|0460|EXERCISE W/ O2 SAT & VITA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.36||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Medicare Advantage|UHC MEDICARE GOLD MA|457.70||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Medicare Advantage|UHC MEDICARE GOLD MA|11.90||||457.70||| 94640|EAP|0410|EZPAP THERAPY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|180.50||||180.50||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Medicare Advantage|UHC AARP MCR HMO MA|457.70||||457.70||| 94640|EAP|0410|EZPAP THERAPY|United Medicare Advantage|UHC AARP WELLMED HMO MA|180.50||||457.70||| 94640|EAP|0410|AEROMED THERAPY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|457.70||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.90||||3.98||| 94640|EAP|0410|AEROMED THERAPY|United Medicare Advantage|UHC MEDICARE GOLD MA|3.98||||3.98||| 94640|EAP|0410|AEROMED THERAPY|United Medicare Advantage|UHC AARP WELLMED HMO MA|457.70||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|457.70||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Access Direct Platinum|HEALTHFIRST TPA UMR|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|180.50||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|457.70||||3.98||| 94640|EAP|0410|AEROMED THERAPY|United Medicare Advantage|UHC AARP MCR HMO MA|457.70||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Access Direct Platinum|HEALTHFIRST TPA UMR|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Workers Compensation|BROOKSHIRES WORKERS COMP|3.98||||||| 94640|EAP|0410|EZPAP THERAPY|Workers Compensation|WORKERS COMPENSATION OTHER|180.50||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Workers Compensation|TEXAS MUTUAL INSURANCE|3.98||||||| 94640|EAP|0410|AEROMED THERAPY|Workers Compensation|WORKERS COMPENSATION OTHER|457.70||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Workers Compensation|TRAVELERS INSURANCE COMPANY|3.98||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Workers Compensation|TEXAS MUTUAL INSURANCE|3.98||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Veterans Affairs|VETERANS ADMINISTRATION|457.70||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Workers Compensation|WORKERS COMPENSATION OTHER|457.70||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Workers Compensation|TRAVELERS INSURANCE COMPANY|3.98||||||| 94640|EAP|0410|AEROMED THERAPY|Workers Compensation|UT EMPLOYEE INJURY|457.70||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Veterans Affairs|VETERANS ADMINISTRATION|180.50||||3.98||| 94640|EAP|0410|HHN TREATMENT|Veterans Affairs|VETERANS ADMINISTRATION|11.90||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Cigna|CIGNA OTHER|457.70||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Cigna|CIGNA|427.85||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Cigna|CIGNA|180.50||||457.70||| 94640|EAP|0410|EZPAP THERAPY|Cigna|CIGNA|180.50||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|ChampVA|CHAMPVA CENTER|457.70||||||| 94640|EAP|0410|AEROMED THERAPY|Cigna|CIGNA|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Cigna|CIGNA|3.98||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Cigna|CIGNA OTHER|457.70||||||| 94640|EAP|0410|EZPAP THERAPY|Humana Medicare Advantage|HUMANA MA|180.50||||180.50||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Humana Medicare Advantage|HUMANA MA|11.90||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Humana Medicare Advantage|HUMANA MA|457.70||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicaid|MEDICAID SUPERIOR|180.50||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicaid|MEDICAID AMERIGROUP|457.70||||457.70||| 94640|EAP|0410|HHN TREATMENT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|457.70||||11.90||| 94640|EAP|0410|HHN TREATMENT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.90||||457.70||| 94640|EAP|0410|EZPAP THERAPY|Managed Medicaid|MEDICAID AMERIGROUP|180.50||||180.50||| 94640|EAP|0410|AEROMED THERAPY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|457.70||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Managed Medicaid|MEDICAID SUPERIOR|457.70||||3.98||| 94640|EAP|0410|EZPAP THERAPY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.50||||180.50||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicaid|MEDICAID UNITED HEALTHCARE|457.70||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Blue Cross PPO Specialty|BCBSTX PPO|457.70||||3.98||| 94640|EAP|0410|EZPAP THERAPY|Blue Cross PPO Specialty|BCBSTX PPO|180.50||||180.50||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Blue Cross PPO Specialty|BCBSTX OTHER|457.70||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Blue Cross PPO Specialty|BCBSTX PPO|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|457.70||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Blue Cross PPO Specialty|BCBSTX PPO|11.90||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|180.50||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|457.70||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Brinson Benefits|THE HEALTH PLAN SMITH CO|180.50||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Brinson Benefits|THE HEALTH PLAN SMITH CO|457.70||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Blue Cross HMO Specialty|BCBSTX HMO|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Blue Cross HMO Specialty|BCBSTX HMO|180.50||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Blue Cross HMO Specialty|BCBSTX HMO|457.70||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.98||||457.70||| 94640|EAP|0410|HHN TREATMENT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.90||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Aetna|AETNA OTHER|3.98||||||| 94640|EAP|0410|HHN TREATMENT|Aetna|AETNA PPO|11.90||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Aetna|AETNA PPO|3.98||||427.85||| 94640|EAP|0410|AEROMED THERAPY|Aetna|AETNA OTHER|457.70||||||| 94640|EAP|0410|AEROMED THERAPY|Aetna|BOON CHAPMAN|457.70||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Aenta Medicare Advantage|AETNA MEDICARE MA|457.70||||427.85||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Aenta Medicare Advantage|AETNA MEDICARE MA|180.50||||427.85||| 94640|EAP|0410|AEROMED THERAPY|Aenta Medicare Advantage|AETNA MEDICARE MA|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Aetna|AETNA PPO|457.70||||457.70||| 94640|EAP|0410|EZPAP THERAPY|Aetna|AETNA QHP HMO|180.50||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Aetna|AETNA PPO|180.50||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Aetna|AETNA QHP HMO|457.70||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Tricare|TRICARE EAST REGION|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Tricare|TRICARE EAST REGION|180.50||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|UTMB|UTMB CORRECTIONAL MANAGED CARE|457.70||||427.85||| 94640|EAP|0410|AEROMED THERAPY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.98||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Tricare|TRICARE EAST REGION|3.98||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|UTMB|UTMB CORRECTIONAL MANAGED CARE|180.50||||427.85||| 94640|EAP|0410|AEROMED THERAPY|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|180.50||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Blue Cross PPO Specialty|BCBSTX OTHER|457.70||||457.70||| 94640|EAP|0410|AEROMED THERAPY|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.98||||457.70||| 94640|EAP|0410|EZPAP THERAPY|Blue Cross PPO Specialty|BCBSTX OTHER|180.50||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Managed Medicaid|MEDICAID AMERIGROUP|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Healthcare|UNITED HEALTHCARE OTHER|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Aetna|BOON CHAPMAN|3.98||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.50||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Healthcare|UNITED HEALTHCARE OTHER|180.50||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Healthcare|UNITED HEALTHCARE|457.70||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Healthcare|UNITED HEALTHCARE|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Healthcare|TML GROUP BENEFITS|457.70||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Healthcare|GEHA|427.85||||||| 94640|EAP|0410|AEROMED THERAPY|United Healthcare|UNITED HEALTHCARE OTHER|457.70||||3.98||| 94640|EAP|0410|AEROMED THERAPY|United Healthcare|UNITED HEALTHCARE|457.70||||3.98||| 94640|EAP|0410|AEROMED THERAPY|United Healthcare|UNITED HEALTHCARE|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|NON CONTRACTED|COMMERCIAL OTHER 1|457.70||||3.98||| 94640|EAP|0410|AEROMED THERAPY|NON CONTRACTED|COMMERCIAL OTHER 2|457.70||||||| 94640|EAP|0410|AEROMED THERAPY|NON CONTRACTED|COMMERCIAL OTHER 1|457.70||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|NON CONTRACTED|COMMERCIAL OTHER 1|180.50||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|NON CONTRACTED|COMMERCIAL OTHER 2|457.70||||||| 94640|EAP|0410|EZPAP THERAPY|Cigna|CIGNA OTHER|180.50||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicaid|MEDICAID SUPERIOR|3.98||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Rusk State Hospital|RUSK STATE HOSP|457.70||||||| 94640|EAP|0410|EZPAP THERAPY|United Healthcare|UNITED HEALTHCARE|180.50||||180.50||| 94640|EAP|0410|AEROMED THERAPY|Texas Workforce Commission|DIS DETER SERV (DDS)|||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Humana Medicare Advantage|HUMANA MA|3.98||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Cigna|CIGNA|457.70||||457.70||| 94640|EAP|0410|AEROMED THERAPY|ChampVA|CHAMPVA CENTER|457.70||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Healthcare|TML GROUP BENEFITS|427.85||||3.98||| 94640|EAP|0410|AEROMED THERAPY|PHCS|HUMANA|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|PHCS|GROUP AND PENSION|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicare|MEDICARE PART B ONLY IP|3.98||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicare|MEDICARE ACUTE|11.90||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicare|MEDICARE ACUTE|457.70||||457.70||| 94640|EAP|0410|EZPAP THERAPY|Medicare|MEDICARE PART B ONLY IP|180.50||||||| 94640|EAP|0410|AEROMED THERAPY|Veterans Affairs|VETERANS ADMINISTRATION|457.70||||3.98||| 94640|EAP|0410|AIRWAY INHALATION TREATME|Medicare|MEDICARE ACUTE|180.50||||214.17||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|PHCS|HUMANA|457.70||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Medicare|UTSW MC KIDNEY PROGRAM|||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|457.70||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Medicare|MEDICARE PART B ONLY IP|3.98||||||| 94640|EAP|0410|AEROMED THERAPY|United Healthcare|AARP|3.98||||||| 94640|EAP|0410|AEROMED THERAPY|Medicare|MEDICARE ACUTE|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicare|HEALTHSPRING MA|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|180.50||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Workers Compensation|UT EMPLOYEE INJURY|457.70||||||| 94640|EAP|0410|AEROMED THERAPY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.98||||3.98||| 94640|EAP|0410|HHN TREATMENT|Managed Medicare|HEALTHSPRING MA|180.50||||11.90||| 94640|EAP|0410|AEROMED THERAPY|Managed Medicare|OTHER INSTITUTIONS|||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Managed Medicare|HEALTHSPRING MA|3.98||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Access Direct Platinum|HEALTHFIRST TPA|3.98||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicaid|SUPERIOR HEALTHPLAN CHIP|457.70||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Access Direct Platinum|HEALTHFIRST TPA|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.98||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicare|HEALTHSPRING MA|11.90||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Managed Medicare|BCBS MEDICARE PPO MA|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicaid|MEDICAID HMO|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|180.50||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicaid|MEDICAID|180.50||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.98||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Managed Medicare|WELLCARE CHOICE MA|457.70||||||| 94640|EAP|0410|EZPAP THERAPY|Medicaid|SMITH COUNTY INDIGENT HEALTH|180.50||||||| 94640|EAP|0410|EZPAP THERAPY|Medicaid|COUNTY INDIGENT HEALTH OTHER|180.50||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Medicare Advantage|UHC AARP WELLMED HMO MA|457.70||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Medicare Advantage|UHC AARP MCR HMO MA|180.50||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Medicaid|SMITH COUNTY JAIL|3.98||||3.98||| 94640|EAP|0410|EZPAP THERAPY|PHCS|HUMANA|180.50||||457.70||| 94640|EAP|0410|AEROMED THERAPY|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.98||||||| 94640|EAP|0410|AEROMED THERAPY|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.98||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Medicaid|MEDICAID|3.98||||427.85||| 94640|EAP|0410|EZPAP THERAPY|United Medicare Advantage|UHC MEDICARE GOLD MA|180.50||||180.50||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|457.70||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicaid|SMITH COUNTY JAIL|180.50||||3.98||| 94640|EAP|0410|HHN TREATMENT|Medicaid|MEDICAID|11.90||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicare|BCBS MEDICARE PPO MA|457.70||||3.98||| 94640|EAP|0410|EZPAP THERAPY|Medicaid|CRIME VICTIMS COMPENSATION|180.50||||||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicaid|MEDICAID|3.98||||457.70||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicaid|MOLINA HEALTHCARE OF TEXAS|457.70||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Medicaid|MEDICAID HMO|457.70||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Medicaid|CRIME VICTIMS COMPENSATION|457.70||||||| 94640|EAP|0410|AEROMED THERAPY|Medicaid|SUPERIOR HEALTHPLAN CHIP|3.98||||3.98||| 94640|EAP|0410|INCENTIVE SPIROMETRY TX|Managed Medicare|BCBS MEDICARE PPO MA|180.50||||3.98||| 94640|EAP|0410|AEROMED THERAPY|Medicaid|CRIME VICTIMS COMPENSATION|3.98||||||| 94640|EAP|0410|AEROMED THERAPY|Medicaid|LAW ENFORCEMENT OTHER|457.70||||3.98||| 94642|EAP|0410|PENTAMIDINE TX|Managed Medicare|HEALTHSPRING MA|763.60||||||| 94642|EAP|0410|PENTAMIDINE TX|Medicare|MEDICARE ACUTE|||||6.64||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Aetna|AETNA OTHER|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Aetna|BOON CHAPMAN|51.03||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Aetna|AETNA PPO|41.62||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Aenta Medicare Advantage|AETNA MEDICARE MA|41.62||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Blue Cross PPO Specialty|BCBSTX OTHER|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Blue Cross PPO Specialty|BCBSTX OTHER|51.03||||41.62||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Aetna|AETNA OTHER|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|51.03||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Managed Medicaid|MEDICAID SUPERIOR|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Managed Medicaid|MEDICAID AMERIGROUP|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicaid|MEDICAID SUPERIOR|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Humana Medicare Advantage|HUMANA MA|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Humana Medicare Advantage|HUMANA MA|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Cigna|CIGNA|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Cigna|CIGNA|51.03||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Workers Compensation|WORKERS COMPENSATION OTHER|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Workers Compensation|WORKERS COMPENSATION OTHER|51.03||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Veterans Affairs|VETERANS ADMINISTRATION|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Veterans Affairs|VETERANS ADMINISTRATION|51.03||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Access Direct Platinum|HEALTHFIRST TPA UMR|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Brinson Benefits|THE HEALTH PLAN SMITH CO|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Access Direct Platinum|HEALTHFIRST TPA UMR|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Access Direct Platinum|HEALTHFIRST TPA|51.03||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|United Medicare Advantage|UHC AARP MCR HMO MA|41.62||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|United Medicare Advantage|UHC AARP WELLMED HMO MA|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Blue Cross PPO Specialty|BCBSTX PPO|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Blue Cross HMO Specialty|BCBSTX HMO|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|United Medicare Advantage|UHC AARP MCR HMO MA|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|United Medicare Advantage|UHC AARP WELLMED HMO MA|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Aetna|BOON CHAPMAN|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Blue Cross HMO Specialty|BCBSTX HMO|41.62||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Blue Cross PPO Specialty|BCBSTX PPO|41.62||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|51.03||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Brinson Benefits|THE HEALTH PLAN SMITH CO|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Access Direct Platinum|HEALTHFIRST TPA|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|United Medicare Advantage|UHC MEDICARE GOLD MA|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|United Medicare Advantage|UHC MEDICARE GOLD MA|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|United Healthcare|UNITED HEALTHCARE OTHER|41.62||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Aetna|AETNA QHP HMO|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|United Healthcare|UNITED HEALTHCARE|41.62||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|United Healthcare|UNITED HEALTHCARE|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|United Healthcare|UNITED HEALTHCARE OTHER|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|United Healthcare|UNITED HEALTHCARE|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Aetna|AETNA PPO|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|United Healthcare|UNITED HEALTHCARE|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|United Healthcare|TML GROUP BENEFITS|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Tricare|TRICARE FOR LIFE|||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Tricare|TRICARE EAST REGION|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Tricare|TRICARE EAST REGION|41.62||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|UTMB|UTMB CORRECTIONAL MANAGED CARE|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|UTMB|UTMB CORRECTIONAL MANAGED CARE|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Aenta Medicare Advantage|AETNA MEDICARE MA|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|PHCS|HUMANA|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|PHCS|GROUP AND PENSION|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|PHCS|GROUP AND PENSION|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|PHCS|HUMANA|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|NON CONTRACTED|COMMERCIAL OTHER 1|41.62||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|NON CONTRACTED|COMMERCIAL OTHER 1|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Rusk State Hospital|RUSK STATE HOSP|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Medicare|MEDICARE PART B ONLY IP|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Medicare|MEDICARE ACUTE|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Medicare|MEDICARE PART B ONLY IP|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Medicare|MEDICARE ACUTE|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Multiplan|WEB TPA|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Medicaid|MEDICAID|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicaid|MEDICAID AMERIGROUP|51.03||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Medicaid|COUNTY INDIGENT HEALTH OTHER|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Medicaid|SMITH COUNTY INDIGENT HEALTH|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Medicaid|SMITH COUNTY JAIL|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Medicaid|CRIME VICTIMS COMPENSATION|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Medicaid|SMITH COUNTY INDIGENT HEALTH|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Medicaid|COUNTY INDIGENT HEALTH OTHER|51.03||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Medicaid|CRIME VICTIMS COMPENSATION|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Medicaid|SMITH COUNTY JAIL|41.62||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicare|HOSPICE OF EAST TEXAS|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Medicaid|MEDICAID|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicare|HEALTHSPRING MA|51.03||||51.03||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Managed Medicare|HOSPICE OF EAST TEXAS|41.62||||||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Managed Medicare|HEALTHSPRING MA|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP SUBSEQ DAY|Managed Medicare|BCBS MEDICARE PPO MA|41.62||||41.62||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicare|OTHER INSTITUTIONS|||||51.03||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicare|WELLCARE CHOICE MA|51.03||||||| 94660|EAP|0410|CPAP/BIPAP FIRST DAY|Managed Medicare|BCBS MEDICARE PPO MA|51.03||||51.03||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|PHCS|HUMANA INSURANCE|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Medicare|MEDICARE ACUTE|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|United Healthcare|UNITED HEALTHCARE OTHER|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|United Medicare Advantage|UHC AARP MCR HMO MA|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|United Healthcare|UNITED HEALTHCARE|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Managed Medicare|HEALTHSPRING MA|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.14||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Veterans Affairs|VETERANS ADMINISTRATION|||||364.09||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Cigna|CIGNA|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Humana Medicare Advantage|HUMANA MA|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Managed Medicare|BCBS MEDICARE PPO MA|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Blue Cross HMO Specialty|BCBSTX HMO|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Blue Cross PPO Specialty|BCBSTX OTHER|||||214.17||| 94664|EAP|0410|EVALUATE PT USE OF INHALE|Blue Cross PPO Specialty|BCBSTX PPO|||||214.17||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Managed Medicaid|MEDICAID SUPERIOR|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Blue Cross PPO Specialty|BCBSTX PPO|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Humana Medicare Advantage|HUMANA MA|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Cigna|CIGNA|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Managed Medicaid|MEDICAID AMERIGROUP|3.46||||3.46||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Workers Compensation|TEXAS MUTUAL INSURANCE|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Veterans Affairs|VETERANS ADMINISTRATION|397.90||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Aenta Medicare Advantage|AETNA MEDICARE MA|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|United Medicare Advantage|UHC AARP WELLMED HMO MA|397.90||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|United Medicare Advantage|UHC AARP MCR HMO MA|397.90||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|United Medicare Advantage|UHC MEDICARE GOLD MA|397.90||||3.46||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|397.90||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Tricare|TRICARE EAST REGION|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|UTMB|UTMB CORRECTIONAL MANAGED CARE|397.90||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|United Healthcare|UNITED HEALTHCARE OTHER|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|United Healthcare|UNITED HEALTHCARE|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|NON CONTRACTED|COMMERCIAL OTHER 1|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|NON CONTRACTED|COMMERCIAL OTHER 2|397.90||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Medicare|MEDICARE ACUTE|3.46||||3.46||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Medicaid|MEDICAID HMO|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Medicaid|CRIME VICTIMS COMPENSATION|397.90||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Medicaid|MEDICAID|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Managed Medicare|BCBS MEDICARE PPO MA|3.46||||||| 94667|EAP|0410|CHEST PHYSIOTHERAPY|Managed Medicare|HEALTHSPRING MA|397.90||||||| 947|DRG||SIGNS & SYMPTOMS W MCC|Medicare|MEDICARE PART B ONLY IP|32,869.97|908.59|7825.79|160.74|||| 947|DRG||SIGNS & SYMPTOMS W MCC|Medicare|MEDICARE ACUTE|32,668.99|7825.79|7825.79|160.74|||| 947|DRG||SIGNS & SYMPTOMS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|69,685.68|160.74|7825.79|160.74|||| 947|DRG||SIGNS & SYMPTOMS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|69,214.02|6958.72|7825.79|160.74|||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|United Medicare Advantage|UHC MEDICARE GOLD MA|||||622.80||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|United Medicare Advantage|UHC AARP MCR HMO MA|622.80||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Access Direct Platinum|HEALTHFIRST TPA|||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Workers Compensation|WORKERS COMPENSATION OTHER|||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Veterans Affairs|VETERANS ADMINISTRATION|570.90||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Cigna|CIGNA OTHER|||||479.54||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Humana Medicare Advantage|HUMANA MA|6.77||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Managed Medicaid|MEDICAID SUPERIOR|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|622.80||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Blue Cross HMO Specialty|BCBSTX HMO|||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Blue Cross HMO Specialty|BCBSTX HMO|||||570.90||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Blue Cross PPO Specialty|BCBSTX OTHER|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Managed Medicaid|MEDICAID AMERIGROUP|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Blue Cross PPO Specialty|BCBSTX PPO|||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Blue Cross PPO Specialty|BCBSTX PPO|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|570.90||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Aenta Medicare Advantage|AETNA MEDICARE MA|570.90||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Managed Medicaid|MEDICAID AMERIGROUP|||||5.19||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Humana Medicare Advantage|HUMANA MA|570.90||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Aetna|AETNA PPO|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Aetna|BOON CHAPMAN|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Aetna|AETNA OTHER|||||479.54||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Aetna Value Network|AETNA VALUE NETWORK|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.19||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Cigna|CIGNA|||||479.54||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Veterans Affairs|VETERANS ADMINISTRATION|282.08||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.19||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Medicare|MEDICARE ACUTE|282.08||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Medicare|UTSW MC KIDNEY PROGRAM|||||570.90||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Medicare|MEDICARE ACUTE|5.19||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|PHCS|HUMANA INSURANCE|||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|PHCS|HUMANA|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|NON CONTRACTED|COMMERCIAL OTHER 1|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|United Healthcare|UNITED HEALTHCARE|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|United Healthcare|GEHA|||||479.54||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|United Healthcare|UNITED HEALTHCARE OTHER|||||5.19||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Tricare|TRICARE EAST REGION|5.19||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|622.80||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|United Medicare Advantage|UHC AARP MCR HMO MA|622.80||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||5.19||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|United Healthcare|GOLDEN RULE|||||282.08||| 94726|EAP|0460|PFT THORACIC GAS VOLUME|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||622.80||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|United Healthcare|UNITED HEALTHCARE OTHER|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Managed Medicare|BCBS MEDICARE PPO MA|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Managed Medicare|HEALTHSPRING MA|282.08||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Managed Medicare|HEALTHSPRING MA|570.90||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Medicaid|MEDICAID|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Medicaid|SMITH COUNTY JAIL|||||6.77||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||282.08||| 94726|EAP|0460|PULM FUNCT TST PLETHYSMOG|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||282.08||| 94727|EAP|0460|PULM FUNCTION TEST BY GAS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.65||| 94727|EAP|0460|PULM FUNCTION TEST BY GAS|Managed Medicare|HEALTHSPRING MA|||||3.65||| 94727|EAP|0460|PULM FUNCTION TEST BY GAS|United Healthcare|UNITED HEALTHCARE OTHER|||||152.08||| 94727|EAP|0460|PULM FUNCTION TEST BY GAS|United Healthcare|UNITED HEALTHCARE|||||152.08||| 94727|EAP|0460|PULM FUNCTION TEST BY GAS|Medicare|MEDICARE ACUTE|||||152.08||| 94727|EAP|0460|PULM FUNCTION TEST BY GAS|Blue Cross PPO Specialty|BCBSTX PPO|||||152.08||| 94727|EAP|0460|PULM FUNCTION TEST BY GAS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||152.08||| 94727|EAP|0460|PULM FUNCTION TEST BY GAS|Humana Medicare Advantage|HUMANA MA|||||152.08||| 94727|EAP|0460|PULM FUNCTION TEST BY GAS|Cigna|CIGNA|||||3.65||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Workers Compensation|WORKERS COMPENSATION OTHER|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Veterans Affairs|VETERANS ADMINISTRATION|9.06||||7.55||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.06||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.06||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.06||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Access Direct Platinum|HEALTHFIRST TPA|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|United Medicare Advantage|UHC AARP MCR HMO MA|9.06||||9.06||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|United Medicare Advantage|UHC MEDICARE GOLD MA|7.55||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.06||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Cigna|CIGNA OTHER|||||534.79||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Cigna|CIGNA|||||7.55||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Cigna|CIGNA|||||534.79||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|ChampVA|CHAMPVA CENTER|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Humana Medicare Advantage|HUMANA MA|830.50||||7.55||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|United Medicare Advantage|UHC AARP MCR HMO MA|9.06||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|830.50||||9.06||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Managed Medicaid|MEDICAID SUPERIOR|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Managed Medicaid|MEDICAID AMERIGROUP|||||7.55||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Managed Medicaid|MEDICAID AMERIGROUP|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.06||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Aetna Value Network|AETNA VALUE NETWORK|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Aetna|BOON CHAPMAN|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Aetna|AETNA PPO|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Blue Cross HMO Specialty|BCBSTX HMO|||||830.50||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Blue Cross HMO Specialty|BCBSTX HMO|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||534.79||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Blue Cross PPO Specialty|BCBSTX PPO|||||9.06||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Blue Cross PPO Specialty|BCBSTX PPO|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|830.50||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Blue Cross PPO Specialty|BCBSTX OTHER|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.55||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Humana Medicare Advantage|HUMANA MA|7.55||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.55||||7.55||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.06||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|PHCS|HUMANA INSURANCE|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Cigna|CIGNA|||||9.06||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|PHCS|HUMANA|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Texas Workforce Commission|DIS DETER SERV (DDS)|||||7.55||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Aetna|AETNA OTHER|||||534.79||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|NON CONTRACTED|COMMERCIAL OTHER 1|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Medicare|UTSW MC KIDNEY PROGRAM|||||9.06||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Medicare|MEDICARE ACUTE|830.50||||9.06||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Aenta Medicare Advantage|AETNA MEDICARE MA|830.50||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Medicare|MEDICARE ACUTE|314.58||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|United Medicare Advantage|UHC MEDICARE GOLD MA|7.55||||830.50||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Tricare|TRICARE EAST REGION|7.55||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Aenta Medicare Advantage|AETNA MEDICARE MA|830.50||||7.55||| 94729|EAP|0460|PFT EXP GAS COLLECTION|United Healthcare|UNITED HEALTHCARE OTHER|||||7.55||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|United Healthcare|UNITED HEALTHCARE|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|United Healthcare|GOLDEN RULE|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Veterans Affairs|VETERANS ADMINISTRATION|314.58||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.06||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Medicaid|SMITH COUNTY JAIL|||||7.55||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Managed Medicare|HEALTHSPRING MA|314.58||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Managed Medicare|BCBS MEDICARE PPO MA|||||7.55||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Managed Medicare|HEALTHSPRING MA|9.06||||7.55||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|United Healthcare|GEHA|||||534.79||| 94729|EAP|0460|PFT EXP GAS COLLECTION|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||7.55||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|United Healthcare|UNITED HEALTHCARE OTHER|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Managed Medicare|BCBS MEDICARE PPO MA|||||314.58||| 94729|EAP|0460|CO/MEMBANE DIFFUSE CAPACI|Medicaid|MEDICAID|||||314.58||| 94729|EAP|0460|PFT EXP GAS COLLECTION|United Healthcare|UNITED HEALTHCARE|||||9.06||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|Managed Medicare|HEALTHSPRING MA|1,799.60||||||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,963.20||||||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|Medicare|MEDICARE ACUTE|16.36||||||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|Blue Cross PPO Specialty|BCBSTX PPO|1,963.20||||||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|Aenta Medicare Advantage|AETNA MEDICARE MA|16.36||||||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,963.20||||||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,799.60||||||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|Humana Medicare Advantage|HUMANA MA|1,963.20||||||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|United Medicare Advantage|UHC MEDICARE GOLD MA|1,963.20||||||| 94762|EAP|0460|PULSE OX OVERNIGHT REC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,963.20||||||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|58,416.75|7206.36|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35,494.49|7202.18|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|40,435.52|5605.29|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Humana Medicare Advantage|HUMANA MA|71,148.96|5145.505|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|97,170.02|5262.19|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16,624.85|5262.19|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16,722.75|55.61|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Managed Medicare|HEALTHSPRING MA|48,231.12|8022.08|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|428.53|35.72|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Aetna|AETNA OTHER|23,176.90|10059.18|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|45,254.75|5297.56|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|49,593.15|5649.58|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Medicare|MEDICARE PART B ONLY IP|33,038.75|5533.72|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Medicare|MEDICARE ACUTE|52,462.32|5561.44|10059.18|35.72|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Medicaid|MEDICAID|20,595.25|3309.55|10059.18|35.72|||| 949|DRG||AFTERCARE W CC/MCC|Medicare|MEDICARE ACUTE|51,337.62|7230.97|7230.97|7230.97|||| 949|DRG||AFTERCARE W CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|14,241.50|7230.97|7230.97|7230.97|||| 95|DRG||BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC|Managed Medicare|HEALTHSPRING MA|88,150.05|14768.61|28490.44|14492.52|||| 95|DRG||BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC|United Healthcare|UNITED HEALTHCARE|93,858.56|28490.44|28490.44|14492.52|||| 95|DRG||BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC|Medicare|MEDICARE ACUTE|114,917.72|14492.52|28490.44|14492.52|||| 950|DRG||AFTERCARE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|121.58|5057.87|5057.87|5057.87|||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Medicaid|MEDICAID HMO|||||11.75||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Medicaid|MEDICAID|||||11.75||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|United Healthcare|UNITED HEALTHCARE|||||11.75||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.75||||11.75||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.75||||||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Managed Medicaid|MEDICAID AMERIGROUP|||||11.75||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Managed Medicaid|MEDICAID SUPERIOR|11.75||||11.75||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Managed Medicare|HEALTHSPRING MA|11.75||||||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Blue Cross HMO Specialty|BCBSTX HMO|11.75||||11.75||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Blue Cross PPO Specialty|BCBSTX PPO|||||11.75||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Blue Cross PPO Specialty|BCBSTX OTHER|11.75||||||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.75||||||| 9500067|ERX|0250|HALOPERIDOL CONC 2MG/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19.25||||||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|Medicaid|BH TEXAS CHILDRENS MEDICAID|9.25||||9.25||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|Medicaid|MEDICAID|9.25||||||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|9.25||||||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|Managed Medicaid|MEDICAID SUPERIOR|9.25||||||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9500117|ERX|0250|METOCLOPRAMIDE 5MG/5ML, 1|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicare|JACKSONVILLE ACCESS|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Cigna|CIGNA|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Cigna|CIGNA OTHER|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Humana Medicare Advantage|HUMANA MA|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Aetna|BH AETNA|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Aetna|AETNA OTHER|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Aetna|AETNA QHP HMO|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID SUPERIOR|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Aetna|AETNA PPO|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross HMO Specialty|BCBSTX HMO|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Cigna Behavioral Health|BH CIGNA|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|ChampVA|CHAMPVA CENTER|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Veterans Affairs|VETERANS ADMINISTRATION|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross PPO Specialty|BCBSTX OTHER|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Access Direct Platinum|HEALTHFIRST TPA|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Access Direct Platinum|ANDREWS CENTER|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Aetna|BOON CHAPMAN|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Workers Compensation|WORKERS COMPENSATION OTHER|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Magellan Behavioral Health|BH MAGELLAN|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicaid|MEDICAID|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicare|HEALTHSPRING MA|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicare|MEDICARE ACUTE|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID AMERIGROUP|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicare|MEDICARE PART B ONLY IP|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Tricare|TRICARE EAST REGION|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicare|BCBS MEDICARE PPO MA|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Optum Behavioral Health|BH OPTUM UHC|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|PHCS|HUMANA|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|NON CONTRACTED|COMMUNITY HEALTH CENTER|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Multiplan|WEB TPA|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|NON CONTRACTED|COMMERCIAL OTHER 1|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Healthcare|UNITED HEALTHCARE OTHER|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Healthcare|UNITED HEALTHCARE|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Healthcare|UNITED HEALTHCARE|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|11.50||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Medicare Advantage|UHC AARP MCR HMO MA|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||11.50||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.50||||11.50||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||9.25||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Access Direct Platinum|HEALTHFIRST TPA|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Blue Cross PPO Specialty|BCBSTX OTHER|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Cigna|CIGNA|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|9.25||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Medicaid|MEDICAID|9.25||||||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||60.25||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|Humana Medicare Advantage|HUMANA MA|||||60.25||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|60.25||||||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|60.25||||||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|||||60.25||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|60.25||||||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|60.25||||||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|Medicare|MEDICARE ACUTE|60.25||||60.25||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|Medicaid|MEDICAID|60.25||||||| 9500174|ERX|0250|GLYCERIN SUPP|Medicare|MEDICARE ACUTE|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|United Healthcare|UNITED HEALTHCARE|||||2.50||| 9500174|ERX|0250|GLYCERIN SUPP|Medicaid|MEDICAID|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Humana Medicare Advantage|HUMANA MA|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Magellan Behavioral Health|BH MAGELLAN|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.75||||8.75||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Managed Medicaid|MEDICAID AMERIGROUP|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Cigna Behavioral Health|BH CIGNA|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Managed Medicare|JACKSONVILLE ACCESS|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Aetna|BH AETNA|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Blue Cross PPO Specialty|BCBSTX PPO|8.75||||8.75||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Veterans Affairs|VETERANS ADMINISTRATION|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Access Direct Platinum|HEALTHFIRST TPA UMR|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.75||||8.75||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Medicaid|MEDICAID HMO|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Medicaid|MEDICAID|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Medicare|MEDICARE ACUTE|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Multiplan|WEB TPA|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|NON CONTRACTED|COMMUNITY HEALTH CENTER|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|NON CONTRACTED|COMMERCIAL OTHER 1|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Tricare|TRICARE EAST REGION|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Medicaid|BH TEXAS CHILDRENS MEDICAID|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Access Direct Platinum|ANDREWS CENTER|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Optum Behavioral Health|BH OPTUM UHC|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|United Healthcare|UNITED HEALTHCARE OTHER|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|United Medicare Advantage|UHC AARP MCR HMO MA|8.75||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|United Medicare Advantage|UHC MEDICARE GOLD MA|8.75||||||| 9500281|ERX|0250|HYDROCORTISONE 20MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|4.75||||||| 9500281|ERX|0250|HYDROCORTISONE 20MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|4.75||||||| 9500281|ERX|0250|HYDROCORTISONE 20MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|4.75||||4.75||| 9500281|ERX|0250|HYDROCORTISONE 20MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.75||||||| 9500281|ERX|0250|HYDROCORTISONE 20MG TABLE|Humana Medicare Advantage|HUMANA MA|4.75||||4.75||| 9500281|ERX|0250|HYDROCORTISONE 20MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.75||||||| 9500281|ERX|0250|HYDROCORTISONE 20MG TABLE|Medicaid|MEDICAID|4.75||||||| 9500281|ERX|0250|HYDROCORTISONE 20MG TABLE|Medicare|MEDICARE ACUTE|4.75||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.09||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.09||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.09||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.09||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|Aetna|BH AETNA|0.09||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.09||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|Medicare|MEDICARE ACUTE|0.09||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|Multiplan|WEB TPA|0.09||||||| 9500299|ERX|0250|LITHIUM 450MG TABLET|United Healthcare|UNITED HEALTHCARE|||||0.09||| 9500307|ERX|0250|PROPYLTHIOURACIL 50MG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.03||||||| 9500307|ERX|0250|PROPYLTHIOURACIL 50MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||||| 9500315|ERX|0250|CODEINE-BUTALBIT-ACETAM-C|Medicaid|MEDICAID|19.25||||||| 9500315|ERX|0250|CODEINE-BUTALBIT-ACETAM-C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19.25||||||| 9500315|ERX|0250|CODEINE-BUTALBIT-ACETAM-C|Blue Cross PPO Specialty|BCBSTX PPO|19.25||||||| 9500315|ERX|0250|CODEINE-BUTALBIT-ACETAM-C|Medicare|MEDICARE ACUTE|19.25||||||| 9500323|ERX|0250|GLYBURIDE,MICRONIZED 3MG|Humana Medicare Advantage|HUMANA MA|||||9.25||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|United Healthcare|UNITED HEALTHCARE OTHER|||||87.50||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Medicare|MEDICARE ACUTE|87.50||||||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Medicaid|SMITH COUNTY INDIGENT HEALTH|87.50||||||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Veterans Affairs|VETERANS ADMINISTRATION|87.50||||||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|87.50||||||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Brinson Benefits|THE HEALTH PLAN SMITH CO|87.50||||||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Blue Cross PPO Specialty|BCBSTX PPO|87.50||||||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|87.50||||||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Managed Medicare|HEALTHSPRING MA|87.50||||||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|87.50||||||| 9500331|ERX|0250|MENTHOL-CAMPHOR LOTION,22|Humana Medicare Advantage|HUMANA MA|87.50||||87.50||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|851.25||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|851.25||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Humana Medicare Advantage|HUMANA MA|851.25||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|851.25||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|851.25||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Managed Medicare|HEALTHSPRING MA|851.25||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|ChampVA|CHAMPVA CENTER|851.25||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|851.25||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|851.25||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|851.25||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|851.25||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|851.25||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|United Healthcare|UNITED HEALTHCARE|||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|851.25||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|851.25||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|851.25||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Medicare|MEDICARE ACUTE|851.25||||851.25||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Medicaid|MEDICAID|851.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Tricare|TRICARE EAST REGION|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|PHCS|HUMANA|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|United Healthcare|UNITED HEALTHCARE OTHER|||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.25||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|United Medicare Advantage|UHC MEDICARE GOLD MA|28.25||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Medicaid|MEDICAID|28.25||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|United Medicare Advantage|UHC AARP MCR HMO MA|||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Medicare|MEDICARE ACUTE|28.25||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Medicaid|BH TEXAS CHILDRENS MEDICAID|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|United Medicare Advantage|UHC AARP WELLMED HMO MA|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Veterans Affairs|VETERANS ADMINISTRATION|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Multiplan|WEB TPA|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Workers Compensation|WORKERS COMPENSATION OTHER|||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|NON CONTRACTED|COMMERCIAL OTHER 1|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.25||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Blue Cross PPO Specialty|BCBSTX PPO|28.25||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicare|HEALTHSPRING MA|28.25||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|MEDICAID AMERIGROUP|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Humana Medicare Advantage|HUMANA MA|28.25||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Cigna|CIGNA OTHER|||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.25||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|MEDICAID SUPERIOR|||||28.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|28.25||||||| 9500372|ERX|0250|DANTROLENE 20MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|9.11||||||| 9500372|ERX|0250|DANTROLENE 20MG VIAL|Managed Medicare|HEALTHSPRING MA|9.11||||||| 9500372|ERX|0250|DANTROLENE 20MG VIAL|Medicare|MEDICARE ACUTE|9.11||||||| 9500380|ERX|0250|MESALAMINE 400MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||19.75||| 9500380|ERX|0250|MESALAMINE 400MG TABLET|United Healthcare|UNITED HEALTHCARE|19.75||||||| 9500380|ERX|0250|MESALAMINE 400MG TABLET|Medicare|MEDICARE ACUTE|19.75||||||| 9500380|ERX|0250|MESALAMINE 400MG TABLET|Medicare|MEDICARE PART B ONLY IP|19.75||||||| 9500380|ERX|0250|MESALAMINE 400MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|19.75||||||| 9500380|ERX|0250|MESALAMINE 400MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|19.75||||||| 9500380|ERX|0250|MESALAMINE 400MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.75||||||| 9500380|ERX|0250|MESALAMINE 400MG TABLET|Managed Medicare|HEALTHSPRING MA|19.75||||||| 9500380|ERX|0250|MESALAMINE 400MG TABLET|Humana Medicare Advantage|HUMANA MA|19.75||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicaid|MEDICAID SUPERIOR|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Cigna|CIGNA OTHER|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Aetna|AETNA QHP HMO|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Aetna|AETNA PPO|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Aetna|AETNA OTHER|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Aetna|BH AETNA|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|ChampVA|CHAMPVA CENTER|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Aetna Value Network|AETNA VALUE NETWORK|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross PPO Specialty|BCBSTX OTHER|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Workers Compensation|UT EMPLOYEE INJURY|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Access Direct Platinum|HEALTHFIRST TPA UMR|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Workers Compensation|WORKERS COMPENSATION OTHER|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Access Direct Platinum|HEALTHFIRST TPA|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|MEDICAID|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|SUPERIOR HEALTHPLAN CHIP|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|MEDICAID HMO|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|CRIME VICTIMS COMPENSATION|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|SMITH COUNTY JAIL|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Cigna|CIGNA|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Tricare|TRICARE EAST REGION|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Rusk State Hospital|RUSK STATE HOSP|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|PHCS|HUMANA|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Healthcare|UNITED HEALTHCARE|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Healthcare|GOLDEN RULE|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Healthcare|UNITED HEALTHCARE|5.25||||5.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Healthcare|GEHA|5.25||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|PHCS|GROUP AND PENSION|5.25||||||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Blue Cross PPO Specialty|BCBSTX PPO|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Aetna|AETNA PPO|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Managed Medicaid|MEDICAID SUPERIOR|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Managed Medicaid|MEDICAID AMERIGROUP|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Cigna|CIGNA OTHER|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Cigna|CIGNA|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Humana Medicare Advantage|HUMANA MA|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|United Healthcare|UNITED HEALTHCARE OTHER|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|United Healthcare|UNITED HEALTHCARE|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Tricare|TRICARE EAST REGION|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|NON CONTRACTED|COMMERCIAL OTHER 1|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Medicare|MEDICARE ACUTE|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Medicaid|MEDICAID|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|United Medicare Advantage|UHC AARP MCR HMO MA|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Blue Cross HMO Specialty|BCBSTX HMO|||||28.88||| 95004|EAP|0510|PERCUT ALLERGY SKIN TESTS|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||28.88||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.25||||44.25||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Humana Medicare Advantage|HUMANA MA|44.25||||44.25||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Managed Medicare|HEALTHSPRING MA|||||44.25||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44.25||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.25||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Blue Cross PPO Specialty|BCBSTX PPO|44.25||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Veterans Affairs|VETERANS ADMINISTRATION|44.25||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|44.25||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Aenta Medicare Advantage|AETNA MEDICARE MA|44.25||||44.25||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Medicare|MEDICARE ACUTE|44.25||||44.25||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|NON CONTRACTED|COMMERCIAL OTHER 1|44.25||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|United Healthcare|UNITED HEALTHCARE|44.25||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|UTMB|UTMB CORRECTIONAL MANAGED CARE|44.25||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|United Medicare Advantage|UHC MEDICARE GOLD MA|44.25||||44.25||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|United Medicare Advantage|UHC AARP MCR HMO MA|44.25||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||44.25||| 9500414|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|United Medicare Advantage|UHC AARP MCR HMO MA|||||44.25||| 9500414|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Medicare|MEDICARE ACUTE|44.25||||||| 9500414|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Blue Cross PPO Specialty|BCBSTX PPO|44.25||||44.25||| 9500414|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Managed Medicare|HEALTHSPRING MA|||||44.25||| 9500414|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Cigna|CIGNA|||||44.25||| 9500422|ERX|0250|NYSTATIN OINT, 15 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.37||||||| 9500422|ERX|0250|NYSTATIN OINT, 15 GM|Blue Cross PPO Specialty|BCBSTX PPO|0.37||||||| 9500422|ERX|0250|NYSTATIN OINT, 15 GM|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9500422|ERX|0250|NYSTATIN OINT, 15 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|0.37||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Texas Workforce Commission|DIS DETER SERV (DDS)|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Tricare|TRICARE EAST REGION|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|PHCS|HUMANA|35.50||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|NON CONTRACTED|COMMERCIAL OTHER 1|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|NON CONTRACTED|COMMERCIAL OTHER 2|35.50||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|United Healthcare|UNITED HEALTHCARE OTHER|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|United Healthcare|UNITED HEALTHCARE|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|UTMB|UTMB CORRECTIONAL MANAGED CARE|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|United Medicare Advantage|UHC AARP WELLMED HMO MA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicaid|MEDICAID HMO|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicaid|MEDICAID|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicaid|SUPERIOR HEALTHPLAN CHIP|35.50||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicaid|SMITH COUNTY JAIL|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicare|MEDICARE ACUTE|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicare|MEDICARE PART B ONLY IP|35.50||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Workers Compensation|UT EMPLOYEE INJURY|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Workers Compensation|TEXAS MUTUAL INSURANCE|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Workers Compensation|WORKERS COMPENSATION OTHER|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicaid|LAW ENFORCEMENT OTHER|35.50||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Workers Compensation|BROOKSHIRES WORKERS COMP|35.50||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicaid|CRIME VICTIMS COMPENSATION|35.50||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Access Direct Platinum|HEALTHFIRST TPA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|United Medicare Advantage|UHC AARP MCR HMO MA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Access Direct Platinum|HEALTHFIRST TPA UMR|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Veterans Affairs|VETERANS ADMINISTRATION|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Aetna|AETNA OTHER|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Aetna|AETNA PPO|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Blue Cross HMO Specialty|BCBSTX HMO|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|NON CONTRACTED|COMMERCIAL OTHER 4|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Brinson Benefits|THE HEALTH PLAN SMITH CO|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Blue Cross PPO Specialty|BCBSTX PPO|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicare|BCBS MEDICARE PPO MA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicare|HEALTHSPRING MA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Cigna|CIGNA OTHER|||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Cigna|CIGNA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Humana Medicare Advantage|HUMANA MA|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicaid|MEDICAID AMERIGROUP|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicaid|MEDICAID SUPERIOR|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35.50||||35.50||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|35.50||||35.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Magellan Behavioral Health|BH MAGELLAN|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|MEDICAID AMERIGROUP|||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|MEDICAID SUPERIOR|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Cigna|CIGNA OTHER|||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Cigna|CIGNA|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicare|BCBS MEDICARE PPO MA|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicare|JACKSONVILLE ACCESS|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Blue Cross PPO Specialty|BCBSTX OTHER|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Aetna|BH AETNA|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Aetna|AETNA OTHER|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Aetna|AETNA PPO|||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|ChampVA|CHAMPVA CENTER|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicare|HEALTHSPRING MA|||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Access Direct Platinum|HEALTHFIRST TPA UMR|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Access Direct Platinum|HEALTHFIRST TPA|||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Humana Medicare Advantage|HUMANA MA|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Aenta Medicare Advantage|AETNA MEDICARE MA|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Workers Compensation|WORKERS COMPENSATION OTHER|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicare|MEDICARE PART B ONLY IP|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicaid|MEDICAID|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicaid|SMITH COUNTY JAIL|||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Medicare Advantage|UHC AARP MCR HMO MA|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Healthcare|GOLDEN RULE|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Healthcare|UNITED HEALTHCARE|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Healthcare|UNITED HEALTHCARE OTHER|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||0.10||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Optum Behavioral Health|BH OPTUM UHC|0.10||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|PHCS|HUMANA|0.10||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Healthcare|UNITED HEALTHCARE OTHER|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.25||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Healthcare|UNITED HEALTHCARE|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.25||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Medicare Advantage|UHC MEDICARE GOLD MA|46.25||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Medicare Advantage|UHC AARP MCR HMO MA|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Medicaid|SMITH COUNTY JAIL|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Medicare|MEDICARE ACUTE|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Workers Compensation|WORKERS COMPENSATION OTHER|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Workers Compensation|TEXAS MUTUAL INSURANCE|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Aenta Medicare Advantage|AETNA MEDICARE MA|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Access Direct Platinum|HEALTHFIRST TPA UMR|46.25||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Medicaid|MEDICAID|46.25||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Access Direct Platinum|HEALTHFIRST TPA|46.25||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Veterans Affairs|VETERANS ADMINISTRATION|46.25||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Aetna|AETNA QHP HMO|46.25||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Aetna|AETNA PPO|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Blue Cross HMO Specialty|BCBSTX HMO|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Blue Cross PPO Specialty|BCBSTX PPO|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Tricare|TRICARE EAST REGION|46.25||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicare|HEALTHSPRING MA|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicare|BCBS MEDICARE PPO MA|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Cigna|CIGNA OTHER|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Cigna|CIGNA|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Humana Medicare Advantage|HUMANA MA|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicaid|MEDICAID AMERIGROUP|||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.25||||46.25||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicaid|MEDICAID SUPERIOR|46.25||||46.25||| 9500463|ERX|0250|HYDROCORTISONE 0.5% CREAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32.50||||||| 9500463|ERX|0250|HYDROCORTISONE 0.5% CREAM|Medicare|MEDICARE ACUTE|32.50||||||| 9500463|ERX|0250|HYDROCORTISONE 0.5% CREAM|Medicaid|MEDICAID|32.50||||||| 9500471|ERX|0250|GANCICLOVIR 500MG VIAL|Medicaid|MEDICAID|617.50||||||| 9500471|ERX|0250|GANCICLOVIR 500MG VIAL|Medicare|MEDICARE ACUTE|617.50||||||| 9500471|ERX|0250|GANCICLOVIR 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|617.50||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Blue Cross PPO Specialty|BCBSTX PPO|44.25||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Aetna|AETNA PPO|44.25||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Humana Medicare Advantage|HUMANA MA|44.25||||44.25||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Magellan Behavioral Health|BH MAGELLAN|44.25||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Managed Medicaid|MEDICAID AMERIGROUP|44.25||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.25||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Managed Medicaid|MEDICAID SUPERIOR|44.25||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|NON CONTRACTED|COMMERCIAL OTHER 1|44.25||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Medicare|MEDICARE ACUTE|44.25||||44.25||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Medicaid|COUNTY INDIGENT HEALTH OTHER|44.25||||||| 9500505|ERX|0250|HYDROCORTISONE 1% OINT, 3|Blue Cross PPO Specialty|BCBSTX PPO|0.46||||||| 9500513|ERX|0250|BACITRAC-POLYMYX B UD PA|Medicare|MEDICARE ACUTE|7.50||||||| 9500521|ERX|0250|BACITRACIN EYE OINT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Workers Compensation|WORKERS COMPENSATION OTHER|56.25||||||| 9500521|ERX|0250|BACITRACIN EYE OINT|Managed Medicare|HEALTHSPRING MA|||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Managed Medicare|BCBS MEDICARE PPO MA|56.25||||||| 9500521|ERX|0250|BACITRACIN EYE OINT|Managed Medicaid|MEDICAID AMERIGROUP|||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Managed Medicaid|MEDICAID SUPERIOR|56.25||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Cigna|CIGNA OTHER|||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Blue Cross HMO Specialty|BCBSTX HMO|||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|56.25||||||| 9500521|ERX|0250|BACITRACIN EYE OINT|Blue Cross PPO Specialty|BCBSTX OTHER|||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|United Healthcare|UNITED HEALTHCARE OTHER|56.25||||||| 9500521|ERX|0250|BACITRACIN EYE OINT|UTMB|UTMB CORRECTIONAL MANAGED CARE|56.25||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Tricare|TRICARE EAST REGION|||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Multiplan|WEB TPA|||||56.25||| 9500521|ERX|0250|BACITRACIN EYE OINT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||56.25||| 9500539|ERX|0250|NEOMYC-BACITR-POLYMYX ,3.|Medicare|MEDICARE ACUTE|1.03||||||| 9500539|ERX|0250|NEOMYC-BACITR-POLYMYX ,3.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.03||||||| 9500554|ERX|0250|VITAMINS A AND D OINT, 60|Humana Medicare Advantage|HUMANA MA|26.75||||||| 9500554|ERX|0250|VITAMINS A AND D OINT, 60|Managed Medicare|HEALTHSPRING MA|26.75||||||| 9500554|ERX|0250|VITAMINS A AND D OINT, 60|Workers Compensation|UT EMPLOYEE INJURY|26.75||||||| 9500554|ERX|0250|VITAMINS A AND D OINT, 60|Medicare|MEDICARE ACUTE|26.75||||||| 9500562|ERX|0250|BETAMETHASONE VAL 0.1% 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|71.25||||||| 9500562|ERX|0250|BETAMETHASONE VAL 0.1% 1|United Medicare Advantage|UHC AARP MCR HMO MA|||||71.25||| 9500562|ERX|0250|BETAMETHASONE VAL 0.1% 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|71.25||||||| 9500562|ERX|0250|BETAMETHASONE VAL 0.1% 1|Medicare|MEDICARE ACUTE|71.25||||71.25||| 9500562|ERX|0250|BETAMETHASONE VAL 0.1% 1|Veterans Affairs|VETERANS ADMINISTRATION|71.25||||||| 9500562|ERX|0250|BETAMETHASONE VAL 0.1% 1|Aenta Medicare Advantage|AETNA MEDICARE MA|71.25||||||| 9500562|ERX|0250|BETAMETHASONE VAL 0.1% 1|Access Direct Platinum|HEALTHFIRST TPA|71.25||||||| 9500562|ERX|0250|BETAMETHASONE VAL 0.1% 1|Blue Cross HMO Specialty|BCBSTX HMO|71.25||||||| 9500562|ERX|0250|BETAMETHASONE VAL 0.1% 1|Humana Medicare Advantage|HUMANA MA|71.25||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Managed Medicare|HEALTHSPRING MA|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Managed Medicaid|MEDICAID AMERIGROUP|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Managed Medicaid|MEDICAID SUPERIOR|16.50||||16.50||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Cigna|CIGNA|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Humana Medicare Advantage|HUMANA MA|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|ChampVA|CHAMPVA CENTER|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Blue Cross PPO Specialty|BCBSTX OTHER|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Blue Cross PPO Specialty|BCBSTX PPO|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Workers Compensation|WORKERS COMPENSATION OTHER|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Access Direct Platinum|HEALTHFIRST TPA|16.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|NON CONTRACTED|COMMERCIAL OTHER 1|16.50||||16.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicaid|SUPERIOR HEALTHPLAN CHIP|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicaid|MEDICAID|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicaid|MOLINA HEALTHCARE OF TEXAS|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicaid|MEDICAID HMO|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicare|MEDICARE ACUTE|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|United Healthcare|TML GROUP BENEFITS|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|UTMB|UTMB CORRECTIONAL MANAGED CARE|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|United Healthcare|UNITED HEALTHCARE OTHER|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|United Medicare Advantage|UHC MEDICARE GOLD MA|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Tricare|TRICARE EAST REGION|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Tricare|TRICARE FOR LIFE|||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|PHCS|GROUP AND PENSION|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|PHCS|HUMANA INSURANCE|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Multiplan|WEB TPA|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|NON CONTRACTED|COMMERCIAL OTHER 2|||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|NON CONTRACTED|COMMERCIAL OTHER 1|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|NON CONTRACTED|COMMERCIAL OTHER 4|||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Access Direct Platinum|HEALTHFIRST TPA|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Access Direct Platinum|HEALTHFIRST TPA UMR|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Workers Compensation|WORKERS COMPENSATION OTHER|||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Aetna|AETNA PPO|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Aetna|AETNA OTHER|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|United Healthcare|UNITED HEALTHCARE|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicaid|SMITH COUNTY JAIL|||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Blue Cross HMO Specialty|BCBSTX HMO|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Aetna Value Network|AETNA VALUE NETWORK|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Blue Cross PPO Specialty|BCBSTX PPO|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Blue Cross PPO Specialty|BCBSTX OTHER|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|ChampVA|CHAMPVA CENTER|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Cigna|CIGNA|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Cigna|CIGNA OTHER|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Humana Medicare Advantage|HUMANA MA|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Managed Medicaid|MEDICAID AMERIGROUP|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Managed Medicaid|MEDICAID SUPERIOR|112.50||||112.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|112.50||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||112.50||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.46||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|Humana Medicare Advantage|HUMANA MA|0.46||||0.46||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|Blue Cross PPO Specialty|BCBSTX PPO|0.46||||0.46||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|Blue Cross PPO Specialty|BCBSTX OTHER|0.46||||||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.46||||||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|Veterans Affairs|VETERANS ADMINISTRATION|0.46||||||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|Tricare|TRICARE EAST REGION|0.46||||||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.46||||||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|United Medicare Advantage|UHC MEDICARE GOLD MA|0.46||||0.46||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|United Medicare Advantage|UHC AARP MCR HMO MA|0.46||||||| 9500638|ERX|0250|GENTAMICIN 0.1% CREAM, 15|Medicare|MEDICARE ACUTE|0.46||||0.46||| 9500646|ERX|0250|GENTAMICIN 0.1% OINT, 15|Medicare|MEDICARE PART B ONLY IP|0.46||||||| 9500646|ERX|0250|GENTAMICIN 0.1% OINT, 15|Medicare|MEDICARE ACUTE|0.46||||||| 9500646|ERX|0250|GENTAMICIN 0.1% OINT, 15|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.46||||||| 9500646|ERX|0250|GENTAMICIN 0.1% OINT, 15|Humana Medicare Advantage|HUMANA MA|0.46||||||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|Workers Compensation|UT EMPLOYEE INJURY|54.50||||||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|54.50||||||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|Humana Medicare Advantage|HUMANA MA|54.50||||||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|Blue Cross PPO Specialty|BCBSTX PPO|54.50||||||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54.50||||||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54.50||||||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|Medicare|MEDICARE ACUTE|54.50||||54.50||| 9500661|ERX|0250|NYSTATIN-TRIAMCINOLONE ,1|Medicare|MEDICARE PART B ONLY IP|54.50||||||| 9500661|ERX|0250|NYSTATIN-TRIAMCINOLONE ,1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54.50||||||| 9500661|ERX|0250|NYSTATIN-TRIAMCINOLONE ,1|Humana Medicare Advantage|HUMANA MA|54.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Veterans Affairs|VETERANS ADMINISTRATION|||||39.50||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Magellan Behavioral Health|BH MAGELLAN|39.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|39.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Humana Medicare Advantage|HUMANA MA|39.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Aetna|AETNA PPO|39.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|39.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|United Medicare Advantage|UHC AARP MCR HMO MA|39.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Medicaid|MEDICAID|39.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|39.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Medicare|MEDICARE ACUTE|39.50||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Medicare|MEDICARE ACUTE|0.47||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Medicaid|CRIME VICTIMS COMPENSATION|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Medicaid|SMITH COUNTY JAIL|||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|NON CONTRACTED|COMMERCIAL OTHER 2|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|NON CONTRACTED|COMMERCIAL OTHER 1|0.47||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Rusk State Hospital|RUSK STATE HOSP|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Tricare|TRICARE EAST REGION|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|United Healthcare|UNITED HEALTHCARE|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|United Healthcare|UNITED HEALTHCARE OTHER|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|United Medicare Advantage|UHC AARP MCR HMO MA|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|United Healthcare|TML GROUP BENEFITS|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|ChampVA|CHAMPVA CENTER|||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Blue Cross PPO Specialty|BCBSTX OTHER|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Blue Cross PPO Specialty|BCBSTX PPO|0.47||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Blue Cross HMO Specialty|BCBSTX HMO|0.47||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.47||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Aetna|AETNA PPO|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Managed Medicare|BCBS MEDICARE PPO MA|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Managed Medicare|HEALTHSPRING MA|0.47||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Cigna|CIGNA OTHER|||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Cigna|CIGNA|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Humana Medicare Advantage|HUMANA MA|0.47||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Medicaid|MEDICAID|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Managed Medicaid|MEDICAID SUPERIOR|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Managed Medicaid|MEDICAID AMERIGROUP|||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.47||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Workers Compensation|WORKERS COMPENSATION OTHER|0.47||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|United Medicare Advantage|UHC MEDICARE GOLD MA|0.47||||0.47||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Veterans Affairs|VETERANS ADMINISTRATION|0.47||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|United Medicare Advantage|UHC AARP MCR HMO MA|1.56||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Workers Compensation|WORKERS COMPENSATION OTHER|1.56||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.56||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|1.56||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.56||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Managed Medicaid|MEDICAID AMERIGROUP|||||1.56||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Humana Medicare Advantage|HUMANA MA|1.56||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Managed Medicare|HEALTHSPRING MA|1.56||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.56||||1.56||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Aetna|AETNA PPO|1.56||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.56||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|United Healthcare|UNITED HEALTHCARE OTHER|||||1.56||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Medicaid|MEDICAID HMO|||||1.56||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Medicare|MEDICARE ACUTE|1.56||||1.56||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Medicare|MEDICARE PART B ONLY IP|1.56||||||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Medicare|MEDICARE PART B ONLY IP|21.75||||||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Medicare|MEDICARE ACUTE|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Medicaid|MEDICAID|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Tricare|TRICARE EAST REGION|21.75||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|NON CONTRACTED|COMMERCIAL OTHER 1|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|United Healthcare|GOLDEN RULE|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|United Healthcare|UNITED HEALTHCARE OTHER|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|United Healthcare|GEHA|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|United Healthcare|UNITED HEALTHCARE|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Blue Cross PPO Specialty|BCBSTX PPO|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.75||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Blue Cross HMO Specialty|BCBSTX HMO|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Aetna|AETNA PPO|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Aetna|BOON CHAPMAN|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Managed Medicare|BCBS MEDICARE PPO MA|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Managed Medicare|HEALTHSPRING MA|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Cigna|CIGNA OTHER|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Texas Workforce Commission|DIS DETER SERV (DDS)|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Humana Medicare Advantage|HUMANA MA|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Managed Medicaid|MEDICAID SUPERIOR|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Managed Medicaid|MEDICAID AMERIGROUP|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Access Direct Platinum|HEALTHFIRST TPA|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|Workers Compensation|WORKERS COMPENSATION OTHER|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21.75||| 9500703|ERX|0250|SURGICAL LUBRICANT, 60 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||21.75||| 9500711|ERX|0250|SURGICAL LUBRICANT, 120 G|Managed Medicaid|MEDICAID SUPERIOR|||||31.50||| 9500711|ERX|0250|SURGICAL LUBRICANT, 120 G|Blue Cross PPO Specialty|BCBSTX PPO|||||31.50||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|United Healthcare|UNITED HEALTHCARE OTHER|||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Tricare|TRICARE EAST REGION|||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.10||||||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Medicare|MEDICARE PART B ONLY IP|0.10||||||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|United Healthcare|UNITED HEALTHCARE|||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Aetna|AETNA PPO|0.10||||||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Aetna|BOON CHAPMAN|0.10||||||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Managed Medicare|HEALTHSPRING MA|||||0.10||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9500729|ERX|0250|SURGICAL LUBRICANT, 3 GM|Cigna|CIGNA OTHER|||||0.10||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Cigna|CIGNA|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.75||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Managed Medicare|HEALTHSPRING MA|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|2.75||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Medicare|MEDICARE PART B ONLY IP|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Medicare|MEDICARE ACUTE|2.75||||2.75||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|2.75||||||| 9500745|ERX|0250|ERYTHROMYCIN 2% SOLUTION,|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|76.25||||||| 9500745|ERX|0250|ERYTHROMYCIN 2% SOLUTION,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|76.25||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Healthcare|UNITED HEALTHCARE OTHER|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Healthcare|UNITED HEALTHCARE|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Rusk State Hospital|RUSK STATE HOSP|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Tricare|TRICARE FOR LIFE|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Tricare|TRICARE EAST REGION|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|PHCS|HUMANA INSURANCE|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|PHCS|GROUP AND PENSION|||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|PHCS|HUMANA|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicaid|LAW ENFORCEMENT OTHER|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicaid|MEDICAID|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicaid|SMITH COUNTY JAIL|||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicare|MEDICARE PART B ONLY IP|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Medicare Advantage|UHC AARP MCR HMO MA|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Access Direct Platinum|HEALTHFIRST TPA UMR|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Access Direct Platinum|HEALTHFIRST TPA|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Aenta Medicare Advantage|AETNA MEDICARE MA|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Aetna|AETNA PPO|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Aetna|AETNA OTHER|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Blue Cross PPO Specialty|BCBSTX OTHER|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicare|BCBS MEDICARE PPO MA|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicare|HEALTHSPRING MA|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Cigna|CIGNA OTHER|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Cigna|CIGNA|0.10||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Cigna|CIGNA|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Humana Medicare Advantage|HUMANA MA|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||0.10||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicaid|MEDICAID SUPERIOR|0.10||||||| 9500786|ERX|0250|REPAGLINIDE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|21.75||||||| 9500786|ERX|0250|REPAGLINIDE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|21.75||||||| 9500786|ERX|0250|REPAGLINIDE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|21.75||||||| 9500786|ERX|0250|REPAGLINIDE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.75||||||| 9500786|ERX|0250|REPAGLINIDE 1MG TABLET|Medicare|MEDICARE ACUTE|21.75||||||| 9500794|ERX|0250|INSULIN,REG 100 UNIT/ML,1|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.27||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|PHCS|HUMANA|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Healthcare|UNITED HEALTHCARE|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Medicaid|MEDICAID|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Medicare|MEDICARE ACUTE|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Aetna|BH AETNA|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Aetna|AETNA OTHER|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Aetna|BOON CHAPMAN|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|ChampVA|CHAMPVA CENTER|||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Cigna|CIGNA OTHER|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Cigna|CIGNA|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Aetna|AETNA PPO|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Humana Medicare Advantage|HUMANA MA|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Cigna|CIGNA|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicare|HEALTHSPRING MA|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Tricare|TRICARE EAST REGION|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|43.50||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|43.50||||43.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|43.50||||43.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Cigna|CIGNA OTHER|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Cigna|CIGNA|||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Cigna|CIGNA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|ChampVA|CHAMPVA CENTER|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Aetna|AETNA PPO|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Aetna|AETNA OTHER|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Aetna|BH AETNA|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Aetna|BOON CHAPMAN|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicaid|MEDICAID HMO|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicaid|MEDICAID|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicaid|SMITH COUNTY JAIL|||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Healthcare|GOLDEN RULE|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Healthcare|UNITED HEALTHCARE|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Healthcare|GEHA|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||15.50||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Healthcare|TML GROUP BENEFITS|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Tricare|TRICARE EAST REGION|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|15.50||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|15.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Rusk State Hospital|RUSK STATE HOSP|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Tricare|TRICARE EAST REGION|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Healthcare|GOLDEN RULE|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicaid|SMITH COUNTY JAIL|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicaid|MEDICAID|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Aetna|AETNA PPO|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Magellan Behavioral Health|BH MAGELLAN|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Healthcare|TML GROUP BENEFITS|||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Cigna|CIGNA|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Cigna Behavioral Health|BH CIGNA|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|PHCS|GROUP AND PENSION|||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9500919|ERX|0250|CITALOPRAM 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|26.50||||||| 9500919|ERX|0250|CITALOPRAM 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|26.50||||||| 9500919|ERX|0250|CITALOPRAM 40MG TABLET|Humana Medicare Advantage|HUMANA MA|26.50||||||| 9500919|ERX|0250|CITALOPRAM 40MG TABLET|Magellan Behavioral Health|BH MAGELLAN|26.50||||||| 9500919|ERX|0250|CITALOPRAM 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|26.50||||||| 9500919|ERX|0250|CITALOPRAM 40MG TABLET|Medicare|MEDICARE ACUTE|26.50||||26.50||| 9500919|ERX|0250|CITALOPRAM 40MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|26.50||||||| 9500919|ERX|0250|CITALOPRAM 40MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|26.50||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|51.75||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|United Healthcare|UNITED HEALTHCARE|51.75||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|51.75||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|Medicare|MEDICARE ACUTE|51.75||||51.75||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|51.75||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|51.75||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|Aetna|AETNA PPO|51.75||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|51.75||||51.75||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|51.75||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|51.75||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|Humana Medicare Advantage|HUMANA MA|51.75||||||| 9500927|ERX|0250|MINOCYCLINE 50MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|51.75||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Access Direct Platinum|HEALTHFIRST TPA|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|||||15.50||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||15.50||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Aetna|BH AETNA|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Medicaid|MEDICAID|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|Tricare|TRICARE EAST REGION|15.50||||15.50||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|PHCS|GROUP AND PENSION|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||||| 9500950|ERX|0250|LISIN-HCTZ 10-12.5MG TABL|United Healthcare|UNITED HEALTHCARE|15.50||||||| 9500968|ERX|0250|TAMOXIFEN 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|24.25||||||| 9500968|ERX|0250|TAMOXIFEN 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|24.25||||||| 9500968|ERX|0250|TAMOXIFEN 10MG TABLET|Medicare|MEDICARE ACUTE|24.25||||||| 9500968|ERX|0250|TAMOXIFEN 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||24.25||| 9500968|ERX|0250|TAMOXIFEN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||24.25||| 9500968|ERX|0250|TAMOXIFEN 10MG TABLET|Managed Medicare|HEALTHSPRING MA|24.25||||||| 9500968|ERX|0250|TAMOXIFEN 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.25||||||| 9500968|ERX|0250|TAMOXIFEN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|24.25||||24.25||| 9500968|ERX|0250|TAMOXIFEN 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Access Direct Platinum|ANDREWS CENTER|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|28.25||||28.25||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.25||||28.25||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Cigna|CIGNA|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|28.25||||28.25||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.25||||28.25||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Magellan Behavioral Health|BH MAGELLAN|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.25||||28.25||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Aetna|AETNA PPO|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.25||||28.25||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|28.25||||28.25||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Medicaid|MEDICAID|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Medicaid|MEDICAID HMO|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Medicare|MEDICARE PART B ONLY IP|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Medicare|MEDICARE ACUTE|28.25||||28.25||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|28.25||||28.25||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Optum Behavioral Health|BH OPTUM UHC|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|Tricare|TRICARE EAST REGION|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|28.25||||||| 9500976|ERX|0250|SERTRALINE 25MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|28.25||||||| 9500992|ERX|0250|MINOCYCLINE 100MG CAPSULE|Medicare|MEDICARE ACUTE|||||103.50||| 9500992|ERX|0250|MINOCYCLINE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|103.50||||103.50||| 9500992|ERX|0250|MINOCYCLINE 100MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|103.50||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|38.25||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.25||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Access Direct Platinum|ANDREWS CENTER|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|38.25||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Managed Medicare|HEALTHSPRING MA|38.25||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38.25||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Cigna|CIGNA OTHER|||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Humana Medicare Advantage|HUMANA MA|38.25||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.25||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.25||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Aetna|AETNA PPO|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Aetna|BH AETNA|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|38.25||||38.25||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Medicaid|MEDICAID|38.25||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Medicare|MEDICARE ACUTE|38.25||||38.25||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Medicare|MEDICARE ACUTE|25.50||||||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Tricare|TRICARE EAST REGION|||||25.50||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Multiplan|WEB TPA|25.50||||||| 9501024|ERX|0250|BUPROPION 75MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|25.50||||||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||25.50||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||25.50||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||25.50||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9501024|ERX|0250|BUPROPION 75MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9501024|ERX|0250|BUPROPION 75MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9501024|ERX|0250|BUPROPION 75MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.25||||31.25||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|31.25||||31.25||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||31.25||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Managed Medicare|HEALTHSPRING MA|||||31.25||| 9501032|ERX|0250|BUPROPION 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|31.25||||31.25||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Humana Medicare Advantage|HUMANA MA|31.25||||31.25||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|31.25||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Aetna|BH AETNA|31.25||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||31.25||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|31.25||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|31.25||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|31.25||||31.25||| 9501032|ERX|0250|BUPROPION 100MG TABLET|United Healthcare|UNITED HEALTHCARE|31.25||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|31.25||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Medicare|MEDICARE ACUTE|31.25||||||| 9501040|ERX|0250|PYRIMETHAMINE 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,391.50||||||| 9501040|ERX|0250|PYRIMETHAMINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|3,391.50||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.25||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|7.25||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.25||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.25||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.25||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Humana Medicare Advantage|HUMANA MA|7.25||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Managed Medicare|HEALTHSPRING MA|7.25||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Medicaid|MEDICAID|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Medicare|MEDICARE PART B ONLY IP|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Medicare|MEDICARE ACUTE|7.25||||7.25||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.25||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|United Healthcare|UNITED HEALTHCARE|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Medicare|MEDICARE ACUTE|7.25||||7.25||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Medicaid|MEDICAID|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.25||||7.25||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.25||||7.25||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Managed Medicare|HEALTHSPRING MA|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Humana Medicare Advantage|HUMANA MA|7.25||||7.25||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.25||||7.25||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|7.25||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.25||||||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|Veterans Affairs|VETERANS ADMINISTRATION|527.75||||||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|United Medicare Advantage|UHC AARP MCR HMO MA|527.75||||||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|527.75||||||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|United Medicare Advantage|UHC MEDICARE GOLD MA|527.75||||||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|527.75||||527.75||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|Humana Medicare Advantage|HUMANA MA|527.75||||||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|527.75||||||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|Blue Cross PPO Specialty|BCBSTX PPO|527.75||||||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|Medicare|MEDICARE ACUTE|527.75||||527.75||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|United Healthcare|UNITED HEALTHCARE OTHER|527.75||||||| 9501115|ERX|0250|CLOBETASOL 0.05% CREAM, 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|527.75||||||| 9501172|ERX|0636||PHCS|HUMANA INSURANCE|16.80||||||| 9501172|ERX|0636||PHCS|HUMANA|16.80||||||| 9501172|ERX|0636||PHCS|GROUP AND PENSION|16.80||||||| 9501172|ERX|0636||NON CONTRACTED|COMMERCIAL OTHER 1|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Rusk State Hospital|RUSK STATE HOSP|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Texas Workforce Commission|DIS DETER SERV (DDS)|16.80||||16.80||| 9501172|ERX|0636||Texas Workforce Commission|DIS DETER SERV (DDS)|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Tricare|TRICARE EAST REGION|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Tricare|TRICARE FOR LIFE|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|PHCS|HUMANA INSURANCE|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|PHCS|HUMANA|16.80||||16.80||| 9501172|ERX|0636||Optum Behavioral Health|BH OPTUM UHC|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Multiplan|PACIFICARE|16.80||||||| 9501172|ERX|0636||Multiplan|TRUSTMARK|16.80||||||| 9501172|ERX|0636||Multiplan|WEB TPA|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 2|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 4|||||16.80||| 9501172|ERX|0636||Medicare|MEDICARE PART B ONLY IP|16.80||||||| 9501172|ERX|0636||Medicare|MEDICARE ACUTE|16.80||||16.80||| 9501172|ERX|0636||United Healthcare|UNITED HEALTHCARE OTHER|16.80||||16.80||| 9501172|ERX|0636||United Healthcare|UNITED HEALTHCARE|16.80||||16.80||| 9501172|ERX|0636||United Healthcare|GEHA|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|United Healthcare|GEHA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|United Healthcare|GOLDEN RULE|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|United Healthcare|TML GROUP BENEFITS|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.80||||||| 9501172|ERX|0636||UTMB|UTMB CORRECTIONAL MANAGED CARE|16.80||||||| 9501172|ERX|0636||Tricare|TRICARE EAST REGION|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|MEDICAID|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|MEDICAID HMO|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|MEDICAID BCBSTX|||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|16.80||||16.80||| 9501172|ERX|0636||Managed Medicare|ETMC SPECIALTY HOSPITAL|||||16.80||| 9501172|ERX|0636||Managed Medicare|ETMC REHABILITATION HOSPITAL|||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|16.80||||16.80||| 9501172|ERX|0636||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.80||||16.80||| 9501172|ERX|0636||Managed Medicare|HEALTHSPRING MA|16.80||||16.80||| 9501172|ERX|0636||Managed Medicare|BCBS MEDICARE PPO MA|16.80||||||| 9501172|ERX|0636||Managed Medicare|HOSPICE OF EAST TEXAS|16.80||||||| 9501172|ERX|0636||Medicaid|SUPERIOR HEALTHPLAN CHIP|16.80||||||| 9501172|ERX|0636||Medicaid|SMITH COUNTY JAIL|16.80||||||| 9501172|ERX|0636||Medicaid|MEDICAID HMO|16.80||||16.80||| 9501172|ERX|0636||Medicaid|COUNTY INDIGENT HEALTH OTHER|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|16.80||||16.80||| 9501172|ERX|0636||Medicaid|BH TEXAS CHILDRENS MEDICAID|||||16.80||| 9501172|ERX|0636||Medicaid|SMITH COUNTY INDIGENT HEALTH|16.80||||||| 9501172|ERX|0636||Medicaid|MEDICAID|16.80||||16.80||| 9501172|ERX|0636||Medicaid|MOLINA HEALTHCARE OF TEXAS|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicare|MEDICARE PART B ONLY IP|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicare|MEDICARE ACUTE|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|16.80||||16.80||| 9501172|ERX|0636||Blue Cross PPO Specialty|BCBSTX OTHER|16.80||||||| 9501172|ERX|0636||Blue Cross PPO Specialty|BCBSTX PPO|16.80||||16.80||| 9501172|ERX|0636||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|ChampVA|CHAMPVA CENTER|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|16.80||||16.80||| 9501172|ERX|0636||Blue Cross HMO Specialty|BCBSTX HMO|16.80||||16.80||| 9501172|ERX|0636||Brinson Benefits|THE HEALTH PLAN SMITH CO|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|16.80||||||| 9501172|ERX|0636||Aenta Medicare Advantage|AETNA MEDICARE MA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Aetna|BOON CHAPMAN|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Aetna|AETNA OTHER|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Aetna|AETNA PPO|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Aetna|AETNA QHP HMO|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|16.80||||16.80||| 9501172|ERX|0636||Aetna|BOON CHAPMAN|16.80||||||| 9501172|ERX|0636||Aetna|BH AETNA|16.80||||||| 9501172|ERX|0636||Aetna|AETNA PPO|16.80||||16.80||| 9501172|ERX|0636||Aetna|AETNA OTHER|16.80||||16.80||| 9501172|ERX|0636||Aetna|AETNA QHP HMO|16.80||||||| 9501172|ERX|0636||Medicaid Out of State|MEDICAID OUT OF STATE OTHER|16.80||||||| 9501172|ERX|0636||Medicaid|CRIME VICTIMS COMPENSATION|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Aetna Value Network|AETNA VALUE NETWORK|16.80||||||| 9501172|ERX|0636||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.80||||16.80||| 9501172|ERX|0636||Medicaid|LAW ENFORCEMENT OTHER|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.80||||16.80||| 9501172|ERX|0636||Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.80||||16.80||| 9501172|ERX|0636||Managed Medicaid|MEDICAID SUPERIOR|16.80||||16.80||| 9501172|ERX|0636||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.80||||16.80||| 9501172|ERX|0636||Managed Medicaid|MEDICAID AMERIGROUP|16.80||||16.80||| 9501172|ERX|0636||Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|LAW ENFORCEMENT OTHER|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|16.80||||16.80||| 9501172|ERX|0636||Managed Medicare|MA PART B ONLY IP|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|WELLCARE CHOICE MA|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|HEALTHSPRING MA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Humana Medicare Advantage|HUMANA MA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Cigna|CIGNA OTHER|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|CRIME VICTIMS COMPENSATION|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Cigna|CIGNA|16.80||||||| 9501172|ERX|0636||Cigna|CIGNA OTHER|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Cigna|CIGNA|16.80||||16.80||| 9501172|ERX|0636||Cigna|CIGNA|16.80||||16.80||| 9501172|ERX|0636||ChampVA|CHAMPVA CENTER|16.80||||16.80||| 9501172|ERX|0636||Humana Medicare Advantage|HUMANA MA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|United Healthcare|UNITED HEALTHCARE|16.80||||16.80||| 9501172|ERX|0636||United Healthcare|TML GROUP BENEFITS|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.80||||16.80||| 9501172|ERX|0636||Veterans Affairs|VETERANS ADMINISTRATION|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|TEXAS MUTUAL INSURANCE|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|BROOKSHIRES WORKERS COMP|16.80||||||| 9501172|ERX|0636||United Healthcare|UNITED HEALTHCARE ERS|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|ZURICH COMPANY|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|UT EMPLOYEE INJURY|16.80||||||| 9501172|ERX|0636||Workers Compensation|WORKERS COMPENSATION OTHER|16.80||||16.80||| 9501172|ERX|0636||Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Multiplan|WEB TPA|||||16.80||| 9501172|ERX|0636||Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|16.80||||||| 9501172|ERX|0636||Workers Compensation|BROOKSHIRES WORKERS COMP|16.80||||||| 9501172|ERX|0636||Workers Compensation|TRAVELERS INSURANCE COMPANY|16.80||||||| 9501172|ERX|0636||Workers Compensation|TEXAS MUTUAL INSURANCE|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|PHCS|GROUP AND PENSION|16.80||||||| 9501172|ERX|0636||Rusk State Hospital|RUSK STATE HOSP|16.80||||||| 9501172|ERX|0636||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.80||||16.80||| 9501172|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.80||||16.80||| 9501172|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA UMR|16.80||||16.80||| 9501172|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|16.80||||16.80||| 9501172|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST TPA|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|16.80||||16.80||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|16.80||||16.80||| 9501172|ERX|0636||United Medicare Advantage|UHC MEDICARE GOLD MA|16.80||||16.80||| 9501172|ERX|0636||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.80||||16.80||| 9501172|ERX|0636||United Medicare Advantage|UHC AARP WELLMED HMO MA|16.80||||||| 9501172|ERX|0636||United Medicare Advantage|UHC AARP MCR HMO MA|16.80||||||| 9501172|ERX|0250|ONDANSETRON 4MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|16.80||||16.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Access Direct Platinum|ANDREWS CENTER|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Magellan Behavioral Health|BH MAGELLAN|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Cigna|CIGNA|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Humana Medicare Advantage|HUMANA MA|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Managed Medicare|HEALTHSPRING MA|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Aetna|BOON CHAPMAN|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Aetna|AETNA PPO|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Medicare|MEDICARE ACUTE|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Medicaid|SMITH COUNTY JAIL|||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Medicaid|MEDICAID|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Medicaid|MEDICAID HMO|||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|United Healthcare|UNITED HEALTHCARE|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|8.80||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Optum Behavioral Health|BH OPTUM UHC|8.80||||||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|NON CONTRACTED|COMMERCIAL OTHER 1|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Medicare|MEDICARE ACUTE|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Tricare|TRICARE EAST REGION|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Managed Medicare|BCBS MEDICARE PPO MA|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Blue Cross PPO Specialty|BCBSTX PPO|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Blue Cross HMO Specialty|BCBSTX HMO|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Cigna|CIGNA|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Humana Medicare Advantage|HUMANA MA|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||26.25||| 95012|EAP|0460|EXHALED NITRIC OXIDE MEAS|United Medicare Advantage|UHC AARP MCR HMO MA|||||26.25||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||852.50||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||852.50||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Managed Medicare|HEALTHSPRING MA|852.50||||||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|852.50||||852.50||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Blue Cross HMO Specialty|BCBSTX HMO|||||852.50||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|852.50||||||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Blue Cross PPO Specialty|BCBSTX PPO|852.50||||852.50||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Medicare|MEDICARE ACUTE|852.50||||||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||852.50||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|United Healthcare|UNITED HEALTHCARE OTHER|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|United Healthcare|UNITED HEALTHCARE|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|United Healthcare|UNITED HEALTHCARE|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|NON CONTRACTED|COMMERCIAL OTHER 1|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|NON CONTRACTED|COMMUNITY HEALTH CENTER|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Rusk State Hospital|RUSK STATE HOSP|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Tricare|TRICARE EAST REGION|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Medicaid|MEDICAID|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Medicaid|BH TEXAS CHILDRENS MEDICAID|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Medicare|MEDICARE ACUTE|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Blue Cross PPO Specialty|BCBSTX PPO|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Blue Cross PPO Specialty|BCBSTX OTHER|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Aetna|BH AETNA|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Blue Cross HMO Specialty|BCBSTX HMO|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Humana Medicare Advantage|HUMANA MA|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Aetna|AETNA PPO|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Cigna|CIGNA|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Cigna|CIGNA OTHER|||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Cigna Behavioral Health|BH CIGNA|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicaid|MEDICAID SUPERIOR|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Medicare|MEDICARE PART B ONLY IP|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Medicaid|SMITH COUNTY INDIGENT HEALTH|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Magellan Behavioral Health|BH MAGELLAN|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicaid|MEDICAID AMERIGROUP|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicare|BCBS MEDICARE PPO MA|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicare|HEALTHSPRING MA|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Workers Compensation|WORKERS COMPENSATION OTHER|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Aenta Medicare Advantage|AETNA MEDICARE MA|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Access Direct Platinum|ANDREWS CENTER|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Access Direct Platinum|HEALTHFIRST TPA UMR|536.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Veterans Affairs|VETERANS ADMINISTRATION|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|United Medicare Advantage|UHC AARP MCR HMO MA|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|536.75||||536.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|United Medicare Advantage|UHC MEDICARE GOLD MA|536.75||||536.75||| 9501222|ERX|0250|LAMIVUDINE 150MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|68.75||||||| 9501222|ERX|0250|LAMIVUDINE 150MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|68.75||||||| 9501222|ERX|0250|LAMIVUDINE 150MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||68.75||| 9501222|ERX|0250|LAMIVUDINE 150MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|68.75||||||| 9501222|ERX|0250|LAMIVUDINE 150MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|68.75||||||| 9501222|ERX|0250|LAMIVUDINE 150MG TABLET|Medicare|MEDICARE ACUTE|68.75||||||| 9501222|ERX|0250|LAMIVUDINE 150MG TABLET|Medicare|MEDICARE PART B ONLY IP|68.75||||||| 9501222|ERX|0250|LAMIVUDINE 150MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|68.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Optum Behavioral Health|BH OPTUM UHC|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Multiplan|WEB TPA|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|49.75||||49.75||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Medicare|MEDICARE ACUTE|49.75||||49.75||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Aetna|BH AETNA|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Magellan Behavioral Health|BH MAGELLAN|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Tricare|TRICARE EAST REGION|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|49.75||||49.75||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Access Direct Platinum|ANDREWS CENTER|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|49.75||||49.75||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|49.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|49.75||||||| 9501263|ERX|0250|DEMECLOCYCLINE 150MG TABL|Humana Medicare Advantage|HUMANA MA|1.21||||||| 9501263|ERX|0250|DEMECLOCYCLINE 150MG TABL|Medicare|MEDICARE ACUTE|1.21||||||| 9501271|ERX|0250|ATOVAQUONE 750MG 5ML|Medicare|MEDICARE ACUTE|2.20||||||| 9501271|ERX|0250|ATOVAQUONE 750MG 5ML|Managed Medicare|HEALTHSPRING MA|2.20||||||| 9501271|ERX|0250|ATOVAQUONE 750MG 5ML|Humana Medicare Advantage|HUMANA MA|2.20||||2.20||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Workers Compensation|WORKERS COMP PHYSICIAN|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Access Direct Platinum|HEALTHFIRST TPA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Aetna|BH AETNA|8.80||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Aetna|AETNA OTHER|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Aetna|AETNA PPO|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|ChampVA|CHAMPVA CENTER|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Humana Medicare Advantage|HUMANA MA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Aetna|BOON CHAPMAN|8.80||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Cigna|CIGNA OTHER|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Cigna|CIGNA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicare|JACKSONVILLE ACCESS|8.80||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Access Direct Platinum|ANDREWS CENTER|8.80||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|8.80||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicare|HEALTHSPRING MA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Healthcare|TML GROUP BENEFITS|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Healthcare|UNITED HEALTHCARE|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|NON CONTRACTED|COMMUNITY HEALTH CENTER|8.80||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Workers Compensation|UT EMPLOYEE INJURY|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Rusk State Hospital|RUSK STATE HOSP|8.80||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Tricare|TRICARE EAST REGION|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|PHCS|HUMANA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Tricare|TRICARE FOR LIFE|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|SMITH COUNTY JAIL|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|MEDICAID HMO|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|MEDICAID|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|LAW ENFORCEMENT OTHER|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicare|MEDICARE ACUTE|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicare|MEDICARE PART B ONLY IP|8.80||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Medicare|MEDICARE ACUTE|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Optum Behavioral Health|BH OPTUM UHC|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Cigna|CIGNA|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Magellan Behavioral Health|BH MAGELLAN|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Access Direct Platinum|ANDREWS CENTER|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|54.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54.25||||54.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|54.25||||54.25||| 9501313|ERX|0250|ABACAVIR 300MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.93||||||| 9501313|ERX|0250|ABACAVIR 300MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.93||||||| 9501313|ERX|0250|ABACAVIR 300MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.93||||||| 9501313|ERX|0250|ABACAVIR 300MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.93||||||| 9501313|ERX|0250|ABACAVIR 300MG TABLET|Medicare|MEDICARE ACUTE|0.93||||||| 9501321|ERX|0250|LAMIVUDINE 25MG/5ML, 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.82||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|United Healthcare|UNITED HEALTHCARE OTHER|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|UTMB|UTMB CORRECTIONAL MANAGED CARE|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|NON CONTRACTED|COMMERCIAL OTHER 1|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Rusk State Hospital|RUSK STATE HOSP|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Tricare|TRICARE EAST REGION|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|PHCS|HUMANA|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicaid|MEDICAID|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicare|MEDICARE PART B ONLY IP|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicare|MEDICARE ACUTE|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Workers Compensation|WORKERS COMPENSATION OTHER|||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Aenta Medicare Advantage|AETNA MEDICARE MA|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Access Direct Platinum|ANDREWS CENTER|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Veterans Affairs|VETERANS ADMINISTRATION|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|United Medicare Advantage|UHC MEDICARE GOLD MA|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Workers Compensation|UT EMPLOYEE INJURY|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|United Medicare Advantage|UHC AARP MCR HMO MA|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|MEDICAID AMERIGROUP|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Magellan Behavioral Health|BH MAGELLAN|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|MEDICAID SUPERIOR|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Humana Medicare Advantage|HUMANA MA|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Cigna|CIGNA|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Cigna|CIGNA OTHER|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicare|HEALTHSPRING MA|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|United Healthcare|UNITED HEALTHCARE|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicare|BCBS MEDICARE PPO MA|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross PPO Specialty|BCBSTX OTHER|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross PPO Specialty|BCBSTX PPO|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Aetna|AETNA OTHER|282.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Aetna|AETNA PPO|||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|282.25||||282.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross HMO Specialty|BCBSTX HMO|282.25||||||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.37||||||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.37||||||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|0.37||||||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Managed Medicare|HEALTHSPRING MA|||||0.37||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.37||||0.37||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.37||||0.37||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.37||||0.37||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Tricare|TRICARE EAST REGION|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|PHCS|HUMANA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Multiplan|WEB TPA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|United Healthcare|UNITED HEALTHCARE|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|United Healthcare|UNITED HEALTHCARE|||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Medicare|MEDICARE PART B ONLY IP|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Medicare|MEDICARE ACUTE|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Medicaid|MEDICAID|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Cigna|CIGNA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Cigna|CIGNA|||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|PHCS|GROUP AND PENSION|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Humana Medicare Advantage|HUMANA MA|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Cigna Behavioral Health|BH CIGNA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Cigna|CIGNA OTHER|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Managed Medicare|HEALTHSPRING MA|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Aetna|BH AETNA|54.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54.50||||54.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|54.50||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Aetna|AETNA PPO|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Aetna|BH AETNA|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|ChampVA|CHAMPVA CENTER|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Managed Medicare|HEALTHSPRING MA|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Cigna|CIGNA OTHER|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Humana Medicare Advantage|HUMANA MA|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Cigna|CIGNA|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Medicare|MEDICARE ACUTE|0.72||||0.72||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|United Healthcare|TML GROUP BENEFITS|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.72||||||| 9501461|ERX|0250|BUPROPION XL 300MG TABLET|PHCS|HUMANA|0.72||||||| 9501479|ERX|0250|SUMATRIPTAN 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.82||||||| 9501479|ERX|0250|SUMATRIPTAN 25MG TABLET|United Healthcare|UNITED HEALTHCARE|2.82||||||| 9501479|ERX|0250|SUMATRIPTAN 25MG TABLET|Medicare|MEDICARE ACUTE|2.82||||||| 9501479|ERX|0250|SUMATRIPTAN 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.82||||||| 9501479|ERX|0250|SUMATRIPTAN 25MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.82||||||| 9501479|ERX|0250|SUMATRIPTAN 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.82||||2.82||| 9501479|ERX|0250|SUMATRIPTAN 25MG TABLET|Aetna|BH AETNA|2.82||||||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|262.25||||262.25||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|262.25||||||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Humana Medicare Advantage|HUMANA MA|262.25||||||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||262.25||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|262.25||||262.25||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|262.25||||262.25||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|262.25||||||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|262.25||||||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|262.25||||||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||262.25||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Medicare|MEDICARE ACUTE|262.25||||262.25||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Tricare|TRICARE EAST REGION|262.25||||||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|262.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Medicare|MEDICARE PART B ONLY IP|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Medicare|MEDICARE ACUTE|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Aetna|AETNA OTHER|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Managed Medicare|HEALTHSPRING MA|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Cigna|CIGNA|||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Humana Medicare Advantage|HUMANA MA|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|72.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|72.25||||72.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|72.25||||72.25||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.08||||||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|1.08||||||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Cigna|CIGNA|1.08||||||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Humana Medicare Advantage|HUMANA MA|1.08||||||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|||||1.08||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.08||||||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||1.08||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||1.08||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Medicare|MEDICARE ACUTE|1.08||||||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Medicaid|MEDICAID|1.08||||||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|United Healthcare|UNITED HEALTHCARE|1.08||||||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||1.08||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.08||||1.08||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Optum Behavioral Health|BH OPTUM UHC|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Tricare|TRICARE EAST REGION|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Multiplan|WEB TPA|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Medicaid|MEDICAID|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Medicare|MEDICARE ACUTE|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|35.25||||35.25||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||35.25||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Managed Medicare|HEALTHSPRING MA|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Cigna|CIGNA|||||35.25||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Humana Medicare Advantage|HUMANA MA|35.25||||35.25||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Magellan Behavioral Health|BH MAGELLAN|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|35.25||||35.25||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35.25||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|35.25||||||| 9501552|ERX|0250|ACYCLOVIR SUSP 200MG 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|150.25||||||| 9501552|ERX|0250|ACYCLOVIR SUSP 200MG 5ML|Blue Cross HMO Specialty|BCBSTX HMO|150.25||||||| 9501552|ERX|0250|ACYCLOVIR SUSP 200MG 5ML|Medicare|MEDICARE ACUTE|150.25||||||| 9501552|ERX|0250|ACYCLOVIR SUSP 200MG 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|150.25||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|0.30||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.30||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.30||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Medicaid|MEDICAID|0.30||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Medicare|MEDICARE ACUTE|0.30||||0.30||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.30||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|0.30||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.30||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.30||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.30||||0.30||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.30||||0.30||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.30||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.30||||0.30||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.30||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.30||||0.30||| 9501586|ERX|0250|POTASSIUM CITRATE 10 MEQ|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9501586|ERX|0250|POTASSIUM CITRATE 10 MEQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9501586|ERX|0250|POTASSIUM CITRATE 10 MEQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9501586|ERX|0250|POTASSIUM CITRATE 10 MEQ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||||| 9501586|ERX|0250|POTASSIUM CITRATE 10 MEQ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||||| 9501586|ERX|0250|POTASSIUM CITRATE 10 MEQ|Access Direct Platinum|HEALTHFIRST TPA UMR|9.25||||||| 9501586|ERX|0250|POTASSIUM CITRATE 10 MEQ|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||9.25||| 9501586|ERX|0250|POTASSIUM CITRATE 10 MEQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||||| 9501586|ERX|0250|POTASSIUM CITRATE 10 MEQ|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Medicaid|MEDICAID|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Medicare|MEDICARE ACUTE|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|86.75||||86.75||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|86.75||||86.75||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||86.75||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|86.75||||86.75||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Managed Medicare|OTHER INSTITUTIONS|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||86.75||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|86.75||||86.75||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|86.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|86.75||||86.75||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Cigna|CIGNA|35.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|35.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicare|WELLCARE CHOICE MA|35.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|35.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|35.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|35.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|35.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Medicare|MEDICARE ACUTE|35.50||||35.50||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|35.50||||||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.50||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|Aetna|AETNA QHP HMO|||||2.50||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|Aetna|AETNA OTHER|2.50||||||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.50||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501610|ERX|0250|CALCIUM CITRATE W/VIT D T|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Medicaid|MEDICAID|2.50||||||| 9501628|ERX|0250|ASCORBIC ACID 250MG TABLE|Medicare|MEDICARE ACUTE|2.50||||||| 9501644|ERX|0250|GUAIF-CODEI 100-10MG/5ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||24.25||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Tricare|TRICARE EAST REGION|2.50||||2.50||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.50||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9501651|ERX|0250|CYANOCOBALAMIN 500MCG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Access Direct Platinum|ANDREWS CENTER|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Cigna|CIGNA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Cigna|CIGNA OTHER|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Aetna|BH AETNA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Aetna|AETNA OTHER|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Aetna|AETNA PPO|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicare|MA PART B ONLY IP|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Aetna|AETNA QHP HMO|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|ChampVA|CHAMPVA CENTER|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicaid|MEDICAID|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicaid|MEDICAID HMO|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Healthcare|GOLDEN RULE|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|PHCS|GROUP AND PENSION|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Optum Behavioral Health|BH OPTUM UHC|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Tricare|TRICARE EAST REGION|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|PHCS|HUMANA INSURANCE|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|PHCS|HUMANA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|PHCS|GROUP AND PENSION|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|PHCS|HUMANA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Healthcare|UNITED HEALTHCARE ERS|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Healthcare|TML GROUP BENEFITS|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Medicaid|MEDICAID|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Medicaid|CRIME VICTIMS COMPENSATION|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|ChampVA|CHAMPVA CENTER|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Aetna|AETNA OTHER|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Aetna|AETNA PPO|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Aetna|BH AETNA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicare|WELLCARE CHOICE MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Cigna|CIGNA OTHER|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Cigna|CIGNA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Tricare|TRICARE EAST REGION|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9501693|ERX|0250|VITAMIN E 200 UNIT CAPSUL|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9501693|ERX|0250|VITAMIN E 200 UNIT CAPSUL|Medicare|MEDICARE ACUTE|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|PHCS|GROUP AND PENSION|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.50||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|||||2.50||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Aetna|BH AETNA|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Aetna|AETNA PPO|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.50||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Managed Medicare|HEALTHSPRING MA|||||2.50||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501719|ERX|0250|SITAGLIPTIN 50MG TABLET|Medicare|MEDICARE ACUTE|64.75||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|ChampVA|CHAMPVA CENTER|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Aetna|AETNA PPO|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501743|ERX|0250|DIMENHYDRINATE 50MG TABLE|Medicare|MEDICARE ACUTE|2.50||||||| 9501743|ERX|0250|DIMENHYDRINATE 50MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9501743|ERX|0250|DIMENHYDRINATE 50MG TABLE|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Cigna|CIGNA|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Cigna|CIGNA|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Medicaid|MEDICAID|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicare|UTSW MC KIDNEY PROGRAM|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|2.50||||||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicaid|MEDICAID|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|PHCS|GROUP AND PENSION|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Tricare|TRICARE EAST REGION|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicaid|SMITH COUNTY JAIL|2.50||||||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Cigna|CIGNA OTHER|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Cigna|CIGNA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Aetna|AETNA PPO|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Aetna|AETNA QHP HMO|2.50||||||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Aetna|AETNA OTHER|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Blue Cross HMO Specialty|BCBSTX HMO|4.25||||4.25||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Managed Medicare|HEALTHSPRING MA|4.25||||4.25||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.25||||4.25||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.25||||4.25||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.25||||||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Humana Medicare Advantage|HUMANA MA|4.25||||4.25||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Veterans Affairs|VETERANS ADMINISTRATION|4.25||||4.25||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|United Medicare Advantage|UHC AARP MCR HMO MA|4.25||||4.25||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|United Medicare Advantage|UHC MEDICARE GOLD MA|4.25||||4.25||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.25||||4.25||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Workers Compensation|WORKERS COMPENSATION OTHER|4.25||||||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|United Healthcare|UNITED HEALTHCARE|4.25||||||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.25||||||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Medicaid|MEDICAID|4.25||||||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Medicare|MEDICARE ACUTE|4.25||||4.25||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Medicaid|MEDICAID|2.75||||||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.75||||2.75||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||2.75||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.75||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Veterans Affairs|VETERANS ADMINISTRATION|2.75||||2.75||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Medicare|MEDICARE ACUTE|2.75||||2.75||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Humana Medicare Advantage|HUMANA MA|2.75||||||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||2.75||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Managed Medicare|HEALTHSPRING MA|2.75||||2.75||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Managed Medicare|BCBS MEDICARE PPO MA|2.75||||||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Blue Cross HMO Specialty|BCBSTX HMO|||||2.75||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||2.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Aetna|AETNA OTHER|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicare|WELLCARE CHOICE MA|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Cigna|CIGNA|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Tricare|TRICARE EAST REGION|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|PHCS|HUMANA|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Healthcare|GOLDEN RULE|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Aetna|AETNA PPO|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Medicaid|MEDICAID|6.75||||6.75||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Medicaid|SMITH COUNTY JAIL|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Medicare|MEDICARE PART B ONLY IP|6.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Medicare|MEDICARE ACUTE|6.75||||6.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicaid|MEDICAID|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicaid|SMITH COUNTY JAIL|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Healthcare|UNITED HEALTHCARE|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|PHCS|GROUP AND PENSION|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Tricare|TRICARE EAST REGION|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|PHCS|HUMANA|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Multiplan|WEB TPA|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Humana Medicare Advantage|HUMANA MA|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Cigna|CIGNA|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Cigna Behavioral Health|BH CIGNA|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Cigna|CIGNA OTHER|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicare|MEDICARE ACUTE|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicare|HEALTHSPRING MA|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41.75||||41.75||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Aetna|BH AETNA|41.75||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Aetna|AETNA PPO|41.75||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Aetna|AETNA OTHER|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Managed Medicare|HEALTHSPRING MA|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Cigna|CIGNA|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Aetna|AETNA PPO|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|United Healthcare|TML GROUP BENEFITS|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|United Healthcare|UNITED HEALTHCARE|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Medicaid|MEDICAID|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Medicaid|SMITH COUNTY JAIL|0.08||||||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9501818|ERX|0250|HYDRALAZINE 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.08||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Medicare|MEDICARE ACUTE|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Medicare|MEDICARE PART B ONLY IP|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Medicaid|MEDICAID|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Healthcare|UNITED HEALTHCARE OTHER|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Healthcare|TML GROUP BENEFITS|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Healthcare|UNITED HEALTHCARE|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|PHCS|GROUP AND PENSION|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|PHCS|HUMANA|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|NON CONTRACTED|COMMERCIAL OTHER 1|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Access Direct Platinum|HEALTHFIRST TPA UMR|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Access Direct Platinum|HEALTHFIRST TPA|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Workers Compensation|WORKERS COMPENSATION OTHER|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Access Direct Platinum|ANDREWS CENTER|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Workers Compensation|UT EMPLOYEE INJURY|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Veterans Affairs|VETERANS ADMINISTRATION|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Cigna|CIGNA|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Tricare|TRICARE EAST REGION|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Magellan Behavioral Health|BH MAGELLAN|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicaid|MEDICAID SUPERIOR|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Healthcare|UNITED HEALTHCARE|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicare|ETMC REHABILITATION HOSPITAL|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicare|BCBS MEDICARE PPO MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicare|HEALTHSPRING MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|ChampVA|CHAMPVA CENTER|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Blue Cross PPO Specialty|BCBSTX OTHER|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Aetna|AETNA QHP HMO|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Aetna|BOON CHAPMAN|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Aetna|AETNA PPO|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Aetna|AETNA OTHER|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Aetna|BH AETNA|2.75||||||| 9501834|ERX|0250|NITROGLYCERIN 2.5MG CAPSU|Humana Medicare Advantage|HUMANA MA|||||4.25||| 9501834|ERX|0250|NITROGLYCERIN 2.5MG CAPSU|United Medicare Advantage|UHC MEDICARE GOLD MA|4.25||||||| 9501834|ERX|0250|NITROGLYCERIN 2.5MG CAPSU|Medicare|MEDICARE PART B ONLY IP|4.25||||||| 9501834|ERX|0250|NITROGLYCERIN 2.5MG CAPSU|Medicare|MEDICARE ACUTE|4.25||||||| 9501842|ERX|0250|NITROGLYCERIN 6.5MG CAPSU|Medicaid|MEDICAID|4.75||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Aenta Medicare Advantage|AETNA MEDICARE MA|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.05||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|United Medicare Advantage|UHC AARP MCR HMO MA|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Aetna|AETNA OTHER|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Blue Cross HMO Specialty|BCBSTX HMO|||||0.05||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Managed Medicare|BCBS MEDICARE PPO MA|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Managed Medicare|HEALTHSPRING MA|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||0.05||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|United Healthcare|UNITED HEALTHCARE OTHER|0.05||||0.05||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Medicare|MEDICARE PART B ONLY IP|0.05||||||| 9501867|ERX|0250|ISOSORBIDE DINITRATE 20MG|Medicaid|MEDICAID|0.05||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Medicaid|MEDICAID|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Medicare|MEDICARE ACUTE|4.75||||4.75||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Medicaid|SMITH COUNTY JAIL|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Tricare|TRICARE EAST REGION|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|4.75||||4.75||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.75||||4.75||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|4.75||||4.75||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|4.75||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.75||||4.75||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|4.75||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Aetna|AETNA PPO|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Aetna|BH AETNA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Cigna|CIGNA|||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Tricare|TRICARE EAST REGION|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Aetna|BOON CHAPMAN|||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Tricare|TRICARE EAST REGION|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Cigna|CIGNA OTHER|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Aetna|AETNA PPO|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Medicaid|MEDICAID|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|9.25||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Cigna|CIGNA|9.25||||9.25||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9501917|ERX|0250|CYPROHEPTADINE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||||| 9501917|ERX|0250|CYPROHEPTADINE 4MG TABLET|Humana Medicare Advantage|HUMANA MA|7.75||||||| 9501917|ERX|0250|CYPROHEPTADINE 4MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.75||||||| 9501917|ERX|0250|CYPROHEPTADINE 4MG TABLET|Medicaid|MEDICAID|7.75||||||| 9501917|ERX|0250|CYPROHEPTADINE 4MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|7.75||||||| 9501917|ERX|0250|CYPROHEPTADINE 4MG TABLET|Medicare|MEDICARE ACUTE|7.75||||||| 9501917|ERX|0250|CYPROHEPTADINE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.08||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.08||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.08||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|0.08||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Access Direct Platinum|ANDREWS CENTER|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Magellan Behavioral Health|BH MAGELLAN|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|United Healthcare|UNITED HEALTHCARE|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Medicare|MEDICARE PART B ONLY IP|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|0.08||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Medicaid|MEDICAID|||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Optum Behavioral Health|BH OPTUM UHC|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Humana Medicare Advantage|HUMANA MA|0.08||||0.08||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|PHCS|HUMANA|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Multiplan|WEB TPA|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Cigna|CIGNA|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Medicaid|SMITH COUNTY JAIL|||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.08||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.08||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.08||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|PHCS|HUMANA|0.08||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Cigna|CIGNA|||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.08||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.08||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.08||||0.08||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.08||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.08||||||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.25||||6.25||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|Medicare|MEDICARE ACUTE|6.25||||||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.25||||||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.25||||||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.25||||||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|6.25||||||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|6.25||||||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|6.25||||||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|6.25||||||| 9501941|ERX|0250|BENZTROPINE 0.5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|6.25||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Cigna|CIGNA|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Tricare|TRICARE EAST REGION|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Medicaid|MEDICAID|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Aetna|BH AETNA|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9501966|ERX|0250|HYDROXYZINE HCL 10MG/5ML,|Humana Medicare Advantage|HUMANA MA|18.25||||||| 9501966|ERX|0250|HYDROXYZINE HCL 10MG/5ML,|Managed Medicaid|MEDICAID AMERIGROUP|18.25||||||| 9501966|ERX|0250|HYDROXYZINE HCL 10MG/5ML,|Blue Cross PPO Specialty|BCBSTX PPO|18.25||||||| 9501974|ERX|0250|MONTELUKAST CHEWABLE 5MG|Tricare|TRICARE EAST REGION|41.75||||||| 9501974|ERX|0250|MONTELUKAST CHEWABLE 5MG|Medicaid|BH TEXAS CHILDRENS MEDICAID|41.75||||||| 9501974|ERX|0250|MONTELUKAST CHEWABLE 5MG|Managed Medicaid|MEDICAID SUPERIOR|41.75||||41.75||| 9501974|ERX|0250|MONTELUKAST CHEWABLE 5MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41.75||||||| 9501974|ERX|0250|MONTELUKAST CHEWABLE 5MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|41.75||||||| 9501974|ERX|0250|MONTELUKAST CHEWABLE 5MG|Humana Medicare Advantage|HUMANA MA|41.75||||||| 9501974|ERX|0250|MONTELUKAST CHEWABLE 5MG|Managed Medicaid|MEDICAID AMERIGROUP|41.75||||41.75||| 9501974|ERX|0250|MONTELUKAST CHEWABLE 5MG|Medicare|MEDICARE ACUTE|41.75||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.12||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.12||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.12||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Managed Medicare|HEALTHSPRING MA|0.12||||0.12||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Humana Medicare Advantage|HUMANA MA|0.12||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Medicaid|MEDICAID|0.12||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|0.12||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Medicare|MEDICARE ACUTE|0.12||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.12||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|United Medicare Advantage|UHC AARP MCR HMO MA|0.12||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Healthcare|GOLDEN RULE|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|PHCS|HUMANA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|PHCS|HUMANA INSURANCE|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicaid|MEDICAID|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Tricare|TRICARE EAST REGION|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Healthcare|TML GROUP BENEFITS|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicaid|SMITH COUNTY JAIL|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Tricare|TRICARE FOR LIFE|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|PHCS|GROUP AND PENSION|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Cigna Behavioral Health|BH CIGNA|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Cigna|CIGNA|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Cigna|CIGNA OTHER|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Cigna|CIGNA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Aetna|AETNA OTHER|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|WELLCARE CHOICE MA|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|ChampVA|CHAMPVA CENTER|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Aetna|AETNA QHP HMO|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|OTHER INSTITUTIONS|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Aetna|AETNA PPO|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|||||2.50||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicare|HEALTHSPRING MA|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicaid|MEDICAID AMERIGROUP|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.25||||||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Cigna|CIGNA|26.25||||||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|United Medicare Advantage|UHC AARP MCR HMO MA|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Workers Compensation|WORKERS COMPENSATION OTHER|26.25||||||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Veterans Affairs|VETERANS ADMINISTRATION|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|United Medicare Advantage|UHC MEDICARE GOLD MA|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Access Direct Platinum|HEALTHFIRST TPA|||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|26.25||||||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Cigna|CIGNA OTHER|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicaid|MEDICAID SUPERIOR|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Humana Medicare Advantage|HUMANA MA|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Cigna|CIGNA|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|United Healthcare|UNITED HEALTHCARE|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|26.25||||||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Medicare|MEDICARE PART B ONLY IP|26.25||||||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Medicare|MEDICARE ACUTE|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Medicaid|MEDICAID|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|NON CONTRACTED|COMMERCIAL OTHER 1|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|26.25||||||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|United Healthcare|UNITED HEALTHCARE OTHER|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Tricare|TRICARE FOR LIFE|||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Tricare|TRICARE EAST REGION|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Blue Cross PPO Specialty|BCBSTX PPO|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Aetna|AETNA PPO|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Blue Cross HMO Specialty|BCBSTX HMO|26.25||||26.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicare|BCBS MEDICARE PPO MA|26.25||||||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.25||||26.25||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||0.07||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Medicaid|MEDICAID|0.07||||0.07||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Medicare|MEDICARE ACUTE|0.07||||||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Medicaid|MEDICAID HMO|||||0.07||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Managed Medicare|HEALTHSPRING MA|0.07||||||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Managed Medicaid|MEDICAID AMERIGROUP|||||0.07||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.07||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|||||0.07||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|Managed Medicare|HEALTHSPRING MA|24.50||||||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|United Healthcare|UNITED HEALTHCARE OTHER|24.50||||||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|Managed Medicare|BCBS MEDICARE PPO MA|24.50||||||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|Medicare|MEDICARE ACUTE|24.50||||||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|Veterans Affairs|VETERANS ADMINISTRATION|24.50||||||| 9502048|ERX|0250|TETRAHYDROZOLIN 0.05%, 15|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||||| 9502063|ERX|0250|BISMUTH SUBSAL 262MG/15ML|Aenta Medicare Advantage|AETNA MEDICARE MA|5.75||||||| 9502063|ERX|0250|BISMUTH SUBSAL 262MG/15ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.75||||||| 9502063|ERX|0250|BISMUTH SUBSAL 262MG/15ML|Blue Cross PPO Specialty|BCBSTX OTHER|5.75||||||| 9502063|ERX|0250|BISMUTH SUBSAL 262MG/15ML|Medicare|MEDICARE ACUTE|5.75||||||| 9502063|ERX|0250|BISMUTH SUBSAL 262MG/15ML|Medicare|MEDICARE PART B ONLY IP|5.75||||||| 9502063|ERX|0250|BISMUTH SUBSAL 262MG/15ML|Humana Medicare Advantage|HUMANA MA|5.75||||||| 9502063|ERX|0250|BISMUTH SUBSAL 262MG/15ML|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Managed Medicare|HEALTHSPRING MA|0.05||||0.05||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||0.05||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||0.05||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||0.05||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Aetna|BH AETNA|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.05||||0.05||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Medicaid|MEDICAID|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Medicaid|MEDICAID HMO|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|United Healthcare|UNITED HEALTHCARE|0.05||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.05||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.75||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Cigna|CIGNA|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Aetna|BH AETNA|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Humana Medicare Advantage|HUMANA MA|5.75||||5.75||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.75||||5.75||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Magellan Behavioral Health|BH MAGELLAN|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.75||||5.75||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Optum Behavioral Health|BH OPTUM UHC|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||5.75||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.75||||5.75||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Medicare|MEDICARE ACUTE|5.75||||5.75||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.75||||5.75||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Medicaid|MEDICAID HMO|5.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.75||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Managed Medicare|HEALTHSPRING MA|||||0.08||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Humana Medicare Advantage|HUMANA MA|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Cigna|CIGNA|||||0.08||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||0.08||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.08||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.08||||0.08||| 9502113|ERX|0250|PROPRANOLOL 80MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||||| 9502113|ERX|0250|PROPRANOLOL 80MG TABLET|Medicare|MEDICARE ACUTE|9.25||||||| 9502113|ERX|0250|PROPRANOLOL 80MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.25||| 9502113|ERX|0250|PROPRANOLOL 80MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9502113|ERX|0250|PROPRANOLOL 80MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||9.25||| 9502113|ERX|0250|PROPRANOLOL 80MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9502113|ERX|0250|PROPRANOLOL 80MG TABLET|Tricare|TRICARE EAST REGION|9.25||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.75||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Workers Compensation|ZURICH COMPANY|7.75||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.75||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Aetna|AETNA PPO|||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.75||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.75||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Medicaid|MEDICAID|7.75||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||7.75||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|7.75||||||| 9502139|ERX|0250|NITROFURANTOIN MACRO 50MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9502139|ERX|0250|NITROFURANTOIN MACRO 50MG|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9502139|ERX|0250|NITROFURANTOIN MACRO 50MG|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9502139|ERX|0250|NITROFURANTOIN MACRO 50MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9502139|ERX|0250|NITROFURANTOIN MACRO 50MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||||| 9502139|ERX|0250|NITROFURANTOIN MACRO 50MG|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9502139|ERX|0250|NITROFURANTOIN MACRO 50MG|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9502147|ERX|0250|ACETAMINOPHEN 80MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||||| 9502147|ERX|0250|ACETAMINOPHEN 80MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9502147|ERX|0250|ACETAMINOPHEN 80MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9502147|ERX|0250|ACETAMINOPHEN 80MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Tricare|TRICARE EAST REGION|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Healthcare|TML GROUP BENEFITS|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Healthcare|GEHA|||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Multiplan|WEB TPA|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|PHCS|GROUP AND PENSION|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Multiplan|NALC|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicaid|MEDICAID|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Optum Behavioral Health|BH OPTUM UHC|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Access Direct Platinum|ANDREWS CENTER|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Aetna|BH AETNA|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicare|JACKSONVILLE ACCESS|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Aetna|AETNA PPO|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Cigna|CIGNA OTHER|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Cigna|CIGNA|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Cigna|CIGNA|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.50||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||2.50||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.50||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Optum Behavioral Health|BH OPTUM UHC|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|PHCS|HUMANA|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Tricare|TRICARE EAST REGION|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Medicaid|MEDICAID|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Aetna|AETNA OTHER|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Aetna|AETNA PPO|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Access Direct Platinum|HEALTHFIRST TPA|||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Healthcare|UNITED HEALTHCARE OTHER|||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Aetna|BH AETNA|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Cigna|CIGNA OTHER|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Healthcare|UNITED HEALTHCARE|||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicare|JACKSONVILLE ACCESS|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|Workers Compensation|TEXAS MUTUAL INSURANCE|92.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|Aetna|BOON CHAPMAN|92.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|Medicare|MEDICARE ACUTE|92.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|Blue Cross HMO Specialty|BCBSTX HMO|92.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|Aenta Medicare Advantage|AETNA MEDICARE MA|92.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|92.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|Cigna|CIGNA|92.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|Humana Medicare Advantage|HUMANA MA|92.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|Managed Medicare|HEALTHSPRING MA|92.50||||||| 9502196|ERX|0250|CLOTRIMAZOLE 7 DAY VAG 4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|92.50||||||| 9502204|ERX|0250|TROLAMINE SALIC 10% CRM,8|Medicare|MEDICARE ACUTE|0.31||||||| 9502204|ERX|0250|TROLAMINE SALIC 10% CRM,8|Humana Medicare Advantage|HUMANA MA|0.31||||||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||36.75||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Blue Cross HMO Specialty|BCBSTX HMO|36.75||||||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|36.75||||||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Cigna|CIGNA|||||36.75||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Medicare|MEDICARE ACUTE|36.75||||||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Medicaid|MEDICAID|36.75||||||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Managed Medicaid|MEDICAID SUPERIOR|||||36.75||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Humana Medicare Advantage|HUMANA MA|36.75||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|United Healthcare|UNITED HEALTHCARE|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Medicaid|CRIME VICTIMS COMPENSATION|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Medicaid|MEDICAID HMO|||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Managed Medicare|HEALTHSPRING MA|0.08||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Cigna|CIGNA|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Humana Medicare Advantage|HUMANA MA|0.08||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Managed Medicaid|MEDICAID AMERIGROUP|0.08||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Access Direct Platinum|HEALTHFIRST TPA|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Veterans Affairs|VETERANS ADMINISTRATION|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.08||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|United Medicare Advantage|UHC AARP MCR HMO MA|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Aetna|AETNA PPO|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.08||||||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.08||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|ChampVA|CHAMPVA CENTER|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Aetna|BH AETNA|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Cigna|CIGNA|||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Cigna|CIGNA OTHER|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.10||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|PHCS|GROUP AND PENSION|||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.10||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.10||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Medicaid|MEDICAID|0.10||||0.10||| 9502287|ERX|0250|BISACODYL 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Healthcare|GEHA|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Healthcare|TML GROUP BENEFITS|||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Tricare|TRICARE EAST REGION|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Medicaid|SMITH COUNTY JAIL|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Medicaid|MEDICAID|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Cigna|CIGNA OTHER|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Cigna|CIGNA|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Cigna|CIGNA|2.50||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Aetna|AETNA PPO|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Aetna|AETNA OTHER|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Medicare Advantage|UHC MEDICARE GOLD MA|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Access Direct Platinum|HEALTHFIRST TPA|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Aenta Medicare Advantage|AETNA MEDICARE MA|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Medicare Advantage|UHC AARP MCR HMO MA|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Workers Compensation|WORKERS COMPENSATION OTHER|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Veterans Affairs|VETERANS ADMINISTRATION|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|ChampVA|CHAMPVA CENTER|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Aetna|AETNA PPO|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Aetna|BOON CHAPMAN|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Aetna|AETNA OTHER|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicaid|MEDICAID SUPERIOR|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Cigna|CIGNA|||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicare|BCBS MEDICARE PPO MA|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicaid|MEDICAID AMERIGROUP|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Humana Medicare Advantage|HUMANA MA|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Blue Cross PPO Specialty|BCBSTX OTHER|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Access Direct Platinum|ANDREWS CENTER|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Cigna|CIGNA|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Blue Cross HMO Specialty|BCBSTX HMO|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Access Direct Platinum|HEALTHFIRST TPA UMR|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicare|HEALTHSPRING MA|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicaid|MEDICAID|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Blue Cross PPO Specialty|BCBSTX PPO|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Tricare|TRICARE FOR LIFE|||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|PHCS|HUMANA INSURANCE|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Healthcare|UNITED HEALTHCARE OTHER|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Healthcare|UNITED HEALTHCARE|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Healthcare|GEHA|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Healthcare|TML GROUP BENEFITS|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicare|MEDICARE ACUTE|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Texas Workforce Commission|DIS DETER SERV (DDS)|4.25||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|NON CONTRACTED|COMMERCIAL OTHER 1|4.25||||4.25||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicaid|CRIME VICTIMS COMPENSATION|4.25||||||| 9502345|ERX|0250|ETODOLAC 400MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||16.75||| 9502345|ERX|0250|ETODOLAC 400MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|16.75||||||| 9502345|ERX|0250|ETODOLAC 400MG TABLET|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9502345|ERX|0250|ETODOLAC 400MG TABLET|Cigna|CIGNA|16.75||||||| 9502345|ERX|0250|ETODOLAC 400MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9502345|ERX|0250|ETODOLAC 400MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||||| 9502352|ERX|0250|NABUMETONE 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||||| 9502352|ERX|0250|NABUMETONE 500MG TABLET|Medicare|MEDICARE ACUTE|17.50||||||| 9502360|ERX|0250|NABUMETONE 750MG TABLET|Medicare|MEDICARE ACUTE|20.75||||20.75||| 9502360|ERX|0250|NABUMETONE 750MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|20.75||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Managed Medicare|HEALTHSPRING MA|5.50||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Managed Medicaid|MEDICAID SUPERIOR|||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.50||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Managed Medicaid|MEDICAID AMERIGROUP|5.50||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Cigna|CIGNA|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Humana Medicare Advantage|HUMANA MA|5.50||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Aetna|BH AETNA|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Cigna Behavioral Health|BH CIGNA|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.50||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Blue Cross HMO Specialty|BCBSTX HMO|5.50||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Managed Medicare|JACKSONVILLE ACCESS|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Aenta Medicare Advantage|AETNA MEDICARE MA|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Magellan Behavioral Health|BH MAGELLAN|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Access Direct Platinum|HEALTHFIRST TPA UMR|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|United Healthcare|UNITED HEALTHCARE OTHER|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|NON CONTRACTED|COMMUNITY HEALTH CENTER|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Optum Behavioral Health|BH OPTUM UHC|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Tricare|TRICARE EAST REGION|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|NON CONTRACTED|COMMERCIAL OTHER 1|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|PHCS|HUMANA INSURANCE|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Medicaid|MEDICAID|5.50||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Medicaid|MEDICAID HMO|||||5.50||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.50||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|NON CONTRACTED|COMMUNITY HEALTH CENTER|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|United Healthcare|UNITED HEALTHCARE OTHER|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Medicaid|MEDICAID HMO|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Optum Behavioral Health|BH OPTUM UHC|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Tricare|TRICARE EAST REGION|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Access Direct Platinum|HEALTHFIRST TPA UMR|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Aetna|BH AETNA|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Humana Medicare Advantage|HUMANA MA|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Managed Medicaid|MEDICAID AMERIGROUP|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.75||||5.75||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Managed Medicare|HEALTHSPRING MA|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Medicare|MEDICARE ACUTE|5.75||||5.75||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|Medicaid|SUPERIOR HEALTHPLAN CHIP|5.75||||||| 9502386|ERX|0250|HYDROXYZINE PAMOATE 50MG|NON CONTRACTED|COMMERCIAL OTHER 1|5.75||||||| 9502394|ERX|0250|SULFADIAZINE 500MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9502394|ERX|0250|SULFADIAZINE 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 9502394|ERX|0250|SULFADIAZINE 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 95024|EAP|0510|ICUT ALLERGY TEST DRUG/BU|Blue Cross PPO Specialty|BCBSTX PPO|||||62.50||| 95024|EAP|0510|ICUT ALLERGY TEST DRUG/BU|Blue Cross HMO Specialty|BCBSTX HMO|||||62.50||| 95024|EAP|0510|ICUT ALLERGY TEST DRUG/BU|Medicare|MEDICARE ACUTE|||||62.50||| 95024|EAP|0510|ICUT ALLERGY TEST DRUG/BU|Humana Medicare Advantage|HUMANA MA|||||62.50||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|United Medicare Advantage|UHC AARP MCR HMO MA|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|United Medicare Advantage|UHC MEDICARE GOLD MA|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|Aenta Medicare Advantage|AETNA MEDICARE MA|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|Humana Medicare Advantage|HUMANA MA|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|Blue Cross PPO Specialty|BCBSTX PPO|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|Managed Medicare|HEALTHSPRING MA|34.50||||||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|Medicare|MEDICARE ACUTE|34.50||||34.50||| 9502402|ERX|0250|CHOLESTYRAMINE-ASPART 4G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|34.50||||||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|NON CONTRACTED|COMMERCIAL OTHER 1|34.75||||||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Tricare|TRICARE EAST REGION|34.75||||||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Medicare|MEDICARE ACUTE|34.75||||34.75||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Cigna|CIGNA|34.75||||||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.75||||||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Blue Cross PPO Specialty|BCBSTX PPO|34.75||||34.75||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Access Direct Platinum|HEALTHFIRST TPA|34.75||||||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Veterans Affairs|VETERANS ADMINISTRATION|34.75||||||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|34.75||||34.75||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|United Medicare Advantage|UHC MEDICARE GOLD MA|34.75||||34.75||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Humana Medicare Advantage|HUMANA MA|34.75||||34.75||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Managed Medicare|HEALTHSPRING MA|34.75||||||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34.75||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Aetna|AETNA PPO|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Medicare Advantage|UHC AARP MCR HMO MA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Veterans Affairs|VETERANS ADMINISTRATION|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Workers Compensation|UT EMPLOYEE INJURY|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Workers Compensation|WORKERS COMPENSATION OTHER|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross HMO Specialty|BCBSTX HMO|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Aetna|AETNA QHP HMO|38.25||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|ChampVA|CHAMPVA CENTER|38.25||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross PPO Specialty|BCBSTX OTHER|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicaid|MEDICAID SUPERIOR|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|OTHER INSTITUTIONS|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Cigna|CIGNA OTHER|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross PPO Specialty|BCBSTX PPO|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|BCBS MEDICARE PPO MA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Cigna|CIGNA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Aetna|AETNA OTHER|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Humana Medicare Advantage|HUMANA MA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Workers Compensation|TEXAS MUTUAL INSURANCE|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|CRIME VICTIMS COMPENSATION|38.25||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|38.25||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicare|MEDICARE PART B ONLY IP|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|SMITH COUNTY JAIL|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|MEDICAID HMO|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|HEALTHSPRING MA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|MEDICAID|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicare|MEDICARE ACUTE|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Healthcare|TML GROUP BENEFITS|38.25||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Multiplan|WEB TPA|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|NON CONTRACTED|COMMERCIAL OTHER 1|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Healthcare|UNITED HEALTHCARE|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicare|UTSW MC KIDNEY PROGRAM|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Healthcare|UNITED HEALTHCARE OTHER|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|NON CONTRACTED|COMMERCIAL OTHER 2|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Tricare|TRICARE FOR LIFE|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Tricare|TRICARE EAST REGION|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|PHCS|HUMANA INSURANCE|38.25||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Rusk State Hospital|RUSK STATE HOSP|||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|PHCS|HUMANA|38.25||||38.25||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|PHCS|GROUP AND PENSION|38.25||||38.25||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Tricare|TRICARE EAST REGION|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|United Healthcare|TML GROUP BENEFITS|||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|United Healthcare|UNITED HEALTHCARE|||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|United Healthcare|UNITED HEALTHCARE OTHER|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|United Healthcare|UNITED HEALTHCARE|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Managed Medicaid|MEDICAID AMERIGROUP|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Medicaid|MEDICAID|0.43||||||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Medicare|MEDICARE PART B ONLY IP|0.43||||||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.43||||||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Medicare|MEDICARE ACUTE|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Managed Medicaid|MEDICAID SUPERIOR|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Cigna|CIGNA|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Humana Medicare Advantage|HUMANA MA|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Managed Medicare|BCBS MEDICARE PPO MA|0.43||||||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Cigna|CIGNA OTHER|||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.43||||||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Blue Cross PPO Specialty|BCBSTX PPO|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Aetna|AETNA OTHER|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Aetna|AETNA PPO|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Managed Medicare|HEALTHSPRING MA|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Veterans Affairs|VETERANS ADMINISTRATION|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.43||||0.43||| 9502444|ERX|0250|LIDOCAINE 2%MDV 20ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.43||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||176.50||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||31.64||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||176.50||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|176.50||||||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||176.50||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|176.50||||||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Medicare|MEDICARE ACUTE|||||176.50||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|United Healthcare|UNITED HEALTHCARE|176.50||||31.64||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||176.50||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Blue Cross PPO Specialty|BCBSTX PPO|||||104.07||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|United Healthcare|UNITED HEALTHCARE OTHER|||||31.64||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Managed Medicaid|MEDICAID SUPERIOR|||||31.64||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|United Healthcare|UNITED HEALTHCARE|||||31.64||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|31.64||||||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Humana Medicare Advantage|HUMANA MA|||||176.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Medicaid|SMITH COUNTY JAIL|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Medicaid|MEDICAID|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Medicare|MEDICARE ACUTE|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Access Direct Platinum|ANDREWS CENTER|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|89.50||||89.50||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|89.50||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|89.50||||||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|148.50||||||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Humana Medicare Advantage|HUMANA MA|148.50||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|148.50||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|148.50||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Aetna|AETNA PPO|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Managed Medicaid|MEDICAID SUPERIOR|148.50||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Blue Cross PPO Specialty|BCBSTX PPO|148.50||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Managed Medicaid|MEDICAID AMERIGROUP|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|148.50||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|148.50||||||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|148.50||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Managed Medicare|HEALTHSPRING MA|148.50||||||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Managed Medicare|BCBS MEDICARE PPO MA|148.50||||||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Medicare|MEDICARE ACUTE|148.50||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|United Healthcare|UNITED HEALTHCARE|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|148.50||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Medicaid|MEDICAID|148.50||||||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||148.50||| 9502477|ERX|0250|LIDOCAINE 0.5%PF 50ML|Tricare|TRICARE EAST REGION|||||148.50||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Tricare|TRICARE FOR LIFE|76.25||||||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|PHCS|HUMANA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|United Healthcare|TML GROUP BENEFITS|76.25||||||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|United Healthcare|GOLDEN RULE|76.25||||||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Medicaid|LAW ENFORCEMENT OTHER|76.25||||||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Medicaid|MEDICAID|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Medicare|UTSW MC KIDNEY PROGRAM|||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Medicare|MEDICARE ACUTE|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Managed Medicare|BCBS MEDICARE PPO MA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Medicaid|SMITH COUNTY JAIL|||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Blue Cross PPO Specialty|BCBSTX OTHER|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Managed Medicaid|MEDICAID AMERIGROUP|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|United Healthcare|UNITED HEALTHCARE OTHER|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Humana Medicare Advantage|HUMANA MA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|76.25||||||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Managed Medicaid|MEDICAID SUPERIOR|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Managed Medicare|HEALTHSPRING MA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Cigna|CIGNA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Medicare|MEDICARE PART B ONLY IP|76.25||||||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Cigna|CIGNA OTHER|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|United Healthcare|UNITED HEALTHCARE|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|PHCS|GROUP AND PENSION|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Blue Cross PPO Specialty|BCBSTX PPO|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|NON CONTRACTED|COMMERCIAL OTHER 1|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Tricare|TRICARE EAST REGION|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Blue Cross HMO Specialty|BCBSTX HMO|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Aetna|AETNA QHP HMO|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Aetna|AETNA PPO|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Access Direct Platinum|HEALTHFIRST TPA UMR|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|United Medicare Advantage|UHC AARP MCR HMO MA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|76.25||||||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Veterans Affairs|VETERANS ADMINISTRATION|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Access Direct Platinum|HEALTHFIRST TPA|||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Aetna|AETNA OTHER|76.25||||76.25||| 9502493|ERX|0250|LIDOCAINE 2%MDV 50ML|Aetna|BOON CHAPMAN|||||76.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|MEDICAID HMO|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|SMITH COUNTY JAIL|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Healthcare|GEHA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Healthcare|UNITED HEALTHCARE OTHER|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Tricare|TRICARE EAST REGION|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Healthcare|UNITED HEALTHCARE|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|PHCS|GROUP AND PENSION|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Healthcare|TML GROUP BENEFITS|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Rusk State Hospital|RUSK STATE HOSP|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Tricare|TRICARE FOR LIFE|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Tricare|TRICARE SOUTH PHYSICIAN|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|CRIME VICTIMS COMPENSATION|37.75||||||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Texas Workforce Commission|DIS DETER SERV (DDS)|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|LAW ENFORCEMENT OTHER|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|MEDICAID|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|PHCS|HUMANA INSURANCE|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|PHCS|HUMANA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|MEDICAID BCBSTX|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Multiplan|WEB TPA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Healthcare|UNITED HEALTHCARE ERS|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|NON CONTRACTED|COMMERCIAL OTHER 2|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Medicare Advantage|UHC AARP MCR HMO MA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Veterans Affairs|VETERANS ADMINISTRATION|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|TEXAS MUTUAL INSURANCE|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|GALLAGHER BASSETT|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|WORKERS COMPENSATION OTHER|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|ZURICH COMPANY|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST TPA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aetna|AETNA QHP HMO|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aetna|AETNA OTHER|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aetna|AETNA PPO|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aetna|BOON CHAPMAN|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aetna Value Network|AETNA VALUE NETWORK|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|UT EMPLOYEE INJURY|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|BROOKSHIRES WORKERS COMP|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Blue Cross HMO Specialty|BCBSTX HMO|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|ChampVA|CHAMPVA CENTER|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Blue Cross PPO Specialty|BCBSTX OTHER|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Cigna|CIGNA OTHER|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Cigna|CIGNA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicaid|MEDICAID SUPERIOR|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicaid|MEDICAID AMERIGROUP|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|BCBS MEDICARE PPO MA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|OTHER INSTITUTIONS|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Humana Medicare Advantage|HUMANA MA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Blue Cross PPO Specialty|BCBSTX PPO|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|HEALTHSPRING MA|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicare|UTSW MC KIDNEY PROGRAM|||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicare|MEDICARE ACUTE|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|37.75||||37.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicare|MEDICARE PART B ONLY IP|37.75||||||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|37.75||||||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|NON CONTRACTED|COMMERCIAL OTHER 1|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|United Healthcare|UNITED HEALTHCARE|93.25||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|United Healthcare|UNITED HEALTHCARE OTHER|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|PHCS|HUMANA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|United Healthcare|UNITED HEALTHCARE|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|United Healthcare|GEHA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Managed Medicare|BCBS MEDICARE PPO MA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Tricare|TRICARE EAST REGION|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|93.25||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Managed Medicaid|MEDICAID AMERIGROUP|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Humana Medicare Advantage|HUMANA MA|93.25||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Cigna|CIGNA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Managed Medicaid|MEDICAID SUPERIOR|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Blue Cross PPO Specialty|BCBSTX PPO|93.25||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Blue Cross PPO Specialty|BCBSTX OTHER|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Managed Medicare|HEALTHSPRING MA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|ChampVA|CHAMPVA CENTER|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Blue Cross HMO Specialty|BCBSTX HMO|93.25||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Aetna Value Network|AETNA VALUE NETWORK|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Aetna|BOON CHAPMAN|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Aetna|AETNA OTHER|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Medicare|MEDICARE ACUTE|93.25||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|United Healthcare|TML GROUP BENEFITS|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Aetna|AETNA PPO|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Access Direct Platinum|HEALTHFIRST TPA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Access Direct Platinum|HEALTHFIRST TPA UMR|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Aenta Medicare Advantage|AETNA MEDICARE MA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Workers Compensation|UT EMPLOYEE INJURY|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Workers Compensation|TEXAS MUTUAL INSURANCE|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|Veterans Affairs|VETERANS ADMINISTRATION|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|United Medicare Advantage|UHC MEDICARE GOLD MA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|United Medicare Advantage|UHC AARP MCR HMO MA|||||93.25||| 9502519|ERX|0250|LIDOCAINE 4%PF 40MG/ML, 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|93.25||||93.25||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|United Medicare Advantage|UHC AARP MCR HMO MA|||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Aenta Medicare Advantage|AETNA MEDICARE MA|||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|231.75||||||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|231.75||||||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|United Medicare Advantage|UHC MEDICARE GOLD MA|231.75||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Blue Cross HMO Specialty|BCBSTX HMO|231.75||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Blue Cross PPO Specialty|BCBSTX PPO|231.75||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Cigna|CIGNA|||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Humana Medicare Advantage|HUMANA MA|231.75||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Managed Medicaid|MEDICAID SUPERIOR|||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Medicare|MEDICARE ACUTE|231.75||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|United Healthcare|UNITED HEALTHCARE|231.75||||||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Managed Medicare|HEALTHSPRING MA|231.75||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||231.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|UTMB|UTMB CORRECTIONAL MANAGED CARE|231.75||||||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Tricare|TRICARE FOR LIFE|||||231.75||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Medicare|MEDICARE ACUTE|218.25||||||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|218.25||||||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|218.25||||||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|218.25||||||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Humana Medicare Advantage|HUMANA MA|218.25||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Aetna|AETNA QHP HMO|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Blue Cross HMO Specialty|BCBSTX HMO|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|United Medicare Advantage|UHC AARP MCR HMO MA|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Blue Cross PPO Specialty|BCBSTX PPO|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Managed Medicare|HEALTHSPRING MA|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Veterans Affairs|VETERANS ADMINISTRATION|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Managed Medicare|BCBS MEDICARE PPO MA|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Workers Compensation|WORKERS COMPENSATION OTHER|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Aetna|AETNA PPO|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Managed Medicaid|MEDICAID SUPERIOR|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Managed Medicaid|MEDICAID AMERIGROUP|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Cigna|CIGNA|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Cigna|CIGNA OTHER|||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Cigna|CIGNA|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Humana Medicare Advantage|HUMANA MA|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|NON CONTRACTED|COMMERCIAL OTHER 2|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Tricare|TRICARE EAST REGION|||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Tricare|TRICARE FOR LIFE|||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|United Healthcare|UNITED HEALTHCARE|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Multiplan|WEB TPA|||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|United Healthcare|UNITED HEALTHCARE OTHER|94.50||||94.50||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Medicaid|MEDICAID|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Medicaid|CRIME VICTIMS COMPENSATION|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|94.50||||||| 9502543|ERX|0250|LIDOCAINE 2% JELLY, 5ML|Medicare|MEDICARE ACUTE|94.50||||94.50||| 9502576|ERX|0250|BUDESONIDE 3MG CAPSULE|Medicare|MEDICARE ACUTE|51.50||||51.50||| 9502576|ERX|0250|BUDESONIDE 3MG CAPSULE|Tricare|TRICARE EAST REGION|51.50||||||| 9502576|ERX|0250|BUDESONIDE 3MG CAPSULE|Humana Medicare Advantage|HUMANA MA|51.50||||||| 9502576|ERX|0250|BUDESONIDE 3MG CAPSULE|Managed Medicare|HEALTHSPRING MA|51.50||||||| 9502576|ERX|0250|BUDESONIDE 3MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|51.50||||51.50||| 9502576|ERX|0250|BUDESONIDE 3MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|51.50||||||| 9502576|ERX|0250|BUDESONIDE 3MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|51.50||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.91||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.91||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.91||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Blue Cross HMO Specialty|BCBSTX HMO|0.91||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Blue Cross PPO Specialty|BCBSTX PPO|0.91||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Cigna|CIGNA|0.91||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|United Healthcare|UNITED HEALTHCARE|0.91||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Tricare|TRICARE EAST REGION|0.91||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|United Healthcare|UNITED HEALTHCARE OTHER|0.91||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Cigna|CIGNA|2.54||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|United Healthcare|UNITED HEALTHCARE OTHER|2.54||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Blue Cross PPO Specialty|BCBSTX PPO|2.54||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Medicare Advantage|UHC AARP MCR HMO MA|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Veterans Affairs|VETERANS ADMINISTRATION|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Workers Compensation|WORKERS COMPENSATION OTHER|171.75||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|171.75||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Access Direct Platinum|HEALTHFIRST TPA|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Aetna|AETNA OTHER|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Aetna|AETNA QHP HMO|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Blue Cross HMO Specialty|BCBSTX HMO|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|171.75||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|ChampVA|CHAMPVA CENTER|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Aetna|AETNA PPO|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Blue Cross PPO Specialty|BCBSTX OTHER|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicare|BCBS MEDICARE PPO MA|||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicare|HEALTHSPRING MA|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicaid|MEDICAID AMERIGROUP|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicaid|MEDICAID SUPERIOR|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Cigna|CIGNA|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Cigna|CIGNA OTHER|171.75||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Humana Medicare Advantage|HUMANA MA|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Medicaid|MEDICAID|171.75||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Medicare|MEDICARE ACUTE|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Medicare|MEDICARE PART B ONLY IP|171.75||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Tricare|TRICARE EAST REGION|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Healthcare|UNITED HEALTHCARE OTHER|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Healthcare|UNITED HEALTHCARE|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Healthcare|TML GROUP BENEFITS|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Texas Workforce Commission|DIS DETER SERV (DDS)|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|171.75||||171.75||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||171.75||| 9502642|ERX|0250|BUPIVACAINE W/DEX 0.75%PF|Cigna|CIGNA|60.50||||||| 9502642|ERX|0250|BUPIVACAINE W/DEX 0.75%PF|Managed Medicaid|MEDICAID AMERIGROUP|60.50||||||| 9502642|ERX|0250|BUPIVACAINE W/DEX 0.75%PF|Blue Cross PPO Specialty|BCBSTX PPO|60.50||||||| 9502642|ERX|0250|BUPIVACAINE W/DEX 0.75%PF|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||60.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|United Healthcare|UNITED HEALTHCARE|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|United Healthcare|GOLDEN RULE|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|PHCS|HUMANA|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Medicaid|MEDICAID|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Aetna|AETNA PPO|||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Aetna|AETNA OTHER|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Tricare|TRICARE EAST REGION|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Blue Cross PPO Specialty|BCBSTX OTHER|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Workers Compensation|TEXAS MUTUAL INSURANCE|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicaid|MEDICAID SUPERIOR|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Cigna Behavioral Health|BH CIGNA|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Cigna|CIGNA|15.50||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Cigna Behavioral Health|BH CIGNA|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Cigna|CIGNA OTHER|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Cigna|CIGNA|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Magellan Behavioral Health|BH MAGELLAN|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Access Direct Platinum|HEALTHFIRST TPA|||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Access Direct Platinum|ANDREWS CENTER|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Workers Compensation|WORKERS COMPENSATION OTHER|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Medicaid|MEDICAID|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Tricare|TRICARE EAST REGION|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|PHCS|HUMANA|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Healthcare|UNITED HEALTHCARE|15.50||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Healthcare|UNITED HEALTHCARE|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||15.50||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|United Healthcare|UNITED HEALTHCARE|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|United Healthcare|GOLDEN RULE|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|United Healthcare|UNITED HEALTHCARE OTHER|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Rusk State Hospital|RUSK STATE HOSP|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|PHCS|HUMANA|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Medicare|MEDICARE ACUTE|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Medicare|MEDICARE PART B ONLY IP|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Medicaid|MEDICAID|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Veterans Affairs|VETERANS ADMINISTRATION|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|United Medicare Advantage|UHC AARP MCR HMO MA|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|United Medicare Advantage|UHC MEDICARE GOLD MA|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Access Direct Platinum|HEALTHFIRST TPA UMR|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Aetna|AETNA PPO|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Managed Medicare|HEALTHSPRING MA|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Blue Cross PPO Specialty|BCBSTX OTHER|||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Blue Cross PPO Specialty|BCBSTX PPO|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Managed Medicare|BCBS MEDICARE PPO MA|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|NON CONTRACTED|COMMERCIAL OTHER 1|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|United Healthcare|UNITED HEALTHCARE|||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Blue Cross HMO Specialty|BCBSTX HMO|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Managed Medicaid|MEDICAID SUPERIOR|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Cigna|CIGNA|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Cigna|CIGNA OTHER|||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Aetna|BOON CHAPMAN|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Humana Medicare Advantage|HUMANA MA|20.75||||20.75||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Access Direct Platinum|HEALTHFIRST TPA|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Aenta Medicare Advantage|AETNA MEDICARE MA|20.75||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Managed Medicare|WELLCARE CHOICE MA|20.75||||||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|89.25||||||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Blue Cross HMO Specialty|BCBSTX HMO|89.25||||89.25||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|89.25||||||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Veterans Affairs|VETERANS ADMINISTRATION|89.25||||||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Medicare|MEDICARE ACUTE|89.25||||89.25||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|United Healthcare|UNITED HEALTHCARE OTHER|89.25||||||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||89.25||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|89.25||||||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|89.25||||||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Managed Medicare|HEALTHSPRING MA|||||89.25||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||89.25||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||89.25||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Managed Medicaid|MEDICAID SUPERIOR|89.25||||||| 9502691|ERX|0250|MORPHINE (PF) 5MG, 10ML|Humana Medicare Advantage|HUMANA MA|89.25||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||135.75||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|United Healthcare|UNITED HEALTHCARE OTHER|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Medicare|MEDICARE ACUTE|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Access Direct Platinum|HEALTHFIRST TPA|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Aetna|AETNA PPO|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|135.75||||135.75||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Blue Cross HMO Specialty|BCBSTX HMO|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Managed Medicaid|MEDICAID AMERIGROUP|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Managed Medicaid|MEDICAID SUPERIOR|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|135.75||||||| 9502717|ERX|0636|MORPHINE (PF) 1MG, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|118.50||||||| 9502717|ERX|0636|MORPHINE (PF) 1MG, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|118.50||||||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|United Healthcare|UNITED HEALTHCARE OTHER|1.05||||||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Access Direct Platinum|ANDREWS CENTER|1.05||||||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Blue Cross PPO Specialty|BCBSTX PPO|1.05||||||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Magellan Behavioral Health|BH MAGELLAN|1.05||||||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Managed Medicaid|MEDICAID SUPERIOR|||||1.05||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.05||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Managed Medicare|HEALTHSPRING MA|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Cigna|CIGNA OTHER|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Cigna|CIGNA|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Humana Medicare Advantage|HUMANA MA|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Medicare|MEDICARE PART B ONLY IP|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Medicare|MEDICARE ACUTE|71.25||||71.25||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||71.25||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Rusk State Hospital|RUSK STATE HOSP|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|United Healthcare|UNITED HEALTHCARE|71.25||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|71.25||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Healthcare|TML GROUP BENEFITS|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Healthcare|UNITED HEALTHCARE|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Rusk State Hospital|RUSK STATE HOSP|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|PHCS|HUMANA|||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicaid|MEDICAID|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicaid|MEDICAID HMO|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicaid|SMITH COUNTY JAIL|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicare|MEDICARE PART B ONLY IP|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Access Direct Platinum|HEALTHFIRST TPA|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicare|MEDICARE ACUTE|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Tricare|TRICARE EAST REGION|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Aetna|AETNA OTHER|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Cigna|CIGNA|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Humana Medicare Advantage|HUMANA MA|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Cigna|CIGNA OTHER|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicare|HEALTHSPRING MA|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|72.50||||72.50||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|72.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicare|HOSPICE OF EAST TEXAS|72.50||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Managed Medicare|BCBS MEDICARE PPO MA|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Humana Medicare Advantage|HUMANA MA|43.25||||43.25||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Cigna|CIGNA|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Managed Medicaid|MEDICAID SUPERIOR|||||43.25||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.25||||43.25||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Blue Cross HMO Specialty|BCBSTX HMO|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|ChampVA|CHAMPVA CENTER|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Veterans Affairs|VETERANS ADMINISTRATION|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|United Medicare Advantage|UHC MEDICARE GOLD MA|43.25||||43.25||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Blue Cross PPO Specialty|BCBSTX OTHER|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|United Medicare Advantage|UHC AARP MCR HMO MA|43.25||||43.25||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|43.25||||43.25||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Aenta Medicare Advantage|AETNA MEDICARE MA|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Medicare|MEDICARE PART B ONLY IP|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Medicare|MEDICARE ACUTE|43.25||||43.25||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Medicaid|COUNTY INDIGENT HEALTH OTHER|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Managed Medicare|HEALTHSPRING MA|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|United Healthcare|UNITED HEALTHCARE|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|UTMB|UTMB CORRECTIONAL MANAGED CARE|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Aetna|BOON CHAPMAN|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Multiplan|WEB TPA|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|NON CONTRACTED|COMMERCIAL OTHER 1|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Rusk State Hospital|RUSK STATE HOSP|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Medicaid|SMITH COUNTY INDIGENT HEALTH|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Medicaid|MEDICAID|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|United Healthcare|UNITED HEALTHCARE OTHER|43.25||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Blue Cross PPO Specialty|BCBSTX PPO|43.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|United Healthcare|UNITED HEALTHCARE|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|United Healthcare|UNITED HEALTHCARE OTHER|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Medicaid|MEDICAID|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|NON CONTRACTED|COMMERCIAL OTHER 1|27.25||||27.25||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Access Direct Platinum|HEALTHFIRST TPA|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Blue Cross PPO Specialty|BCBSTX PPO|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Aetna|AETNA PPO|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Blue Cross HMO Specialty|BCBSTX HMO|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Managed Medicaid|MEDICAID SUPERIOR|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Managed Medicaid|MEDICAID AMERIGROUP|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Cigna|CIGNA|27.25||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9502824|ERX|0250|PYRIDOSTIGMINE 60MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||||| 9502832|ERX|0250|PYRIDOSTIGINE 60MG/5ML,30|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|50.50||||||| 9502840|ERX|0250|PYRIDOSTIGINE TIMESPAN 18|United Healthcare|UNITED HEALTHCARE|23.50||||||| 9502840|ERX|0250|PYRIDOSTIGINE TIMESPAN 18|United Healthcare|UNITED HEALTHCARE OTHER|23.50||||||| 9502840|ERX|0250|PYRIDOSTIGINE TIMESPAN 18|Medicare|MEDICARE ACUTE|23.50||||||| 9502857|ERX|0250|FLUOROURACIL 5% CREAM, 40|Humana Medicare Advantage|HUMANA MA|2,941.75||||||| 9502865|ERX|0250|FLUCYTOSINE 250MG CAPSULE|Medicare|MEDICARE ACUTE|65.75||||||| 9502865|ERX|0250|FLUCYTOSINE 250MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|65.75||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Access Direct Platinum|HEALTHFIRST TPA|39.25||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|United Medicare Advantage|UHC MEDICARE GOLD MA|39.25||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|United Medicare Advantage|UHC AARP MCR HMO MA|39.25||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Blue Cross PPO Specialty|BCBSTX PPO|39.25||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|39.25||||39.25||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Humana Medicare Advantage|HUMANA MA|39.25||||39.25||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Veterans Affairs|VETERANS ADMINISTRATION|39.25||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|39.25||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Managed Medicaid|MEDICAID SUPERIOR|39.25||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Managed Medicaid|MEDICAID AMERIGROUP|39.25||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Medicaid|MEDICAID|39.25||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Medicare|MEDICARE ACUTE|39.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|PHCS|HUMANA|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Medicare|MEDICARE ACUTE|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Medicaid|MEDICAID|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Humana Medicare Advantage|HUMANA MA|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Cigna Behavioral Health|BH CIGNA|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Managed Medicare|HEALTHSPRING MA|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Cigna|CIGNA|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Aetna|AETNA QHP HMO|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|United Healthcare|UNITED HEALTHCARE|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.25||||0.25||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.25||||||| 9502956|ERX|0250|LOSARTAN 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.25||||0.25||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||216.25||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|Blue Cross PPO Specialty|BCBSTX PPO|216.25||||216.25||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|216.25||||||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|Humana Medicare Advantage|HUMANA MA|||||216.25||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|Managed Medicaid|MEDICAID SUPERIOR|216.25||||||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|Medicare|MEDICARE ACUTE|216.25||||216.25||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|United Medicare Advantage|UHC AARP MCR HMO MA|216.25||||||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|Blue Cross HMO Specialty|BCBSTX HMO|216.25||||||| 9502972|ERX|0250|PIPERACILLIN-TAZOBACTAM 4|United Medicare Advantage|UHC AARP MCR HMO MA|267.50||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Rusk State Hospital|RUSK STATE HOSP|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|United Healthcare|UNITED HEALTHCARE OTHER|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|United Healthcare|TML GROUP BENEFITS|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|United Healthcare|GEHA|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|United Healthcare|AARP|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|United Healthcare|UNITED HEALTHCARE|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Multiplan|TRUSTMARK|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|NON CONTRACTED|COMMERCIAL OTHER 1|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|NON CONTRACTED|COMMERCIAL OTHER 2|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|PHCS|HUMANA|||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|PHCS|HUMANA INSURANCE|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Tricare|TRICARE EAST REGION|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid|SMITH COUNTY JAIL|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid|MEDICAID|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicare|MEDICARE ACUTE|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid|LAW ENFORCEMENT OTHER|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicare|HEALTHSPRING MA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid|MEDICAID HMO|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicare|WELLCARE CHOICE MA|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicare|BCBS MEDICARE PPO MA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicare|OTHER INSTITUTIONS|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicare|MEDICARE PART B ONLY IP|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicaid|MEDICAID AMERIGROUP|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Humana Medicare Advantage|HUMANA MA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Cigna|CIGNA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Cigna|CIGNA OTHER|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Aetna|BOON CHAPMAN|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Aetna|AETNA OTHER|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Aenta Medicare Advantage|AETNA MEDICARE MA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|ChampVA|CHAMPVA CENTER|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|PHCS|GROUP AND PENSION|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Blue Cross HMO Specialty|BCBSTX HMO|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Blue Cross PPO Specialty|BCBSTX PPO|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Blue Cross PPO Specialty|BCBSTX OTHER|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Aetna|AETNA QHP HMO|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Medicaid|CRIME VICTIMS COMPENSATION|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Workers Compensation|TEXAS MUTUAL INSURANCE|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Workers Compensation|WORKERS COMPENSATION OTHER|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Managed Medicaid|MEDICAID SUPERIOR|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Aetna|AETNA PPO|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Workers Compensation|BROOKSHIRES WORKERS COMP|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Veterans Affairs|VETERANS ADMINISTRATION|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Access Direct Platinum|HEALTHFIRST TPA|2.88||||||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Access Direct Platinum|HEALTHFIRST TPA UMR|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|United Medicare Advantage|UHC MEDICARE GOLD MA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|United Medicare Advantage|UHC AARP MCR HMO MA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.88||||2.88||| 9502980|ERX|0258|PIPERACIL-TAZO 3.375G/50M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.88||||2.88||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|United Medicare Advantage|UHC MEDICARE GOLD MA|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Workers Compensation|TEXAS MUTUAL INSURANCE|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Workers Compensation|WORKERS COMPENSATION OTHER|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Workers Compensation|BROOKSHIRES WORKERS COMP|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Blue Cross PPO Specialty|BCBSTX OTHER|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Blue Cross HMO Specialty|BCBSTX HMO|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Aetna|AETNA PPO|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Aenta Medicare Advantage|AETNA MEDICARE MA|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Cigna|CIGNA OTHER|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|United Medicare Advantage|UHC AARP MCR HMO MA|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Cigna|CIGNA|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Humana Medicare Advantage|HUMANA MA|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Managed Medicaid|MEDICAID AMERIGROUP|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Managed Medicaid|MEDICAID SUPERIOR|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Veterans Affairs|VETERANS ADMINISTRATION|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Managed Medicare|OTHER INSTITUTIONS|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|United Medicare Advantage|UHC AARP WELLMED HMO MA|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Cigna|CIGNA|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Aetna|BOON CHAPMAN|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Access Direct Platinum|HEALTHFIRST TPA UMR|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Access Direct Platinum|HEALTHFIRST TPA|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Blue Cross PPO Specialty|BCBSTX PPO|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Managed Medicare|BCBS MEDICARE PPO MA|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Managed Medicare|HEALTHSPRING MA|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicare|MEDICARE ACUTE|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicaid|MEDICAID|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicaid|CRIME VICTIMS COMPENSATION|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicaid|MOLINA HEALTHCARE OF TEXAS|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicaid|COUNTY INDIGENT HEALTH OTHER|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicare|MEDICARE PART B ONLY IP|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicaid|SUPERIOR HEALTHPLAN CHIP|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicaid|SMITH COUNTY JAIL|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicaid|SMITH COUNTY INDIGENT HEALTH|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Rusk State Hospital|RUSK STATE HOSP|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Medicaid|MEDICAID HMO|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|PHCS|HUMANA INSURANCE|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|PHCS|GROUP AND PENSION|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|UTMB|UTMB CORRECTIONAL MANAGED CARE|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|United Healthcare|UNITED HEALTHCARE|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|United Healthcare|TML GROUP BENEFITS|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|NON CONTRACTED|COMMERCIAL OTHER 1|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|United Healthcare|AARP|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Multiplan|NALC|357.25||||||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|Tricare|TRICARE EAST REGION|357.25||||357.25||| 9502998|ERX|0258|PIPERACIL-TAZO 4.5 G/100M|United Healthcare|UNITED HEALTHCARE OTHER|357.25||||357.25||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|PHCS|HUMANA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Medicaid|MEDICAID|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Cigna|CIGNA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|United Healthcare|GOLDEN RULE|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.50||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Aetna|AETNA OTHER|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Aetna|AETNA PPO|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Cigna Behavioral Health|BH CIGNA|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Cigna|CIGNA OTHER|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Cigna|CIGNA|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Cigna|CIGNA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Aetna|BH AETNA|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|ChampVA|CHAMPVA CENTER|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Rusk State Hospital|RUSK STATE HOSP|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Tricare|TRICARE EAST REGION|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|PHCS|GROUP AND PENSION|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|PHCS|HUMANA|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Healthcare|GOLDEN RULE|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Medicaid|MEDICAID|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Healthcare|TML GROUP BENEFITS|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicare|WELLCARE CHOICE MA|25.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|25.50||||||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||0.13||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Medicare|MEDICARE ACUTE|0.13||||||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.13||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.13||||||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Cigna|CIGNA|||||0.13||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||0.13||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.13||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|United Medicare Advantage|UHC AARP MCR HMO MA|0.12||||||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Managed Medicare|HEALTHSPRING MA|0.12||||||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Medicare|MEDICARE ACUTE|0.12||||||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|United Healthcare|UNITED HEALTHCARE OTHER|0.12||||||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.12||||||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Managed Medicaid|MEDICAID AMERIGROUP|0.12||||0.12||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.12||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.12||||||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|United Medicare Advantage|UHC MEDICARE GOLD MA|0.12||||||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Humana Medicare Advantage|HUMANA MA|0.12||||||| 9503095|ERX|0250|CHLORHEXIDINE 4% LIQUID,1|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.54||||||| 9503103|ERX|0250|K IODIDE 1000MG/ML,30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|63.25||||||| 9503103|ERX|0250|K IODIDE 1000MG/ML,30ML|Blue Cross PPO Specialty|BCBSTX PPO|63.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Healthcare|TML GROUP BENEFITS|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Rusk State Hospital|RUSK STATE HOSP|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|PHCS|HUMANA|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Healthcare|UNITED HEALTHCARE|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Healthcare|UNITED HEALTHCARE OTHER|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|MEDICAID|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|LAW ENFORCEMENT OTHER|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|MEDICAID HMO|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|NON CONTRACTED|COMMERCIAL OTHER 1|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicare|MEDICARE PART B ONLY IP|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicare|BCBS MEDICARE PPO MA|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicare|OTHER INSTITUTIONS|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicare|WELLCARE CHOICE MA|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Humana Medicare Advantage|HUMANA MA|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Cigna|CIGNA|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Cigna|CIGNA OTHER|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Cigna|CIGNA|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicaid|MEDICAID AMERIGROUP|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Aetna|AETNA PPO|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicare|HEALTHSPRING MA|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Aetna|AETNA OTHER|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross HMO Specialty|BCBSTX HMO|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Tricare|TRICARE EAST REGION|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicare|MEDICARE ACUTE|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Healthcare|UNITED HEALTHCARE|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|SMITH COUNTY JAIL|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|CRIME VICTIMS COMPENSATION|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross PPO Specialty|BCBSTX PPO|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross PPO Specialty|BCBSTX OTHER|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|ChampVA|CHAMPVA CENTER|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Medicare Advantage|UHC AARP MCR HMO MA|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Medicare Advantage|UHC AARP WELLMED HMO MA|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Medicare Advantage|UHC MEDICARE GOLD MA|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Workers Compensation|TRAVELERS INSURANCE COMPANY|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Workers Compensation|TEXAS MUTUAL INSURANCE|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Aetna|AETNA QHP HMO|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Workers Compensation|WORKERS COMPENSATION OTHER|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Aenta Medicare Advantage|AETNA MEDICARE MA|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Aetna|BOON CHAPMAN|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Access Direct Platinum|HEALTHFIRST TPA UMR|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicaid|MEDICAID SUPERIOR|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Access Direct Platinum|HEALTHFIRST TPA|4.50||||4.50||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Veterans Affairs|VETERANS ADMINISTRATION|4.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Access Direct Platinum|HEALTHFIRST TPA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Access Direct Platinum|HEALTHFIRST TPA UMR|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Aenta Medicare Advantage|AETNA MEDICARE MA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Workers Compensation|UT EMPLOYEE INJURY|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Workers Compensation|WORKERS COMPENSATION OTHER|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Workers Compensation|TEXAS MUTUAL INSURANCE|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Veterans Affairs|VETERANS ADMINISTRATION|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross HMO Specialty|BCBSTX HMO|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Aetna|AETNA PPO|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Aetna|BH AETNA|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Aetna|BOON CHAPMAN|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Aetna|AETNA OTHER|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicaid|MEDICAID SUPERIOR|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicaid|MEDICAID AMERIGROUP|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Cigna Behavioral Health|BH CIGNA|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Cigna|CIGNA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Humana Medicare Advantage|HUMANA MA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicare|WELLCARE CHOICE MA|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicare|HEALTHSPRING MA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicare|MEDICARE PART B ONLY IP|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|CRIME VICTIMS COMPENSATION|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Aetna|AETNA QHP HMO|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Medicare Advantage|UHC AARP MCR HMO MA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross PPO Specialty|BCBSTX OTHER|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicare|BCBS MEDICARE PPO MA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|MEDICAID|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|SMITH COUNTY JAIL|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|MEDICAID HMO|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Workers Compensation|ZURICH COMPANY|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicare|JACKSONVILLE ACCESS|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Cigna|CIGNA OTHER|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Healthcare|TML GROUP BENEFITS|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Healthcare|UNITED HEALTHCARE|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Healthcare|UNITED HEALTHCARE OTHER|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Multiplan|WEB TPA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Multiplan|TRUSTMARK|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|NON CONTRACTED|COMMERCIAL OTHER 1|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Rusk State Hospital|RUSK STATE HOSP|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Texas Workforce Commission|DIS DETER SERV (DDS)|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|PHCS|HUMANA|5.50||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|PHCS|HUMANA INSURANCE|||||5.50||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|NON CONTRACTED|COMMUNITY HEALTH CENTER|5.50||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Tricare|TRICARE EAST REGION|5.50||||5.50||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Rusk State Hospital|RUSK STATE HOSP|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Tricare|TRICARE EAST REGION|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Tricare|TRICARE FOR LIFE|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|PHCS|GROUP AND PENSION|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|PHCS|HUMANA|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Texas Workforce Commission|DIS DETER SERV (DDS)|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|PHCS|HUMANA INSURANCE|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Multiplan|TRUSTMARK|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|NON CONTRACTED|COMMUNITY HEALTH CENTER|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|UNITED HEALTHCARE OTHER|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|AARP|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|SMITH COUNTY INDIGENT HEALTH|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|MOLINA HEALTHCARE OF TEXAS|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|MEDICAID|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|SMITH COUNTY JAIL|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|UNITED HEALTHCARE|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|LAW ENFORCEMENT OTHER|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|SUPERIOR HEALTHPLAN CHIP|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|CRIME VICTIMS COMPENSATION|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|OTHER INSTITUTIONS|||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|WELLCARE CHOICE MA|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|JACKSONVILLE ACCESS|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|ETMC AFFILIATE HOSPITALS|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|MA PART B ONLY IP|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Cigna|CIGNA OTHER|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Cigna|CIGNA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Cigna Behavioral Health|BH CIGNA|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicaid|MEDICAID SUPERIOR|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Aetna|AETNA OTHER|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Aetna|BOON CHAPMAN|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|COUNTY INDIGENT HEALTH OTHER|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|GEHA|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|MEDICAID HMO|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Aetna|AETNA QHP HMO|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|GOLDEN RULE|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|TML GROUP BENEFITS|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|ChampVA|CHAMPVA CENTER|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross PPO Specialty|BCBSTX OTHER|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Medicare Advantage|UHC AARP WELLMED HMO MA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|NON CONTRACTED|COMMERCIAL OTHER 2|||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Workers Compensation|TEXAS MUTUAL INSURANCE|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Brinson Benefits|THE HEALTH PLAN SMITH CO|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Workers Compensation|TRAVELERS INSURANCE COMPANY|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Workers Compensation|BROOKSHIRES WORKERS COMP|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Aetna|AETNA PPO|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Workers Compensation|UT EMPLOYEE INJURY|9.25||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Access Direct Platinum|HEALTHFIRST TPA|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Access Direct Platinum|HEALTHFIRST TPA UMR|9.25||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||9.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||9.25||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Access Direct Platinum|ANDREWS CENTER|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|ChampVA|CHAMPVA CENTER|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Aetna|AETNA OTHER|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Aetna|BH AETNA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Aetna|AETNA PPO|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Cigna|CIGNA OTHER|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Cigna|CIGNA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicare|WELLCARE CHOICE MA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Medicaid|MEDICAID|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Medicaid|CRIME VICTIMS COMPENSATION|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Healthcare|UNITED HEALTHCARE ERS|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Healthcare|TML GROUP BENEFITS|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Tricare|TRICARE EAST REGION|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|PHCS|GROUP AND PENSION|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Access Direct Platinum|ANDREWS CENTER|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Optum Behavioral Health|BH OPTUM UHC|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Tricare|TRICARE EAST REGION|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|PHCS|HUMANA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Multiplan|WEB TPA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicaid|MEDICAID HMO|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicaid|MEDICAID|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicare|MA PART B ONLY IP|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicare|JACKSONVILLE ACCESS|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Healthcare|GOLDEN RULE|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Cigna|CIGNA OTHER|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Cigna|CIGNA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|PHCS|HUMANA INSURANCE|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Aetna|BOON CHAPMAN|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Aetna|AETNA OTHER|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Aetna|BH AETNA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Aetna|AETNA PPO|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||102.75||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Veterans Affairs|VETERANS ADMINISTRATION|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Blue Cross PPO Specialty|BCBSTX PPO|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Blue Cross HMO Specialty|BCBSTX HMO|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|United Medicare Advantage|UHC MEDICARE GOLD MA|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Aetna|AETNA OTHER|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Aetna|BOON CHAPMAN|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Cigna|CIGNA|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Humana Medicare Advantage|HUMANA MA|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Managed Medicare|BCBS MEDICARE PPO MA|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Managed Medicare|HEALTHSPRING MA|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Medicare|MEDICARE ACUTE|102.75||||102.75||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|Medicaid|MEDICAID|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|United Healthcare|UNITED HEALTHCARE|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|United Healthcare|UNITED HEALTHCARE OTHER|102.75||||||| 9503160|ERX|0250|DEXAMETHASONE DOSEPACK|UTMB|UTMB CORRECTIONAL MANAGED CARE|102.75||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|NON CONTRACTED|COMMERCIAL OTHER 1|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|UTMB|UTMB CORRECTIONAL MANAGED CARE|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|United Healthcare|TML GROUP BENEFITS|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|United Healthcare|UNITED HEALTHCARE OTHER|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Medicaid|MEDICAID|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Medicare|MEDICARE ACUTE|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Medicare|MEDICARE PART B ONLY IP|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Managed Medicare|HEALTHSPRING MA|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Humana Medicare Advantage|HUMANA MA|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Cigna|CIGNA|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Cigna|CIGNA OTHER|||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Managed Medicaid|MEDICAID SUPERIOR|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Managed Medicare|ETMC AFFILIATE HOSPITALS|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Medicaid|COUNTY INDIGENT HEALTH OTHER|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Aetna|AETNA PPO|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Blue Cross HMO Specialty|BCBSTX HMO|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|United Healthcare|UNITED HEALTHCARE|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Brinson Benefits|THE HEALTH PLAN SMITH CO|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Blue Cross PPO Specialty|BCBSTX PPO|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Veterans Affairs|VETERANS ADMINISTRATION|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|United Medicare Advantage|UHC AARP MCR HMO MA|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|United Medicare Advantage|UHC MEDICARE GOLD MA|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Aenta Medicare Advantage|AETNA MEDICARE MA|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|39.50||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|39.50||||39.50||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|39.50||||||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|United Medicare Advantage|UHC MEDICARE GOLD MA|4.25||||4.25||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|Blue Cross PPO Specialty|BCBSTX PPO|4.25||||4.25||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.25||||||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.25||||4.25||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|Managed Medicaid|MEDICAID SUPERIOR|4.25||||||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|Humana Medicare Advantage|HUMANA MA|4.25||||||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|Managed Medicare|HEALTHSPRING MA|4.25||||||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|Medicare|MEDICARE ACUTE|4.25||||4.25||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|Medicare|MEDICARE PART B ONLY IP|4.25||||||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|Medicaid|MEDICAID|4.25||||||| 9503210|ERX|0250|MAGNESIUM GLUCONATE 500MG|United Healthcare|UNITED HEALTHCARE OTHER|||||4.25||| 9503244|ERX|0250|CEFOXITIN 2 G VIAL|Medicare|MEDICARE ACUTE|245.50||||||| 9503244|ERX|0250|CEFOXITIN 2 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|245.50||||||| 9503244|ERX|0250|CEFOXITIN 2 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|245.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Veterans Affairs|VETERANS ADMINISTRATION|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|United Medicare Advantage|UHC MEDICARE GOLD MA|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||89.50||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|United Medicare Advantage|UHC AARP MCR HMO MA|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||89.50||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Managed Medicare|HEALTHSPRING MA|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Humana Medicare Advantage|HUMANA MA|89.50||||89.50||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Managed Medicaid|MEDICAID AMERIGROUP|||||89.50||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Managed Medicaid|MEDICAID SUPERIOR|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Access Direct Platinum|HEALTHFIRST TPA UMR|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Blue Cross PPO Specialty|BCBSTX PPO|89.50||||89.50||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Aetna|AETNA PPO|||||89.50||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Blue Cross HMO Specialty|BCBSTX HMO|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|United Healthcare|UNITED HEALTHCARE OTHER|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|United Healthcare|UNITED HEALTHCARE|89.50||||89.50||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Medicaid|MEDICAID|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|89.50||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Medicare|MEDICARE ACUTE|89.50||||89.50||| 9503327|ERX|0250|PARAB-CET ALC-STRYL ALC,2|Medicare|MEDICARE ACUTE|71.50||||||| 9503327|ERX|0250|PARAB-CET ALC-STRYL ALC,2|Aenta Medicare Advantage|AETNA MEDICARE MA|71.50||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Blue Cross HMO Specialty|BCBSTX HMO|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Aetna|AETNA PPO|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Cigna|CIGNA|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Cigna|CIGNA|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Humana Medicare Advantage|HUMANA MA|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Managed Medicare|HEALTHSPRING MA|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Veterans Affairs|VETERANS ADMINISTRATION|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Workers Compensation|WORKERS COMPENSATION OTHER|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Access Direct Platinum|HEALTHFIRST TPA|||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|United Healthcare|UNITED HEALTHCARE|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|United Healthcare|UNITED HEALTHCARE OTHER|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Medicaid|MEDICAID|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.23||||0.23||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Medicare|MEDICARE PART B ONLY IP|0.23||||||| 9503418|ERX|0250|LISIN-HCTZ 20-12.5MG TABL|Medicare|MEDICARE ACUTE|0.23||||0.23||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Medicare|MEDICARE ACUTE|23.50||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Medicare|MEDICARE PART B ONLY IP|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|United Healthcare|UNITED HEALTHCARE|23.50||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|NON CONTRACTED|COMMERCIAL OTHER 2|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|NON CONTRACTED|COMMERCIAL OTHER 1|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|23.50||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Workers Compensation|WORKERS COMPENSATION OTHER|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|United Healthcare|TML GROUP BENEFITS|||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Veterans Affairs|VETERANS ADMINISTRATION|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|United Medicare Advantage|UHC AARP MCR HMO MA|23.50||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|United Medicare Advantage|UHC MEDICARE GOLD MA|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Managed Medicare|HEALTHSPRING MA|23.50||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Humana Medicare Advantage|HUMANA MA|23.50||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|23.50||||||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Blue Cross PPO Specialty|BCBSTX PPO|23.50||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|23.50||||23.50||| 9503426|ERX|0250|LISINOPRIL-HCTZ 20-25MG T|Blue Cross HMO Specialty|BCBSTX HMO|23.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|113.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|113.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|113.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Cigna Behavioral Health|BH CIGNA|113.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|113.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|113.50||||113.50||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|113.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|113.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|113.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||113.50||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|113.50||||113.50||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|113.50||||113.50||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|113.50||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||113.50||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Medicare|MEDICARE ACUTE|113.50||||113.50||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Medicaid|SMITH COUNTY JAIL|||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Medicaid|MEDICAID|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Medicaid|MEDICAID HMO|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|United Healthcare|GEHA|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Tricare|TRICARE EAST REGION|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Multiplan|WEB TPA|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Medicare|MEDICARE ACUTE|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Cigna|CIGNA|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Cigna Behavioral Health|BH CIGNA|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Aetna|BH AETNA|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Aetna|AETNA PPO|0.46||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.46||||0.46||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.46||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Aetna|BH AETNA|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.86||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Cigna Behavioral Health|BH CIGNA|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Humana Medicare Advantage|HUMANA MA|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Multiplan|WEB TPA|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Tricare|TRICARE EAST REGION|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Medicare|MEDICARE ACUTE|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Medicaid|MEDICAID|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.86||||||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|Medicare|MEDICARE ACUTE|514.50||||514.50||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|United Healthcare|GOLDEN RULE|514.50||||||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|United Medicare Advantage|UHC AARP MCR HMO MA|514.50||||||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|514.50||||||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|United Medicare Advantage|UHC MEDICARE GOLD MA|514.50||||514.50||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|Aenta Medicare Advantage|AETNA MEDICARE MA|514.50||||||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|Access Direct Platinum|HEALTHFIRST TPA UMR|514.50||||||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|Managed Medicare|HEALTHSPRING MA|514.50||||||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|Humana Medicare Advantage|HUMANA MA|514.50||||||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|514.50||||||| 9503475|ERX|0250|DORZOLAMIDE 2% EYE DROP,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|514.50||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Aetna|AETNA PPO|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Aetna|BH AETNA|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Cigna|CIGNA|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Cigna Behavioral Health|BH CIGNA|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Magellan Behavioral Health|BH MAGELLAN|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Tricare|TRICARE EAST REGION|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Optum Behavioral Health|BH OPTUM UHC|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicaid|SMITH COUNTY JAIL|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicaid|MEDICAID HMO|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicaid|MEDICAID|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|26.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicare|MEDICARE ACUTE|26.75||||26.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicare|MEDICARE PART B ONLY IP|26.75||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Medicare|MEDICARE ACUTE|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Medicaid|MEDICAID HMO|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Multiplan|WEB TPA|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Optum Behavioral Health|BH OPTUM UHC|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Tricare|TRICARE EAST REGION|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Medicaid|MEDICAID|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Access Direct Platinum|ANDREWS CENTER|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Magellan Behavioral Health|BH MAGELLAN|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|43.50||||||| 9503491|ERX|0250|QUETIAPINE 50MG TABLET|Aetna|BH AETNA|43.50||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Blue Cross HMO Specialty|BCBSTX HMO|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Aetna|AETNA PPO|||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Blue Cross PPO Specialty|BCBSTX PPO|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Managed Medicare|BCBS MEDICARE PPO MA|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Managed Medicaid|MEDICAID SUPERIOR|||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Cigna|CIGNA|||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Cigna|CIGNA|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Cigna|CIGNA OTHER|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Humana Medicare Advantage|HUMANA MA|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|United Medicare Advantage|UHC AARP MCR HMO MA|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Managed Medicare|HEALTHSPRING MA|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Veterans Affairs|VETERANS ADMINISTRATION|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Workers Compensation|BROOKSHIRES WORKERS COMP|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Access Direct Platinum|HEALTHFIRST TPA UMR|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|United Healthcare|UNITED HEALTHCARE|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|United Healthcare|UNITED HEALTHCARE OTHER|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Tricare|TRICARE EAST REGION|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|NON CONTRACTED|COMMERCIAL OTHER 1|499.75||||499.75||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Medicaid|MEDICAID|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Medicaid|CRIME VICTIMS COMPENSATION|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Medicare|MEDICARE PART B ONLY IP|499.75||||||| 9503509|ERX|0250|PROPOFOL 500MG/50ML|Medicare|MEDICARE ACUTE|499.75||||499.75||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|Medicare|MEDICARE ACUTE|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|United Healthcare|UNITED HEALTHCARE OTHER|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|Humana Medicare Advantage|HUMANA MA|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|Managed Medicare|HEALTHSPRING MA|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|Aetna|AETNA PPO|709.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|709.75||||||| 9503525|ERX|0250|MEROPENEM 500MG VIAL|Humana Medicare Advantage|HUMANA MA|394.25||||||| 9503541|ERX|0250|ZAFIRLUKAST 20MG TABLET|Medicare|MEDICARE ACUTE|0.22||||||| 9503541|ERX|0250|ZAFIRLUKAST 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.22||||||| 9503558|ERX|0250|BICALUTAMIDE 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|187.25||||||| 9503558|ERX|0250|BICALUTAMIDE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|187.25||||||| 9503558|ERX|0250|BICALUTAMIDE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|187.25||||||| 9503558|ERX|0250|BICALUTAMIDE 50MG TABLET|Managed Medicare|HEALTHSPRING MA|187.25||||||| 9503558|ERX|0250|BICALUTAMIDE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|187.25||||||| 9503558|ERX|0250|BICALUTAMIDE 50MG TABLET|Medicare|MEDICARE ACUTE|187.25||||187.25||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|United Healthcare|UNITED HEALTHCARE|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|United Healthcare|UNITED HEALTHCARE|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Tricare|TRICARE EAST REGION|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|PHCS|GROUP AND PENSION|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Medicare|MEDICARE ACUTE|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Aetna|AETNA PPO|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Aetna|AETNA OTHER|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Cigna|CIGNA OTHER|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Managed Medicare|HEALTHSPRING MA|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.39||||||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.39||||0.39||| 9503574|ERX|0250|ROSUVASTATIN 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Cigna|CIGNA|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Cigna|CIGNA|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Managed Medicare|HEALTHSPRING MA|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Aetna|AETNA PPO|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Aetna|AETNA QHP HMO|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Medicare|MEDICARE ACUTE|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Medicaid|MEDICAID|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Tricare|TRICARE EAST REGION|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|PHCS|HUMANA|||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|United Healthcare|TML GROUP BENEFITS|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|United Healthcare|UNITED HEALTHCARE|0.39||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.39||||0.39||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.39||||||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.39||||||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|Medicare|MEDICARE ACUTE|0.39||||0.39||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.39||||||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.39||||||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.39||||0.39||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.39||||||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.39||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Access Direct Platinum|HEALTHFIRST TPA UMR|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Access Direct Platinum|HEALTHFIRST TPA|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Workers Compensation|WORKERS COMPENSATION OTHER|105.75||||||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|United Medicare Advantage|UHC MEDICARE GOLD MA|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Managed Medicaid|MEDICAID SUPERIOR|105.75||||||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Managed Medicaid|MEDICAID AMERIGROUP|105.75||||||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Managed Medicaid|MEDICAID UNITED HEALTHCARE|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Humana Medicare Advantage|HUMANA MA|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Aenta Medicare Advantage|AETNA MEDICARE MA|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Blue Cross HMO Specialty|BCBSTX HMO|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|United Medicare Advantage|UHC AARP MCR HMO MA|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Blue Cross PPO Specialty|BCBSTX PPO|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Blue Cross PPO Specialty|BCBSTX OTHER|||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Managed Medicare|HEALTHSPRING MA|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Medicare|MEDICARE ACUTE|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Medicare|MEDICARE PART B ONLY IP|105.75||||||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Tricare|TRICARE EAST REGION|||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|Multiplan|PACIFICARE|105.75||||||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|NON CONTRACTED|COMMERCIAL OTHER 1|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|United Healthcare|UNITED HEALTHCARE OTHER|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|United Healthcare|UNITED HEALTHCARE|105.75||||105.75||| 9503608|ERX|0258|WATER FOR IRRIGATION 3000|UTMB|UTMB CORRECTIONAL MANAGED CARE|105.75||||||| 9503616|ERX|0258|LACTATED RINGERS 1000ML I|United Healthcare|UNITED HEALTHCARE|122.75||||||| 9503616|ERX|0258|LACTATED RINGERS 1000ML I|Medicare|MEDICARE ACUTE|122.75||||122.75||| 9503616|ERX|0258|LACTATED RINGERS 1000ML I|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|122.75||||||| 9503616|ERX|0258|LACTATED RINGERS 1000ML I|Aenta Medicare Advantage|AETNA MEDICARE MA|122.75||||||| 9503616|ERX|0258|LACTATED RINGERS 1000ML I|Humana Medicare Advantage|HUMANA MA|122.75||||||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|United Medicare Advantage|UHC AARP MCR HMO MA|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Managed Medicare|BCBS MEDICARE PPO MA|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Managed Medicare|HEALTHSPRING MA|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Humana Medicare Advantage|HUMANA MA|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Blue Cross HMO Specialty|BCBSTX HMO|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Aetna|AETNA PPO|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Blue Cross PPO Specialty|BCBSTX PPO|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Blue Cross PPO Specialty|BCBSTX OTHER|||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Medicare|MEDICARE ACUTE|125.25||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|Multiplan|PACIFICARE|125.25||||||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|NON CONTRACTED|COMMERCIAL OTHER 1|125.25||||||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|United Healthcare|UNITED HEALTHCARE OTHER|125.25||||125.25||| 9503624|ERX|0250|GLYCINE 3000ML IRRIG|United Healthcare|UNITED HEALTHCARE|||||125.25||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|United Healthcare|UNITED HEALTHCARE ERS|110.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|United Healthcare|UNITED HEALTHCARE OTHER|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|United Healthcare|UNITED HEALTHCARE|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|United Healthcare|GEHA|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|PHCS|HUMANA|110.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|PHCS|GROUP AND PENSION|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Tricare|TRICARE FOR LIFE|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|NON CONTRACTED|COMMERCIAL OTHER 1|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|NON CONTRACTED|COMMERCIAL OTHER 2|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicare|HEALTHSPRING MA|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicaid|MOLINA HEALTHCARE OF TEXAS|110.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicaid|MEDICAID HMO|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicaid|MEDICAID BCBSTX|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicaid|LAW ENFORCEMENT OTHER|110.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicare|MEDICARE ACUTE|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicare|MEDICARE PART B ONLY IP|110.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Brinson Benefits|THE HEALTH PLAN SMITH CO|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|ChampVA|CHAMPVA CENTER|110.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Blue Cross PPO Specialty|BCBSTX OTHER|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Blue Cross PPO Specialty|BCBSTX PPO|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Blue Cross HMO Specialty|BCBSTX HMO|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Aetna|AETNA PPO|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicaid|MEDICAID|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Aetna|BOON CHAPMAN|110.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Aetna|AETNA OTHER|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Aenta Medicare Advantage|AETNA MEDICARE MA|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Aetna Value Network|AETNA VALUE NETWORK|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Humana Medicare Advantage|HUMANA MA|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicare|BCBS MEDICARE PPO MA|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Cigna|CIGNA|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Cigna|CIGNA|110.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Tricare|TRICARE EAST REGION|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Cigna|CIGNA OTHER|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicaid|MEDICAID AMERIGROUP|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicaid|MEDICAID SUPERIOR|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|UTMB|UTMB CORRECTIONAL MANAGED CARE|110.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Workers Compensation|UT EMPLOYEE INJURY|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Workers Compensation|WORKERS COMPENSATION OTHER|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Workers Compensation|GALLAGHER BASSETT|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Workers Compensation|WORKERS COMP PHYSICIAN|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Veterans Affairs|VETERANS ADMINISTRATION|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Access Direct Platinum|HEALTHFIRST TPA|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Access Direct Platinum|HEALTHFIRST TPA UMR|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|United Medicare Advantage|UHC AARP MCR HMO MA|110.50||||110.50||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|110.50||||110.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|United Medicare Advantage|UHC MEDICARE GOLD MA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|United Medicare Advantage|UHC AARP MCR HMO MA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Access Direct Platinum|HEALTHFIRST TPA UMR|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Workers Compensation|BROOKSHIRES WORKERS COMP|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Veterans Affairs|VETERANS ADMINISTRATION|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicaid|MEDICAID AMERIGROUP|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicaid|MEDICAID SUPERIOR|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Cigna|CIGNA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Cigna|CIGNA OTHER|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Humana Medicare Advantage|HUMANA MA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Aetna|AETNA OTHER|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Aetna|AETNA QHP HMO|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Aetna|AETNA PPO|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Blue Cross HMO Specialty|BCBSTX HMO|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Blue Cross PPO Specialty|BCBSTX PPO|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Blue Cross PPO Specialty|BCBSTX OTHER|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Brinson Benefits|THE HEALTH PLAN SMITH CO|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|ChampVA|CHAMPVA CENTER|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Aenta Medicare Advantage|AETNA MEDICARE MA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicare|MEDICARE ACUTE|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicare|MEDICARE PART B ONLY IP|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicaid|SMITH COUNTY JAIL|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicaid|SMITH COUNTY INDIGENT HEALTH|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicaid|MOLINA HEALTHCARE OF TEXAS|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicaid|MEDICAID HMO|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicaid|MEDICAID|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicaid|LAW ENFORCEMENT OTHER|||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicaid|CRIME VICTIMS COMPENSATION|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Medicaid|COUNTY INDIGENT HEALTH OTHER|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicare|HEALTHSPRING MA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Workers Compensation|WORKERS COMPENSATION OTHER|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicare|BCBS MEDICARE PPO MA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Managed Medicare|ETMC AFFILIATE HOSPITALS|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Access Direct Platinum|HEALTHFIRST TPA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|NON CONTRACTED|COMMERCIAL OTHER 2|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|NON CONTRACTED|COMMERCIAL OTHER 1|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Rusk State Hospital|RUSK STATE HOSP|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|PHCS|HUMANA INSURANCE|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|PHCS|GROUP AND PENSION|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|Tricare|TRICARE EAST REGION|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|UTMB|UTMB CORRECTIONAL MANAGED CARE|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|United Healthcare|UNITED HEALTHCARE ERS|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|United Healthcare|UNITED HEALTHCARE OTHER|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|United Healthcare|UNITED HEALTHCARE|377.50||||377.50||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|United Healthcare|TML GROUP BENEFITS|377.50||||||| 9503657|ERX|0258|VANCOMYCIN 1000MG/200ML D|United Healthcare|AARP|377.50||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Healthcare|UNITED HEALTHCARE|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Healthcare|UNITED HEALTHCARE|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Healthcare|TML GROUP BENEFITS|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Rusk State Hospital|RUSK STATE HOSP|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Tricare|TRICARE EAST REGION|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|PHCS|HUMANA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|PHCS|HUMANA INSURANCE|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|PHCS|GROUP AND PENSION|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicaid|MEDICAID|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicaid|SMITH COUNTY JAIL|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicaid|LAW ENFORCEMENT OTHER|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|ChampVA|CHAMPVA CENTER|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Blue Cross PPO Specialty|BCBSTX OTHER|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Aetna|AETNA PPO|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Aetna|BH AETNA|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Aetna|AETNA OTHER|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicaid|MEDICAID SUPERIOR|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicaid|CRIME VICTIMS COMPENSATION|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Cigna|CIGNA OTHER|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Cigna|CIGNA|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Cigna|CIGNA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Tricare|TRICARE FOR LIFE|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicare|ETMC REHABILITATION HOSPITAL|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Workers Compensation|BROOKSHIRES WORKERS COMP|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|5.25||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Access Direct Platinum|HEALTHFIRST TPA UMR|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Access Direct Platinum|HEALTHFIRST TPA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9503723|ERX|0250|INDAPAMIDE 1.25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|10.50||||||| 9503723|ERX|0250|INDAPAMIDE 1.25MG TABLET|Humana Medicare Advantage|HUMANA MA|||||10.50||| 9503723|ERX|0250|INDAPAMIDE 1.25MG TABLET|Medicare|MEDICARE ACUTE|10.50||||10.50||| 9503723|ERX|0250|INDAPAMIDE 1.25MG TABLET|Medicare|MEDICARE PART B ONLY IP|10.50||||||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|Medicaid|SMITH COUNTY JAIL|1,010.25||||||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|Medicare|MEDICARE ACUTE|1,010.25||||1,010.25||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,010.25||||||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|Veterans Affairs|VETERANS ADMINISTRATION|1,010.25||||||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|Aenta Medicare Advantage|AETNA MEDICARE MA|1,010.25||||||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|Humana Medicare Advantage|HUMANA MA|1,010.25||||1,010.25||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|Managed Medicare|HEALTHSPRING MA|1,010.25||||1,010.25||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,010.25||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|Managed Medicare|BCBS MEDICARE PPO MA|1,010.25||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Managed Medicare|HEALTHSPRING MA|17.50||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|17.50||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Humana Medicare Advantage|HUMANA MA|17.50||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|17.50||||17.50||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Medicare|MEDICARE ACUTE|17.50||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Medicaid|MEDICAID|17.50||||||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|13.50||||||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|13.50||||||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Medicaid|MEDICAID|13.50||||13.50||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.50||||||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.50||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|||||13.50||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.50||||||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|13.50||||||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|13.50||||||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||13.50||| 9503855|ERX|0250|ACEBUTOLOL 200MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9503855|ERX|0250|ACEBUTOLOL 200MG CAPSULE|Aetna|AETNA PPO|15.50||||||| 9503855|ERX|0250|ACEBUTOLOL 200MG CAPSULE|Managed Medicare|HEALTHSPRING MA|||||15.50||| 9503855|ERX|0250|ACEBUTOLOL 200MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9503855|ERX|0250|ACEBUTOLOL 200MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9503855|ERX|0250|ACEBUTOLOL 200MG CAPSULE|Medicare|MEDICARE ACUTE|||||15.50||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Tricare|TRICARE EAST REGION|||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Healthcare|UNITED HEALTHCARE|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Medicaid|MEDICAID|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Access Direct Platinum|ANDREWS CENTER|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Magellan Behavioral Health|BH MAGELLAN|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Healthcare|GEHA|||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicaid|MEDICAID SUPERIOR|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Cigna|CIGNA|||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Aetna|AETNA PPO|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.25||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|ChampVA|CHAMPVA CENTER|5.25||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Aetna|AETNA PPO|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Cigna|CIGNA|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Cigna|CIGNA OTHER|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Medicaid|MEDICAID|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|United Healthcare|UNITED HEALTHCARE|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|United Healthcare|GOLDEN RULE|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Rusk State Hospital|RUSK STATE HOSP|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Tricare|TRICARE EAST REGION|5.25||||5.25||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|PHCS|HUMANA|5.25||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||5.25||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Multiplan|WEB TPA|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Tricare|TRICARE EAST REGION|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|PHCS|HUMANA|||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Healthcare|UNITED HEALTHCARE|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Medicaid|MEDICAID|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Medicare|MEDICARE PART B ONLY IP|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Magellan Behavioral Health|BH MAGELLAN|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Cigna|CIGNA OTHER|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Cigna|CIGNA|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Humana Medicare Advantage|HUMANA MA|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Healthcare|GOLDEN RULE|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicare|HEALTHSPRING MA|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Aetna|AETNA OTHER|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Aetna|AETNA PPO|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|ChampVA|CHAMPVA CENTER|5.50||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||5.50||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Aetna|AETNA PPO|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Aetna|BH AETNA|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Aetna|AETNA OTHER|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Aetna|AETNA QHP HMO|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicare|HEALTHSPRING MA|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Humana Medicare Advantage|HUMANA MA|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Cigna|CIGNA|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Cigna Behavioral Health|BH CIGNA|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicaid|MEDICAID AMERIGROUP|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Veterans Affairs|VETERANS ADMINISTRATION|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Magellan Behavioral Health|BH MAGELLAN|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicare|BCBS MEDICARE PPO MA|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Workers Compensation|WORKERS COMPENSATION OTHER|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross HMO Specialty|BCBSTX HMO|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Access Direct Platinum|HEALTHFIRST TPA|||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Access Direct Platinum|HEALTHFIRST TPA UMR|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Aenta Medicare Advantage|AETNA MEDICARE MA|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Medicare|MEDICARE PART B ONLY IP|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Medicaid|MEDICAID|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Healthcare|UNITED HEALTHCARE OTHER|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Healthcare|UNITED HEALTHCARE|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Rusk State Hospital|RUSK STATE HOSP|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Optum Behavioral Health|BH OPTUM UHC|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Tricare|TRICARE EAST REGION|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Multiplan|WEB TPA|5.50||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|5.50||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|PHCS|GROUP AND PENSION|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|United Healthcare|UNITED HEALTHCARE OTHER|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|United Healthcare|UNITED HEALTHCARE|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Medicare|MEDICARE PART B ONLY IP|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Medicare|MEDICARE ACUTE|6.75||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Aenta Medicare Advantage|AETNA MEDICARE MA|6.75||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|6.75||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.75||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Magellan Behavioral Health|BH MAGELLAN|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Managed Medicaid|MEDICAID SUPERIOR|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Managed Medicaid|MEDICAID AMERIGROUP|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Humana Medicare Advantage|HUMANA MA|6.75||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Medicaid|MEDICAID|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Cigna|CIGNA|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.75||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Managed Medicare|HEALTHSPRING MA|6.75||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Managed Medicare|BCBS MEDICARE PPO MA|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.75||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Blue Cross HMO Specialty|BCBSTX HMO|6.75||||6.75||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Aetna|BH AETNA|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Brinson Benefits|THE HEALTH PLAN SMITH CO|6.75||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Blue Cross PPO Specialty|BCBSTX PPO|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Blue Cross PPO Specialty|BCBSTX PPO|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Aetna|BOON CHAPMAN|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Aetna|AETNA PPO|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Managed Medicare|BCBS MEDICARE PPO MA|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Managed Medicare|HEALTHSPRING MA|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Humana Medicare Advantage|HUMANA MA|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Cigna|CIGNA|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Managed Medicaid|MEDICAID AMERIGROUP|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Managed Medicaid|MEDICAID SUPERIOR|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Blue Cross HMO Specialty|BCBSTX HMO|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|ChampVA|CHAMPVA CENTER|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Veterans Affairs|VETERANS ADMINISTRATION|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Medicare|MEDICARE ACUTE|6.75||||6.75||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Medicare|MEDICARE PART B ONLY IP|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|United Healthcare|UNITED HEALTHCARE OTHER|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Multiplan|WEB TPA|6.75||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Rusk State Hospital|RUSK STATE HOSP|6.75||||||| 9503921|ERX|0250|LEVOTHYROXINE 150MCG TABL|Multiplan|WEB TPA|0.07||||||| 9503921|ERX|0250|LEVOTHYROXINE 150MCG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|0.07||||||| 9503921|ERX|0250|LEVOTHYROXINE 150MCG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.07||||||| 9503921|ERX|0250|LEVOTHYROXINE 150MCG TABL|Veterans Affairs|VETERANS ADMINISTRATION|0.07||||||| 9503921|ERX|0250|LEVOTHYROXINE 150MCG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||||| 9503954|ERX|0250|NITROGLYCERIN 0.1MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||20.50||| 9503954|ERX|0250|NITROGLYCERIN 0.1MG PATCH|Medicare|MEDICARE ACUTE|20.50||||||| 9503954|ERX|0250|NITROGLYCERIN 0.1MG PATCH|United Healthcare|UNITED HEALTHCARE|20.50||||||| 9503962|ERX|0250|NITROGLYCERIN 0.2MG PATCH|Tricare|TRICARE EAST REGION|||||20.75||| 9503962|ERX|0250|NITROGLYCERIN 0.2MG PATCH|Medicare|MEDICARE ACUTE|20.75||||20.75||| 9503962|ERX|0250|NITROGLYCERIN 0.2MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.75||||||| 9503962|ERX|0250|NITROGLYCERIN 0.2MG PATCH|Humana Medicare Advantage|HUMANA MA|20.75||||||| 9503962|ERX|0250|NITROGLYCERIN 0.2MG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|||||20.75||| 9503962|ERX|0250|NITROGLYCERIN 0.2MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.75||||20.75||| 9503970|ERX|0250|NITROGLYCERIN 0.4MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.24||||||| 9503970|ERX|0250|NITROGLYCERIN 0.4MG PATCH|Humana Medicare Advantage|HUMANA MA|0.24||||||| 9503970|ERX|0250|NITROGLYCERIN 0.4MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.24||||||| 9503970|ERX|0250|NITROGLYCERIN 0.4MG PATCH|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.24||||||| 9503970|ERX|0250|NITROGLYCERIN 0.4MG PATCH|Medicare|MEDICARE ACUTE|0.24||||0.24||| 9503996|ERX|0250|BENZOIN TINCTURE 60ML BOT|Access Direct Platinum|HEALTHFIRST TPA|54.50||||||| 9504002|ERX|0250|GLYCERIN 30ML|United Healthcare|UNITED HEALTHCARE|0.10||||||| 9504002|ERX|0250|GLYCERIN 30ML|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9504002|ERX|0250|GLYCERIN 30ML|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||0.10||| 9504002|ERX|0250|GLYCERIN 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.10||| 9504002|ERX|0250|GLYCERIN 30ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.10||| 9504002|ERX|0250|GLYCERIN 30ML|Managed Medicare|HEALTHSPRING MA|0.10||||||| 9504002|ERX|0250|GLYCERIN 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.10||| 9504002|ERX|0250|GLYCERIN 30ML|Cigna|CIGNA|0.10||||||| 9504002|ERX|0250|GLYCERIN 30ML|Humana Medicare Advantage|HUMANA MA|||||0.10||| 9504002|ERX|0250|GLYCERIN 30ML|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||||| 9504002|ERX|0250|GLYCERIN 30ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.10||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Access Direct Platinum|ANDREWS CENTER|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Aetna|AETNA PPO|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Medicaid|MEDICAID|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Medicaid|MEDICAID HMO|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Medicare|MEDICARE ACUTE|134.50||||134.50||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|Rusk State Hospital|RUSK STATE HOSP|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|134.50||||||| 9504028|ERX|0250|OLANZAPINE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|134.50||||||| 9504044|ERX|0250|K IODIDE-IODINE 50MG/ML,3|Medicare|MEDICARE ACUTE|18.75||||||| 9504044|ERX|0250|K IODIDE-IODINE 50MG/ML,3|Medicaid|MEDICAID|18.75||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Managed Medicare|HEALTHSPRING MA|0.14||||0.14||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.14||||0.14||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Cigna|CIGNA|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Humana Medicare Advantage|HUMANA MA|0.14||||0.14||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.14||||0.14||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.14||||0.14||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.14||||0.14||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|United Healthcare|UNITED HEALTHCARE|||||0.14||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Medicaid|MEDICAID|0.14||||||| 9504051|ERX|0250|MORPHINE ER 15MG TABLET|Medicare|MEDICARE ACUTE|0.14||||0.14||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Medicare|MEDICARE ACUTE|21.75||||21.75||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Medicaid|MEDICAID|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|United Healthcare|UNITED HEALTHCARE|||||21.75||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Humana Medicare Advantage|HUMANA MA|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Managed Medicare|HEALTHSPRING MA|21.75||||21.75||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|21.75||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|21.75||||||| 9504077|ERX|0250|MORPHINE ER 60MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.25||||||| 9504077|ERX|0250|MORPHINE ER 60MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|34.25||||||| 9504077|ERX|0250|MORPHINE ER 60MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34.25||||||| 9504077|ERX|0250|MORPHINE ER 60MG TABLET|Tricare|TRICARE EAST REGION|34.25||||||| 9504077|ERX|0250|MORPHINE ER 60MG TABLET|Medicare|MEDICARE ACUTE|34.25||||34.25||| 9504085|ERX|0250|MORPHINE ER 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|50.50||||||| 9504085|ERX|0250|MORPHINE ER 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||50.50||| 9504093|ERX|0250|NORTRIPTYLINE 75MG CAPSUL|Medicaid|MEDICAID|||||1.95||| 9504093|ERX|0250|NORTRIPTYLINE 75MG CAPSUL|Medicare|MEDICARE ACUTE|||||1.95||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|76.25||||76.25||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|76.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|76.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|76.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|76.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Managed Medicare|HEALTHSPRING MA|76.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Cigna|CIGNA|76.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Humana Medicare Advantage|HUMANA MA|76.25||||76.25||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|76.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|United Healthcare|UNITED HEALTHCARE|76.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Medicare|MEDICARE ACUTE|76.25||||76.25||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Medicaid|CRIME VICTIMS COMPENSATION|76.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Medicaid|MEDICAID|76.25||||||| 9504119|ERX|0250|IMIPRAMINE 10MG TABLET|Medicare|MEDICARE ACUTE|48.50||||||| 9504119|ERX|0250|IMIPRAMINE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|48.50||||||| 9504119|ERX|0250|IMIPRAMINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|48.50||||||| 9504127|ERX|0250|ERTAPENEM 1 G VIAL|Aetna|AETNA OTHER|604.50||||||| 9504127|ERX|0250|ERTAPENEM 1 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|604.50||||||| 9504127|ERX|0250|ERTAPENEM 1 G VIAL|Medicare|MEDICARE ACUTE|604.50||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Tricare|TRICARE EAST REGION|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|PHCS|HUMANA|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|PHCS|HUMANA INSURANCE|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|United Healthcare|UNITED HEALTHCARE|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|United Healthcare|UNITED HEALTHCARE|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|United Healthcare|TML GROUP BENEFITS|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Medicaid|SMITH COUNTY JAIL|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Medicare|MEDICARE PART B ONLY IP|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Medicare|MEDICARE ACUTE|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Medicaid|MEDICAID|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Cigna|CIGNA|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Cigna|CIGNA OTHER|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Cigna|CIGNA|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Humana Medicare Advantage|HUMANA MA|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|PHCS|GROUP AND PENSION|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicare|HEALTHSPRING MA|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.25||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Aetna|AETNA QHP HMO|||||17.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Aetna|AETNA PPO|17.25||||17.25||| 9504192|ERX|0250|HEPARIN LOCK 100 UNIT/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Healthcare|AARP|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Healthcare|TML GROUP BENEFITS|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Healthcare|GEHA|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|PHCS|HUMANA INSURANCE|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Aetna|AETNA QHP HMO|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|PHCS|GROUP AND PENSION|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Aetna|AETNA PPO|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Aetna|AETNA OTHER|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Aetna Value Network|AETNA VALUE NETWORK|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicaid|MEDICAID|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Cigna|CIGNA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Cigna|CIGNA OTHER|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Cigna|CIGNA|0.13||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Humana Medicare Advantage|HUMANA MA|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Cigna|CIGNA OTHER|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Cigna|CIGNA|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicare|HEALTHSPRING MA|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Aetna|AETNA PPO|||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Aetna|AETNA QHP HMO|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.55||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Rusk State Hospital|RUSK STATE HOSP|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|United Healthcare|UNITED HEALTHCARE|||||0.55||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Medicaid|MEDICAID|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Medicare|MEDICARE PART B ONLY IP|0.55||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Medicare|MEDICARE ACUTE|0.55||||0.55||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicare|MEDICARE PART B ONLY IP|17.50||||||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicaid|SMITH COUNTY JAIL|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicaid|MEDICAID|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Healthcare|UNITED HEALTHCARE|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Healthcare|TML GROUP BENEFITS|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Healthcare|GEHA|17.50||||||| 9504234|ERX|0250|MORPHINE 10MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Rusk State Hospital|RUSK STATE HOSP|17.50||||||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Tricare|TRICARE EAST REGION|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|PHCS|GROUP AND PENSION|17.50||||||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Multiplan|PACIFICARE|17.50||||||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Workers Compensation|BROOKSHIRES WORKERS COMP|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Aetna|AETNA PPO|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Aetna|AETNA OTHER|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Healthcare|GOLDEN RULE|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|17.50||||||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|ChampVA|CHAMPVA CENTER|17.50||||||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicare|HEALTHSPRING MA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Cigna|CIGNA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Cigna|CIGNA OTHER|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Humana Medicare Advantage|HUMANA MA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|17.50||||17.50||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.60||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Cigna|CIGNA|||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|0.60||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.60||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.60||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|0.60||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.60||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Aetna|AETNA OTHER|||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|0.60||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Veterans Affairs|VETERANS ADMINISTRATION|||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.60||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.60||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.60||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.60||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Tricare|TRICARE EAST REGION|0.60||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE OTHER|0.60||||0.60||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.60||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Medicaid|MEDICAID|0.60||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Medicare|MEDICARE PART B ONLY IP|0.60||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Medicare|MEDICARE ACUTE|0.60||||0.60||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicare|MEDICARE PART B ONLY IP|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|LAW ENFORCEMENT OTHER|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|MEDICAID BCBSTX|||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|SMITH COUNTY JAIL|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|MEDICAID HMO|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|MEDICAID|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Healthcare|UNITED HEALTHCARE ERS|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Healthcare|GEHA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Healthcare|GOLDEN RULE|||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Texas Workforce Commission|DIS DETER SERV (DDS)|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Tricare|TRICARE FOR LIFE|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Tricare|TRICARE EAST REGION|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Rusk State Hospital|RUSK STATE HOSP|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|PHCS|GROUP AND PENSION|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|PHCS|HUMANA|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Multiplan|WEB TPA|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Multiplan|PACIFICARE|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 4|||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|BROOKSHIRES WORKERS COMP|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|UT EMPLOYEE INJURY|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|ZURICH COMPANY|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|GALLAGHER BASSETT|||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|TEXAS MUTUAL INSURANCE|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|PHCS|HUMANA INSURANCE|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Aetna|AETNA QHP HMO|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Aetna|BH AETNA|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Healthcare|UNITED HEALTHCARE|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Aetna|AETNA PPO|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Aetna|BOON CHAPMAN|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Aetna|AETNA OTHER|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Aetna Value Network|AETNA VALUE NETWORK|||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Healthcare|TML GROUP BENEFITS|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|ChampVA|CHAMPVA CENTER|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|WELLCARE CHOICE MA|||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|HEALTHSPRING MA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|HOSPICE OF EAST TEXAS|17.50||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Cigna|CIGNA OTHER|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Cigna|CIGNA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Humana Medicare Advantage|HUMANA MA|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||17.50||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|17.50||||17.50||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|Humana Medicare Advantage|HUMANA MA|0.23||||||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.23||||||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.23||||||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.23||||||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|Medicare|MEDICARE ACUTE|0.23||||||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|Medicare|MEDICARE PART B ONLY IP|0.23||||||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Medicare|MEDICARE ACUTE|6,282.75||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|United Healthcare|UNITED HEALTHCARE|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Aetna|AETNA OTHER|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,282.75||||||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Cigna|CIGNA|||||6,282.75||| 9504309|ERX|0250|ISOPROTERENOL 0.2MG/1ML|Humana Medicare Advantage|HUMANA MA|6,282.75||||6,282.75||| 9504317|ERX|0250|ISOPROTERENOL 0.2MG/ML, 5|Managed Medicare|HEALTHSPRING MA|5,607.75||||||| 9504317|ERX|0250|ISOPROTERENOL 0.2MG/ML, 5|Blue Cross HMO Specialty|BCBSTX HMO|5,607.75||||||| 9504317|ERX|0250|ISOPROTERENOL 0.2MG/ML, 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,607.75||||||| 9504317|ERX|0250|ISOPROTERENOL 0.2MG/ML, 5|United Healthcare|UNITED HEALTHCARE OTHER|5,607.75||||||| 9504317|ERX|0250|ISOPROTERENOL 0.2MG/ML, 5|Medicaid|MEDICAID|5,607.75||||||| 9504317|ERX|0250|ISOPROTERENOL 0.2MG/ML, 5|Medicare|MEDICARE ACUTE|5,607.75||||5,607.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicare|MEDICARE PART B ONLY IP|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicare|MEDICARE ACUTE|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicaid|CRIME VICTIMS COMPENSATION|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|NON CONTRACTED|COMMERCIAL OTHER 1|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|NON CONTRACTED|COMMERCIAL OTHER 2|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Tricare|TRICARE EAST REGION|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|PHCS|HUMANA INSURANCE|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|PHCS|HUMANA|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Healthcare|UNITED HEALTHCARE|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Healthcare|GOLDEN RULE|||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Healthcare|UNITED HEALTHCARE OTHER|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Workers Compensation|TEXAS MUTUAL INSURANCE|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Workers Compensation|WORKERS COMPENSATION OTHER|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Access Direct Platinum|HEALTHFIRST TPA UMR|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Veterans Affairs|VETERANS ADMINISTRATION|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Medicare Advantage|UHC AARP MCR HMO MA|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Healthcare|TML GROUP BENEFITS|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Rusk State Hospital|RUSK STATE HOSP|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|ChampVA|CHAMPVA CENTER|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Blue Cross PPO Specialty|BCBSTX OTHER|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Blue Cross PPO Specialty|BCBSTX PPO|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Aetna|AETNA QHP HMO|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Aetna|AETNA PPO|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Aetna|AETNA OTHER|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicaid|MEDICAID|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Blue Cross HMO Specialty|BCBSTX HMO|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Cigna|CIGNA OTHER|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Humana Medicare Advantage|HUMANA MA|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Cigna|CIGNA|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicaid|MEDICAID AMERIGROUP|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicaid|MEDICAID SUPERIOR|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicare|HEALTHSPRING MA|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicare|BCBS MEDICARE PPO MA|84.75||||84.75||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|84.75||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicare|WELLCARE CHOICE MA|84.75||||||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|131.25||||131.25||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|Humana Medicare Advantage|HUMANA MA|131.25||||||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|131.25||||||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|Aenta Medicare Advantage|AETNA MEDICARE MA|131.25||||||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||131.25||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|United Medicare Advantage|UHC MEDICARE GOLD MA|131.25||||||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|United Medicare Advantage|UHC AARP MCR HMO MA|131.25||||||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|Access Direct Platinum|HEALTHFIRST TPA|131.25||||||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|Veterans Affairs|VETERANS ADMINISTRATION|131.25||||||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|United Healthcare|UNITED HEALTHCARE|||||131.25||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|Medicaid|MEDICAID|131.25||||||| 9504341|ERX|0258|DEXTROSE 5%-WATER,GLASS 2|Medicare|MEDICARE ACUTE|131.25||||131.25||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Medicaid|MEDICAID|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Tricare|TRICARE EAST REGION|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Tricare|TRICARE FOR LIFE|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|PHCS|HUMANA|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Healthcare|UNITED HEALTHCARE|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Healthcare|UNITED HEALTHCARE OTHER|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Workers Compensation|TEXAS MUTUAL INSURANCE|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Veterans Affairs|VETERANS ADMINISTRATION|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Workers Compensation|UT EMPLOYEE INJURY|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross PPO Specialty|BCBSTX PPO|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross PPO Specialty|BCBSTX OTHER|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Medicare|MEDICARE ACUTE|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|ChampVA|CHAMPVA CENTER|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Aetna|AETNA PPO|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross HMO Specialty|BCBSTX HMO|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Cigna|CIGNA|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Humana Medicare Advantage|HUMANA MA|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicaid|MEDICAID SUPERIOR|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|30.75||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicare|BCBS MEDICARE PPO MA|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicare|OTHER INSTITUTIONS|||||30.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicare|HEALTHSPRING MA|30.75||||30.75||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicare|BCBS MEDICARE PPO MA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicare|HEALTHSPRING MA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicaid|MEDICAID SUPERIOR|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicaid|MEDICAID AMERIGROUP|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Cigna|CIGNA OTHER|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Humana Medicare Advantage|HUMANA MA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Aetna Value Network|AETNA VALUE NETWORK|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Blue Cross HMO Specialty|BCBSTX HMO|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Aetna|AETNA QHP HMO|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Aetna|AETNA PPO|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Aetna|BOON CHAPMAN|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|ChampVA|CHAMPVA CENTER|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Blue Cross PPO Specialty|BCBSTX PPO|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Veterans Affairs|VETERANS ADMINISTRATION|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Workers Compensation|UT EMPLOYEE INJURY|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Workers Compensation|BROOKSHIRES WORKERS COMP|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Healthcare|UNITED HEALTHCARE OTHER|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Healthcare|TML GROUP BENEFITS|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Healthcare|GEHA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Aetna|AETNA OTHER|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Cigna|CIGNA|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Healthcare|UNITED HEALTHCARE|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|NON CONTRACTED|COMMERCIAL OTHER 2|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Tricare|TRICARE EAST REGION|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Tricare|TRICARE FOR LIFE|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Tricare|TRICARE SOUTH PHYSICIAN|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|PHCS|GROUP AND PENSION|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|PHCS|HUMANA|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicare|MEDICARE ACUTE|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicare|MEDICARE PART B ONLY IP|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicaid|MEDICAID HMO|||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicaid|SMITH COUNTY JAIL|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicaid|MEDICAID|0.36||||0.36||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicaid|CRIME VICTIMS COMPENSATION|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicaid|LAW ENFORCEMENT OTHER|0.36||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.36||||0.36||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Medicaid|SMITH COUNTY JAIL|0.37||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Medicare|MEDICARE PART B ONLY IP|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Tricare|TRICARE EAST REGION|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|PHCS|GROUP AND PENSION|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|PHCS|HUMANA|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Healthcare|UNITED HEALTHCARE OTHER|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Healthcare|TML GROUP BENEFITS|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Healthcare|GEHA|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.37||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Workers Compensation|ZURICH COMPANY|0.37||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.37||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Workers Compensation|GALLAGHER BASSETT|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Workers Compensation|BROOKSHIRES WORKERS COMP|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Healthcare|UNITED HEALTHCARE|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Veterans Affairs|VETERANS ADMINISTRATION|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Healthcare|UNITED HEALTHCARE|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|ChampVA|CHAMPVA CENTER|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Aetna|AETNA OTHER|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Aetna|AETNA PPO|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.37||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Blue Cross HMO Specialty|BCBSTX HMO|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Cigna|CIGNA|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Cigna|CIGNA OTHER|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Medicaid|MEDICAID|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Humana Medicare Advantage|HUMANA MA|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Cigna|CIGNA|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicaid|MEDICAID SUPERIOR|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicare|BCBS MEDICARE PPO MA|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.37||||0.37||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicare|HEALTHSPRING MA|0.37||||0.37||| 95044|EAP|0510|ALLERGY PATCH TESTS|Blue Cross PPO Specialty|BCBSTX PPO|||||28.88||| 95044|EAP|0510|ALLERGY PATCH TESTS|United Medicare Advantage|UHC AARP MCR HMO MA|||||28.88||| 95044|EAP|0510|ALLERGY PATCH TESTS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||28.88||| 95044|EAP|0510|ALLERGY PATCH TESTS|Tricare|TRICARE EAST REGION|||||28.88||| 95044|EAP|0510|ALLERGY PATCH TESTS|Medicare|MEDICARE ACUTE|||||28.88||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|34.75||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicare|MEDICARE ACUTE|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicare|MEDICARE PART B ONLY IP|34.75||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid|CRIME VICTIMS COMPENSATION|34.75||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|34.75||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid|MEDICAID HMO|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid|SMITH COUNTY JAIL|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid|LAW ENFORCEMENT OTHER|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Rusk State Hospital|RUSK STATE HOSP|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Tricare|TRICARE EAST REGION|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|PHCS|HUMANA INSURANCE|34.75||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|PHCS|HUMANA|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|PHCS|GROUP AND PENSION|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Multiplan|WEB TPA|34.75||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Healthcare|UNITED HEALTHCARE OTHER|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Healthcare|UNITED HEALTHCARE ERS|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Healthcare|TML GROUP BENEFITS|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|WORKERS COMPENSATION OTHER|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|UT EMPLOYEE INJURY|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|34.75||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|ZURICH COMPANY|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|TEXAS MUTUAL INSURANCE|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|BROOKSHIRES WORKERS COMP|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Healthcare|UNITED HEALTHCARE|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Medicare Advantage|UHC AARP MCR HMO MA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Veterans Affairs|VETERANS ADMINISTRATION|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Tricare|TRICARE FOR LIFE|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicare|HEALTHSPRING MA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid|MEDICAID|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicare|BCBS MEDICARE PPO MA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicaid|MEDICAID AMERIGROUP|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicaid|MEDICAID SUPERIOR|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Cigna|CIGNA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Cigna|CIGNA OTHER|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Humana Medicare Advantage|HUMANA MA|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Aetna Value Network|AETNA VALUE NETWORK|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Blue Cross HMO Specialty|BCBSTX HMO|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Aetna|AETNA QHP HMO|||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Aetna|AETNA PPO|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Aetna|AETNA OTHER|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Blue Cross PPO Specialty|BCBSTX PPO|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Blue Cross PPO Specialty|BCBSTX OTHER|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|34.75||||34.75||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|ChampVA|CHAMPVA CENTER|34.75||||34.75||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|ChampVA|CHAMPVA CENTER|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Aetna|BOON CHAPMAN|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Aetna|AETNA OTHER|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Blue Cross HMO Specialty|BCBSTX HMO|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Aetna Value Network|AETNA VALUE NETWORK|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Cigna|CIGNA OTHER|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Cigna|CIGNA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Humana Medicare Advantage|HUMANA MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicaid|MEDICAID SUPERIOR|39.25||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicare|BCBS MEDICARE PPO MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Veterans Affairs|VETERANS ADMINISTRATION|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicare|TEXAS COMMUNITY CARE MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicare|HEALTHSPRING MA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Workers Compensation|UT EMPLOYEE INJURY|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Workers Compensation|TEXAS MUTUAL INSURANCE|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Aetna|AETNA PPO|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Healthcare|GEHA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Healthcare|UNITED HEALTHCARE|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Healthcare|GOLDEN RULE|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Blue Cross PPO Specialty|BCBSTX PPO|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Healthcare|UNITED HEALTHCARE OTHER|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Healthcare|AARP|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|United Healthcare|TML GROUP BENEFITS|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Tricare|TRICARE EAST REGION|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Tricare|TRICARE FOR LIFE|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|PHCS|GROUP AND PENSION|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|PHCS|HUMANA|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Medicaid|MEDICAID|||||39.25||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Medicare|MEDICARE ACUTE|39.25||||39.25||| 9504424|ERX|0250|BUPIVACAINE 0.75%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA|||||0.65||| 9504424|ERX|0250|BUPIVACAINE 0.75%PF 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.65||| 9504424|ERX|0250|BUPIVACAINE 0.75%PF 30ML|Managed Medicaid|MEDICAID SUPERIOR|||||0.65||| 9504424|ERX|0250|BUPIVACAINE 0.75%PF 30ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.65||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Medicaid|MEDICAID|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Medicare|MEDICARE PART B ONLY IP|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Managed Medicare|HEALTHSPRING MA|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Managed Medicare|BCBS MEDICARE PPO MA|||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Rusk State Hospital|RUSK STATE HOSP|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|PHCS|GROUP AND PENSION|||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|NON CONTRACTED|COMMERCIAL OTHER 1|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|United Healthcare|UNITED HEALTHCARE OTHER|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|United Healthcare|UNITED HEALTHCARE|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Aetna|AETNA PPO|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Aetna|AETNA OTHER|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|UTMB|UTMB CORRECTIONAL MANAGED CARE|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Aenta Medicare Advantage|AETNA MEDICARE MA|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Blue Cross HMO Specialty|BCBSTX HMO|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Tricare|TRICARE EAST REGION|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Blue Cross PPO Specialty|BCBSTX PPO|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Blue Cross PPO Specialty|BCBSTX OTHER|||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Managed Medicaid|MEDICAID SUPERIOR|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Cigna|CIGNA|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Medicare|MEDICARE ACUTE|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Cigna|CIGNA OTHER|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Cigna|CIGNA|||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Humana Medicare Advantage|HUMANA MA|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|United Medicare Advantage|UHC AARP MCR HMO MA|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|United Medicare Advantage|UHC MEDICARE GOLD MA|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Workers Compensation|WORKERS COMPENSATION OTHER|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Veterans Affairs|VETERANS ADMINISTRATION|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Access Direct Platinum|HEALTHFIRST TPA|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|118.50||||||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|118.50||||118.50||| 9504432|ERX|0258|NA CHLORIDE 0.9%,250MLGLA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||118.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Aenta Medicare Advantage|AETNA MEDICARE MA|59.50||||||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Access Direct Platinum|HEALTHFIRST TPA UMR|||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Veterans Affairs|VETERANS ADMINISTRATION|59.50||||||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59.50||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|United Medicare Advantage|UHC AARP MCR HMO MA|||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Managed Medicaid|MEDICAID SUPERIOR|59.50||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|United Medicare Advantage|UHC MEDICARE GOLD MA|59.50||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Managed Medicaid|MEDICAID AMERIGROUP|||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|59.50||||||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|59.50||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|59.50||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Cigna|CIGNA OTHER|||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Humana Medicare Advantage|HUMANA MA|59.50||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Managed Medicare|HEALTHSPRING MA|59.50||||||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Blue Cross PPO Specialty|BCBSTX PPO|59.50||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Aetna|AETNA PPO|||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.50||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Blue Cross HMO Specialty|BCBSTX HMO|59.50||||||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|NON CONTRACTED|COMMERCIAL OTHER 1|||||59.50||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Medicaid|CRIME VICTIMS COMPENSATION|59.50||||||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Medicaid|MEDICAID|59.50||||||| 9504457|ERX|0250|BUPIVACAINE 0.25% MDV 50M|Medicare|MEDICARE ACUTE|59.50||||59.50||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Medicare|MEDICARE PART B ONLY IP|0.46||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Medicare|MEDICARE ACUTE|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Medicaid|MEDICAID|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Medicaid|CRIME VICTIMS COMPENSATION|0.46||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|United Healthcare|UNITED HEALTHCARE|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|United Healthcare|UNITED HEALTHCARE|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Rusk State Hospital|RUSK STATE HOSP|0.46||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Tricare|TRICARE EAST REGION|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|PHCS|HUMANA|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Blue Cross HMO Specialty|BCBSTX HMO|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Aetna Value Network|AETNA VALUE NETWORK|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Aetna|AETNA PPO|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Aetna|AETNA OTHER|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.46||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Blue Cross PPO Specialty|BCBSTX PPO|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicare|HEALTHSPRING MA|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicare|BCBS MEDICARE PPO MA|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Cigna|CIGNA OTHER|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Cigna|CIGNA|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Cigna|CIGNA|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Humana Medicare Advantage|HUMANA MA|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Magellan Behavioral Health|BH MAGELLAN|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicaid|MEDICAID SUPERIOR|0.46||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|United Healthcare|UNITED HEALTHCARE OTHER|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Veterans Affairs|VETERANS ADMINISTRATION|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.46||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Workers Compensation|UT EMPLOYEE INJURY|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Workers Compensation|TEXAS MUTUAL INSURANCE|||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Workers Compensation|BROOKSHIRES WORKERS COMP|0.46||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Access Direct Platinum|HEALTHFIRST TPA|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.46||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.46||||0.46||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.46||||0.46||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Veterans Affairs|VETERANS ADMINISTRATION|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|United Medicare Advantage|UHC MEDICARE GOLD MA|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Managed Medicaid|MEDICAID AMERIGROUP|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Cigna|CIGNA|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Humana Medicare Advantage|HUMANA MA|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Managed Medicare|BCBS MEDICARE PPO MA|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Managed Medicare|HEALTHSPRING MA|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Blue Cross PPO Specialty|BCBSTX PPO|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|United Medicare Advantage|UHC AARP MCR HMO MA|7.29||||7.29||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Aenta Medicare Advantage|AETNA MEDICARE MA|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Aetna|AETNA PPO|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Blue Cross HMO Specialty|BCBSTX HMO|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|United Healthcare|UNITED HEALTHCARE|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|United Healthcare|UNITED HEALTHCARE OTHER|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Medicaid|CRIME VICTIMS COMPENSATION|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Medicaid|MEDICAID|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Medicaid|MOLINA HEALTHCARE OF TEXAS|7.29||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Medicare|MEDICARE ACUTE|7.29||||7.29||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|Medicare|MEDICARE ACUTE|0.38||||0.38||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|NON CONTRACTED|COMMERCIAL OTHER 1|0.38||||||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|United Healthcare|UNITED HEALTHCARE OTHER|||||0.38||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.38||||0.38||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|Blue Cross HMO Specialty|BCBSTX HMO|||||0.38||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|Aetna|AETNA PPO|0.38||||||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|Blue Cross PPO Specialty|BCBSTX PPO|0.38||||0.38||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.38||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|Managed Medicare|HEALTHSPRING MA|||||0.38||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|United Medicare Advantage|UHC MEDICARE GOLD MA|0.38||||||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|Workers Compensation|TEXAS MUTUAL INSURANCE|||||0.38||| 9504499|ERX|0250|BUPIVACAINE-EPI 0.25%PF 1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.38||||||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Access Direct Platinum|HEALTHFIRST TPA|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Access Direct Platinum|HEALTHFIRST TPA UMR|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Veterans Affairs|VETERANS ADMINISTRATION|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Medicare Advantage|UHC MEDICARE GOLD MA|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Cigna|CIGNA|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Humana Medicare Advantage|HUMANA MA|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Managed Medicaid|MEDICAID AMERIGROUP|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Managed Medicare|HEALTHSPRING MA|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Blue Cross PPO Specialty|BCBSTX PPO|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Aetna|AETNA PPO|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Blue Cross HMO Specialty|BCBSTX HMO|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Healthcare|UNITED HEALTHCARE|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Healthcare|UNITED HEALTHCARE OTHER|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Healthcare|TML GROUP BENEFITS|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Healthcare|GOLDEN RULE|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Healthcare|UNITED HEALTHCARE|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Texas Workforce Commission|DIS DETER SERV (DDS)|0.87||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Rusk State Hospital|RUSK STATE HOSP|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.87||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.87||||||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Medicare|MEDICARE ACUTE|0.87||||0.87||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Medicare|MEDICARE ACUTE|0.39||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.39||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|United Healthcare|GOLDEN RULE|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|United Healthcare|UNITED HEALTHCARE OTHER|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Blue Cross HMO Specialty|BCBSTX HMO|0.39||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Blue Cross PPO Specialty|BCBSTX PPO|0.39||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|United Healthcare|UNITED HEALTHCARE|0.39||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Managed Medicare|HEALTHSPRING MA|0.39||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Managed Medicare|BCBS MEDICARE PPO MA|0.39||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Managed Medicaid|MEDICAID SUPERIOR|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.39||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Cigna|CIGNA|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Humana Medicare Advantage|HUMANA MA|0.39||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|United Medicare Advantage|UHC MEDICARE GOLD MA|0.39||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.39||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|United Medicare Advantage|UHC AARP MCR HMO MA|0.39||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Veterans Affairs|VETERANS ADMINISTRATION|0.39||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.39||||0.39||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.39||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Workers Compensation|WORKERS COMPENSATION OTHER|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Workers Compensation|TEXAS MUTUAL INSURANCE|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Access Direct Platinum|HEALTHFIRST TPA|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Access Direct Platinum|HEALTHFIRST TPA UMR|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Veterans Affairs|VETERANS ADMINISTRATION|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Medicare Advantage|UHC AARP MCR HMO MA|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Cigna|CIGNA|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Cigna|CIGNA OTHER|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Humana Medicare Advantage|HUMANA MA|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicaid|MEDICAID SUPERIOR|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicaid|MEDICAID AMERIGROUP|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicare|BCBS MEDICARE PPO MA|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicare|HEALTHSPRING MA|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|ChampVA|CHAMPVA CENTER|67.25||||||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross PPO Specialty|BCBSTX PPO|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Medicare Advantage|UHC MEDICARE GOLD MA|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross PPO Specialty|BCBSTX OTHER|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Aetna|AETNA OTHER|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Aenta Medicare Advantage|AETNA MEDICARE MA|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Aetna|AETNA PPO|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Aetna|BOON CHAPMAN|67.25||||||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross HMO Specialty|BCBSTX HMO|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Healthcare|GEHA|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Healthcare|UNITED HEALTHCARE|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Healthcare|UNITED HEALTHCARE OTHER|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Healthcare|TML GROUP BENEFITS|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Tricare|TRICARE FOR LIFE|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Tricare|TRICARE EAST REGION|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|NON CONTRACTED|COMMERCIAL OTHER 2|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|NON CONTRACTED|COMMERCIAL OTHER 1|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicaid|MEDICAID|67.25||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicaid|CRIME VICTIMS COMPENSATION|67.25||||||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicaid|LAW ENFORCEMENT OTHER|||||67.25||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicare|MEDICARE PART B ONLY IP|67.25||||||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicare|MEDICARE ACUTE|67.25||||67.25||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Humana Medicare Advantage|HUMANA MA|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Cigna|CIGNA|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|United Medicare Advantage|UHC MEDICARE GOLD MA|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|United Medicare Advantage|UHC AARP MCR HMO MA|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Veterans Affairs|VETERANS ADMINISTRATION|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Aenta Medicare Advantage|AETNA MEDICARE MA|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Access Direct Platinum|HEALTHFIRST TPA UMR|0.70||||||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.70||||||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|United Healthcare|UNITED HEALTHCARE|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Managed Medicare|BCBS MEDICARE PPO MA|0.70||||||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|United Healthcare|UNITED HEALTHCARE OTHER|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|PHCS|GROUP AND PENSION|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Blue Cross PPO Specialty|BCBSTX PPO|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Medicaid|MEDICAID|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|United Healthcare|GOLDEN RULE|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|United Healthcare|UNITED HEALTHCARE|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.70||||||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Tricare|TRICARE EAST REGION|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|United Healthcare|TML GROUP BENEFITS|0.70||||||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Blue Cross HMO Specialty|BCBSTX HMO|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Managed Medicare|HEALTHSPRING MA|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Medicare|MEDICARE PART B ONLY IP|0.70||||||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Aetna|AETNA PPO|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Managed Medicaid|MEDICAID SUPERIOR|||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Medicare|MEDICARE ACUTE|0.70||||0.70||| 9504531|ERX|0250|BUPIVACAINE-EPI 0.25%MDV|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.70||||||| 9504556|ERX|0250|DEX 25%-WATER,ABBOJECT 10|Medicare|MEDICARE ACUTE|41.25||||41.25||| 9504556|ERX|0250|DEX 25%-WATER,ABBOJECT 10|Medicaid|COUNTY INDIGENT HEALTH OTHER|41.25||||||| 9504556|ERX|0250|DEX 25%-WATER,ABBOJECT 10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||41.25||| 9504556|ERX|0250|DEX 25%-WATER,ABBOJECT 10|Managed Medicare|HEALTHSPRING MA|41.25||||41.25||| 9504556|ERX|0250|DEX 25%-WATER,ABBOJECT 10|Managed Medicaid|MEDICAID SUPERIOR|||||41.25||| 9504556|ERX|0250|DEX 25%-WATER,ABBOJECT 10|Blue Cross HMO Specialty|BCBSTX HMO|||||41.25||| 9504580|ERX|0250|PROCAINAMIDE 500MG/ML, 2M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.87||||||| 9504580|ERX|0250|PROCAINAMIDE 500MG/ML, 2M|Humana Medicare Advantage|HUMANA MA|0.87||||||| 9504580|ERX|0250|PROCAINAMIDE 500MG/ML, 2M|Medicare|MEDICARE ACUTE|0.87||||||| 9504580|ERX|0250|PROCAINAMIDE 500MG/ML, 2M|Veterans Affairs|VETERANS ADMINISTRATION|0.87||||||| 9504598|ERX|0250|AMIKACIN 250MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|129.50||||||| 9504598|ERX|0250|AMIKACIN 250MG/ML|Medicare|MEDICARE ACUTE|129.50||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Aetna|AETNA PPO|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Cigna|CIGNA|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Managed Medicare|BCBS MEDICARE PPO MA|||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Medicaid|MEDICAID|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|PHCS|HUMANA|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|NON CONTRACTED|COMMERCIAL OTHER 2|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Access Direct Platinum|HEALTHFIRST TPA|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|ChampVA|CHAMPVA CENTER|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Cigna|CIGNA OTHER|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Aetna|AETNA OTHER|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9504606|ERX|0250|NA CHLORIDE 0.9%(B'STAT)|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Managed Medicaid|MEDICAID AMERIGROUP|1.41||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.41||||||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Medicaid|SMITH COUNTY JAIL|1.41||||||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.41||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.41||||||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|United Healthcare|UNITED HEALTHCARE|1.41||||||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Managed Medicaid|MEDICAID SUPERIOR|||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Cigna|CIGNA|1.41||||||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|United Healthcare|TML GROUP BENEFITS|||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.41||||||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Humana Medicare Advantage|HUMANA MA|1.41||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Managed Medicare|HEALTHSPRING MA|1.41||||||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Medicaid|MEDICAID HMO|||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.41||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Medicare|MEDICARE ACUTE|1.41||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.41||||1.41||| 9504622|ERX|0250|KETAMINE 100MG/ML, 5ML|Medicaid|MEDICAID|1.41||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Medicare|MEDICARE ACUTE|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Medicaid|CRIME VICTIMS COMPENSATION|103.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|103.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Medicaid|MEDICAID|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Managed Medicare|HEALTHSPRING MA|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|103.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|103.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Managed Medicaid|MEDICAID SUPERIOR|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|103.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Tricare|TRICARE EAST REGION|103.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Cigna|CIGNA|||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Aetna|AETNA PPO|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|103.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Humana Medicare Advantage|HUMANA MA|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.75||||103.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|United Healthcare|UNITED HEALTHCARE|103.75||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Workers Compensation|GALLAGHER BASSETT|||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Workers Compensation|UT EMPLOYEE INJURY|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Medicare Advantage|UHC AARP MCR HMO MA|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicare|BCBS MEDICARE PPO MA|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Access Direct Platinum|HEALTHFIRST TPA|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Veterans Affairs|VETERANS ADMINISTRATION|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID SUPERIOR|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Cigna|CIGNA|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Workers Compensation|WORKERS COMPENSATION OTHER|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Cigna|CIGNA OTHER|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicare|HEALTHSPRING MA|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID AMERIGROUP|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicare|MEDICARE PART B ONLY IP|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Aetna|AETNA QHP HMO|||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Blue Cross PPO Specialty|BCBSTX PPO|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Aetna|AETNA OTHER|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicare|MEDICARE ACUTE|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|ChampVA|CHAMPVA CENTER|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Humana Medicare Advantage|HUMANA MA|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicaid|SMITH COUNTY JAIL|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|NON CONTRACTED|COMMERCIAL OTHER 1|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Aetna|AETNA PPO|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Blue Cross PPO Specialty|BCBSTX OTHER|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Tricare|TRICARE EAST REGION|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicaid|MEDICAID|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Healthcare|UNITED HEALTHCARE OTHER|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Healthcare|UNITED HEALTHCARE|4.66||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Rusk State Hospital|RUSK STATE HOSP|||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Healthcare|UNITED HEALTHCARE|4.66||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||4.66||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Blue Cross HMO Specialty|BCBSTX HMO|4.66||||4.66||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Medicaid|MEDICAID|48.50||||||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Medicare|UTSW MC KIDNEY PROGRAM|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Medicare|MEDICARE ACUTE|48.50||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Veterans Affairs|VETERANS ADMINISTRATION|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|48.50||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Humana Medicare Advantage|HUMANA MA|48.50||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Blue Cross HMO Specialty|BCBSTX HMO|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Managed Medicare|HEALTHSPRING MA|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Blue Cross PPO Specialty|BCBSTX PPO|48.50||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Managed Medicare|OTHER INSTITUTIONS|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|Cigna|CIGNA|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||48.50||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||48.50||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Aetna|AETNA QHP HMO|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|United Medicare Advantage|UHC AARP MCR HMO MA|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Veterans Affairs|VETERANS ADMINISTRATION|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Workers Compensation|WORKERS COMPENSATION OTHER|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Cigna|CIGNA OTHER|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Access Direct Platinum|HEALTHFIRST TPA UMR|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Blue Cross PPO Specialty|BCBSTX OTHER|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|United Medicare Advantage|UHC AARP WELLMED HMO MA|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|PHCS|GROUP AND PENSION|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|United Healthcare|UNITED HEALTHCARE|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|United Healthcare|UNITED HEALTHCARE OTHER|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Blue Cross HMO Specialty|BCBSTX HMO|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|186.25||||186.25||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|United Medicare Advantage|UHC MEDICARE GOLD MA|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Blue Cross PPO Specialty|BCBSTX PPO|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Cigna|CIGNA|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|UTMB|UTMB CORRECTIONAL MANAGED CARE|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Aenta Medicare Advantage|AETNA MEDICARE MA|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Tricare|TRICARE EAST REGION|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|NON CONTRACTED|COMMERCIAL OTHER 1|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Managed Medicaid|MEDICAID AMERIGROUP|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Managed Medicare|HEALTHSPRING MA|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Medicaid|MOLINA HEALTHCARE OF TEXAS|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Managed Medicare|BCBS MEDICARE PPO MA|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Humana Medicare Advantage|HUMANA MA|186.25||||186.25||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Medicaid|COUNTY INDIGENT HEALTH OTHER|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Medicaid|MEDICAID|186.25||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Medicare|MEDICARE ACUTE|186.25||||186.25||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|15.48||||||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.48||||||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|United Healthcare|UNITED HEALTHCARE|15.48||||||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|Medicare|MEDICARE ACUTE|15.48||||15.48||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|Humana Medicare Advantage|HUMANA MA|15.48||||15.48||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.48||||||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||15.48||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|Managed Medicare|HEALTHSPRING MA|15.48||||||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|15.48||||15.48||| 9504689|ERX|0250|NITROPRUSSIDE 50MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|15.48||||15.48||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicaid|MEDICAID HMO|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Healthcare|TML GROUP BENEFITS|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Tricare|TRICARE EAST REGION|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|ChampVA|CHAMPVA CENTER|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Healthcare|UNITED HEALTHCARE|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicaid|MEDICAID|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicaid|SMITH COUNTY JAIL|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Cigna|CIGNA|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Cigna|CIGNA OTHER|||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Aetna|AETNA PPO|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Aetna|AETNA OTHER|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Medicare|MEDICARE PART B ONLY IP|62.50||||||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Tricare|TRICARE EAST REGION|||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Medicaid|MEDICAID|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|United Healthcare|UNITED HEALTHCARE OTHER|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Medicare|MEDICARE ACUTE|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|62.50||||||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Aetna|AETNA PPO|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Blue Cross HMO Specialty|BCBSTX HMO|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|United Healthcare|UNITED HEALTHCARE|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|62.50||||||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Blue Cross PPO Specialty|BCBSTX OTHER|62.50||||||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Humana Medicare Advantage|HUMANA MA|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Managed Medicaid|MEDICAID AMERIGROUP|||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Managed Medicare|BCBS MEDICARE PPO MA|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Veterans Affairs|VETERANS ADMINISTRATION|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Blue Cross PPO Specialty|BCBSTX PPO|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|United Medicare Advantage|UHC AARP MCR HMO MA|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Cigna|CIGNA|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Managed Medicaid|MEDICAID SUPERIOR|||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Managed Medicare|HEALTHSPRING MA|62.50||||62.50||| 9504705|ERX|0250|LIDOCAINE-EPI 1% MDV 30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|62.50||||62.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Workers Compensation|UT EMPLOYEE INJURY|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Cigna|CIGNA|32.50||||||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Workers Compensation|GALLAGHER BASSETT|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Veterans Affairs|VETERANS ADMINISTRATION|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|32.50||||||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Cigna|CIGNA OTHER|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Workers Compensation|TEXAS MUTUAL INSURANCE|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|United Medicare Advantage|UHC AARP MCR HMO MA|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Humana Medicare Advantage|HUMANA MA|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Aetna|AETNA PPO|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicaid|MEDICAID AMERIGROUP|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicare|BCBS MEDICARE PPO MA|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Aetna|AETNA OTHER|32.50||||||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicaid|SMITH COUNTY JAIL|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Aetna|AETNA QHP HMO|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Aetna Value Network|AETNA VALUE NETWORK|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicare|HEALTHSPRING MA|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Blue Cross PPO Specialty|BCBSTX OTHER|32.50||||||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|32.50||||||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|United Healthcare|UNITED HEALTHCARE OTHER|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Tricare|TRICARE EAST REGION|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Blue Cross HMO Specialty|BCBSTX HMO|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicaid|MEDICAID|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|United Healthcare|UNITED HEALTHCARE|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Workers Compensation|WORKERS COMPENSATION OTHER|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Blue Cross PPO Specialty|BCBSTX PPO|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|United Healthcare|UNITED HEALTHCARE ERS|32.50||||||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|United Healthcare|TML GROUP BENEFITS|32.50||||||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|United Healthcare|UNITED HEALTHCARE|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|PHCS|HUMANA|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicaid|MEDICAID SUPERIOR|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicaid|CRIME VICTIMS COMPENSATION|32.50||||||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicaid|MEDICAID HMO|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|NON CONTRACTED|COMMERCIAL OTHER 1|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicare|MEDICARE PART B ONLY IP|32.50||||||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicare|MEDICARE ACUTE|32.50||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicaid|LAW ENFORCEMENT OTHER|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Cigna|CIGNA|||||32.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32.50||||32.50||| 9504739|ERX|0250|ACETYLCYSTEINE 20%, 30ML|Medicare|MEDICARE ACUTE|75.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|69.75||||69.75||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Aetna|AETNA PPO|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Aetna|AETNA OTHER|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Managed Medicare|HEALTHSPRING MA|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Humana Medicare Advantage|HUMANA MA|69.75||||69.75||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Cigna|CIGNA|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Cigna|CIGNA OTHER|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Tricare|TRICARE EAST REGION|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Medicare|MEDICARE ACUTE|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Medicaid|MEDICAID|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|United Healthcare|UNITED HEALTHCARE|69.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||69.75||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|United Healthcare|UNITED HEALTHCARE|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Medicaid|MEDICAID|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||117.75||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|PHCS|GROUP AND PENSION|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Humana Medicare Advantage|HUMANA MA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Cigna|CIGNA OTHER|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Medicare|MEDICARE ACUTE|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Managed Medicare|HEALTHSPRING MA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Aetna|AETNA QHP HMO|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Cigna|CIGNA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|117.75||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|117.75||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Managed Medicare|HEALTHSPRING MA|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|United Healthcare|UNITED HEALTHCARE|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Managed Medicare|BCBS MEDICARE PPO MA|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Blue Cross HMO Specialty|BCBSTX HMO|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Blue Cross PPO Specialty|BCBSTX PPO|15.25||||15.25||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Cigna|CIGNA OTHER|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Cigna|CIGNA|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Managed Medicaid|MEDICAID AMERIGROUP|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Humana Medicare Advantage|HUMANA MA|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|United Medicare Advantage|UHC AARP MCR HMO MA|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|NON CONTRACTED|COMMERCIAL OTHER 1|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Medicaid|MEDICAID|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Veterans Affairs|VETERANS ADMINISTRATION|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Medicare|MEDICARE ACUTE|15.25||||||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Managed Medicaid|MEDICAID SUPERIOR|||||15.25||| 9504796|ERX|0250|RALOXIFENE 60MG TABLET|Managed Medicare|HEALTHSPRING MA|36.75||||36.75||| 9504796|ERX|0250|RALOXIFENE 60MG TABLET|Medicare|MEDICARE ACUTE|36.75||||36.75||| 9504796|ERX|0250|RALOXIFENE 60MG TABLET|Humana Medicare Advantage|HUMANA MA|36.75||||36.75||| 9504796|ERX|0250|RALOXIFENE 60MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36.75||||||| 9504796|ERX|0250|RALOXIFENE 60MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|36.75||||||| 9504796|ERX|0250|RALOXIFENE 60MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|36.75||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Veterans Affairs|VETERANS ADMINISTRATION|4.47||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||4.47||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|4.47||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Medicare|MEDICARE ACUTE|4.47||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||4.47||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.47||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.47||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Managed Medicare|HEALTHSPRING MA|4.47||||||| 9504838|ERX|0250|LIDOCAINE 1%MDV 50ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.21||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|PHCS|HUMANA INSURANCE|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|PHCS|GROUP AND PENSION|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Medicaid|MEDICAID HMO|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Medicaid|MEDICAID|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|United Healthcare|UNITED HEALTHCARE|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Tricare|TRICARE EAST REGION|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|United Healthcare|UNITED HEALTHCARE OTHER|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Cigna|CIGNA|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Cigna|CIGNA OTHER|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Humana Medicare Advantage|HUMANA MA|28.50||||28.50||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Managed Medicaid|MEDICAID AMERIGROUP|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Managed Medicaid|MEDICAID SUPERIOR|28.50||||28.50||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Managed Medicare|BCBS MEDICARE PPO MA|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Aetna|AETNA PPO|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||28.50||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.50||||28.50||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Aetna Value Network|AETNA VALUE NETWORK|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Blue Cross HMO Specialty|BCBSTX HMO|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Blue Cross PPO Specialty|BCBSTX OTHER|28.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Blue Cross PPO Specialty|BCBSTX PPO|28.50||||28.50||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|United Healthcare|UNITED HEALTHCARE|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Medicaid|MEDICAID|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Tricare|TRICARE EAST REGION|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|PHCS|GROUP AND PENSION|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|United Healthcare|UNITED HEALTHCARE|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|United Healthcare|UNITED HEALTHCARE OTHER|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Rusk State Hospital|RUSK STATE HOSP|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Medicare|MEDICARE ACUTE|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Cigna|CIGNA|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Blue Cross PPO Specialty|BCBSTX OTHER|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Managed Medicaid|MEDICAID SUPERIOR|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Cigna|CIGNA OTHER|||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Aetna|AETNA PPO|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Humana Medicare Advantage|HUMANA MA|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Managed Medicare|HEALTHSPRING MA|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Managed Medicaid|MEDICAID AMERIGROUP|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Blue Cross HMO Specialty|BCBSTX HMO|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Blue Cross PPO Specialty|BCBSTX PPO|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|46.25||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|46.25||||||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Workers Compensation|ZURICH COMPANY|||||46.25||| 9504853|ERX|0250|LIDOCAINE 2%PF 10ML|Workers Compensation|BROOKSHIRES WORKERS COMP|46.25||||||| 9504861|ERX|0250|FONDAPARINUX 7.5MG/0.6ML|Medicare|MEDICARE ACUTE|10.14||||||| 9504861|ERX|0250|FONDAPARINUX 7.5MG/0.6ML|Managed Medicare|HEALTHSPRING MA|10.14||||||| 9504861|ERX|0250|FONDAPARINUX 7.5MG/0.6ML|United Medicare Advantage|UHC MEDICARE GOLD MA|10.14||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Aetna|AETNA PPO|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Aetna|AETNA OTHER|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Cigna|CIGNA OTHER|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicare|HEALTHSPRING MA|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Workers Compensation|TEXAS MUTUAL INSURANCE|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Rusk State Hospital|RUSK STATE HOSP|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Aetna|AETNA QHP HMO|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Humana Medicare Advantage|HUMANA MA|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|PHCS|HUMANA|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|United Healthcare|UNITED HEALTHCARE|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|United Healthcare|UNITED HEALTHCARE|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Tricare|TRICARE EAST REGION|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|United Healthcare|TML GROUP BENEFITS|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Cigna|CIGNA|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicaid|LAW ENFORCEMENT OTHER|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicaid|CRIME VICTIMS COMPENSATION|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|PHCS|GROUP AND PENSION|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicaid|MEDICAID HMO|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicaid|MEDICAID|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicare|MEDICARE PART B ONLY IP|58.25||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicare|MEDICARE ACUTE|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|58.25||||58.25||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|58.25||||58.25||| 9504887|ERX|0250|PANCURONIUM 10MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|26.25||||26.25||| 9504887|ERX|0250|PANCURONIUM 10MG/10ML|Workers Compensation|WORKERS COMPENSATION OTHER|26.25||||||| 9504887|ERX|0250|PANCURONIUM 10MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|26.25||||26.25||| 9504887|ERX|0250|PANCURONIUM 10MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.25||||||| 9504887|ERX|0250|PANCURONIUM 10MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|26.25||||||| 9504887|ERX|0250|PANCURONIUM 10MG/10ML|Medicare|MEDICARE ACUTE|26.25||||||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.50||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Managed Medicaid|MEDICAID SUPERIOR|15.50||||||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Medicare|MEDICARE ACUTE|||||15.50||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Tricare|TRICARE FOR LIFE|||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Medicaid|MEDICAID HMO|||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|United Healthcare|GEHA|||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Multiplan|WEB TPA|0.13||||||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|NON CONTRACTED|COMMERCIAL OTHER 2|0.13||||||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|PHCS|MULTIPLAN PHCS|||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.13||||||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Medicaid|MEDICAID|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Medicaid|SMITH COUNTY JAIL|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Workers Compensation|TEXAS MUTUAL INSURANCE|0.13||||||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST TPA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|PHCS|HUMANA|0.13||||||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Aetna|AETNA OTHER|0.13||||||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|ChampVA|CHAMPVA CENTER|0.13||||||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|United Healthcare|AARP|||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Aetna|AETNA PPO|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Cigna|CIGNA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9504911|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Cigna|CIGNA|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicaid|MEDICAID SUPERIOR|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicaid|MEDICAID AMERIGROUP|||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicare|BCBS MEDICARE PPO MA|||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Medicaid|SMITH COUNTY JAIL|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Medicaid|MEDICAID|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Tricare|TRICARE EAST REGION|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|United Healthcare|UNITED HEALTHCARE|||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|United Healthcare|UNITED HEALTHCARE|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|United Healthcare|GOLDEN RULE|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.13||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|United Healthcare|UNITED HEALTHCARE|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Veterans Affairs|VETERANS ADMINISTRATION|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Managed Medicare|HEALTHSPRING MA|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|United Medicare Advantage|UHC AARP MCR HMO MA|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Access Direct Platinum|HEALTHFIRST TPA UMR|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Aenta Medicare Advantage|AETNA MEDICARE MA|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Managed Medicare|BCBS MEDICARE PPO MA|||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Blue Cross PPO Specialty|BCBSTX OTHER|16.75||||||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|United Medicare Advantage|UHC MEDICARE GOLD MA|16.75||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|United Healthcare|UNITED HEALTHCARE OTHER|16.75||||||| 9504937|ERX|0250|WATER FOR INJ.,STERILE 50|Cigna|CIGNA|16.75||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Cigna|CIGNA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Cigna|CIGNA OTHER|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Aetna|AETNA OTHER|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Aetna|BOON CHAPMAN|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Workers Compensation|BROOKSHIRES WORKERS COMP|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicare|WELLCARE CHOICE MA|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Aetna|AETNA PPO|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Aetna|AETNA QHP HMO|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Workers Compensation|UT EMPLOYEE INJURY|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicaid|MEDICAID|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Multiplan|WEB TPA|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|ChampVA|CHAMPVA CENTER|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|PHCS|GROUP AND PENSION|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Rusk State Hospital|RUSK STATE HOSP|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Tricare|TRICARE FOR LIFE|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Tricare|TRICARE SOUTH PHYSICIAN|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Healthcare|GEHA|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Healthcare|UNITED HEALTHCARE ERS|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Healthcare|GOLDEN RULE|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Healthcare|TML GROUP BENEFITS|0.13||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.13||| 9504945|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|NON CONTRACTED|COMMERCIAL OTHER 1|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Tricare|TRICARE EAST REGION|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|United Medicare Advantage|UHC AARP MCR HMO MA|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|UNITED HEALTHCARE|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|TML GROUP BENEFITS|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|PHCS|GROUP AND PENSION|||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|UNITED HEALTHCARE OTHER|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Medicare|MEDICARE PART B ONLY IP|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Medicare|MEDICARE ACUTE|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|ChampVA|CHAMPVA CENTER|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Veterans Affairs|VETERANS ADMINISTRATION|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Aetna|AETNA PPO|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Rusk State Hospital|RUSK STATE HOSP|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST TPA UMR|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Blue Cross PPO Specialty|BCBSTX PPO|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Medicaid|MEDICAID|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Aetna|AETNA OTHER|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Blue Cross HMO Specialty|BCBSTX HMO|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Multiplan|WEB TPA|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Blue Cross PPO Specialty|BCBSTX OTHER|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Managed Medicare|HEALTHSPRING MA|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.25||||||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Humana Medicare Advantage|HUMANA MA|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST TPA|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID AMERIGROUP|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Cigna|CIGNA|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID SUPERIOR|20.25||||20.25||| 9504952|ERX|0250|SODIUM CHLORIDE 0.9% 50ML|Cigna|CIGNA OTHER|20.25||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Managed Medicaid|MEDICAID SUPERIOR|60.50||||60.50||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Managed Medicaid|MEDICAID AMERIGROUP|||||60.50||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Humana Medicare Advantage|HUMANA MA|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Managed Medicare|HEALTHSPRING MA|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Managed Medicare|BCBS MEDICARE PPO MA|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Blue Cross HMO Specialty|BCBSTX HMO|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|United Medicare Advantage|UHC MEDICARE GOLD MA|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Medicare|MEDICARE ACUTE|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|NON CONTRACTED|COMMERCIAL OTHER 1|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|United Medicare Advantage|UHC AARP MCR HMO MA|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|United Healthcare|UNITED HEALTHCARE|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Access Direct Platinum|HEALTHFIRST TPA UMR|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Blue Cross PPO Specialty|BCBSTX PPO|60.50||||||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Medicaid|SMITH COUNTY INDIGENT HEALTH|60.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Healthcare|UNITED HEALTHCARE|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicaid|MOLINA HEALTHCARE OF TEXAS|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|NON CONTRACTED|COMMERCIAL OTHER 1|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicaid|SUPERIOR HEALTHPLAN CHIP|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicare|MEDICARE PART B ONLY IP|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Healthcare|UNITED HEALTHCARE OTHER|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Healthcare|UNITED HEALTHCARE|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|UTMB|UTMB CORRECTIONAL MANAGED CARE|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|PHCS|HUMANA|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Access Direct Platinum|HEALTHFIRST TPA|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicaid|COUNTY INDIGENT HEALTH OTHER|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Veterans Affairs|VETERANS ADMINISTRATION|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Blue Cross PPO Specialty|BCBSTX OTHER|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Medicare Advantage|UHC AARP MCR HMO MA|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Medicare Advantage|UHC MEDICARE GOLD MA|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicaid|CRIME VICTIMS COMPENSATION|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Access Direct Platinum|HEALTHFIRST TPA UMR|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicaid|MEDICAID|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Aenta Medicare Advantage|AETNA MEDICARE MA|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Workers Compensation|WORKERS COMPENSATION OTHER|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicare|MEDICARE ACUTE|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Aetna|AETNA PPO|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Blue Cross HMO Specialty|BCBSTX HMO|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Healthcare|TML GROUP BENEFITS|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Blue Cross PPO Specialty|BCBSTX PPO|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Cigna|CIGNA OTHER|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Humana Medicare Advantage|HUMANA MA|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicaid|MEDICAID SUPERIOR|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicaid|MEDICAID AMERIGROUP|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicare|BCBS MEDICARE PPO MA|61.50||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicare|HEALTHSPRING MA|61.50||||61.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Cigna|CIGNA|61.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Blue Cross PPO Specialty|BCBSTX PPO|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Managed Medicare|BCBS MEDICARE PPO MA|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Cigna|CIGNA|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Cigna|CIGNA OTHER|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Humana Medicare Advantage|HUMANA MA|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Managed Medicare|HEALTHSPRING MA|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Cigna|CIGNA|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Blue Cross HMO Specialty|BCBSTX HMO|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Aetna|AETNA OTHER|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Aetna|AETNA QHP HMO|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Access Direct Platinum|HEALTHFIRST TPA|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Aenta Medicare Advantage|AETNA MEDICARE MA|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Workers Compensation|UT EMPLOYEE INJURY|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Workers Compensation|TEXAS MUTUAL INSURANCE|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Managed Medicaid|MEDICAID AMERIGROUP|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Aetna|AETNA PPO|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|United Medicare Advantage|UHC AARP MCR HMO MA|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Managed Medicaid|MEDICAID SUPERIOR|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|United Medicare Advantage|UHC MEDICARE GOLD MA|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Veterans Affairs|VETERANS ADMINISTRATION|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|NON CONTRACTED|COMMERCIAL OTHER 1|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|PHCS|GROUP AND PENSION|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Tricare|TRICARE EAST REGION|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|United Healthcare|UNITED HEALTHCARE|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|United Healthcare|UNITED HEALTHCARE OTHER|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Rusk State Hospital|RUSK STATE HOSP|||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Medicare|MEDICARE PART B ONLY IP|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Medicare|MEDICARE ACUTE|46.50||||46.50||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Medicaid|MEDICAID|46.50||||||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Access Direct Platinum|HEALTHFIRST TPA UMR|46.50||||46.50||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|United Healthcare|UNITED HEALTHCARE|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Medicare|MEDICARE PART B ONLY IP|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|NON CONTRACTED|COMMERCIAL OTHER 1|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Medicare|MEDICARE ACUTE|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Medicaid|MEDICAID|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Medicaid|CRIME VICTIMS COMPENSATION|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Veterans Affairs|VETERANS ADMINISTRATION|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|United Medicare Advantage|UHC AARP MCR HMO MA|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|United Healthcare|TML GROUP BENEFITS|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Workers Compensation|TEXAS MUTUAL INSURANCE|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|United Healthcare|UNITED HEALTHCARE OTHER|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Blue Cross HMO Specialty|BCBSTX HMO|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Aetna|AETNA PPO|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicare|OTHER INSTITUTIONS|||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|NON CONTRACTED|COMMERCIAL OTHER 2|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Blue Cross PPO Specialty|BCBSTX PPO|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Blue Cross PPO Specialty|BCBSTX OTHER|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicare|BCBS MEDICARE PPO MA|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicare|HEALTHSPRING MA|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Humana Medicare Advantage|HUMANA MA|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicaid|MEDICAID AMERIGROUP|||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicaid|MEDICAID SUPERIOR|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Aetna|AETNA OTHER|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Cigna|CIGNA|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Workers Compensation|WORKERS COMPENSATION OTHER|0.48||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.48||||0.48||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.48||||0.48||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Cigna|CIGNA|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicaid|MEDICAID SUPERIOR|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicaid|MEDICAID AMERIGROUP|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Humana Medicare Advantage|HUMANA MA|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicare|OTHER INSTITUTIONS|||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicare|BCBS MEDICARE PPO MA|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Blue Cross PPO Specialty|BCBSTX PPO|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|ChampVA|CHAMPVA CENTER|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Blue Cross PPO Specialty|BCBSTX OTHER|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Aetna|AETNA OTHER|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Veterans Affairs|VETERANS ADMINISTRATION|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Blue Cross HMO Specialty|BCBSTX HMO|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Access Direct Platinum|HEALTHFIRST TPA UMR|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Medicare Advantage|UHC MEDICARE GOLD MA|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Workers Compensation|WORKERS COMPENSATION OTHER|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicare|HEALTHSPRING MA|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Medicare Advantage|UHC AARP MCR HMO MA|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Aetna|AETNA QHP HMO|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Aenta Medicare Advantage|AETNA MEDICARE MA|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicaid|MEDICAID|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicaid|LAW ENFORCEMENT OTHER|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicaid|COUNTY INDIGENT HEALTH OTHER|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Tricare|TRICARE EAST REGION|||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicare|MEDICARE ACUTE|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicaid|SMITH COUNTY INDIGENT HEALTH|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|NON CONTRACTED|COMMERCIAL OTHER 2|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicaid|CRIME VICTIMS COMPENSATION|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|NON CONTRACTED|COMMERCIAL OTHER 1|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Healthcare|UNITED HEALTHCARE|||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Healthcare|UNITED HEALTHCARE OTHER|150.25||||150.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|UTMB|UTMB CORRECTIONAL MANAGED CARE|150.25||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|150.25||||150.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|PHCS|GROUP AND PENSION|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Healthcare|UNITED HEALTHCARE|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Tricare|TRICARE EAST REGION|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Medicare|MEDICARE ACUTE|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Medicaid|CRIME VICTIMS COMPENSATION|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Medicaid|MEDICAID|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Healthcare|UNITED HEALTHCARE|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Aetna|AETNA PPO|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Aetna|AETNA OTHER|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Aetna|AETNA QHP HMO|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Cigna|CIGNA|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Cigna|CIGNA OTHER|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Managed Medicare|BCBS MEDICARE PPO MA|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Managed Medicare|HEALTHSPRING MA|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Humana Medicare Advantage|HUMANA MA|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Managed Medicare|OTHER INSTITUTIONS|||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Managed Medicaid|MEDICAID AMERIGROUP|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Managed Medicaid|MEDICAID SUPERIOR|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|49.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|49.25||||49.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Blue Cross PPO Specialty|BCBSTX OTHER|49.25||||||| 9505033|ERX|0250|CEFTAZIDIME 1 G VIAL|Medicare|MEDICARE ACUTE|115.75||||||| 9505033|ERX|0250|CEFTAZIDIME 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|115.75||||||| 9505033|ERX|0250|CEFTAZIDIME 1 G VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|115.75||||||| 9505033|ERX|0250|CEFTAZIDIME 1 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|115.75||||||| 9505033|ERX|0250|CEFTAZIDIME 1 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|115.75||||||| 9505033|ERX|0250|CEFTAZIDIME 1 G VIAL|Humana Medicare Advantage|HUMANA MA|115.75||||115.75||| 9505041|ERX|0250|NA BICARB 4.2% 5 MEQ/10ML|Blue Cross PPO Specialty|BCBSTX PPO|||||1.19||| 9505041|ERX|0250|NA BICARB 4.2% 5 MEQ/10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||1.19||| 9505041|ERX|0250|NA BICARB 4.2% 5 MEQ/10ML|Managed Medicaid|MEDICAID SUPERIOR|||||1.19||| 9505058|ERX|0250|AMINOPHYLLINE 25MG/ML|Tricare|TRICARE EAST REGION|||||17.25||| 9505058|ERX|0250|AMINOPHYLLINE 25MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|17.25||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Cigna|CIGNA|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Aetna|BOON CHAPMAN|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicaid|MEDICAID HMO|||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Cigna|CIGNA OTHER|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Aetna|AETNA PPO|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicaid|MEDICAID|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Healthcare|TML GROUP BENEFITS|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Healthcare|UNITED HEALTHCARE|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|PHCS|HUMANA|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|PHCS|GROUP AND PENSION|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Tricare|TRICARE EAST REGION|||||0.13||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Rusk State Hospital|RUSK STATE HOSP|0.13||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|PHCS|HUMANA|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Healthcare|UNITED HEALTHCARE|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Healthcare|TML GROUP BENEFITS|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Healthcare|GOLDEN RULE|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|MEDICAID HMO|||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|SMITH COUNTY JAIL|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|ChampVA|CHAMPVA CENTER|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Aetna|AETNA OTHER|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Aetna|AETNA QHP HMO|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Aetna|AETNA PPO|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|MEDICAID|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|LAW ENFORCEMENT OTHER|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Cigna|CIGNA OTHER|||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Cigna|CIGNA|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Workers Compensation|UT EMPLOYEE INJURY|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Rusk State Hospital|RUSK STATE HOSP|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicare|WELLCARE CHOICE MA|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Cigna|CIGNA|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Managed Medicare|HEALTHSPRING MA|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Aetna|AETNA OTHER|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Aetna|BOON CHAPMAN|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Aetna|AETNA QHP HMO|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Aetna|AETNA PPO|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Medicaid|MEDICAID|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|United Healthcare|UNITED HEALTHCARE|0.13||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Tricare|TRICARE EAST REGION|||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|United Healthcare|UNITED HEALTHCARE|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|UTMB|UTMB CORRECTIONAL MANAGED CARE|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Medicaid|MEDICAID|142.25||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Medicare|MEDICARE PART B ONLY IP|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Medicare|MEDICARE ACUTE|142.25||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|NON CONTRACTED|COMMERCIAL OTHER 1|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicare|BCBS MEDICARE PPO MA|||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicare|HEALTHSPRING MA|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Blue Cross PPO Specialty|BCBSTX PPO|142.25||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Blue Cross HMO Specialty|BCBSTX HMO|142.25||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|142.25||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|United Healthcare|UNITED HEALTHCARE OTHER|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Aetna|AETNA PPO|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|United Healthcare|UNITED HEALTHCARE|||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicaid|MEDICAID AMERIGROUP|||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Access Direct Platinum|HEALTHFIRST TPA|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|United Medicare Advantage|UHC MEDICARE GOLD MA|142.25||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|United Medicare Advantage|UHC AARP MCR HMO MA|142.25||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|142.25||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicaid|MEDICAID SUPERIOR|||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Cigna|CIGNA|||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Veterans Affairs|VETERANS ADMINISTRATION|142.25||||142.25||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Humana Medicare Advantage|HUMANA MA|142.25||||142.25||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Access Direct Platinum|HEALTHFIRST TPA UMR|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|United Medicare Advantage|UHC AARP MCR HMO MA|||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|United Medicare Advantage|UHC MEDICARE GOLD MA|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|133.75||||||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|133.75||||||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Workers Compensation|WORKERS COMPENSATION OTHER|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Veterans Affairs|VETERANS ADMINISTRATION|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Managed Medicaid|MEDICAID AMERIGROUP|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Aetna|AETNA PPO|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Humana Medicare Advantage|HUMANA MA|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Blue Cross PPO Specialty|BCBSTX PPO|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Blue Cross HMO Specialty|BCBSTX HMO|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Cigna|CIGNA|||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Managed Medicare|BCBS MEDICARE PPO MA|||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Managed Medicaid|MEDICAID SUPERIOR|133.75||||||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Managed Medicare|HEALTHSPRING MA|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Medicare|MEDICARE ACUTE|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Medicaid|MEDICAID|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|UTMB|UTMB CORRECTIONAL MANAGED CARE|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|United Healthcare|UNITED HEALTHCARE OTHER|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|Tricare|TRICARE EAST REGION|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|United Healthcare|UNITED HEALTHCARE|133.75||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|United Healthcare|UNITED HEALTHCARE|||||133.75||| 9505132|ERX|0258|NA CHLORIDE 0.9%,250ML IR|NON CONTRACTED|COMMERCIAL OTHER 1|||||133.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|PHCS|GROUP AND PENSION|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Tricare|TRICARE EAST REGION|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Tricare|TRICARE FOR LIFE|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|NON CONTRACTED|COMMERCIAL OTHER 1|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|United Healthcare|UNITED HEALTHCARE|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|United Healthcare|UNITED HEALTHCARE|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|United Healthcare|TML GROUP BENEFITS|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Medicaid|MOLINA HEALTHCARE OF TEXAS|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Medicaid|MEDICAID HMO|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Medicaid|MEDICAID|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Brinson Benefits|THE HEALTH PLAN SMITH CO|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Blue Cross HMO Specialty|BCBSTX HMO|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Medicare|MEDICARE ACUTE|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Blue Cross PPO Specialty|BCBSTX OTHER|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Blue Cross PPO Specialty|BCBSTX PPO|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Aetna|AETNA PPO|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Aetna|AETNA OTHER|||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Aenta Medicare Advantage|AETNA MEDICARE MA|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Managed Medicare|BCBS MEDICARE PPO MA|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Aetna Value Network|AETNA VALUE NETWORK|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|United Healthcare|UNITED HEALTHCARE OTHER|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Managed Medicaid|MEDICAID SUPERIOR|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Access Direct Platinum|HEALTHFIRST TPA UMR|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Access Direct Platinum|HEALTHFIRST TPA|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Cigna|CIGNA OTHER|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Cigna|CIGNA|146.50||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Managed Medicaid|MEDICAID AMERIGROUP|146.50||||146.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Humana Medicare Advantage|HUMANA MA|146.50||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|UT EMPLOYEE INJURY|||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|TRAVELERS INSURANCE COMPANY|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|BROOKSHIRES WORKERS COMP|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|GALLAGHER BASSETT|||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Cigna|CIGNA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Cigna|CIGNA OTHER|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Humana Medicare Advantage|HUMANA MA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicare|ETMC AFFILIATE HOSPITALS|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Aetna|AETNA QHP HMO|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Aetna|AETNA OTHER|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Aetna|AETNA PPO|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|ChampVA|CHAMPVA CENTER|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|MEDICAID HMO|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|SMITH COUNTY JAIL|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|CRIME VICTIMS COMPENSATION|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicare|HEALTHSPRING MA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|MEDICAID BCBSTX|||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|MEDICAID|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|TEXAS MUTUAL INSURANCE|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicare|MEDICARE PART B ONLY IP|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicare|MEDICARE ACUTE|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Healthcare|TML GROUP BENEFITS|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|PHCS|GROUP AND PENSION|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|PHCS|HUMANA|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Rusk State Hospital|RUSK STATE HOSP|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|PHCS|HUMANA INSURANCE|114.25||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Tricare|TRICARE EAST REGION|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Healthcare|UNITED HEALTHCARE|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 2|114.25||||114.25||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Healthcare|AARP|114.25||||||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|United Healthcare|UNITED HEALTHCARE|||||64.75||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Medicare|MEDICARE ACUTE|64.75||||64.75||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Blue Cross PPO Specialty|BCBSTX PPO|64.75||||64.75||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||64.75||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Blue Cross HMO Specialty|BCBSTX HMO|||||64.75||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|64.75||||||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Managed Medicaid|MEDICAID SUPERIOR|||||64.75||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Humana Medicare Advantage|HUMANA MA|64.75||||64.75||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Workers Compensation|TEXAS MUTUAL INSURANCE|64.75||||||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Workers Compensation|WORKERS COMPENSATION OTHER|||||64.75||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||64.75||| 9505199|ERX|0250|SODIUM BICARBONATE 4%, 5M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||64.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Medicare Advantage|UHC AARP WELLMED HMO MA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Medicare Advantage|UHC AARP MCR HMO MA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Veterans Affairs|VETERANS ADMINISTRATION|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Workers Compensation|WORKERS COMPENSATION OTHER|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Aenta Medicare Advantage|AETNA MEDICARE MA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Workers Compensation|TEXAS MUTUAL INSURANCE|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Access Direct Platinum|HEALTHFIRST TPA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Access Direct Platinum|HEALTHFIRST TPA UMR|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|WELLCARE CHOICE MA|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Cigna|CIGNA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Workers Compensation|BROOKSHIRES WORKERS COMP|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Humana Medicare Advantage|HUMANA MA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicaid|MEDICAID AMERIGROUP|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicaid|MEDICAID SUPERIOR|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Aetna|AETNA OTHER|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Aetna|AETNA QHP HMO|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Blue Cross HMO Specialty|BCBSTX HMO|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|ChampVA|CHAMPVA CENTER|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Cigna|CIGNA OTHER|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|BCBS MEDICARE PPO MA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Blue Cross PPO Specialty|BCBSTX PPO|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|HEALTHSPRING MA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Blue Cross PPO Specialty|BCBSTX OTHER|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Brinson Benefits|THE HEALTH PLAN SMITH CO|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|MOLINA HEALTHCARE OF TEXAS|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|MEDICAID HMO|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|LAW ENFORCEMENT OTHER|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|MEDICAID|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|COUNTY INDIGENT HEALTH OTHER|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|SMITH COUNTY INDIGENT HEALTH|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|CRIME VICTIMS COMPENSATION|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Aetna|AETNA PPO|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|SMITH COUNTY JAIL|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicare|MEDICARE PART B ONLY IP|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicare|MEDICARE ACUTE|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|PHCS|HUMANA|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Tricare|TRICARE EAST REGION|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|NON CONTRACTED|COMMERCIAL OTHER 1|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Healthcare|TML GROUP BENEFITS|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Healthcare|UNITED HEALTHCARE OTHER|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Healthcare|GEHA|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|UTMB|UTMB CORRECTIONAL MANAGED CARE|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Texas Workforce Commission|DIS DETER SERV (DDS)|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Rusk State Hospital|RUSK STATE HOSP|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|PHCS|GROUP AND PENSION|36.75||||36.75||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Aetna|BOON CHAPMAN|36.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Healthcare|UNITED HEALTHCARE|36.75||||36.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Healthcare|UNITED HEALTHCARE OTHER|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|UTMB|UTMB CORRECTIONAL MANAGED CARE|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|NON CONTRACTED|COMMERCIAL OTHER 2|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|PHCS|GROUP AND PENSION|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Tricare|TRICARE EAST REGION|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Rusk State Hospital|RUSK STATE HOSP|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Medicare|MEDICARE ACUTE|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|NON CONTRACTED|COMMERCIAL OTHER 1|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Medicaid|COUNTY INDIGENT HEALTH OTHER|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|PHCS|HUMANA|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Medicaid|MOLINA HEALTHCARE OF TEXAS|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Medicaid|CRIME VICTIMS COMPENSATION|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Blue Cross PPO Specialty|BCBSTX OTHER|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Healthcare|UNITED HEALTHCARE|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Aetna|AETNA PPO|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|ChampVA|CHAMPVA CENTER|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Aetna|AETNA QHP HMO|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Healthcare|UNITED HEALTHCARE|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Blue Cross HMO Specialty|BCBSTX HMO|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Aetna|AETNA OTHER|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Blue Cross PPO Specialty|BCBSTX PPO|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicaid|MEDICAID AMERIGROUP|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicaid|MEDICAID SUPERIOR|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Cigna|CIGNA OTHER|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Cigna|CIGNA|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Medicaid|MEDICAID|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Medicare|MEDICARE PART B ONLY IP|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Humana Medicare Advantage|HUMANA MA|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicare|WELLCARE CHOICE MA|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Access Direct Platinum|HEALTHFIRST TPA|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Access Direct Platinum|HEALTHFIRST TPA UMR|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Aenta Medicare Advantage|AETNA MEDICARE MA|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Workers Compensation|WORKERS COMPENSATION OTHER|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Veterans Affairs|VETERANS ADMINISTRATION|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|UHC AARP MCR HMO MA|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|UHC AARP WELLMED HMO MA|42.75||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicare|BCBS MEDICARE PPO MA|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|UHC MEDICARE GOLD MA|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicare|HEALTHSPRING MA|42.75||||42.75||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicare|OTHER INSTITUTIONS|||||42.75||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicare|MA PART B ONLY IP|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Cigna|CIGNA|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Aetna|AETNA PPO|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Aetna|BOON CHAPMAN|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Medicaid|SMITH COUNTY JAIL|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|PHCS|HUMANA|||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Medicaid|MEDICAID|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Tricare|TRICARE EAST REGION|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|United Healthcare|TML GROUP BENEFITS|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Medicaid|SMITH COUNTY JAIL|||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Medicaid|MEDICAID HMO|||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Medicaid|MEDICAID|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Aetna|AETNA OTHER|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Aetna|AETNA QHP HMO|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Aetna|AETNA PPO|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Cigna|CIGNA OTHER|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicare|WELLCARE CHOICE MA|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Tricare|TRICARE EAST REGION|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|25.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||25.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|98.50||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Access Direct Platinum|HEALTHFIRST TPA UMR|98.50||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|98.50||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|98.50||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Managed Medicaid|MEDICAID SUPERIOR|98.50||||98.50||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Managed Medicaid|MEDICAID AMERIGROUP|98.50||||98.50||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98.50||||98.50||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Blue Cross PPO Specialty|BCBSTX PPO|98.50||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Blue Cross HMO Specialty|BCBSTX HMO|98.50||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|United Healthcare|UNITED HEALTHCARE OTHER|||||98.50||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Medicaid|MEDICAID|98.50||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|United Healthcare|UNITED HEALTHCARE|||||98.50||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|United Healthcare|UNITED HEALTHCARE|98.50||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Medicare|MEDICARE ACUTE|195.25||||195.25||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Medicaid|MEDICAID|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Blue Cross PPO Specialty|BCBSTX PPO|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Cigna|CIGNA|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Humana Medicare Advantage|HUMANA MA|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Managed Medicare|HEALTHSPRING MA|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|United Medicare Advantage|UHC AARP MCR HMO MA|195.25||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|195.25||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Veterans Affairs|VETERANS ADMINISTRATION|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Workers Compensation|TEXAS MUTUAL INSURANCE|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Access Direct Platinum|HEALTHFIRST TPA|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Medicare Advantage|UHC AARP MCR HMO MA|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicaid|MEDICAID SUPERIOR|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Cigna|CIGNA OTHER|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicaid|MEDICAID AMERIGROUP|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Aetna|AETNA QHP HMO|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Aetna|AETNA PPO|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Aetna|BOON CHAPMAN|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Aetna|AETNA OTHER|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Access Direct Platinum|HEALTHFIRST TPA UMR|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|ChampVA|CHAMPVA CENTER|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross HMO Specialty|BCBSTX HMO|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Cigna|CIGNA|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Humana Medicare Advantage|HUMANA MA|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross PPO Specialty|BCBSTX PPO|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Workers Compensation|WORKERS COMPENSATION OTHER|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross PPO Specialty|BCBSTX OTHER|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicaid|SMITH COUNTY JAIL|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicaid|MEDICAID|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicaid|CRIME VICTIMS COMPENSATION|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Healthcare|UNITED HEALTHCARE|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|PHCS|GROUP AND PENSION|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Tricare|TRICARE EAST REGION|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Rusk State Hospital|RUSK STATE HOSP|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Healthcare|UNITED HEALTHCARE|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Healthcare|UNITED HEALTHCARE OTHER|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicare|BCBS MEDICARE PPO MA|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicare|HEALTHSPRING MA|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicare|MEDICARE PART B ONLY IP|1.19||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicare|MEDICARE ACUTE|1.19||||1.19||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.19||||1.19||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Rusk State Hospital|RUSK STATE HOSP|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|PHCS|GROUP AND PENSION|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Tricare|TRICARE EAST REGION|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Healthcare|UNITED HEALTHCARE OTHER|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Healthcare|UNITED HEALTHCARE|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicare|WELLCARE CHOICE MA|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicare|HEALTHSPRING MA|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Medicare|MEDICARE ACUTE|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Medicare|MEDICARE PART B ONLY IP|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Medicaid|CRIME VICTIMS COMPENSATION|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Medicaid|MEDICAID|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross PPO Specialty|BCBSTX OTHER|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Aetna|AETNA PPO|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Aetna|AETNA QHP HMO|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Cigna|CIGNA OTHER|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Humana Medicare Advantage|HUMANA MA|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Aetna|AETNA OTHER|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicare|BCBS MEDICARE PPO MA|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicaid|MEDICAID SUPERIOR|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Aetna|BOON CHAPMAN|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicaid|MEDICAID AMERIGROUP|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Healthcare|TML GROUP BENEFITS|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross HMO Specialty|BCBSTX HMO|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Cigna|CIGNA|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Medicare Advantage|UHC AARP MCR HMO MA|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|NON CONTRACTED|COMMERCIAL OTHER 2|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Access Direct Platinum|HEALTHFIRST TPA|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Access Direct Platinum|HEALTHFIRST TPA UMR|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Workers Compensation|WORKERS COMPENSATION OTHER|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Workers Compensation|TEXAS MUTUAL INSURANCE|207.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Veterans Affairs|VETERANS ADMINISTRATION|207.75||||207.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross PPO Specialty|BCBSTX PPO|207.75||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Cigna|CIGNA|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Cigna|CIGNA OTHER|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Aetna|AETNA PPO|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Medicaid|MEDICAID|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|PHCS|HUMANA|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Rusk State Hospital|RUSK STATE HOSP|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Optum Behavioral Health|BH OPTUM UHC|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Tricare|TRICARE EAST REGION|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Cigna|CIGNA|25.50||||25.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Aetna|AETNA OTHER|25.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Aetna|AETNA QHP HMO|25.50||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|NON CONTRACTED|COMMERCIAL OTHER 1|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Tricare|TRICARE EAST REGION|2.15||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|United Healthcare|UNITED HEALTHCARE|2.15||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|United Healthcare|GEHA|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicare|HEALTHSPRING MA|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Medicaid|SMITH COUNTY JAIL|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Medicaid|MEDICAID HMO|||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Blue Cross PPO Specialty|BCBSTX PPO|2.15||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Aetna|AETNA OTHER|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Aenta Medicare Advantage|AETNA MEDICARE MA|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicare|BCBS MEDICARE PPO MA|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|United Healthcare|UNITED HEALTHCARE OTHER|2.15||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|United Medicare Advantage|UHC MEDICARE GOLD MA|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicaid|MEDICAID AMERIGROUP|2.15||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicaid|MEDICAID SUPERIOR|2.15||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Humana Medicare Advantage|HUMANA MA|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Cigna|CIGNA|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Access Direct Platinum|HEALTHFIRST TPA|2.15||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Blue Cross HMO Specialty|BCBSTX HMO|2.15||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Medicare|MEDICARE ACUTE|2.15||||2.15||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Medicaid|MEDICAID|2.15||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|United Medicare Advantage|UHC AARP MCR HMO MA|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|United Medicare Advantage|UHC MEDICARE GOLD MA|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Humana Medicare Advantage|HUMANA MA|2.49||||2.49||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Aetna|AETNA PPO|2.49||||2.49||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Aenta Medicare Advantage|AETNA MEDICARE MA|2.49||||2.49||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Cigna|CIGNA|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Blue Cross HMO Specialty|BCBSTX HMO|2.49||||2.49||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Blue Cross PPO Specialty|BCBSTX PPO|2.49||||2.49||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Medicare|MEDICARE PART B ONLY IP|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Medicare|MEDICARE ACUTE|2.49||||2.49||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Medicaid|MEDICAID HMO|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Medicaid|MEDICAID|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Medicaid|CRIME VICTIMS COMPENSATION|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Workers Compensation|WORKERS COMPENSATION OTHER|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Managed Medicare|HEALTHSPRING MA|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.49||||2.49||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|United Healthcare|UNITED HEALTHCARE|2.49||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|NON CONTRACTED|COMMERCIAL OTHER 1|2.49||||2.49||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Veterans Affairs|VETERANS ADMINISTRATION|2.49||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Rusk State Hospital|RUSK STATE HOSP|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|PHCS|HUMANA|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Tricare|TRICARE EAST REGION|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Multiplan|WEB TPA|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|NON CONTRACTED|COMMERCIAL OTHER 1|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Healthcare|UNITED HEALTHCARE|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Healthcare|TML GROUP BENEFITS|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|UTMB|UTMB CORRECTIONAL MANAGED CARE|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicaid|SUPERIOR HEALTHPLAN CHIP|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicaid|COUNTY INDIGENT HEALTH OTHER|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicare|MEDICARE ACUTE|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross PPO Specialty|BCBSTX PPO|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|ChampVA|CHAMPVA CENTER|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross PPO Specialty|BCBSTX OTHER|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Aetna|AETNA OTHER|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Aetna|AETNA PPO|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicare|MEDICARE PART B ONLY IP|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Aetna|AETNA QHP HMO|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicaid|MEDICAID|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Aetna|BOON CHAPMAN|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Aenta Medicare Advantage|AETNA MEDICARE MA|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Cigna|CIGNA|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross HMO Specialty|BCBSTX HMO|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Cigna|CIGNA|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicaid|SMITH COUNTY INDIGENT HEALTH|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Cigna|CIGNA OTHER|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Humana Medicare Advantage|HUMANA MA|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicaid|MEDICAID AMERIGROUP|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicaid|MEDICAID SUPERIOR|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Medicare Advantage|UHC AARP MCR HMO MA|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Medicare Advantage|UHC MEDICARE GOLD MA|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Healthcare|UNITED HEALTHCARE OTHER|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Medicare Advantage|UHC AARP WELLMED HMO MA|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Access Direct Platinum|HEALTHFIRST TPA|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|PHCS|GROUP AND PENSION|||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Access Direct Platinum|HEALTHFIRST TPA UMR|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicare|BCBS MEDICARE PPO MA|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Workers Compensation|ZURICH COMPANY|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Workers Compensation|WORKERS COMPENSATION OTHER|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Workers Compensation|TEXAS MUTUAL INSURANCE|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicare|HEALTHSPRING MA|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Veterans Affairs|VETERANS ADMINISTRATION|218.50||||218.50||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicaid|SMITH COUNTY JAIL|218.50||||||| 9505330|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Workers Compensation|BROOKSHIRES WORKERS COMP|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Veterans Affairs|VETERANS ADMINISTRATION|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Humana Medicare Advantage|HUMANA MA|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Aetna|AETNA PPO|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Blue Cross PPO Specialty|BCBSTX PPO|218.50||||218.50||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|218.50||||218.50||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Medicare|MEDICARE ACUTE|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Medicaid|MOLINA HEALTHCARE OF TEXAS|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|218.50||||218.50||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|United Medicare Advantage|UHC MEDICARE GOLD MA|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Managed Medicare|HEALTHSPRING MA|218.50||||218.50||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Access Direct Platinum|HEALTHFIRST TPA|218.50||||||| 9505348|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|United Medicare Advantage|UHC AARP MCR HMO MA|218.50||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|United Healthcare|UNITED HEALTHCARE|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|NON CONTRACTED|COMMERCIAL OTHER 1|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Tricare|TRICARE EAST REGION|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Managed Medicare|BCBS MEDICARE PPO MA|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Managed Medicare|HEALTHSPRING MA|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Medicaid|MEDICAID|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Medicare|MEDICARE ACUTE|19.25||||19.25||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Blue Cross PPO Specialty|BCBSTX PPO|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Blue Cross HMO Specialty|BCBSTX HMO|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Aetna|BOON CHAPMAN|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Managed Medicaid|MEDICAID SUPERIOR|19.25||||19.25||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Humana Medicare Advantage|HUMANA MA|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Managed Medicaid|MEDICAID AMERIGROUP|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|United Medicare Advantage|UHC AARP MCR HMO MA|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|United Healthcare|UNITED HEALTHCARE OTHER|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Access Direct Platinum|HEALTHFIRST TPA|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|19.25||||||| 9505355|ERX|0258|WATER FOR INJECTION 100ML|Veterans Affairs|VETERANS ADMINISTRATION|19.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Access Direct Platinum|HEALTHFIRST TPA|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Blue Cross PPO Specialty|BCBSTX PPO|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Blue Cross HMO Specialty|BCBSTX HMO|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Medicare|MEDICARE ACUTE|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Medicaid|MEDICAID|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|NON CONTRACTED|COMMERCIAL OTHER 1|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Humana Medicare Advantage|HUMANA MA|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|Aetna|BOON CHAPMAN|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|United Medicare Advantage|UHC AARP MCR HMO MA|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|United Medicare Advantage|UHC MEDICARE GOLD MA|35.25||||||| 9505363|ERX|0258|DEX 70%-WATER 238 KCAL 10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|35.25||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Blue Cross PPO Specialty|BCBSTX PPO|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Blue Cross HMO Specialty|BCBSTX HMO|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Aetna|BOON CHAPMAN|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Medicare|MEDICARE ACUTE|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Medicaid|MEDICAID|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Humana Medicare Advantage|HUMANA MA|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|United Medicare Advantage|UHC AARP MCR HMO MA|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Access Direct Platinum|HEALTHFIRST TPA|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|62.80||||||| 9505371|ERX|0258|AMINO ACID 15% 15 G/100ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|62.80||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Cigna|CIGNA|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Aetna|AETNA PPO|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Medicaid|SMITH COUNTY JAIL|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Medicaid|MEDICAID|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Healthcare|TML GROUP BENEFITS|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Aetna|AETNA QHP HMO|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Healthcare|UNITED HEALTHCARE|||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|PHCS|GROUP AND PENSION|25.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Rusk State Hospital|RUSK STATE HOSP|25.50||||||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Multiplan|PACIFICARE|145.50||||||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Multiplan|WEB TPA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|NON CONTRACTED|COMMERCIAL OTHER 1|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Texas Workforce Commission|DIS DETER SERV (DDS)|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Rusk State Hospital|RUSK STATE HOSP|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|PHCS|GROUP AND PENSION|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|PHCS|HUMANA INSURANCE|145.50||||||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Tricare|TRICARE SOUTH PHYSICIAN|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Healthcare|UNITED HEALTHCARE ERS|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Healthcare|UNITED HEALTHCARE OTHER|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Healthcare|UNITED HEALTHCARE|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Healthcare|TML GROUP BENEFITS|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Healthcare|GOLDEN RULE|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Healthcare|GEHA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|UTMB|UTMB CORRECTIONAL MANAGED CARE|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|SMITH COUNTY JAIL|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|MOLINA HEALTHCARE OF TEXAS|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|MEDICAID HMO|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|MEDICAID|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|LAW ENFORCEMENT OTHER|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|COUNTY INDIGENT HEALTH OTHER|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicare|MEDICARE PART B ONLY IP|145.50||||||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicare|MEDICARE ACUTE|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|SUPERIOR HEALTHPLAN CHIP|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Managed Medicare|HEALTHSPRING MA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Blue Cross HMO Specialty|BCBSTX HMO|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Blue Cross PPO Specialty|BCBSTX PPO|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|ChampVA|CHAMPVA CENTER|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Tricare|TRICARE EAST REGION|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Managed Medicare|BCBS MEDICARE PPO MA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Aetna Value Network|AETNA VALUE NETWORK|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Aetna|AETNA QHP HMO|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Aetna|AETNA OTHER|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|MEDICAID BCBSTX|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|145.50||||||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Medicaid|CRIME VICTIMS COMPENSATION|145.50||||||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Aetna|BOON CHAPMAN|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Brinson Benefits|THE HEALTH PLAN SMITH CO|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Aetna|AETNA PPO|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Aenta Medicare Advantage|AETNA MEDICARE MA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Humana Medicare Advantage|HUMANA MA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Cigna|CIGNA OTHER|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Cigna|CIGNA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Managed Medicaid|MEDICAID AMERIGROUP|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Managed Medicaid|MEDICAID SUPERIOR|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Medicare Advantage|UHC AARP WELLMED HMO MA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|PHCS|HUMANA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Tricare|TRICARE FOR LIFE|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Medicare Advantage|UHC MEDICARE GOLD MA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Access Direct Platinum|HEALTHFIRST TPA|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Access Direct Platinum|HEALTHFIRST TPA UMR|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|NON CONTRACTED|COMMERCIAL OTHER 2|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|ZURICH COMPANY|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|WORKERS COMPENSATION OTHER|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|WORKERS COMP PHYSICIAN|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Blue Cross PPO Specialty|BCBSTX OTHER|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|UT EMPLOYEE INJURY|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|145.50||||||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|BROOKSHIRES WORKERS COMP|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|TRAVELERS INSURANCE COMPANY|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|GALLAGHER BASSETT|||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Veterans Affairs|VETERANS ADMINISTRATION|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|Workers Compensation|TEXAS MUTUAL INSURANCE|145.50||||145.50||| 9505397|ERX|0258|NA CHLORIDE 0.9%,1000ML I|United Medicare Advantage|UHC AARP MCR HMO MA|145.50||||145.50||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|ChampVA|CHAMPVA CENTER|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Blue Cross HMO Specialty|BCBSTX HMO|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Blue Cross PPO Specialty|BCBSTX PPO|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Managed Medicare|BCBS MEDICARE PPO MA|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Medicare|MEDICARE ACUTE|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Medicare|MEDICARE PART B ONLY IP|190.25||||||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Medicaid|SUPERIOR HEALTHPLAN CHIP|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Medicaid|MEDICAID HMO|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Medicaid|MEDICAID|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Managed Medicare|HEALTHSPRING MA|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Blue Cross PPO Specialty|BCBSTX OTHER|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|UTMB|UTMB CORRECTIONAL MANAGED CARE|190.25||||||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|United Healthcare|UNITED HEALTHCARE OTHER|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|United Healthcare|UNITED HEALTHCARE|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|United Healthcare|UNITED HEALTHCARE|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|United Healthcare|GEHA|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Texas Workforce Commission|DIS DETER SERV (DDS)|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|PHCS|GROUP AND PENSION|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|NON CONTRACTED|COMMERCIAL OTHER 2|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Tricare|TRICARE EAST REGION|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Multiplan|PACIFICARE|190.25||||||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|NON CONTRACTED|COMMERCIAL OTHER 1|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Rusk State Hospital|RUSK STATE HOSP|190.25||||||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Workers Compensation|WORKERS COMPENSATION OTHER|190.25||||||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Veterans Affairs|VETERANS ADMINISTRATION|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Access Direct Platinum|HEALTHFIRST TPA UMR|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Access Direct Platinum|HEALTHFIRST TPA|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|United Medicare Advantage|UHC AARP MCR HMO MA|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|United Medicare Advantage|UHC MEDICARE GOLD MA|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Managed Medicaid|MEDICAID UNITED HEALTHCARE|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Managed Medicaid|MEDICAID AMERIGROUP|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Managed Medicaid|MEDICAID SUPERIOR|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Cigna|CIGNA OTHER|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Cigna|CIGNA|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Humana Medicare Advantage|HUMANA MA|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Aetna|AETNA QHP HMO|||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Aetna|AETNA PPO|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Aetna|AETNA OTHER|190.25||||190.25||| 9505405|ERX|0258|WATER FOR IRRIGATION 1000|Aenta Medicare Advantage|AETNA MEDICARE MA|190.25||||190.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|PHCS|GROUP AND PENSION|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Tricare|TRICARE EAST REGION|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Tricare|TRICARE SOUTH PHYSICIAN|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Healthcare|UNITED HEALTHCARE|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.19||||||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicare|MEDICARE ACUTE|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicare|MEDICARE PART B ONLY IP|0.19||||||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicaid|MEDICAID HMO|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicaid|CRIME VICTIMS COMPENSATION|0.19||||||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.19||||||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|ChampVA|CHAMPVA CENTER|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Aetna|AETNA OTHER|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Aetna|AETNA QHP HMO|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Aetna|AETNA PPO|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID SUPERIOR|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Cigna|CIGNA|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicaid|MEDICAID|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Cigna|CIGNA|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Cigna|CIGNA OTHER|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Humana Medicare Advantage|HUMANA MA|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.19||||||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicare|HEALTHSPRING MA|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|0.19||||||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Tricare|TRICARE FOR LIFE|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Workers Compensation|ZURICH COMPANY|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Workers Compensation|BROOKSHIRES WORKERS COMP|0.19||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Workers Compensation|UT EMPLOYEE INJURY|||||0.19||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.19||||0.19||| 9505421|ERX|0250|HETASTARCH IN NS 500ML|United Medicare Advantage|UHC AARP MCR HMO MA|323.50||||||| 9505421|ERX|0250|HETASTARCH IN NS 500ML|Veterans Affairs|VETERANS ADMINISTRATION|323.50||||||| 9505421|ERX|0250|HETASTARCH IN NS 500ML|Humana Medicare Advantage|HUMANA MA|323.50||||||| 9505421|ERX|0250|HETASTARCH IN NS 500ML|Managed Medicaid|MEDICAID AMERIGROUP|||||323.50||| 9505421|ERX|0250|HETASTARCH IN NS 500ML|Blue Cross PPO Specialty|BCBSTX PPO|323.50||||323.50||| 9505421|ERX|0250|HETASTARCH IN NS 500ML|Medicare|MEDICARE ACUTE|323.50||||||| 9505421|ERX|0250|HETASTARCH IN NS 500ML|United Healthcare|UNITED HEALTHCARE|323.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|United Healthcare|UNITED HEALTHCARE|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Aetna|BOON CHAPMAN|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Managed Medicare|HEALTHSPRING MA|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Managed Medicaid|MEDICAID SUPERIOR|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Medicaid|MEDICAID|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|NON CONTRACTED|COMMERCIAL OTHER 2|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Cigna|CIGNA|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Humana Medicare Advantage|HUMANA MA|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Workers Compensation|TEXAS MUTUAL INSURANCE|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Access Direct Platinum|HEALTHFIRST TPA|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Workers Compensation|TEXAS MUTUAL INSURANCE|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Cigna|CIGNA|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Cigna|CIGNA OTHER|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicaid|MEDICAID SUPERIOR|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|ChampVA|CHAMPVA CENTER|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Aetna|AETNA PPO|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Aetna|AETNA OTHER|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Aetna|BOON CHAPMAN|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Access Direct Platinum|HEALTHFIRST TPA|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicaid|MEDICAID|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicaid|MEDICAID HMO|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicaid|SMITH COUNTY JAIL|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|PHCS|HUMANA|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|PHCS|GROUP AND PENSION|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Rusk State Hospital|RUSK STATE HOSP|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Tricare|TRICARE EAST REGION|0.13||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Tricare|TRICARE EAST REGION|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|United Healthcare|UNITED HEALTHCARE|||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Medicaid|MEDICAID|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Medicaid|SMITH COUNTY JAIL|||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Aetna|AETNA PPO|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Aetna|AETNA OTHER|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Aetna|AETNA QHP HMO|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Cigna|CIGNA|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|PHCS|GROUP AND PENSION|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9505488|ERX|0250|MEPIVACAINE 3% 30MG/ML,1.|Managed Medicaid|MEDICAID SUPERIOR|||||8.25||| 9505488|ERX|0250|MEPIVACAINE 3% 30MG/ML,1.|Blue Cross PPO Specialty|BCBSTX PPO|||||8.25||| 9505488|ERX|0250|MEPIVACAINE 3% 30MG/ML,1.|Medicaid|MEDICAID|||||8.25||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|United Healthcare|GEHA|||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Tricare|TRICARE EAST REGION|0.13||||||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Medicaid|LAW ENFORCEMENT OTHER|||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Medicaid|SMITH COUNTY JAIL|0.13||||||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Medicaid|MEDICAID|||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Aetna|AETNA PPO|0.13||||||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|ChampVA|CHAMPVA CENTER|0.13||||||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Cigna|CIGNA OTHER|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Cigna|CIGNA|||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Managed Medicaid|MEDICAID AMERIGROUP|||||0.13||| 9505496|ERX|0250|BUPIVACAINE-EPI 0.5% 1.8M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Managed Medicaid|MEDICAID AMERIGROUP|||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Humana Medicare Advantage|HUMANA MA|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Cigna|CIGNA OTHER|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Cigna|CIGNA|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Blue Cross HMO Specialty|BCBSTX HMO|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Blue Cross PPO Specialty|BCBSTX OTHER|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Blue Cross PPO Specialty|BCBSTX PPO|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Aetna|AETNA PPO|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Aetna|AETNA QHP HMO|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Aetna|AETNA OTHER|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Aenta Medicare Advantage|AETNA MEDICARE MA|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Veterans Affairs|VETERANS ADMINISTRATION|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Access Direct Platinum|HEALTHFIRST TPA|||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Access Direct Platinum|HEALTHFIRST TPA UMR|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|United Medicare Advantage|UHC AARP MCR HMO MA|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|United Medicare Advantage|UHC MEDICARE GOLD MA|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Managed Medicare|HEALTHSPRING MA|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Managed Medicare|BCBS MEDICARE PPO MA|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Medicaid|MEDICAID|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Medicare|MEDICARE PART B ONLY IP|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Medicare|MEDICARE ACUTE|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|NON CONTRACTED|COMMERCIAL OTHER 1|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|PHCS|GROUP AND PENSION|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|Tricare|TRICARE EAST REGION|146.50||||||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|United Healthcare|UNITED HEALTHCARE OTHER|146.50||||146.50||| 9505504|ERX|0258|HEPARIN 1000 UNITS/500ML|United Healthcare|UNITED HEALTHCARE|146.50||||146.50||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|United Healthcare|UNITED HEALTHCARE OTHER|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|United Healthcare|UNITED HEALTHCARE|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|United Healthcare|TML GROUP BENEFITS|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Tricare|TRICARE EAST REGION|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|NON CONTRACTED|COMMERCIAL OTHER 1|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Medicare|MEDICARE ACUTE|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Managed Medicare|HEALTHSPRING MA|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|United Medicare Advantage|UHC AARP MCR HMO MA|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|538.75||||538.75||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Managed Medicare|BCBS MEDICARE PPO MA|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Medicaid|MEDICAID|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Access Direct Platinum|HEALTHFIRST TPA UMR|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Veterans Affairs|VETERANS ADMINISTRATION|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|538.75||||538.75||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Aetna|AETNA OTHER|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|PHCS|GROUP AND PENSION|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Aetna|AETNA QHP HMO|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Aetna|AETNA PPO|538.75||||538.75||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Aenta Medicare Advantage|AETNA MEDICARE MA|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||538.75||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|538.75||||538.75||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Blue Cross PPO Specialty|BCBSTX OTHER|538.75||||538.75||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Blue Cross PPO Specialty|BCBSTX PPO|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Blue Cross HMO Specialty|BCBSTX HMO|538.75||||538.75||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Cigna|CIGNA OTHER|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Cigna|CIGNA|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Humana Medicare Advantage|HUMANA MA|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|538.75||||538.75||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|538.75||||||| 9505520|ERX|0258|MANNITOL 20% 50 G/250ML|Managed Medicaid|MEDICAID AMERIGROUP|538.75||||||| 9505538|ERX|0258|MANNITOL 20% 100 G/500ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.03||||||| 9505538|ERX|0258|MANNITOL 20% 100 G/500ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.03||||||| 9505538|ERX|0258|MANNITOL 20% 100 G/500ML|Medicare|MEDICARE ACUTE|7.03||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|NON CONTRACTED|COMMERCIAL OTHER 1|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Tricare|TRICARE EAST REGION|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Tricare|TRICARE FOR LIFE|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Healthcare|UNITED HEALTHCARE|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Healthcare|UNITED HEALTHCARE|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Medicaid|CRIME VICTIMS COMPENSATION|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Medicaid|MEDICAID|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Medicare|MEDICARE ACUTE|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Medicare|MEDICARE PART B ONLY IP|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Workers Compensation|WORKERS COMPENSATION OTHER|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Aenta Medicare Advantage|AETNA MEDICARE MA|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Access Direct Platinum|HEALTHFIRST TPA UMR|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Access Direct Platinum|HEALTHFIRST TPA|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Veterans Affairs|VETERANS ADMINISTRATION|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Medicare Advantage|UHC AARP MCR HMO MA|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Medicare Advantage|UHC MEDICARE GOLD MA|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Blue Cross PPO Specialty|BCBSTX PPO|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Aetna|AETNA QHP HMO|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Aetna|AETNA PPO|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Blue Cross HMO Specialty|BCBSTX HMO|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Healthcare|UNITED HEALTHCARE OTHER|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|NON CONTRACTED|COMMERCIAL OTHER 2|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Managed Medicaid|MEDICAID AMERIGROUP|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Managed Medicaid|MEDICAID SUPERIOR|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Cigna|CIGNA|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Humana Medicare Advantage|HUMANA MA|1.69||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Managed Medicare|HEALTHSPRING MA|1.69||||1.69||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Managed Medicare|BCBS MEDICARE PPO MA|1.69||||1.69||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Managed Medicaid|MEDICAID AMERIGROUP|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Humana Medicare Advantage|HUMANA MA|2.31||||2.31||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Aetna|AETNA OTHER|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Aetna|AETNA PPO|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Aetna|AETNA QHP HMO|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Blue Cross HMO Specialty|BCBSTX HMO|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Blue Cross PPO Specialty|BCBSTX PPO|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Blue Cross PPO Specialty|BCBSTX OTHER|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|United Medicare Advantage|UHC AARP MCR HMO MA|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|2.31||||2.31||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.31||||2.31||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Aenta Medicare Advantage|AETNA MEDICARE MA|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.31||||2.31||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Access Direct Platinum|HEALTHFIRST TPA UMR|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Workers Compensation|TEXAS MUTUAL INSURANCE|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Managed Medicaid|MEDICAID SUPERIOR|||||2.31||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Veterans Affairs|VETERANS ADMINISTRATION|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Medicaid|MEDICAID|2.31||||2.31||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Medicare|MEDICARE ACUTE|2.31||||2.31||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Medicare|MEDICARE PART B ONLY IP|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Managed Medicare|BCBS MEDICARE PPO MA|2.31||||2.31||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Managed Medicare|HEALTHSPRING MA|2.31||||2.31||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|United Healthcare|UNITED HEALTHCARE OTHER|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|United Healthcare|UNITED HEALTHCARE|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.31||||||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|NON CONTRACTED|COMMERCIAL OTHER 1|2.31||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|PHCS|GROUP AND PENSION|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Tricare|TRICARE EAST REGION|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Tricare|TRICARE SOUTH PHYSICIAN|||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Healthcare|UNITED HEALTHCARE|||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Healthcare|UNITED HEALTHCARE OTHER|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicaid|CRIME VICTIMS COMPENSATION|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicaid|MEDICAID|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicare|MEDICARE ACUTE|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicare|MEDICARE PART B ONLY IP|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Access Direct Platinum|HEALTHFIRST TPA|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Access Direct Platinum|HEALTHFIRST TPA UMR|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Veterans Affairs|VETERANS ADMINISTRATION|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Medicare Advantage|UHC AARP MCR HMO MA|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross PPO Specialty|BCBSTX PPO|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|ChampVA|CHAMPVA CENTER|||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Aetna|BOON CHAPMAN|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicaid|SMITH COUNTY JAIL|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Aetna|AETNA OTHER|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Aetna|AETNA PPO|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross HMO Specialty|BCBSTX HMO|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Cigna|CIGNA|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Cigna|CIGNA OTHER|107.50||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Humana Medicare Advantage|HUMANA MA|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicaid|MEDICAID SUPERIOR|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicaid|MEDICAID AMERIGROUP|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicare|HEALTHSPRING MA|107.50||||107.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicare|BCBS MEDICARE PPO MA|107.50||||107.50||| 9505587|ERX|0258|LACTATED RINGERS 3000ML I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||218.25||| 9505587|ERX|0258|LACTATED RINGERS 3000ML I|Aetna|AETNA QHP HMO|||||218.25||| 9505587|ERX|0258|LACTATED RINGERS 3000ML I|Blue Cross PPO Specialty|BCBSTX PPO|218.25||||218.25||| 9505587|ERX|0258|LACTATED RINGERS 3000ML I|Access Direct Platinum|HEALTHFIRST TPA|||||218.25||| 9505587|ERX|0258|LACTATED RINGERS 3000ML I|United Healthcare|UNITED HEALTHCARE|218.25||||||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Medicare|MEDICARE ACUTE|107.50||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Tricare|TRICARE EAST REGION|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|United Healthcare|UNITED HEALTHCARE OTHER|107.50||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|United Medicare Advantage|UHC AARP MCR HMO MA|107.50||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|United Healthcare|UNITED HEALTHCARE|107.50||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA|107.50||||||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicare|HEALTHSPRING MA|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Cigna|CIGNA|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Humana Medicare Advantage|HUMANA MA|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|107.50||||107.50||| 9505603|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.50||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|186.25||||||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Blue Cross PPO Specialty|BCBSTX PPO|186.25||||||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Humana Medicare Advantage|HUMANA MA|186.25||||||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|186.25||||||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|NON CONTRACTED|COMMERCIAL OTHER 1|186.25||||||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Medicare|MEDICARE ACUTE|186.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicare|BCBS MEDICARE PPO MA|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicare|HEALTHSPRING MA|127.25||||127.25||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicaid|SMITH COUNTY INDIGENT HEALTH|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicaid|MEDICAID|127.25||||127.25||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicaid|CRIME VICTIMS COMPENSATION|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicaid|COUNTY INDIGENT HEALTH OTHER|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Healthcare|UNITED HEALTHCARE OTHER|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Healthcare|UNITED HEALTHCARE|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|NON CONTRACTED|COMMERCIAL OTHER 1|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Workers Compensation|WORKERS COMPENSATION OTHER|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Veterans Affairs|VETERANS ADMINISTRATION|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Tricare|TRICARE EAST REGION|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Access Direct Platinum|HEALTHFIRST TPA UMR|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Access Direct Platinum|HEALTHFIRST TPA|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicare|MEDICARE ACUTE|127.25||||127.25||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicaid|MEDICAID HMO|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Medicare Advantage|UHC MEDICARE GOLD MA|127.25||||127.25||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Medicare Advantage|UHC AARP MCR HMO MA|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID AMERIGROUP|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|127.25||||127.25||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID SUPERIOR|127.25||||127.25||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Cigna|CIGNA OTHER|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Humana Medicare Advantage|HUMANA MA|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|ChampVA|CHAMPVA CENTER|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Blue Cross HMO Specialty|BCBSTX HMO|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Blue Cross PPO Specialty|BCBSTX PPO|127.25||||127.25||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Aetna|AETNA PPO|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Aetna|AETNA OTHER|127.25||||||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Aenta Medicare Advantage|AETNA MEDICARE MA|127.25||||127.25||| 9505629|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127.25||||127.25||| 9505637|ERX|0258|DEX 5%-1/2NS KCL 30 MEQ 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|186.25||||||| 9505637|ERX|0258|DEX 5%-1/2NS KCL 30 MEQ 1|Humana Medicare Advantage|HUMANA MA|186.25||||||| 9505637|ERX|0258|DEX 5%-1/2NS KCL 30 MEQ 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|186.25||||||| 9505637|ERX|0258|DEX 5%-1/2NS KCL 30 MEQ 1|Medicare|MEDICARE ACUTE|186.25||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|168.75||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Managed Medicare|HEALTHSPRING MA|168.75||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Medicare|MEDICARE ACUTE|168.75||||168.75||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Medicare|MEDICARE PART B ONLY IP|168.75||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||168.75||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|United Medicare Advantage|UHC MEDICARE GOLD MA|168.75||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|168.75||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Humana Medicare Advantage|HUMANA MA|168.75||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Blue Cross PPO Specialty|BCBSTX PPO|168.75||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Blue Cross HMO Specialty|BCBSTX HMO|168.75||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|168.75||||||| 9505652|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Aetna|AETNA PPO|168.75||||||| 9505660|ERX|0258|DEXTROSE 5% KCL 20 MEQ 10|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|186.25||||||| 9505660|ERX|0258|DEXTROSE 5% KCL 20 MEQ 10|Blue Cross PPO Specialty|BCBSTX PPO|186.25||||||| 9505660|ERX|0258|DEXTROSE 5% KCL 20 MEQ 10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|186.25||||||| 9505660|ERX|0258|DEXTROSE 5% KCL 20 MEQ 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|186.25||||||| 9505660|ERX|0258|DEXTROSE 5% KCL 20 MEQ 10|United Medicare Advantage|UHC AARP MCR HMO MA|186.25||||||| 9505660|ERX|0258|DEXTROSE 5% KCL 20 MEQ 10|Medicaid|SMITH COUNTY JAIL|186.25||||||| 9505660|ERX|0258|DEXTROSE 5% KCL 20 MEQ 10|Medicare|MEDICARE ACUTE|186.25||||||| 9505660|ERX|0258|DEXTROSE 5% KCL 20 MEQ 10|Managed Medicare|HEALTHSPRING MA|186.25||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Rusk State Hospital|RUSK STATE HOSP|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|PHCS|HUMANA|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|PHCS|HUMANA INSURANCE|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|PHCS|GROUP AND PENSION|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Tricare|TRICARE EAST REGION|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|United Healthcare|TML GROUP BENEFITS|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|United Healthcare|UNITED HEALTHCARE OTHER|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|United Healthcare|UNITED HEALTHCARE|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|United Healthcare|UNITED HEALTHCARE|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicare|HEALTHSPRING MA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicare|BCBS MEDICARE PPO MA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicare|MEDICARE PART B ONLY IP|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicare|MEDICARE ACUTE|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicaid|SMITH COUNTY JAIL|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicaid|MEDICAID HMO|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicaid|CRIME VICTIMS COMPENSATION|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Workers Compensation|WORKERS COMPENSATION OTHER|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicaid|MEDICAID|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Workers Compensation|TEXAS MUTUAL INSURANCE|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Workers Compensation|BROOKSHIRES WORKERS COMP|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Veterans Affairs|VETERANS ADMINISTRATION|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Access Direct Platinum|HEALTHFIRST TPA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Access Direct Platinum|HEALTHFIRST TPA UMR|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|United Medicare Advantage|UHC AARP MCR HMO MA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|United Healthcare|GOLDEN RULE|||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Cigna|CIGNA OTHER|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Cigna|CIGNA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Humana Medicare Advantage|HUMANA MA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicaid|MEDICAID SUPERIOR|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicaid|MEDICAID AMERIGROUP|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|NON CONTRACTED|COMMERCIAL OTHER 2|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Aetna|AETNA OTHER|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Aetna|AETNA QHP HMO|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Aetna|AETNA PPO|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross HMO Specialty|BCBSTX HMO|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross PPO Specialty|BCBSTX OTHER|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross PPO Specialty|BCBSTX PPO|1.67||||1.67||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.67||||||| 9505686|ERX|0258|DEXTROSE 5%-WATER 250ML|ChampVA|CHAMPVA CENTER|1.67||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Blue Cross HMO Specialty|BCBSTX HMO|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Blue Cross PPO Specialty|BCBSTX PPO|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Aenta Medicare Advantage|AETNA MEDICARE MA|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|171.75||||171.75||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicaid|MEDICAID AMERIGROUP|171.75||||171.75||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|171.75||||171.75||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|171.75||||171.75||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Humana Medicare Advantage|HUMANA MA|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Cigna|CIGNA|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|United Medicare Advantage|UHC AARP MCR HMO MA|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|United Medicare Advantage|UHC MEDICARE GOLD MA|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|171.75||||171.75||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Access Direct Platinum|HEALTHFIRST TPA|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Access Direct Platinum|HEALTHFIRST TPA UMR|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Workers Compensation|WORKERS COMPENSATION OTHER|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Veterans Affairs|VETERANS ADMINISTRATION|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Medicaid|SMITH COUNTY JAIL|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicaid|MEDICAID SUPERIOR|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Medicaid|MEDICAID HMO|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Medicaid|MEDICAID|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Medicaid|CRIME VICTIMS COMPENSATION|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Aetna|AETNA PPO|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Medicare|MEDICARE ACUTE|171.75||||171.75||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicare|BCBS MEDICARE PPO MA|171.75||||171.75||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicare|HEALTHSPRING MA|171.75||||171.75||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|United Healthcare|UNITED HEALTHCARE OTHER|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|United Healthcare|UNITED HEALTHCARE|171.75||||171.75||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Rusk State Hospital|RUSK STATE HOSP|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|PHCS|GROUP AND PENSION|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|PHCS|HUMANA INSURANCE|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|Tricare|TRICARE EAST REGION|171.75||||||| 9505694|ERX|0258|DEXTROSE 5%-WATER 500ML|NON CONTRACTED|COMMERCIAL OTHER 1|171.75||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Rusk State Hospital|RUSK STATE HOSP|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Tricare|TRICARE EAST REGION|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|United Healthcare|UNITED HEALTHCARE OTHER|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|United Healthcare|UNITED HEALTHCARE|1.61||||1.61||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicare|HEALTHSPRING MA|1.61||||1.61||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Medicare|MEDICARE ACUTE|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Medicare|MEDICARE PART B ONLY IP|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Medicaid|MEDICAID|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Access Direct Platinum|HEALTHFIRST TPA|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Medicaid|MEDICAID HMO|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicare|BCBS MEDICARE PPO MA|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Access Direct Platinum|HEALTHFIRST TPA UMR|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.61||||1.61||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|United Medicare Advantage|UHC AARP MCR HMO MA|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.61||||1.61||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Cigna|CIGNA OTHER|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Cigna|CIGNA|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Humana Medicare Advantage|HUMANA MA|1.61||||1.61||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicaid|MEDICAID SUPERIOR|1.61||||1.61||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.61||||1.61||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|1.61||||1.61||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.61||||1.61||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Aetna|BOON CHAPMAN|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Aetna|AETNA PPO|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|1.61||||||| 9505702|ERX|0258|DEXTROSE 5%-WATER 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|1.61||||1.61||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Blue Cross PPO Specialty|BCBSTX PPO|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Aetna|AETNA PPO|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.11||||1.11||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Managed Medicaid|MEDICAID AMERIGROUP|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Humana Medicare Advantage|HUMANA MA|1.11||||1.11||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Cigna|CIGNA|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Cigna|CIGNA OTHER|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|United Medicare Advantage|UHC AARP MCR HMO MA|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|United Medicare Advantage|UHC MEDICARE GOLD MA|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.11||||1.11||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Access Direct Platinum|HEALTHFIRST TPA|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Access Direct Platinum|HEALTHFIRST TPA UMR|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Veterans Affairs|VETERANS ADMINISTRATION|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Workers Compensation|WORKERS COMPENSATION OTHER|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Medicaid|MEDICAID HMO|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Medicaid|MEDICAID|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Medicaid|CRIME VICTIMS COMPENSATION|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Medicare|MEDICARE ACUTE|1.11||||1.11||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Medicare|MEDICARE PART B ONLY IP|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Aenta Medicare Advantage|AETNA MEDICARE MA|1.11||||1.11||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Blue Cross HMO Specialty|BCBSTX HMO|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Managed Medicare|HEALTHSPRING MA|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Managed Medicare|BCBS MEDICARE PPO MA|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|United Healthcare|UNITED HEALTHCARE OTHER|1.11||||1.11||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|United Healthcare|UNITED HEALTHCARE|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|United Healthcare|UNITED HEALTHCARE|||||1.11||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|United Healthcare|AARP|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Tricare|TRICARE FOR LIFE|1.11||||||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|Tricare|TRICARE EAST REGION|1.11||||1.11||| 9505710|ERX|0258|DEXTROSE 5%-WATER 150ML 1|NON CONTRACTED|COMMERCIAL OTHER 1|1.11||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Rusk State Hospital|RUSK STATE HOSP|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Tricare|TRICARE EAST REGION|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Healthcare|UNITED HEALTHCARE OTHER|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Healthcare|UNITED HEALTHCARE|||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicare|WELLCARE CHOICE MA|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicare|MEDICARE ACUTE|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicare|MEDICARE PART B ONLY IP|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicaid|SMITH COUNTY JAIL|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicaid|MEDICAID HMO|||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicaid|MEDICAID|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Veterans Affairs|VETERANS ADMINISTRATION|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Workers Compensation|WORKERS COMPENSATION OTHER|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Access Direct Platinum|HEALTHFIRST TPA UMR|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Medicare Advantage|UHC AARP MCR HMO MA|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Cigna|CIGNA|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Cigna|CIGNA|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicare|HEALTHSPRING MA|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Cigna|CIGNA OTHER|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Humana Medicare Advantage|HUMANA MA|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Healthcare|UNITED HEALTHCARE|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicaid|MEDICAID SUPERIOR|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicaid|MEDICAID AMERIGROUP|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|NON CONTRACTED|COMMERCIAL OTHER 1|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Aetna|AETNA OTHER|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Aetna|BOON CHAPMAN|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Aetna|AETNA PPO|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|ChampVA|CHAMPVA CENTER|203.50||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Blue Cross PPO Specialty|BCBSTX PPO|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Blue Cross HMO Specialty|BCBSTX HMO|203.50||||203.50||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Blue Cross PPO Specialty|BCBSTX OTHER|203.50||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Blue Cross PPO Specialty|BCBSTX PPO|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Blue Cross HMO Specialty|BCBSTX HMO|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Blue Cross PPO Specialty|BCBSTX OTHER|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Aetna|AETNA OTHER|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Aetna|AETNA PPO|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Aetna Value Network|AETNA VALUE NETWORK|||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Managed Medicaid|MEDICAID AMERIGROUP|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Humana Medicare Advantage|HUMANA MA|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Cigna|CIGNA OTHER|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Cigna|CIGNA|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Cigna|CIGNA|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|United Medicare Advantage|UHC AARP MCR HMO MA|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Access Direct Platinum|HEALTHFIRST TPA UMR|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Access Direct Platinum|HEALTHFIRST TPA|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Veterans Affairs|VETERANS ADMINISTRATION|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Workers Compensation|WORKERS COMPENSATION OTHER|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Workers Compensation|TEXAS MUTUAL INSURANCE|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Workers Compensation|BROOKSHIRES WORKERS COMP|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Medicaid|MEDICAID|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Medicaid|CRIME VICTIMS COMPENSATION|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Medicare|MEDICARE PART B ONLY IP|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Managed Medicaid|MEDICAID SUPERIOR|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Medicare|MEDICARE ACUTE|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Managed Medicare|OTHER INSTITUTIONS|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Managed Medicare|HEALTHSPRING MA|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Managed Medicare|BCBS MEDICARE PPO MA|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|United Healthcare|UNITED HEALTHCARE OTHER|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|United Healthcare|UNITED HEALTHCARE|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|United Healthcare|UNITED HEALTHCARE|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|United Healthcare|TML GROUP BENEFITS|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|United Healthcare|GEHA|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Rusk State Hospital|RUSK STATE HOSP|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|PHCS|GROUP AND PENSION|122.25||||122.25||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|Tricare|TRICARE EAST REGION|122.25||||||| 9505736|ERX|0258|DEXTROSE 5%-WATER 100ML|NON CONTRACTED|COMMERCIAL OTHER 1|122.25||||122.25||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|United Healthcare|UNITED HEALTHCARE OTHER|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Managed Medicare|HEALTHSPRING MA|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Medicare|MEDICARE ACUTE|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|181.75||||181.75||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|United Medicare Advantage|UHC AARP MCR HMO MA|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|181.75||||181.75||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Humana Medicare Advantage|HUMANA MA|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|181.75||||181.75||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Managed Medicaid|MEDICAID SUPERIOR|181.75||||181.75||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|181.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|181.75||||181.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Aetna|AETNA PPO|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicaid|MEDICAID SUPERIOR|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Cigna|CIGNA|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Cigna|CIGNA OTHER|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Humana Medicare Advantage|HUMANA MA|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Medicare Advantage|UHC AARP MCR HMO MA|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UMR|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Workers Compensation|WORKERS COMPENSATION OTHER|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicaid|SMITH COUNTY JAIL|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicaid|MEDICAID|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicaid|CRIME VICTIMS COMPENSATION|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicaid|MEDICAID HMO|||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicare|MEDICARE ACUTE|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicare|WELLCARE CHOICE MA|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicare|HEALTHSPRING MA|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicare|BCBS MEDICARE PPO MA|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Multiplan|PACIFICARE|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Rusk State Hospital|RUSK STATE HOSP|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Texas Workforce Commission|DIS DETER SERV (DDS)|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|179.75||||||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Healthcare|UNITED HEALTHCARE OTHER|179.75||||179.75||| 9505769|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Healthcare|UNITED HEALTHCARE|179.75||||179.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|United Healthcare|UNITED HEALTHCARE OTHER|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|United Healthcare|UNITED HEALTHCARE|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Rusk State Hospital|RUSK STATE HOSP|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicare|HEALTHSPRING MA|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicare|MEDICARE ACUTE|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicaid|SMITH COUNTY JAIL|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicaid|MEDICAID|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicaid|CRIME VICTIMS COMPENSATION|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicare|BCBS MEDICARE PPO MA|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Access Direct Platinum|HEALTHFIRST TPA|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|United Medicare Advantage|UHC AARP MCR HMO MA|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Humana Medicare Advantage|HUMANA MA|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Cigna|CIGNA|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicaid|MEDICAID SUPERIOR|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Aetna|AETNA PPO|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|185.75||||||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Blue Cross PPO Specialty|BCBSTX OTHER|185.75||||185.75||| 9505777|ERX|0258|DEXTROSE 5%-LR 1000ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|185.75||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Blue Cross PPO Specialty|BCBSTX PPO|1.38||||1.38||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.38||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Aetna Value Network|AETNA VALUE NETWORK|||||1.38||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Managed Medicaid|MEDICAID SUPERIOR|1.38||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Humana Medicare Advantage|HUMANA MA|1.38||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.38||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.38||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Medicaid|MEDICAID|1.38||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Medicare|MEDICARE ACUTE|1.38||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Managed Medicare|HEALTHSPRING MA|1.38||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Multiplan|WEB TPA|1.38||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|United Healthcare|UNITED HEALTHCARE|1.38||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|United Healthcare|UNITED HEALTHCARE OTHER|206.50||||206.50||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|United Healthcare|UNITED HEALTHCARE|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Managed Medicare|WELLCARE CHOICE MA|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Managed Medicare|HEALTHSPRING MA|206.50||||206.50||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Medicare|MEDICARE ACUTE|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Medicare|MEDICARE PART B ONLY IP|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Medicaid|MEDICAID|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Workers Compensation|WORKERS COMPENSATION OTHER|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Access Direct Platinum|HEALTHFIRST TPA|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Access Direct Platinum|HEALTHFIRST TPA UMR|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|PHCS|HUMANA|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|United Medicare Advantage|UHC AARP MCR HMO MA|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Humana Medicare Advantage|HUMANA MA|206.50||||206.50||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Managed Medicaid|MEDICAID SUPERIOR|206.50||||206.50||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|206.50||||206.50||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Aetna|BOON CHAPMAN|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Aetna|AETNA OTHER|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|206.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|206.50||||||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Blue Cross PPO Specialty|BCBSTX PPO|168.75||||||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|168.75||||168.75||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Managed Medicaid|MEDICAID UNITED HEALTHCARE|168.75||||||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|168.75||||||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Humana Medicare Advantage|HUMANA MA|168.75||||168.75||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|United Medicare Advantage|UHC MEDICARE GOLD MA|168.75||||||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|168.75||||||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||168.75||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Veterans Affairs|VETERANS ADMINISTRATION|168.75||||||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Medicare|MEDICARE ACUTE|168.75||||168.75||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|28.50||||28.50||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Medicare|MEDICARE PART B ONLY IP|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|28.50||||28.50||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|28.50||||28.50||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Cigna|CIGNA OTHER|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Cigna|CIGNA|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Humana Medicare Advantage|HUMANA MA|28.50||||28.50||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.50||||28.50||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|28.50||||28.50||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Managed Medicare|HEALTHSPRING MA|28.50||||28.50||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.50||||28.50||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|28.50||||||| 9505819|ERX|0250|ROPINIROLE 0.25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|28.50||||28.50||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Blue Cross PPO Specialty|BCBSTX OTHER|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Aetna|BOON CHAPMAN|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Humana Medicare Advantage|HUMANA MA|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Cigna|CIGNA OTHER|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Cigna|CIGNA|||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|United Medicare Advantage|UHC AARP MCR HMO MA|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Cigna|CIGNA|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicaid|MEDICAID SUPERIOR|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Workers Compensation|WORKERS COMPENSATION OTHER|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Aetna|AETNA PPO|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UMR|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicare|WELLCARE CHOICE MA|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicare|HEALTHSPRING MA|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicaid|MEDICAID|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicaid|CRIME VICTIMS COMPENSATION|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicare|MEDICARE ACUTE|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|United Healthcare|UNITED HEALTHCARE OTHER|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|United Healthcare|UNITED HEALTHCARE|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.96||||||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|Tricare|TRICARE EAST REGION|1.96||||1.96||| 9505827|ERX|0258|DEXTROSE 5%-NS 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.96||||1.96||| 9505835|ERX|0258|LACTATED RINGERS 500ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Tricare|TRICARE EAST REGION|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|United Healthcare|UNITED HEALTHCARE OTHER|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|United Healthcare|UNITED HEALTHCARE|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Medicare|MEDICARE ACUTE|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Medicaid|MEDICAID HMO|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Medicaid|MEDICAID|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Access Direct Platinum|HEALTHFIRST TPA UMR|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Veterans Affairs|VETERANS ADMINISTRATION|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|United Medicare Advantage|UHC AARP MCR HMO MA|171.75||||||| 9505835|ERX|0258|LACTATED RINGERS 500ML|United Medicare Advantage|UHC MEDICARE GOLD MA|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Cigna|CIGNA OTHER|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Humana Medicare Advantage|HUMANA MA|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicaid|MEDICAID AMERIGROUP|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicare|HEALTHSPRING MA|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicaid|MEDICAID SUPERIOR|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|171.75||||||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Aetna|AETNA OTHER|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Aetna|AETNA PPO|||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Blue Cross PPO Specialty|BCBSTX OTHER|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Blue Cross HMO Specialty|BCBSTX HMO|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Blue Cross PPO Specialty|BCBSTX PPO|171.75||||171.75||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|171.75||||171.75||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|ChampVA|CHAMPVA CENTER|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross PPO Specialty|BCBSTX OTHER|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Aetna|BOON CHAPMAN|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Aetna|AETNA QHP HMO|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Aetna|AETNA PPO|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Aetna Value Network|AETNA VALUE NETWORK|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicaid|MEDICAID SUPERIOR|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Humana Medicare Advantage|HUMANA MA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Cigna|CIGNA OTHER|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Cigna|CIGNA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Medicare Advantage|UHC AARP MCR HMO MA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|ZURICH COMPANY|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|WORKERS COMPENSATION OTHER|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|UT EMPLOYEE INJURY|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|TEXAS MUTUAL INSURANCE|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|BROOKSHIRES WORKERS COMP|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|GALLAGHER BASSETT|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST TPA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UMR|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|WELLCARE CHOICE MA|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|BCBS MEDICARE PPO MA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|HEALTHSPRING MA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|SMITH COUNTY JAIL|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|MEDICAID HMO|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|MEDICAID BCBSTX|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|MEDICAID|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|LAW ENFORCEMENT OTHER|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|CRIME VICTIMS COMPENSATION|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicare|MEDICARE ACUTE|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicare|MEDICARE PART B ONLY IP|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Aetna|AETNA OTHER|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|UNITED HEALTHCARE ERS|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|UNITED HEALTHCARE OTHER|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|UNITED HEALTHCARE|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|TML GROUP BENEFITS|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|GOLDEN RULE|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|GEHA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Texas Workforce Commission|DIS DETER SERV (DDS)|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|PHCS|GROUP AND PENSION|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|PHCS|HUMANA|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|PHCS|HUMANA INSURANCE|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Tricare|TRICARE SOUTH PHYSICIAN|||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Rusk State Hospital|RUSK STATE HOSP|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Tricare|TRICARE EAST REGION|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Tricare|TRICARE FOR LIFE|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Multiplan|PACIFICARE|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Multiplan|WEB TPA|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|Multiplan|NALC|180.25||||||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|NON CONTRACTED|COMMERCIAL OTHER 2|180.25||||180.25||| 9505843|ERX|0258|LACTATED RINGERS 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|180.25||||180.25||| 9505850|ERX|0258|CARDIOPLEGIC SOLUTION 100|Medicare|MEDICARE ACUTE|556.75||||||| 9505850|ERX|0258|CARDIOPLEGIC SOLUTION 100|Humana Medicare Advantage|HUMANA MA|556.75||||||| 9505850|ERX|0258|CARDIOPLEGIC SOLUTION 100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|556.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Access Direct Platinum|HEALTHFIRST TPA UMR|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Access Direct Platinum|HEALTHFIRST TPA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Workers Compensation|ZURICH COMPANY|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Workers Compensation|WORKERS COMPENSATION OTHER|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Workers Compensation|UT EMPLOYEE INJURY|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Workers Compensation|GALLAGHER BASSETT|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Workers Compensation|BROOKSHIRES WORKERS COMP|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|United Medicare Advantage|UHC AARP MCR HMO MA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|United Medicare Advantage|UHC MEDICARE GOLD MA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Aetna Value Network|AETNA VALUE NETWORK|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Aetna|AETNA OTHER|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Aetna|BOON CHAPMAN|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Aetna|AETNA QHP HMO|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Aetna|AETNA PPO|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Blue Cross PPO Specialty|BCBSTX PPO|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Blue Cross PPO Specialty|BCBSTX OTHER|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Brinson Benefits|THE HEALTH PLAN SMITH CO|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|ChampVA|CHAMPVA CENTER|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Managed Medicaid|MEDICAID SUPERIOR|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Managed Medicaid|MEDICAID AMERIGROUP|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Cigna|CIGNA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Cigna|CIGNA OTHER|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Humana Medicare Advantage|HUMANA MA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Multiplan|WEB TPA|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Multiplan|PACIFICARE|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|NON CONTRACTED|COMMERCIAL OTHER 2|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Blue Cross HMO Specialty|BCBSTX HMO|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|NON CONTRACTED|COMMERCIAL OTHER 1|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Rusk State Hospital|RUSK STATE HOSP|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Texas Workforce Commission|DIS DETER SERV (DDS)|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|PHCS|HUMANA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|PHCS|GROUP AND PENSION|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Tricare|TRICARE EAST REGION|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Tricare|TRICARE SOUTH PHYSICIAN|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Tricare|TRICARE FOR LIFE|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Aenta Medicare Advantage|AETNA MEDICARE MA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|United Medicare Advantage|UHC AARP WELLMED HMO MA|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|United Healthcare|UNITED HEALTHCARE OTHER|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|United Healthcare|UNITED HEALTHCARE|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|United Healthcare|TML GROUP BENEFITS|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|United Healthcare|GOLDEN RULE|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Workers Compensation|TEXAS MUTUAL INSURANCE|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|United Healthcare|GEHA|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|UTMB|UTMB CORRECTIONAL MANAGED CARE|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Managed Medicare|HEALTHSPRING MA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Veterans Affairs|VETERANS ADMINISTRATION|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Managed Medicare|BCBS MEDICARE PPO MA|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicaid|SMITH COUNTY JAIL|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicaid|MOLINA HEALTHCARE OF TEXAS|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicaid|MEDICAID HMO|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicaid|MEDICAID|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicaid|CRIME VICTIMS COMPENSATION|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicaid|COUNTY INDIGENT HEALTH OTHER|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicare|MEDICARE ACUTE|166.75||||166.75||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicare|MEDICARE PART B ONLY IP|166.75||||||| 9505868|ERX|0258|NA CHLORIDE 0.9%,3000ML I|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|166.75||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicare|MEDICARE ACUTE|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicare|MEDICARE PART B ONLY IP|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|SMITH COUNTY JAIL|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|SMITH COUNTY INDIGENT HEALTH|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|MOLINA HEALTHCARE OF TEXAS|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|MEDICAID|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|LAW ENFORCEMENT OTHER|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|CRIME VICTIMS COMPENSATION|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|WELLCARE CHOICE MA|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|HEALTHSPRING MA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|ETMC AFFILIATE HOSPITALS|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|ETMC REHABILITATION HOSPITAL|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|BCBS MEDICARE PPO MA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|UTMB|UTMB CORRECTIONAL MANAGED CARE|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Healthcare|UNITED HEALTHCARE|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Healthcare|TML GROUP BENEFITS|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Healthcare|GEHA|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|PHCS|HUMANA|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|PHCS|GROUP AND PENSION|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Tricare|TRICARE FOR LIFE|||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Multiplan|NALC|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|NON CONTRACTED|COMMERCIAL OTHER 2|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|NON CONTRACTED|COMMERCIAL OTHER 1|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Humana Medicare Advantage|HUMANA MA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Cigna|CIGNA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Cigna|CIGNA OTHER|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID AMERIGROUP|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Tricare|TRICARE EAST REGION|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID SUPERIOR|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Rusk State Hospital|RUSK STATE HOSP|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Healthcare|UNITED HEALTHCARE OTHER|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Brinson Benefits|THE HEALTH PLAN SMITH CO|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|ChampVA|CHAMPVA CENTER|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross HMO Specialty|BCBSTX HMO|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross PPO Specialty|BCBSTX OTHER|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross PPO Specialty|BCBSTX PPO|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Aenta Medicare Advantage|AETNA MEDICARE MA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Aetna|AETNA QHP HMO|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Aetna|AETNA PPO|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Aetna|AETNA OTHER|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|UHC AARP WELLMED HMO MA|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|COUNTY INDIGENT HEALTH OTHER|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|MEDICAID HMO|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|UHC MEDICARE GOLD MA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|UHC AARP MCR HMO MA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Veterans Affairs|VETERANS ADMINISTRATION|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Workers Compensation|ZURICH COMPANY|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Workers Compensation|WORKERS COMPENSATION OTHER|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Workers Compensation|UT EMPLOYEE INJURY|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Workers Compensation|TEXAS MUTUAL INSURANCE|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Workers Compensation|BROOKSHIRES WORKERS COMP|142.25||||||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Access Direct Platinum|HEALTHFIRST TPA UMR|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Access Direct Platinum|HEALTHFIRST TPA|142.25||||142.25||| 9505884|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||142.25||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Access Direct Platinum|HEALTHFIRST TPA UMR|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Access Direct Platinum|HEALTHFIRST TPA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Veterans Affairs|VETERANS ADMINISTRATION|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Workers Compensation|ZURICH COMPANY|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Workers Compensation|WORKERS COMPENSATION OTHER|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Workers Compensation|UT EMPLOYEE INJURY|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Workers Compensation|TRAVELERS INSURANCE COMPANY|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Workers Compensation|TEXAS MUTUAL INSURANCE|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Workers Compensation|BROOKSHIRES WORKERS COMP|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|UHC AARP WELLMED HMO MA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|UHC AARP MCR HMO MA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Aetna|AETNA QHP HMO|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Aetna|AETNA OTHER|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Aenta Medicare Advantage|AETNA MEDICARE MA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross HMO Specialty|BCBSTX HMO|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross PPO Specialty|BCBSTX PPO|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross PPO Specialty|BCBSTX OTHER|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Brinson Benefits|THE HEALTH PLAN SMITH CO|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID AMERIGROUP|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Cigna|CIGNA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Cigna|CIGNA OTHER|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Humana Medicare Advantage|HUMANA MA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID SUPERIOR|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Multiplan|PACIFICARE|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Multiplan|WEB TPA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|NON CONTRACTED|COMMERCIAL OTHER 2|||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|ChampVA|CHAMPVA CENTER|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|NON CONTRACTED|COMMERCIAL OTHER 1|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Rusk State Hospital|RUSK STATE HOSP|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Texas Workforce Commission|DIS DETER SERV (DDS)|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|PHCS|GROUP AND PENSION|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|PHCS|HUMANA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|PHCS|HUMANA INSURANCE|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Tricare|TRICARE EAST REGION|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Tricare|TRICARE FOR LIFE|||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Aetna|AETNA PPO|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Healthcare|UNITED HEALTHCARE OTHER|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Healthcare|UNITED HEALTHCARE|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Healthcare|TML GROUP BENEFITS|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Healthcare|GOLDEN RULE|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|UHC MEDICARE GOLD MA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Healthcare|GEHA|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|UTMB|UTMB CORRECTIONAL MANAGED CARE|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|OTHER INSTITUTIONS|||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|BCBS MEDICARE PPO MA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|HEALTHSPRING MA|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Workers Compensation|GALLAGHER BASSETT|||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|SUPERIOR HEALTHPLAN CHIP|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|SMITH COUNTY INDIGENT HEALTH|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|SMITH COUNTY JAIL|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|MEDICAID HMO|||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|MOLINA HEALTHCARE OF TEXAS|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|LAW ENFORCEMENT OTHER|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|COUNTY INDIGENT HEALTH OTHER|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|MEDICAID|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|CRIME VICTIMS COMPENSATION|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicare|MEDICARE ACUTE|154.75||||154.75||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicare|MEDICARE PART B ONLY IP|154.75||||||| 9505892|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicare|UTSW MC KIDNEY PROGRAM|||||154.75||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicare|MEDICARE ACUTE|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicare|UTSW MC KIDNEY PROGRAM|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MEDICAID|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|SMITH COUNTY JAIL|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MEDICAID HMO|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MEDICAID BCBSTX|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|CRIME VICTIMS COMPENSATION|1.78||||||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|WELLCARE CHOICE MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|MA PART B ONLY IP|1.78||||||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|HEALTHSPRING MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|HOSPICE OF EAST TEXAS|1.78||||||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|ETMC AFFILIATE HOSPITALS|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|UNITED HEALTHCARE OTHER|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|UNITED HEALTHCARE|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|GOLDEN RULE|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|GEHA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|AARP|1.78||||||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|PHCS|HUMANA INSURANCE|1.78||||||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|PHCS|HUMANA INSURANCE|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|PHCS|HUMANA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Tricare|TRICARE FOR LIFE|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Rusk State Hospital|RUSK STATE HOSP|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Tricare|TRICARE SOUTH PHYSICIAN|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Multiplan|NALC|1.78||||||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Multiplan|WEB TPA|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Tricare|TRICARE EAST REGION|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|NON CONTRACTED|COMMERCIAL OTHER 2|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|NON CONTRACTED|COMMERCIAL OTHER 1|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Humana Medicare Advantage|HUMANA MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Cigna|CIGNA OTHER|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Cigna|CIGNA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicaid|MEDICAID SUPERIOR|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|PHCS|GROUP AND PENSION|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicaid|MEDICAID AMERIGROUP|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|TML GROUP BENEFITS|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|ChampVA|CHAMPVA CENTER|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross PPO Specialty|BCBSTX PPO|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross PPO Specialty|BCBSTX OTHER|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross HMO Specialty|BCBSTX HMO|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|BCBS MEDICARE PPO MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|OTHER INSTITUTIONS|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aetna|AETNA OTHER|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aenta Medicare Advantage|AETNA MEDICARE MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aetna|BOON CHAPMAN|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aetna|AETNA QHP HMO|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aetna|AETNA PPO|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aetna Value Network|AETNA VALUE NETWORK|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Medicare Advantage|UHC AARP MCR HMO MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|LAW ENFORCEMENT OTHER|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Medicare Advantage|UHC MEDICARE GOLD MA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Veterans Affairs|VETERANS ADMINISTRATION|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|ZURICH COMPANY|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|WORKERS COMPENSATION OTHER|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|WORKERS COMP PHYSICIAN|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|TRAVELERS INSURANCE COMPANY|1.78||||||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicare|MEDICARE PART B ONLY IP|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|TEXAS MUTUAL INSURANCE|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.78||||||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|BROOKSHIRES WORKERS COMP|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|UT EMPLOYEE INJURY|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|GALLAGHER BASSETT|||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST TPA|1.78||||1.78||| 9505900|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST TPA UMR|1.78||||1.78||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Access Direct Platinum|HEALTHFIRST TPA|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|117.50||||117.50||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Veterans Affairs|VETERANS ADMINISTRATION|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|United Medicare Advantage|UHC MEDICARE GOLD MA|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Blue Cross PPO Specialty|BCBSTX PPO|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Cigna|CIGNA|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Humana Medicare Advantage|HUMANA MA|117.50||||117.50||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Tricare|TRICARE EAST REGION|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Managed Medicare|HEALTHSPRING MA|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Managed Medicare|BCBS MEDICARE PPO MA|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Medicaid|MEDICAID|117.50||||117.50||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Medicare|MEDICARE PART B ONLY IP|117.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Medicare|MEDICARE ACUTE|117.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicare|MEDICARE ACUTE|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|MEDICAID HMO|||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|MEDICAID|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|CRIME VICTIMS COMPENSATION|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicare|WELLCARE CHOICE MA|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicare|HEALTHSPRING MA|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicare|BCBS MEDICARE PPO MA|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|UNITED HEALTHCARE OTHER|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|UNITED HEALTHCARE|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|TML GROUP BENEFITS|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|AARP|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|NON CONTRACTED|COMMERCIAL OTHER 2|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Rusk State Hospital|RUSK STATE HOSP|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|PHCS|GROUP AND PENSION|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|PHCS|HUMANA|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Tricare|TRICARE EAST REGION|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Humana Medicare Advantage|HUMANA MA|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Cigna|CIGNA|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Cigna|CIGNA OTHER|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Cigna|CIGNA|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|NON CONTRACTED|COMMERCIAL OTHER 1|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID SUPERIOR|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID AMERIGROUP|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|GEHA|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Aetna Value Network|AETNA VALUE NETWORK|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Aetna|AETNA QHP HMO|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Aetna|AETNA PPO|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Aetna|AETNA OTHER|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross PPO Specialty|BCBSTX OTHER|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross PPO Specialty|BCBSTX PPO|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross HMO Specialty|BCBSTX HMO|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Medicare Advantage|UHC AARP MCR HMO MA|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicare|MEDICARE PART B ONLY IP|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Veterans Affairs|VETERANS ADMINISTRATION|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Workers Compensation|ZURICH COMPANY|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Workers Compensation|WORKERS COMPENSATION OTHER|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Workers Compensation|TEXAS MUTUAL INSURANCE|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Workers Compensation|BROOKSHIRES WORKERS COMP|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST TPA UMR|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|123.50||||||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|123.50||||123.50||| 9505926|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST TPA|123.50||||123.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Cigna|CIGNA|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.50||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|PHCS|GROUP AND PENSION|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Tricare|TRICARE EAST REGION|||||28.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|28.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|WELLCARE CHOICE MA|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|OTHER INSTITUTIONS|||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|HEALTHSPRING MA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|MA PART B ONLY IP|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|SMITH COUNTY JAIL|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|SMITH COUNTY INDIGENT HEALTH|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|MEDICAID HMO|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|MEDICAID|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|LAW ENFORCEMENT OTHER|||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|CRIME VICTIMS COMPENSATION|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|COUNTY INDIGENT HEALTH OTHER|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicare|MEDICARE ACUTE|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicare|MEDICARE PART B ONLY IP|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|UNITED HEALTHCARE OTHER|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|UNITED HEALTHCARE|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|UTMB|UTMB CORRECTIONAL MANAGED CARE|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|NON CONTRACTED|COMMERCIAL OTHER 2|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|NON CONTRACTED|COMMERCIAL OTHER 1|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Tricare|TRICARE EAST REGION|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|PHCS|GROUP AND PENSION|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|PHCS|HUMANA|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Rusk State Hospital|RUSK STATE HOSP|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Humana Medicare Advantage|HUMANA MA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Cigna|CIGNA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Cigna|CIGNA OTHER|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID AMERIGROUP|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|GEHA|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicare|UTSW MC KIDNEY PROGRAM|||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID SUPERIOR|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aenta Medicare Advantage|AETNA MEDICARE MA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aetna|BOON CHAPMAN|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aetna|AETNA QHP HMO|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aetna|AETNA PPO|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aetna|AETNA OTHER|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|ChampVA|CHAMPVA CENTER|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross PPO Specialty|BCBSTX PPO|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross HMO Specialty|BCBSTX HMO|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross PPO Specialty|BCBSTX OTHER|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|UHC AARP WELLMED HMO MA|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|UHC MEDICARE GOLD MA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|MOLINA HEALTHCARE OF TEXAS|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|BCBS MEDICARE PPO MA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|HOSPICE OF EAST TEXAS|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|UHC AARP MCR HMO MA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Veterans Affairs|VETERANS ADMINISTRATION|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Workers Compensation|ZURICH COMPANY|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Workers Compensation|WORKERS COMPENSATION OTHER|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Workers Compensation|TEXAS MUTUAL INSURANCE|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|121.50||||||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Access Direct Platinum|HEALTHFIRST TPA|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Access Direct Platinum|HEALTHFIRST TPA UMR|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|121.50||||121.50||| 9505942|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|121.50||||121.50||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Access Direct Platinum|HEALTHFIRST TPA UMR|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Access Direct Platinum|HEALTHFIRST TPA|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Veterans Affairs|VETERANS ADMINISTRATION|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Workers Compensation|WORKERS COMPENSATION OTHER|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Medicare Advantage|UHC MEDICARE GOLD MA|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Medicare Advantage|UHC AARP MCR HMO MA|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Blue Cross HMO Specialty|BCBSTX HMO|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Blue Cross PPO Specialty|BCBSTX OTHER|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Aetna|BOON CHAPMAN|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Aetna|AETNA QHP HMO|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Aetna|AETNA PPO|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Aetna|AETNA OTHER|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Aenta Medicare Advantage|AETNA MEDICARE MA|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicaid|MEDICAID AMERIGROUP|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Cigna|CIGNA OTHER|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Cigna|CIGNA|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Cigna|CIGNA|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Blue Cross PPO Specialty|BCBSTX PPO|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Humana Medicare Advantage|HUMANA MA|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|PHCS|GROUP AND PENSION|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Tricare|TRICARE EAST REGION|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Multiplan|TRUSTMARK|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|NON CONTRACTED|COMMERCIAL OTHER 2|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|NON CONTRACTED|COMMERCIAL OTHER 1|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Healthcare|UNITED HEALTHCARE OTHER|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Healthcare|UNITED HEALTHCARE|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Healthcare|UNITED HEALTHCARE|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Healthcare|TML GROUP BENEFITS|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicare|MEDICARE ACUTE|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicare|MEDICARE PART B ONLY IP|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicaid|MEDICAID|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.18||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicare|BCBS MEDICARE PPO MA|2.18||||2.18||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicare|HEALTHSPRING MA|2.18||||2.18||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Medicaid|MEDICAID|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Medicaid|COUNTY INDIGENT HEALTH OTHER|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Medicare|MEDICARE ACUTE|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|United Healthcare|UNITED HEALTHCARE|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|UTMB|UTMB CORRECTIONAL MANAGED CARE|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Humana Medicare Advantage|HUMANA MA|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Managed Medicaid|MEDICAID SUPERIOR|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Managed Medicaid|MEDICAID AMERIGROUP|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|United Healthcare|UNITED HEALTHCARE OTHER|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Managed Medicare|HEALTHSPRING MA|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Aetna|AETNA PPO|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Aetna|AETNA OTHER|||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Aenta Medicare Advantage|AETNA MEDICARE MA|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Blue Cross HMO Specialty|BCBSTX HMO|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Blue Cross PPO Specialty|BCBSTX PPO|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|United Medicare Advantage|UHC AARP MCR HMO MA|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|United Medicare Advantage|UHC MEDICARE GOLD MA|146.50||||146.50||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Veterans Affairs|VETERANS ADMINISTRATION|146.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Workers Compensation|WORKERS COMPENSATION OTHER|146.50||||||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||168.75||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|United Medicare Advantage|UHC MEDICARE GOLD MA|168.75||||||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|Blue Cross HMO Specialty|BCBSTX HMO|168.75||||||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|Blue Cross PPO Specialty|BCBSTX PPO|168.75||||||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|ChampVA|CHAMPVA CENTER|168.75||||||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|Aenta Medicare Advantage|AETNA MEDICARE MA|168.75||||||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|Humana Medicare Advantage|HUMANA MA|168.75||||168.75||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|Medicare|MEDICARE ACUTE|168.75||||||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|Managed Medicare|HEALTHSPRING MA|168.75||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|PHCS|HUMANA|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Tricare|TRICARE EAST REGION|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Healthcare|TML GROUP BENEFITS|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicaid|CRIME VICTIMS COMPENSATION|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicaid|MEDICAID|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicare|MEDICARE ACUTE|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicare|MEDICARE PART B ONLY IP|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicare|WELLCARE CHOICE MA|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicare|OTHER INSTITUTIONS|||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicare|HEALTHSPRING MA|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicare|BCBS MEDICARE PPO MA|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Cigna|CIGNA|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Humana Medicare Advantage|HUMANA MA|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicaid|MEDICAID SUPERIOR|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicaid|MEDICAID AMERIGROUP|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Blue Cross HMO Specialty|BCBSTX HMO|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Aetna|AETNA PPO|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE OTHER|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Aetna|AETNA QHP HMO|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Veterans Affairs|VETERANS ADMINISTRATION|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Rusk State Hospital|RUSK STATE HOSP|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Workers Compensation|TEXAS MUTUAL INSURANCE|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1.70||||1.70||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|1.70||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.70||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|Aetna|BOON CHAPMAN|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|Cigna|CIGNA|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|Humana Medicare Advantage|HUMANA MA|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|Medicare|MEDICARE ACUTE|0.13||||||| 9505991|ERX|0250|K ACETATE 2 MEQ/ML,20ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|United Healthcare|UNITED HEALTHCARE OTHER|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|United Healthcare|UNITED HEALTHCARE|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|United Healthcare|TML GROUP BENEFITS|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|PHCS|HUMANA INSURANCE|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Tricare|TRICARE EAST REGION|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Multiplan|WEB TPA|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|NON CONTRACTED|COMMERCIAL OTHER 1|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Medicaid|SUPERIOR HEALTHPLAN CHIP|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Medicaid|MOLINA HEALTHCARE OF TEXAS|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Medicaid|MEDICAID|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Medicaid|MEDICAID HMO|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Cigna|CIGNA OTHER|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Cigna|CIGNA|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Managed Medicaid|MEDICAID SUPERIOR|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|PHCS|GROUP AND PENSION|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Managed Medicaid|MEDICAID AMERIGROUP|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross HMO Specialty|BCBSTX HMO|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Aetna Value Network|AETNA VALUE NETWORK|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Aetna|AETNA OTHER|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Aetna|AETNA PPO|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|ChampVA|CHAMPVA CENTER|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross PPO Specialty|BCBSTX PPO|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross PPO Specialty|BCBSTX OTHER|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Access Direct Platinum|HEALTHFIRST TPA|63.25||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Access Direct Platinum|HEALTHFIRST TPA UMR|63.25||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|123.50||||123.50||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Aetna|AETNA PPO|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicare|WELLCARE CHOICE MA|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicare|HEALTHSPRING MA|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Cigna|CIGNA OTHER|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Cigna|CIGNA|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Humana Medicare Advantage|HUMANA MA|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Workers Compensation|BROOKSHIRES WORKERS COMP|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicare|MEDICARE ACUTE|123.50||||123.50||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicare|MEDICARE PART B ONLY IP|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|123.50||||123.50||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicaid|MEDICAID|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Tricare|TRICARE EAST REGION|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|United Healthcare|UNITED HEALTHCARE|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|123.50||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|United Healthcare|UNITED HEALTHCARE|123.50||||123.50||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|123.50||||||| 9506023|ERX|0250|ATROPINE PEDI 0.25MG/5ML|Humana Medicare Advantage|HUMANA MA|93.75||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|United Healthcare|UNITED HEALTHCARE OTHER|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Rusk State Hospital|RUSK STATE HOSP|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Managed Medicare|HEALTHSPRING MA|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Medicaid|MEDICAID|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Medicaid|CRIME VICTIMS COMPENSATION|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Medicare|MEDICARE ACUTE|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Access Direct Platinum|HEALTHFIRST TPA|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Veterans Affairs|VETERANS ADMINISTRATION|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|NON CONTRACTED|COMMERCIAL OTHER 1|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|United Medicare Advantage|UHC AARP MCR HMO MA|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Aetna|BOON CHAPMAN|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Aetna|AETNA OTHER|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Blue Cross HMO Specialty|BCBSTX HMO|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Blue Cross PPO Specialty|BCBSTX PPO|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Managed Medicaid|MEDICAID SUPERIOR|95.54||||||| 9506049|ERX|0258|FAT EMULSION 20% 250ML|Humana Medicare Advantage|HUMANA MA|95.54||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Cigna|CIGNA OTHER|22.25||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Cigna|CIGNA|22.25||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Humana Medicare Advantage|HUMANA MA|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Managed Medicare|HEALTHSPRING MA|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|22.25||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|22.25||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Medicare|MEDICARE ACUTE|22.25||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|22.25||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|PHCS|HUMANA|22.25||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Tricare|TRICARE EAST REGION|22.25||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|United Healthcare|UNITED HEALTHCARE|||||22.25||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|22.25||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|United Healthcare|UNITED HEALTHCARE|||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Medicaid|MEDICAID HMO|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Medicaid|MEDICAID|||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Medicaid|CRIME VICTIMS COMPENSATION|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Access Direct Platinum|HEALTHFIRST TPA UMR|||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Aetna|AETNA OTHER|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Managed Medicaid|MEDICAID SUPERIOR|15.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Managed Medicaid|MEDICAID AMERIGROUP|||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Cigna|CIGNA|||||15.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9506080|ERX|0250|ESTRADIOL 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9506080|ERX|0250|ESTRADIOL 2MG TABLET|Medicare|MEDICARE ACUTE|||||25.50||| 9506106|ERX|0250|ESTRADIOL 0.01% VAG CRM,4|Medicare|MEDICARE ACUTE|1,031.25||||1,031.25||| 9506106|ERX|0250|ESTRADIOL 0.01% VAG CRM,4|Medicare|MEDICARE PART B ONLY IP|1,031.25||||||| 9506106|ERX|0250|ESTRADIOL 0.01% VAG CRM,4|United Medicare Advantage|UHC AARP MCR HMO MA|1,031.25||||||| 9506106|ERX|0250|ESTRADIOL 0.01% VAG CRM,4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,031.25||||||| 9506106|ERX|0250|ESTRADIOL 0.01% VAG CRM,4|Humana Medicare Advantage|HUMANA MA|1,031.25||||||| 9506106|ERX|0250|ESTRADIOL 0.01% VAG CRM,4|Managed Medicaid|MEDICAID AMERIGROUP|1,031.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Blue Cross HMO Specialty|BCBSTX HMO|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|ChampVA|CHAMPVA CENTER|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Blue Cross PPO Specialty|BCBSTX PPO|90.25||||90.25||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Managed Medicare|BCBS MEDICARE PPO MA|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Managed Medicare|HEALTHSPRING MA|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Managed Medicaid|MEDICAID AMERIGROUP|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Managed Medicaid|MEDICAID SUPERIOR|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|90.25||||90.25||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Humana Medicare Advantage|HUMANA MA|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Aenta Medicare Advantage|AETNA MEDICARE MA|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Access Direct Platinum|HEALTHFIRST TPA|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Veterans Affairs|VETERANS ADMINISTRATION|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|United Medicare Advantage|UHC AARP MCR HMO MA|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|United Medicare Advantage|UHC MEDICARE GOLD MA|90.25||||90.25||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|PHCS|GROUP AND PENSION|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|NON CONTRACTED|COMMERCIAL OTHER 1|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|UTMB|UTMB CORRECTIONAL MANAGED CARE|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|United Healthcare|UNITED HEALTHCARE OTHER|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Medicaid|MEDICAID HMO|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Medicaid|SMITH COUNTY INDIGENT HEALTH|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Medicaid|MEDICAID|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Medicare|MEDICARE PART B ONLY IP|90.25||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Medicare|MEDICARE ACUTE|90.25||||90.25||| 9506122|ERX|0250|NA HYPOCHLOR 0.5% SOLN,47|Medicare|MEDICARE ACUTE|90.25||||||| 9506122|ERX|0250|NA HYPOCHLOR 0.5% SOLN,47|NON CONTRACTED|COMMERCIAL OTHER 1|90.25||||||| 9506122|ERX|0250|NA HYPOCHLOR 0.5% SOLN,47|Access Direct Platinum|HEALTHFIRST TPA|90.25||||||| 9506122|ERX|0250|NA HYPOCHLOR 0.5% SOLN,47|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|90.25||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Cigna|CIGNA|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Cigna Behavioral Health|BH CIGNA|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Humana Medicare Advantage|HUMANA MA|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Magellan Behavioral Health|BH MAGELLAN|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicare|JACKSONVILLE ACCESS|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Blue Cross PPO Specialty|BCBSTX OTHER|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Aetna|AETNA PPO|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Aetna|BH AETNA|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Blue Cross HMO Specialty|BCBSTX HMO|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|United Medicare Advantage|UHC MEDICARE GOLD MA|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|United Medicare Advantage|UHC AARP MCR HMO MA|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Blue Cross PPO Specialty|BCBSTX PPO|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Veterans Affairs|VETERANS ADMINISTRATION|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Workers Compensation|TEXAS MUTUAL INSURANCE|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Aenta Medicare Advantage|AETNA MEDICARE MA|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicare|HEALTHSPRING MA|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.46||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Access Direct Platinum|HEALTHFIRST TPA|||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicaid|MEDICAID SUPERIOR|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Access Direct Platinum|HEALTHFIRST TPA UMR|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Access Direct Platinum|ANDREWS CENTER|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|United Healthcare|UNITED HEALTHCARE OTHER|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Texas Workforce Commission|DIS DETER SERV (DDS)|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Optum Behavioral Health|BH OPTUM UHC|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Tricare|TRICARE EAST REGION|||||0.46||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|NON CONTRACTED|COMMERCIAL OTHER 1|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Medicare|MEDICARE PART B ONLY IP|0.46||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Medicare|MEDICARE ACUTE|0.46||||0.46||| 9506189|ERX|0250|THYROID 30MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|5.25||||||| 9506189|ERX|0250|THYROID 30MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Tricare|TRICARE EAST REGION|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|United Healthcare|UNITED HEALTHCARE|||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|United Healthcare|TML GROUP BENEFITS|5.25||||||| 9506189|ERX|0250|THYROID 30MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|5.25||||||| 9506189|ERX|0250|THYROID 30MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9506189|ERX|0250|THYROID 30MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9506189|ERX|0250|THYROID 30MG TABLET|Cigna|CIGNA|5.25||||||| 9506189|ERX|0250|THYROID 30MG TABLET|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9506197|ERX|0250|THYROID 60MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9506197|ERX|0250|THYROID 60MG TABLET|Medicare|MEDICARE ACUTE|5.25||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Brinson Benefits|THE HEALTH PLAN SMITH CO|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Blue Cross PPO Specialty|BCBSTX OTHER|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Aetna|AETNA OTHER|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Blue Cross PPO Specialty|BCBSTX PPO|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Blue Cross HMO Specialty|BCBSTX HMO|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicare|BCBS MEDICARE PPO MA|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicare|OTHER INSTITUTIONS|||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicare|HEALTHSPRING MA|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Cigna|CIGNA OTHER|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Humana Medicare Advantage|HUMANA MA|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Cigna Behavioral Health|BH CIGNA|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Magellan Behavioral Health|BH MAGELLAN|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicaid|MEDICAID SUPERIOR|||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicaid|MEDICAID AMERIGROUP|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Veterans Affairs|VETERANS ADMINISTRATION|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|UTMB|UTMB CORRECTIONAL MANAGED CARE|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Tricare|TRICARE EAST REGION|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|NON CONTRACTED|COMMERCIAL OTHER 1|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Access Direct Platinum|HEALTHFIRST TPA UMR|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|United Healthcare|UNITED HEALTHCARE|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Medicare|MEDICARE PART B ONLY IP|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Aenta Medicare Advantage|AETNA MEDICARE MA|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Access Direct Platinum|ANDREWS CENTER|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|United Medicare Advantage|UHC AARP MCR HMO MA|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Medicare|MEDICARE ACUTE|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Texas Workforce Commission|DIS DETER SERV (DDS)|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Medicaid|SMITH COUNTY JAIL|49.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|United Medicare Advantage|UHC MEDICARE GOLD MA|49.75||||49.75||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|49.75||||49.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Cigna|CIGNA OTHER|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Medicaid|MEDICAID|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Tricare|TRICARE EAST REGION|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Medicaid|SMITH COUNTY JAIL|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Aetna|AETNA PPO|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Medicaid|SMITH COUNTY INDIGENT HEALTH|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Healthcare|TML GROUP BENEFITS|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Cigna|CIGNA|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Brinson Benefits|THE HEALTH PLAN SMITH CO|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Workers Compensation|UT EMPLOYEE INJURY|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Aetna|AETNA OTHER|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Aetna|BOON CHAPMAN|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|16.75||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.75||||16.75||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Managed Medicare|HEALTHSPRING MA|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Managed Medicaid|MEDICAID SUPERIOR|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|United Healthcare|UNITED HEALTHCARE OTHER|||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Tricare|TRICARE EAST REGION|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Veterans Affairs|VETERANS ADMINISTRATION|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Medicaid|SMITH COUNTY JAIL|||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Medicare|MEDICARE PART B ONLY IP|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Access Direct Platinum|HEALTHFIRST TPA UMR|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Medicare|MEDICARE ACUTE|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Aetna|AETNA PPO|0.07||||||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|Humana Medicare Advantage|HUMANA MA|0.07||||0.07||| 9506247|ERX|0250|LEVOTHYROXINE 175MCG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.07||||0.07||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Aetna|AETNA PPO|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|United Healthcare|GOLDEN RULE|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|United Healthcare|UNITED HEALTHCARE|5.25||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Tricare|TRICARE EAST REGION|||||5.25||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|||||5.25||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Medicare|MEDICARE ACUTE|5.75||||5.75||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Blue Cross HMO Specialty|BCBSTX HMO|5.75||||||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|PHCS|HUMANA|||||5.75||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.75||||||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.75||||||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Veterans Affairs|VETERANS ADMINISTRATION|5.75||||||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|United Healthcare|UNITED HEALTHCARE|5.75||||||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Aenta Medicare Advantage|AETNA MEDICARE MA|5.75||||||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Managed Medicare|HEALTHSPRING MA|5.75||||5.75||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.75||||||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Humana Medicare Advantage|HUMANA MA|5.75||||5.75||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Optum Behavioral Health|BH OPTUM UHC|5.75||||||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|5.75||||||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|5.75||||5.75||| 9506262|ERX|0250|LEVOTHYROXINE 137MCG TABL|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||5.75||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Medicaid|BH TEXAS CHILDRENS MEDICAID|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|United Healthcare|UNITED HEALTHCARE|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Medicare|MEDICARE ACUTE|40.75||||40.75||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|40.75||||40.75||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Managed Medicaid|MEDICAID SUPERIOR|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Managed Medicare|JACKSONVILLE ACCESS|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Access Direct Platinum|ANDREWS CENTER|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Cigna|CIGNA OTHER|40.75||||40.75||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Managed Medicare|HEALTHSPRING MA|40.75||||40.75||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Managed Medicaid|MEDICAID AMERIGROUP|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Blue Cross PPO Specialty|BCBSTX PPO|40.75||||40.75||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Managed Medicare|BCBS MEDICARE PPO MA|||||40.75||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|40.75||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Blue Cross HMO Specialty|BCBSTX HMO|40.75||||40.75||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Humana Medicare Advantage|HUMANA MA|40.75||||||| 9506288|ERX|0250|NEBIVOLOL 2.5MG TABLET|Medicare|MEDICARE ACUTE|17.25||||||| 9506288|ERX|0250|NEBIVOLOL 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.25||||||| 9506288|ERX|0250|NEBIVOLOL 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||17.25||| 9506288|ERX|0250|NEBIVOLOL 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|||||17.25||| 9506288|ERX|0250|NEBIVOLOL 2.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||17.25||| 9506288|ERX|0250|NEBIVOLOL 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||17.25||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.25||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.25||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||17.25||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|17.25||||17.25||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|17.25||||17.25||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.25||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|17.25||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.25||||17.25||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|United Healthcare|TML GROUP BENEFITS|17.25||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Medicare|MEDICARE ACUTE|17.25||||17.25||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|17.25||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Cigna|CIGNA|17.25||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||17.25||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|United Healthcare|UNITED HEALTHCARE|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Medicare|MEDICARE ACUTE|17.25||||17.25||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||17.25||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.25||||17.25||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Tricare|TRICARE EAST REGION|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|17.25||||17.25||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Aetna|AETNA PPO|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Access Direct Platinum|ANDREWS CENTER|17.25||||||| 9506304|ERX|0250|NEBIVOLOL 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Access Direct Platinum|ANDREWS CENTER|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Aetna|BH AETNA|31.25||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|31.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Healthcare|UNITED HEALTHCARE|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Medicare|MEDICARE ACUTE|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Healthcare|TML GROUP BENEFITS|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Healthcare|UNITED HEALTHCARE|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Multiplan|TRUSTMARK|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Optum Behavioral Health|BH OPTUM UHC|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|PHCS|HUMANA|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Access Direct Platinum|ANDREWS CENTER|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Aetna|BOON CHAPMAN|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Aetna|AETNA PPO|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Medicaid|MEDICAID|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicare|HEALTHSPRING MA|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Multiplan|WEB TPA|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Cigna Behavioral Health|BH CIGNA|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Humana Medicare Advantage|HUMANA MA|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Magellan Behavioral Health|BH MAGELLAN|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Aetna|BH AETNA|33.50||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|33.50||||33.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Cigna|CIGNA|33.50||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Medicaid|MEDICAID|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Medicare|MEDICARE ACUTE|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|United Healthcare|UNITED HEALTHCARE|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Multiplan|WEB TPA|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Tricare|TRICARE FOR LIFE|||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Optum Behavioral Health|BH OPTUM UHC|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Tricare|TRICARE EAST REGION|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Access Direct Platinum|ANDREWS CENTER|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Aetna|AETNA PPO|||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Managed Medicare|HEALTHSPRING MA|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Cigna Behavioral Health|BH CIGNA|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Magellan Behavioral Health|BH MAGELLAN|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Humana Medicare Advantage|HUMANA MA|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Aetna|BH AETNA|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|34.75||||34.75||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|34.75||||||| 9506338|ERX|0250|ESCITALOPRAM 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|34.75||||34.75||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||29.75||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|29.75||||29.75||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|29.75||||||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Medicare|MEDICARE ACUTE|29.75||||29.75||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|29.75||||||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.75||||29.75||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|29.75||||29.75||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|29.75||||||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|29.75||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|29.75||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|29.75||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|29.75||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.75||||29.75||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|29.75||||29.75||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|29.75||||29.75||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|29.75||||29.75||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Medicare|MEDICARE ACUTE|29.75||||29.75||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|29.75||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|29.75||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.75||||29.75||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|29.75||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|29.75||||29.75||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|29.75||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|29.75||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Aetna|AETNA PPO|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Medicaid|MEDICAID|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Medicare|MEDICARE ACUTE|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|United Healthcare|UNITED HEALTHCARE OTHER|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Multiplan|WEB TPA|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Access Direct Platinum|ANDREWS CENTER|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|101.50||||101.50||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Optum Behavioral Health|BH OPTUM UHC|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Tricare|TRICARE EAST REGION|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Blue Cross PPO Specialty|BCBSTX PPO|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Humana Medicare Advantage|HUMANA MA|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Magellan Behavioral Health|BH MAGELLAN|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Managed Medicaid|MEDICAID AMERIGROUP|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Aetna|BH AETNA|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Managed Medicaid|MEDICAID SUPERIOR|101.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|101.50||||101.50||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|UNITED HEALTHCARE ERS|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Cigna Behavioral Health|BH CIGNA|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Cigna|CIGNA OTHER|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Magellan Behavioral Health|BH MAGELLAN|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Humana Medicare Advantage|HUMANA MA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicare|HEALTHSPRING MA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicare|WELLCARE CHOICE MA|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Cigna|CIGNA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aetna Value Network|AETNA VALUE NETWORK|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aetna|AETNA QHP HMO|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aetna|AETNA PPO|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aetna|BH AETNA|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|ZURICH COMPANY|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aetna|BOON CHAPMAN|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|ANDREWS CENTER|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aetna|AETNA OTHER|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|TRAVELERS INSURANCE COMPANY|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|ChampVA|CHAMPVA CENTER|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|PHCS|HUMANA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|TML GROUP BENEFITS|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicare|MEDICARE PART B ONLY IP|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|PHCS|GROUP AND PENSION|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|UNITED HEALTHCARE|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|GEHA|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Optum Behavioral Health|BH OPTUM UHC|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Tricare|TRICARE EAST REGION|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicare|MEDICARE ACUTE|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|MEDICAID|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|SMITH COUNTY JAIL|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Rusk State Hospital|RUSK STATE HOSP|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|PHCS|HUMANA INSURANCE|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|46.75||||46.75||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|MEDICAID HMO|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|46.75||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.75||||46.75||| 9506411|ERX|0250|TACROLIMUS 0.5MG CAPSULE|Aetna|AETNA PPO|||||25.50||| 9506411|ERX|0250|TACROLIMUS 0.5MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9506411|ERX|0250|TACROLIMUS 0.5MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||25.50||| 9506411|ERX|0250|TACROLIMUS 0.5MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||||| 9506411|ERX|0250|TACROLIMUS 0.5MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9506411|ERX|0250|TACROLIMUS 0.5MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9506411|ERX|0250|TACROLIMUS 0.5MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9506411|ERX|0250|TACROLIMUS 0.5MG CAPSULE|Cigna|CIGNA|25.50||||||| 9506411|ERX|0250|TACROLIMUS 0.5MG CAPSULE|Medicaid|MEDICAID|25.50||||||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Humana Medicare Advantage|HUMANA MA|49.25||||49.25||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Cigna|CIGNA|49.25||||||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|49.25||||||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Managed Medicare|HEALTHSPRING MA|49.25||||49.25||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||49.25||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|49.25||||||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|49.25||||49.25||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|49.25||||49.25||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|49.25||||||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|||||49.25||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|||||49.25||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Medicaid|MEDICAID|49.25||||||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Medicaid|SMITH COUNTY JAIL|49.25||||||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|49.25||||||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49.25||||49.25||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|49.25||||||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Aetna|AETNA PPO|||||49.25||| 9506429|ERX|0250|TACROLIMUS 1MG CAPSULE|Medicare|MEDICARE ACUTE|49.25||||49.25||| 9506445|ERX|0250|ADENOSINE 3MG/ML, 20ML VI|Medicare|MEDICARE ACUTE|1,458.25||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Multiplan|NALC|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Workers Compensation|ZURICH COMPANY|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Workers Compensation|TEXAS MUTUAL INSURANCE|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aetna|AETNA OTHER|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aetna|BOON CHAPMAN|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|ChampVA|CHAMPVA CENTER|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aetna|AETNA QHP HMO|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aetna|BH AETNA|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Cigna|CIGNA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|HEALTHSPRING MA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aetna|AETNA PPO|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Cigna|CIGNA OTHER|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|MA PART B ONLY IP|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|WELLCARE CHOICE MA|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|PHCS|GROUP AND PENSION|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Tricare|TRICARE EAST REGION|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|PHCS|HUMANA|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Rusk State Hospital|RUSK STATE HOSP|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|PHCS|HUMANA INSURANCE|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Multiplan|WEB TPA|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Healthcare|UNITED HEALTHCARE|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|MEDICAID|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Humana Medicare Advantage|HUMANA MA|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Healthcare|TML GROUP BENEFITS|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Healthcare|GEHA|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicare|MEDICARE PART B ONLY IP|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|LAW ENFORCEMENT OTHER|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Healthcare|AARP|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|CRIME VICTIMS COMPENSATION|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|MEDICAID HMO|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|SMITH COUNTY JAIL|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicare|MEDICARE ACUTE|169.50||||169.50||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|169.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|169.50||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Managed Medicare|HEALTHSPRING MA|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Humana Medicare Advantage|HUMANA MA|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Medicaid|MEDICAID|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Medicare|MEDICARE ACUTE|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|960.25||||||| 9506494|ERX|0250|MICAFUNGIN 50MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|960.25||||||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|Blue Cross PPO Specialty|BCBSTX PPO|14.25||||14.25||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|Humana Medicare Advantage|HUMANA MA|14.25||||||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|14.25||||||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14.25||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.25||||||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|United Medicare Advantage|UHC AARP MCR HMO MA|14.25||||||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|Managed Medicaid|MEDICAID AMERIGROUP|||||14.25||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|Medicaid|MEDICAID|14.25||||||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||14.25||| 9506536|ERX|0250|HYDROCOD-HOMATROP 5-1.5MG|Medicare|MEDICARE ACUTE|14.25||||||| 9506544|ERX|0250|ACETAMINOPHEN 80MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|||||0.12||| 9506544|ERX|0250|ACETAMINOPHEN 80MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|0.12||||||| 9506551|ERX|0250|SIROLIMUS 1MG TABLET|Medicare|MEDICARE ACUTE|93.75||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|United Medicare Advantage|UHC AARP MCR HMO MA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Veterans Affairs|VETERANS ADMINISTRATION|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Workers Compensation|TEXAS MUTUAL INSURANCE|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Managed Medicare|HEALTHSPRING MA|174.25||||174.25||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Workers Compensation|WORKERS COMPENSATION OTHER|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Humana Medicare Advantage|HUMANA MA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Medicaid|MEDICAID|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Managed Medicaid|MEDICAID AMERIGROUP|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|United Healthcare|UNITED HEALTHCARE OTHER|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|NON CONTRACTED|COMMUNITY HEALTH CENTER|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|United Healthcare|UNITED HEALTHCARE|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Aetna|BOON CHAPMAN|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Medicaid|SMITH COUNTY JAIL|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|PHCS|HUMANA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Rusk State Hospital|RUSK STATE HOSP|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Managed Medicaid|MEDICAID SUPERIOR|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Medicaid|CRIME VICTIMS COMPENSATION|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Managed Medicare|BCBS MEDICARE PPO MA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|NON CONTRACTED|COMMERCIAL OTHER 1|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Medicare|MEDICARE ACUTE|174.25||||174.25||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Access Direct Platinum|HEALTHFIRST TPA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Cigna|CIGNA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Blue Cross HMO Specialty|BCBSTX HMO|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Aetna|AETNA PPO|174.25||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Blue Cross PPO Specialty|BCBSTX PPO|174.25||||||| 9506585|ERX|0250|LACTULOSE 10 G/15ML, 240M|Medicare|MEDICARE ACUTE|2.18||||2.18||| 9506585|ERX|0250|LACTULOSE 10 G/15ML, 240M|Managed Medicare|HEALTHSPRING MA|2.18||||||| 9506585|ERX|0250|LACTULOSE 10 G/15ML, 240M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.18||||2.18||| 9506585|ERX|0250|LACTULOSE 10 G/15ML, 240M|Humana Medicare Advantage|HUMANA MA|2.18||||||| 9506585|ERX|0250|LACTULOSE 10 G/15ML, 240M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.18||||||| 9506585|ERX|0250|LACTULOSE 10 G/15ML, 240M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.18||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Workers Compensation|ZURICH COMPANY|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Veterans Affairs|VETERANS ADMINISTRATION|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Blue Cross HMO Specialty|BCBSTX HMO|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Aetna|AETNA PPO|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Workers Compensation|UT EMPLOYEE INJURY|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Humana Medicare Advantage|HUMANA MA|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Cigna|CIGNA OTHER|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicare|JACKSONVILLE ACCESS|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicare|BCBS MEDICARE PPO MA|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|PHCS|HUMANA|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicare|HEALTHSPRING MA|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicaid|MEDICAID SUPERIOR|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|United Healthcare|UNITED HEALTHCARE|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|United Healthcare|UNITED HEALTHCARE OTHER|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicare|MEDICARE ACUTE|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicaid|SMITH COUNTY JAIL|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicaid|MEDICAID|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.31||||0.31||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicaid|MEDICAID HMO|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Cigna|CIGNA|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicare|MEDICARE PART B ONLY IP|0.31||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicaid|MEDICAID AMERIGROUP|0.31||||0.31||| 9506650|ERX|0250|PHENYTOIN 100MG/4ML|Medicare|MEDICARE ACUTE|0.25||||0.25||| 9506650|ERX|0250|PHENYTOIN 100MG/4ML|Medicaid|MEDICAID|0.25||||||| 9506650|ERX|0250|PHENYTOIN 100MG/4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.25||||||| 9506650|ERX|0250|PHENYTOIN 100MG/4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.25||||||| 9506650|ERX|0250|PHENYTOIN 100MG/4ML|Humana Medicare Advantage|HUMANA MA|0.25||||||| 9506650|ERX|0250|PHENYTOIN 100MG/4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.25||||||| 9506650|ERX|0250|PHENYTOIN 100MG/4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.25||||||| 9506650|ERX|0250|PHENYTOIN 100MG/4ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.25||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|United Healthcare|UNITED HEALTHCARE OTHER|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Cigna|CIGNA|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Managed Medicare|HEALTHSPRING MA|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Aetna|AETNA PPO|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Cigna|CIGNA OTHER|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|United Healthcare|UNITED HEALTHCARE|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.75||||||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Medicare|MEDICARE ACUTE|2.75||||||| 9506676|ERX|0250|POTASS-SOD PHOS 155-852-1|Medicare|MEDICARE ACUTE|0.05||||||| 9506676|ERX|0250|POTASS-SOD PHOS 155-852-1|Humana Medicare Advantage|HUMANA MA|0.05||||||| 9506676|ERX|0250|POTASS-SOD PHOS 155-852-1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||||| 9506676|ERX|0250|POTASS-SOD PHOS 155-852-1|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||||| 9506676|ERX|0250|POTASS-SOD PHOS 155-852-1|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||||| 9506676|ERX|0250|POTASS-SOD PHOS 155-852-1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.05||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Aetna|AETNA PPO|||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Blue Cross HMO Specialty|BCBSTX HMO|||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Managed Medicaid|MEDICAID SUPERIOR|25.50||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Managed Medicaid|MEDICAID AMERIGROUP|||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|PHCS|HUMANA|||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Tricare|TRICARE EAST REGION|||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Medicaid|MEDICAID HMO|25.50||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Medicare|MEDICARE PART B ONLY IP|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Medicaid|SMITH COUNTY INDIGENT HEALTH|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Managed Medicaid|MEDICAID SUPERIOR|||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Managed Medicaid|MEDICAID AMERIGROUP|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Managed Medicare|BCBS MEDICARE PPO MA|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Blue Cross HMO Specialty|BCBSTX HMO|16.75||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|United Medicare Advantage|UHC MEDICARE GOLD MA|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Aenta Medicare Advantage|AETNA MEDICARE MA|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.75||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|United Medicare Advantage|UHC AARP MCR HMO MA|16.75||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.75||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Managed Medicare|HEALTHSPRING MA|16.75||||16.75||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Workers Compensation|WORKERS COMPENSATION OTHER|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Aenta Medicare Advantage|AETNA MEDICARE MA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Access Direct Platinum|HEALTHFIRST TPA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Aetna|AETNA OTHER|8.25||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Aetna|AETNA PPO|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Medicare Advantage|UHC AARP MCR HMO MA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Brinson Benefits|THE HEALTH PLAN SMITH CO|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Blue Cross PPO Specialty|BCBSTX OTHER|8.25||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Blue Cross PPO Specialty|BCBSTX PPO|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Medicare Advantage|UHC MEDICARE GOLD MA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicaid|MEDICAID AMERIGROUP|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Blue Cross HMO Specialty|BCBSTX HMO|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicaid|MEDICAID SUPERIOR|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicare|HEALTHSPRING MA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicare|BCBS MEDICARE PPO MA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicare|OTHER INSTITUTIONS|||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|NON CONTRACTED|COMMERCIAL OTHER 2|8.25||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Cigna|CIGNA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Humana Medicare Advantage|HUMANA MA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Cigna|CIGNA OTHER|8.25||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Veterans Affairs|VETERANS ADMINISTRATION|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|PHCS|HUMANA|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Texas Workforce Commission|DIS DETER SERV (DDS)|||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Tricare|TRICARE FOR LIFE|||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|NON CONTRACTED|COMMERCIAL OTHER 1|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Tricare|TRICARE EAST REGION|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Healthcare|UNITED HEALTHCARE OTHER|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|MEDICAID HMO|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Rusk State Hospital|RUSK STATE HOSP|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|SMITH COUNTY INDIGENT HEALTH|8.25||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Access Direct Platinum|HEALTHFIRST TPA UMR|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Healthcare|UNITED HEALTHCARE|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|LAW ENFORCEMENT OTHER|||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|MEDICAID|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|MOLINA HEALTHCARE OF TEXAS|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicare|MEDICARE PART B ONLY IP|8.25||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|CRIME VICTIMS COMPENSATION|8.25||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicare|MEDICARE ACUTE|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Healthcare|UNITED HEALTHCARE|||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Healthcare|TML GROUP BENEFITS|8.25||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|8.25||||8.25||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|SMITH COUNTY JAIL|8.25||||8.25||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Blue Cross HMO Specialty|BCBSTX HMO|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Medicare|MEDICARE ACUTE|3.71||||3.71||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Medicaid|MEDICAID HMO|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Managed Medicare|HEALTHSPRING MA|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Humana Medicare Advantage|HUMANA MA|3.71||||3.71||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Managed Medicaid|MEDICAID AMERIGROUP|3.71||||3.71||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Managed Medicaid|MEDICAID SUPERIOR|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Rusk State Hospital|RUSK STATE HOSP|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Blue Cross PPO Specialty|BCBSTX PPO|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Cigna|CIGNA|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|United Medicare Advantage|UHC AARP MCR HMO MA|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Veterans Affairs|VETERANS ADMINISTRATION|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|United Medicare Advantage|UHC MEDICARE GOLD MA|3.71||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Access Direct Platinum|HEALTHFIRST TPA|3.71||||||| 9506759|ERX|0250|PSEUDOEPHEDRINE 15MG/5ML,|Cigna|CIGNA OTHER|||||15.75||| 9506759|ERX|0250|PSEUDOEPHEDRINE 15MG/5ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.75||| 9506759|ERX|0250|PSEUDOEPHEDRINE 15MG/5ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.75||| 9506767|ERX|0250|PRAMOXINE HCL-CALAMINE,18|Medicare|MEDICARE ACUTE|55.50||||||| 9506767|ERX|0250|PRAMOXINE HCL-CALAMINE,18|Humana Medicare Advantage|HUMANA MA|55.50||||||| 9506767|ERX|0250|PRAMOXINE HCL-CALAMINE,18|Managed Medicaid|MEDICAID AMERIGROUP|55.50||||||| 9506767|ERX|0250|PRAMOXINE HCL-CALAMINE,18|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|55.50||||||| 9506767|ERX|0250|PRAMOXINE HCL-CALAMINE,18|Blue Cross PPO Specialty|BCBSTX PPO|55.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Aetna|BOON CHAPMAN|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Managed Medicare|HEALTHSPRING MA|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Medicaid|MEDICAID|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|Medicare|MEDICARE ACUTE|865.84||||865.84||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|Managed Medicaid|MEDICAID AMERIGROUP|865.84||||||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|Humana Medicare Advantage|HUMANA MA|865.84||||||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|United Medicare Advantage|UHC MEDICARE GOLD MA|865.84||||||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||865.84||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||865.84||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|106.50||||||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Blue Cross PPO Specialty|BCBSTX OTHER|||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Aetna|AETNA PPO|||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|106.50||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Blue Cross HMO Specialty|BCBSTX HMO|||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|United Healthcare|UNITED HEALTHCARE|||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Medicare|MEDICARE ACUTE|106.50||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Blue Cross PPO Specialty|BCBSTX PPO|||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Cigna|CIGNA|||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Humana Medicare Advantage|HUMANA MA|106.50||||106.50||| 9506791|ERX|0250|INDIGOTINDISULFON 8MG/ML,|Managed Medicare|HEALTHSPRING MA|||||106.50||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Medicaid|MEDICAID|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Medicare|MEDICARE ACUTE|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|PHCS|HUMANA|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Healthcare|UNITED HEALTHCARE|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Managed Medicare|WELLCARE CHOICE MA|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Cigna|CIGNA OTHER|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Cigna|CIGNA|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Humana Medicare Advantage|HUMANA MA|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Managed Medicare|HEALTHSPRING MA|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Aetna|AETNA PPO|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Healthcare|UNITED HEALTHCARE|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Aetna|AETNA QHP HMO|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.48||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.48||||0.48||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.48||||0.48||| 9506817|ERX|0250|ATROPINE 0.4MG/ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.13||||||| 9506817|ERX|0250|ATROPINE 0.4MG/ML|Humana Medicare Advantage|HUMANA MA|||||0.13||| 9506817|ERX|0250|ATROPINE 0.4MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9506817|ERX|0250|ATROPINE 0.4MG/ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9506817|ERX|0250|ATROPINE 0.4MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.13||| 9506817|ERX|0250|ATROPINE 0.4MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||||| 9506817|ERX|0250|ATROPINE 0.4MG/ML|Medicaid|MEDICAID|0.13||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Medicaid|MEDICAID|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Medicare|MEDICARE ACUTE|169.50||||169.50||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|PHCS|GROUP AND PENSION|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Tricare|TRICARE EAST REGION|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Cigna|CIGNA OTHER|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Aetna|AETNA PPO|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Aetna|AETNA OTHER|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Aetna|AETNA QHP HMO|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|United Healthcare|UNITED HEALTHCARE|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Cigna|CIGNA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Blue Cross PPO Specialty|BCBSTX OTHER|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Humana Medicare Advantage|HUMANA MA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Managed Medicare|HEALTHSPRING MA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|169.50||||||| 9506825|ERX|0250|PHENYLEPHRINE 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|169.50||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Workers Compensation|TEXAS MUTUAL INSURANCE|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Cigna|CIGNA|||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Aetna|AETNA PPO|||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Medicaid|MEDICAID HMO|||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|United Healthcare|UNITED HEALTHCARE|||||0.13||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.13||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicare|BCBS MEDICARE PPO MA|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Medicaid|MEDICAID|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Medicare|MEDICARE PART B ONLY IP|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Rusk State Hospital|RUSK STATE HOSP|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Cigna|CIGNA|4.86||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Cigna|CIGNA OTHER|||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicaid|MEDICAID SUPERIOR|4.86||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicaid|MEDICAID AMERIGROUP|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Cigna|CIGNA|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Medicare|MEDICARE ACUTE|4.86||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Humana Medicare Advantage|HUMANA MA|4.86||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX PPO|4.86||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicare|HEALTHSPRING MA|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicare|WELLCARE CHOICE MA|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Tricare|TRICARE EAST REGION|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Blue Cross HMO Specialty|BCBSTX HMO|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|United Healthcare|UNITED HEALTHCARE OTHER|4.86||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.86||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Veterans Affairs|VETERANS ADMINISTRATION|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|4.86||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.86||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4.86||| 9506858|ERX|0250|DOPAMINE 200MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.27||||||| 9506858|ERX|0250|DOPAMINE 200MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.27||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|0.29||||||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|Medicare|MEDICARE ACUTE|0.29||||0.29||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|Medicaid|MEDICAID|0.29||||||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|Access Direct Platinum|HEALTHFIRST TPA|0.29||||||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.29||||||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.29||||||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|Humana Medicare Advantage|HUMANA MA|0.29||||||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.29||||||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|Aetna|BOON CHAPMAN|0.29||||||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|Blue Cross PPO Specialty|BCBSTX PPO|0.29||||||| 9506866|ERX|0250|SODIUM ACETATE 2 MEQ/ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.29||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.23||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.23||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Humana Medicare Advantage|HUMANA MA|0.23||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|United Healthcare|UNITED HEALTHCARE OTHER|0.23||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Medicaid|CRIME VICTIMS COMPENSATION|0.23||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Medicare|MEDICARE ACUTE|0.23||||0.23||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Blue Cross PPO Specialty|BCBSTX PPO|0.23||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Managed Medicare|HEALTHSPRING MA|0.23||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Medicaid|MEDICAID|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Medicare|MEDICARE ACUTE|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|United Healthcare|UNITED HEALTHCARE OTHER|||||17.50||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|United Medicare Advantage|UHC AARP MCR HMO MA|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Managed Medicaid|MEDICAID AMERIGROUP|||||17.50||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Access Direct Platinum|HEALTHFIRST TPA|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Humana Medicare Advantage|HUMANA MA|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Blue Cross HMO Specialty|BCBSTX HMO|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Aetna|BOON CHAPMAN|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Managed Medicaid|MEDICAID SUPERIOR|17.50||||||| 9506908|ERX|0250|NA CHLORIDE 23.4% 4MEQ/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||||| 9506916|ERX|0250|PAPAVERINE 30MG/ML, 10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.74||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Cigna|CIGNA OTHER|||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Managed Medicare|HEALTHSPRING MA|0.13||||||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Humana Medicare Advantage|HUMANA MA|0.13||||||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Cigna|CIGNA|||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|United Healthcare|GEHA|0.13||||||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.13||| 9506924|ERX|0250|HYDROXYZINE HCL 25MG/1ML|Tricare|TRICARE EAST REGION|||||0.13||| 9506932|ERX|0250|NITROGLYCERIN 50MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.72||| 9506932|ERX|0250|NITROGLYCERIN 50MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.72||| 9506932|ERX|0250|NITROGLYCERIN 50MG/10ML|Medicare|MEDICARE ACUTE|0.72||||0.72||| 9506932|ERX|0250|NITROGLYCERIN 50MG/10ML|Humana Medicare Advantage|HUMANA MA|0.72||||0.72||| 9506932|ERX|0250|NITROGLYCERIN 50MG/10ML|Medicaid|MEDICAID|0.72||||||| 9506932|ERX|0250|NITROGLYCERIN 50MG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.72||||||| 9506932|ERX|0250|NITROGLYCERIN 50MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.72||||||| 9506932|ERX|0250|NITROGLYCERIN 50MG/10ML|Managed Medicare|HEALTHSPRING MA|0.72||||||| 9506932|ERX|0250|NITROGLYCERIN 50MG/10ML|United Healthcare|UNITED HEALTHCARE|0.72||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Healthcare|UNITED HEALTHCARE|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|PHCS|HUMANA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|PHCS|HUMANA INSURANCE|13.50||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Rusk State Hospital|RUSK STATE HOSP|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Texas Workforce Commission|DIS DETER SERV (DDS)|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|PHCS|GROUP AND PENSION|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Tricare|TRICARE SOUTH PHYSICIAN|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Tricare|TRICARE FOR LIFE|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Multiplan|PACIFICARE|13.50||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Multiplan|WEB TPA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|NON CONTRACTED|COMMERCIAL OTHER 2|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Healthcare|TML GROUP BENEFITS|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Healthcare|GEHA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Healthcare|UNITED HEALTHCARE ERS|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Healthcare|GOLDEN RULE|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicare|OTHER INSTITUTIONS|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|MEDICAID BCBSTX|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|MEDICAID HMO|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|CRIME VICTIMS COMPENSATION|13.50||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|SMITH COUNTY JAIL|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|LAW ENFORCEMENT OTHER|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|13.50||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Aetna|AETNA OTHER|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicare|MEDICARE PART B ONLY IP|13.50||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Aetna|AETNA PPO|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicare|HEALTHSPRING MA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Aetna|AETNA QHP HMO|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|MEDICAID|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Aetna|BOON CHAPMAN|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Aetna Value Network|AETNA VALUE NETWORK|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|ChampVA|CHAMPVA CENTER|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|13.50||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID SUPERIOR|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Cigna|CIGNA OTHER|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Cigna|CIGNA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Humana Medicare Advantage|HUMANA MA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|BROOKSHIRES WORKERS COMP|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|ZURICH COMPANY|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|UT EMPLOYEE INJURY|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Tricare|TRICARE EAST REGION|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|TEXAS MUTUAL INSURANCE|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST TPA UMR|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST TPA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|GALLAGHER BASSETT|||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|13.50||||13.50||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Medicare Advantage|UHC AARP MCR HMO MA|13.50||||13.50||| 9506957|ERX|0250|NA THIOSULFATE 25% 12.5G/|Medicare|MEDICARE ACUTE|231.50||||||| 9506957|ERX|0250|NA THIOSULFATE 25% 12.5G/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|231.50||||||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.13||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.13||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|Medicare|MEDICARE ACUTE|0.13||||||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|Humana Medicare Advantage|HUMANA MA|||||0.13||| 9506981|ERX|0250|ACETYLCYSTEINE 10%, 4ML V|Medicare|MEDICARE ACUTE|0.63||||||| 9506981|ERX|0250|ACETYLCYSTEINE 10%, 4ML V|Medicaid|MEDICAID|0.63||||||| 9506981|ERX|0250|ACETYLCYSTEINE 10%, 4ML V|Veterans Affairs|VETERANS ADMINISTRATION|0.63||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|United Healthcare|UNITED HEALTHCARE OTHER|0.74||||0.74||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|United Healthcare|UNITED HEALTHCARE|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|United Healthcare|TML GROUP BENEFITS|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|NON CONTRACTED|COMMERCIAL OTHER 1|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Medicaid|CRIME VICTIMS COMPENSATION|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Blue Cross PPO Specialty|BCBSTX OTHER|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Blue Cross PPO Specialty|BCBSTX PPO|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Medicaid|MEDICAID|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Blue Cross HMO Specialty|BCBSTX HMO|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Aetna|AETNA PPO|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.74||||0.74||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Managed Medicaid|MEDICAID SUPERIOR|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Managed Medicaid|MEDICAID AMERIGROUP|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Medicare|MEDICARE ACUTE|0.74||||0.74||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Cigna|CIGNA|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Humana Medicare Advantage|HUMANA MA|0.74||||0.74||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Aenta Medicare Advantage|AETNA MEDICARE MA|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|United Medicare Advantage|UHC MEDICARE GOLD MA|0.74||||0.74||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|United Medicare Advantage|UHC AARP MCR HMO MA|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Veterans Affairs|VETERANS ADMINISTRATION|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.74||||||| 9506999|ERX|0250|.CETYLCYSTEINE 20%, 4ML V|Managed Medicare|HEALTHSPRING MA|0.74||||||| 95070|EAP|0924|METH CHALLENGE/INHALATION|United Medicare Advantage|UHC MEDICARE GOLD MA|||||21.13||| 95070|EAP|0924|METH CHALLENGE/INHALATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||21.13||| 95070|EAP|0924|METH CHALLENGE/INHALATION|Managed Medicare|HEALTHSPRING MA|||||21.13||| 95070|EAP|0924|METH CHALLENGE/INHALATION|Medicare|MEDICARE ACUTE|||||21.13||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|United Healthcare|UNITED HEALTHCARE OTHER|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Rusk State Hospital|RUSK STATE HOSP|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Medicare|MEDICARE ACUTE|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Medicaid|MEDICAID|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Medicaid|CRIME VICTIMS COMPENSATION|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Humana Medicare Advantage|HUMANA MA|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Managed Medicare|HEALTHSPRING MA|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Managed Medicaid|MEDICAID SUPERIOR|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Aetna|AETNA OTHER|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Blue Cross HMO Specialty|BCBSTX HMO|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Access Direct Platinum|HEALTHFIRST TPA|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Aetna|AETNA QHP HMO|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.63||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Aetna|BOON CHAPMAN|0.63||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|United Medicare Advantage|UHC MEDICARE GOLD MA|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|United Medicare Advantage|UHC AARP WELLMED HMO MA|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|United Medicare Advantage|UHC AARP MCR HMO MA|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Aenta Medicare Advantage|AETNA MEDICARE MA|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Blue Cross HMO Specialty|BCBSTX HMO|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Aetna|AETNA OTHER|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Aetna|AETNA QHP HMO|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Blue Cross PPO Specialty|BCBSTX OTHER|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Aetna|AETNA PPO|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Blue Cross PPO Specialty|BCBSTX PPO|33.25||||33.25||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Access Direct Platinum|HEALTHFIRST TPA UMR|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Managed Medicaid|MEDICAID AMERIGROUP|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Cigna|CIGNA|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Cigna|CIGNA OTHER|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Humana Medicare Advantage|HUMANA MA|33.25||||33.25||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Medicaid|SMITH COUNTY INDIGENT HEALTH|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Managed Medicare|HEALTHSPRING MA|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Tricare|TRICARE EAST REGION|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Veterans Affairs|VETERANS ADMINISTRATION|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|UTMB|UTMB CORRECTIONAL MANAGED CARE|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|United Healthcare|UNITED HEALTHCARE|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|PHCS|GROUP AND PENSION|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|United Healthcare|UNITED HEALTHCARE OTHER|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|NON CONTRACTED|COMMERCIAL OTHER 1|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Medicare|MEDICARE ACUTE|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Medicaid|MEDICAID|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Managed Medicare|BCBS MEDICARE PPO MA|33.25||||||| 9507013|ERX|0250|AMINOCAPROIC ACID 250MG/M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|33.25||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Medicare|MEDICARE ACUTE|8.75||||8.75||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Managed Medicare|HEALTHSPRING MA|8.75||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.75||||8.75||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.75||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|8.75||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|8.75||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|8.75||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.75||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|8.75||||8.75||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|8.75||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|8.75||||8.75||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|8.75||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.75||||8.75||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.75||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|8.75||||||| 9507047|ERX|0250|BUTAL-ASPIRIN-CAF 50-325-|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||||| 9507047|ERX|0250|BUTAL-ASPIRIN-CAF 50-325-|Managed Medicaid|MEDICAID AMERIGROUP|||||13.50||| 9507047|ERX|0250|BUTAL-ASPIRIN-CAF 50-325-|Cigna|CIGNA|13.50||||||| 9507047|ERX|0250|BUTAL-ASPIRIN-CAF 50-325-|Humana Medicare Advantage|HUMANA MA|||||13.50||| 9507047|ERX|0250|BUTAL-ASPIRIN-CAF 50-325-|Medicaid|MEDICAID|13.50||||||| 9507070|ERX|0250|SELENIUM 1% SHAMPOO, 207M|Medicare|MEDICARE ACUTE|0.54||||||| 9507070|ERX|0250|SELENIUM 1% SHAMPOO, 207M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.54||||||| 9507070|ERX|0250|SELENIUM 1% SHAMPOO, 207M|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.54||||||| 9507070|ERX|0250|SELENIUM 1% SHAMPOO, 207M|Blue Cross PPO Specialty|BCBSTX PPO|0.54||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|United Medicare Advantage|UHC MEDICARE GOLD MA|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|United Medicare Advantage|UHC AARP MCR HMO MA|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Workers Compensation|UT EMPLOYEE INJURY|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Workers Compensation|WORKERS COMPENSATION OTHER|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Workers Compensation|BROOKSHIRES WORKERS COMP|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Aenta Medicare Advantage|AETNA MEDICARE MA|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Access Direct Platinum|HEALTHFIRST TPA|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Aetna|AETNA PPO|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Aetna|AETNA OTHER|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Blue Cross HMO Specialty|BCBSTX HMO|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|ChampVA|CHAMPVA CENTER|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Cigna|CIGNA|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Blue Cross PPO Specialty|BCBSTX PPO|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Managed Medicaid|MEDICAID AMERIGROUP|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|United Healthcare|TML GROUP BENEFITS|||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|United Healthcare|UNITED HEALTHCARE OTHER|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|United Healthcare|UNITED HEALTHCARE|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|PHCS|HUMANA|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|PHCS|HUMANA INSURANCE|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Tricare|TRICARE EAST REGION|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Humana Medicare Advantage|HUMANA MA|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Blue Cross PPO Specialty|BCBSTX OTHER|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Multiplan|WEB TPA|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|NON CONTRACTED|COMMERCIAL OTHER 2|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|NON CONTRACTED|COMMERCIAL OTHER 1|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Veterans Affairs|VETERANS ADMINISTRATION|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Managed Medicare|HEALTHSPRING MA|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Aetna|BOON CHAPMAN|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Managed Medicare|BCBS MEDICARE PPO MA|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Medicaid|SMITH COUNTY JAIL|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Medicaid|MEDICAID|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Medicare|MEDICARE ACUTE|0.30||||0.30||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Medicare|MEDICARE PART B ONLY IP|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.30||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.30||||||| 9507104|ERX|0250|CYANOCOBALAMIN 100MCG TAB|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9507104|ERX|0250|CYANOCOBALAMIN 100MCG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9507104|ERX|0250|CYANOCOBALAMIN 100MCG TAB|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9507104|ERX|0250|CYANOCOBALAMIN 100MCG TAB|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9507104|ERX|0250|CYANOCOBALAMIN 100MCG TAB|Managed Medicare|HEALTHSPRING MA|||||2.50||| 9507104|ERX|0250|CYANOCOBALAMIN 100MCG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9507104|ERX|0250|CYANOCOBALAMIN 100MCG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.50||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|United Medicare Advantage|UHC AARP MCR HMO MA|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Aenta Medicare Advantage|AETNA MEDICARE MA|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Blue Cross PPO Specialty|BCBSTX PPO|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Blue Cross HMO Specialty|BCBSTX HMO|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Humana Medicare Advantage|HUMANA MA|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|NON CONTRACTED|COMMERCIAL OTHER 1|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Tricare|TRICARE EAST REGION|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|UTMB|UTMB CORRECTIONAL MANAGED CARE|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|United Healthcare|UNITED HEALTHCARE OTHER|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Medicaid|MEDICAID|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Managed Medicare|BCBS MEDICARE PPO MA|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Managed Medicare|ETMC AFFILIATE HOSPITALS|40.75||||||| 9507146|ERX|0250|DIPHENHYDRAMINE CREAM, 30|Medicare|MEDICARE ACUTE|40.75||||40.75||| 9507161|ERX|0250|THIAMINE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9507179|ERX|0250|VITAMIN E 100 UNIT CAPSUL|Medicare|MEDICARE ACUTE|2.50||||||| 9507179|ERX|0250|VITAMIN E 100 UNIT CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|169.50||||169.50||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Managed Medicaid|MEDICAID AMERIGROUP|169.50||||169.50||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Managed Medicaid|MEDICAID SUPERIOR|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Cigna|CIGNA|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Humana Medicare Advantage|HUMANA MA|169.50||||169.50||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Blue Cross PPO Specialty|BCBSTX PPO|169.50||||169.50||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Aetna|BOON CHAPMAN|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Aetna|AETNA OTHER|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Aetna|AETNA PPO|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Veterans Affairs|VETERANS ADMINISTRATION|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|United Medicare Advantage|UHC MEDICARE GOLD MA|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|United Medicare Advantage|UHC AARP MCR HMO MA|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Blue Cross HMO Specialty|BCBSTX HMO|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Aenta Medicare Advantage|AETNA MEDICARE MA|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Access Direct Platinum|HEALTHFIRST TPA|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Access Direct Platinum|HEALTHFIRST TPA UMR|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|ChampVA|CHAMPVA CENTER|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|169.50||||169.50||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|United Healthcare|UNITED HEALTHCARE OTHER|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|United Healthcare|UNITED HEALTHCARE|169.50||||169.50||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Cigna|CIGNA OTHER|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|United Healthcare|UNITED HEALTHCARE|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|UTMB|UTMB CORRECTIONAL MANAGED CARE|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Rusk State Hospital|RUSK STATE HOSP|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Tricare|TRICARE EAST REGION|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Managed Medicare|HEALTHSPRING MA|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Managed Medicare|BCBS MEDICARE PPO MA|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Managed Medicare|HOSPICE OF EAST TEXAS|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Medicaid|COUNTY INDIGENT HEALTH OTHER|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Medicaid|SMITH COUNTY JAIL|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Medicaid|SUPERIOR HEALTHPLAN CHIP|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|NON CONTRACTED|COMMERCIAL OTHER 1|169.50||||169.50||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Medicaid|MEDICAID|169.50||||||| 9507187|ERX|0250|MORPHINE PCA 1MG/ML 30MG/|Medicare|MEDICARE ACUTE|169.50||||169.50||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Tricare|TRICARE EAST REGION|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Medicare|MEDICARE PART B ONLY IP|90.25||||||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Medicare|MEDICARE ACUTE|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Medicaid|MEDICAID|90.25||||||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Managed Medicare|HEALTHSPRING MA|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|United Healthcare|UNITED HEALTHCARE|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|90.25||||||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|90.25||||||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|90.25||||||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|United Healthcare|UNITED HEALTHCARE OTHER|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Managed Medicare|BCBS MEDICARE PPO MA|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Blue Cross HMO Specialty|BCBSTX HMO|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Aetna|AETNA PPO|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Aetna|AETNA OTHER|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Blue Cross PPO Specialty|BCBSTX PPO|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Blue Cross PPO Specialty|BCBSTX OTHER|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Veterans Affairs|VETERANS ADMINISTRATION|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Cigna|CIGNA|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Humana Medicare Advantage|HUMANA MA|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|90.25||||90.25||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Access Direct Platinum|HEALTHFIRST TPA|||||90.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Managed Medicaid|MEDICAID AMERIGROUP|114.25||||||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Cigna|CIGNA|||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Humana Medicare Advantage|HUMANA MA|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Aetna|AETNA PPO|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Blue Cross HMO Specialty|BCBSTX HMO|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Veterans Affairs|VETERANS ADMINISTRATION|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|United Medicare Advantage|UHC AARP MCR HMO MA|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Blue Cross PPO Specialty|BCBSTX PPO|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Managed Medicaid|MEDICAID SUPERIOR|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|United Healthcare|UNITED HEALTHCARE OTHER|114.25||||||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|114.25||||||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Medicare|MEDICARE ACUTE|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Managed Medicare|HEALTHSPRING MA|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Managed Medicare|BCBS MEDICARE PPO MA|114.25||||||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|114.25||||114.25||| 9507203|ERX|0250|LIDOCAINE 2% URO-JET 20ML|Medicaid|MEDICAID|114.25||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Medicare|MEDICARE ACUTE|119.50||||119.50||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Medicaid|SMITH COUNTY JAIL|||||119.50||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||119.50||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|United Medicare Advantage|UHC AARP MCR HMO MA|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Veterans Affairs|VETERANS ADMINISTRATION|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|119.50||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|119.50||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|146.75||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|146.75||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Magellan Behavioral Health|BH MAGELLAN|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Cigna Behavioral Health|BH CIGNA|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Humana Medicare Advantage|HUMANA MA|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Blue Cross PPO Specialty|BCBSTX PPO|146.75||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|146.75||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|146.75||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Veterans Affairs|VETERANS ADMINISTRATION|||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Aetna|AETNA PPO|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Access Direct Platinum|ANDREWS CENTER|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|United Healthcare|UNITED HEALTHCARE OTHER|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Optum Behavioral Health|BH OPTUM UHC|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|146.75||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Managed Medicare|ETMC AFFILIATE HOSPITALS|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Medicaid|MEDICAID|146.75||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Managed Medicaid|MEDICAID AMERIGROUP|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Medicare|MEDICARE ACUTE|146.75||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Managed Medicare|HEALTHSPRING MA|146.75||||146.75||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|NON CONTRACTED|COMMUNITY HEALTH CENTER|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Multiplan|WEB TPA|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Tricare|TRICARE EAST REGION|146.75||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||146.75||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Medicaid|LAW ENFORCEMENT OTHER|||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95.50||||||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Veterans Affairs|VETERANS ADMINISTRATION|||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.50||||||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Blue Cross HMO Specialty|BCBSTX HMO|||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Aetna|AETNA PPO|||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Blue Cross PPO Specialty|BCBSTX PPO|||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|United Healthcare|UNITED HEALTHCARE OTHER|95.50||||||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Humana Medicare Advantage|HUMANA MA|95.50||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|NON CONTRACTED|COMMERCIAL OTHER 1|||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95.50||||||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Access Direct Platinum|HEALTHFIRST TPA|||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Managed Medicare|HEALTHSPRING MA|95.50||||||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|Medicare|MEDICARE ACUTE|95.50||||95.50||| 9507252|ERX|0250|LIDOCAINE 4% SOLUTION, 4M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||95.50||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Cigna|CIGNA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Humana Medicare Advantage|HUMANA MA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Blue Cross PPO Specialty|BCBSTX PPO|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Aetna|AETNA PPO|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Blue Cross HMO Specialty|BCBSTX HMO|308.25||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Veterans Affairs|VETERANS ADMINISTRATION|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|United Medicare Advantage|UHC AARP MCR HMO MA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Access Direct Platinum|HEALTHFIRST TPA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|United Healthcare|UNITED HEALTHCARE|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|United Healthcare|TML GROUP BENEFITS|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|United Healthcare|GEHA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|PHCS|HUMANA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|NON CONTRACTED|COMMERCIAL OTHER 1|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Managed Medicare|HEALTHSPRING MA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Managed Medicare|BCBS MEDICARE PPO MA|||||308.25||| 9507260|ERX|0250|HYALURONIDASE 150 UNIT/1M|Medicare|MEDICARE ACUTE|308.25||||308.25||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Medicare|MEDICARE PART B ONLY IP|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Medicaid|MEDICAID|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Managed Medicare|HEALTHSPRING MA|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Multiplan|WEB TPA|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|PHCS|HUMANA|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Tricare|TRICARE EAST REGION|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Healthcare|UNITED HEALTHCARE|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Healthcare|GEHA|||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Healthcare|GOLDEN RULE|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Aetna|BOON CHAPMAN|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Aetna|AETNA PPO|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Aetna|BH AETNA|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Aetna|AETNA OTHER|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Cigna|CIGNA|17.50||||17.50||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Cigna|CIGNA OTHER|17.50||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Humana Medicare Advantage|HUMANA MA|17.50||||17.50||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Humana Medicare Advantage|HUMANA MA|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Blue Cross PPO Specialty|BCBSTX PPO|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Aetna|AETNA PPO|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Aetna|BH AETNA|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Aetna|AETNA QHP HMO|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Blue Cross HMO Specialty|BCBSTX HMO|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Veterans Affairs|VETERANS ADMINISTRATION|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|United Medicare Advantage|UHC MEDICARE GOLD MA|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Aenta Medicare Advantage|AETNA MEDICARE MA|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Workers Compensation|WORKERS COMPENSATION OTHER|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Multiplan|WEB TPA|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Medicaid|MEDICAID|0.68||||||| 9507328|ERX|0250|PHENYLEPH-SHK LV-MO-PET,W|Medicare|MEDICARE ACUTE|0.68||||||| 9507377|ERX|0250|CHARCOAL AQ 25 G, 120ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||159.50||| 9507377|ERX|0250|CHARCOAL AQ 25 G, 120ML|Managed Medicaid|MEDICAID SUPERIOR|159.50||||159.50||| 9507377|ERX|0250|CHARCOAL AQ 25 G, 120ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|159.50||||159.50||| 9507377|ERX|0250|CHARCOAL AQ 25 G, 120ML|Medicare|MEDICARE ACUTE|159.50||||||| 9507377|ERX|0250|CHARCOAL AQ 25 G, 120ML|Blue Cross PPO Specialty|BCBSTX PPO|159.50||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Access Direct Platinum|HEALTHFIRST TPA|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Managed Medicare|HEALTHSPRING MA|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Medicaid|MEDICAID|9.25||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|Medicare|MEDICARE ACUTE|||||225.50||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|225.50||||225.50||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|United Medicare Advantage|UHC AARP MCR HMO MA|225.50||||||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|United Healthcare|UNITED HEALTHCARE OTHER|||||225.50||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|United Medicare Advantage|UHC MEDICARE GOLD MA|225.50||||||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|Blue Cross PPO Specialty|BCBSTX PPO|225.50||||225.50||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||225.50||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|Managed Medicaid|MEDICAID SUPERIOR|225.50||||225.50||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|Humana Medicare Advantage|HUMANA MA|||||225.50||| 9507419|ERX|0250|CASTOR OIL 60ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||28.25||| 9507419|ERX|0250|CASTOR OIL 60ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||28.25||| 9507419|ERX|0250|CASTOR OIL 60ML|Medicare|MEDICARE ACUTE|||||28.25||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Medicaid|MEDICAID|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Managed Medicare|BCBS MEDICARE PPO MA|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Medicare|MEDICARE ACUTE|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|NON CONTRACTED|COMMERCIAL OTHER 1|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|United Healthcare|UNITED HEALTHCARE OTHER|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Humana Medicare Advantage|HUMANA MA|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|United Medicare Advantage|UHC MEDICARE GOLD MA|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|United Medicare Advantage|UHC AARP MCR HMO MA|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Access Direct Platinum|HEALTHFIRST TPA|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Aenta Medicare Advantage|AETNA MEDICARE MA|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Blue Cross PPO Specialty|BCBSTX OTHER|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Blue Cross HMO Specialty|BCBSTX HMO|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.12||||||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.12||||||| 9507435|ERX|0250|ASPIRIN 600MG SUPP|United Medicare Advantage|UHC MEDICARE GOLD MA|0.12||||||| 9507435|ERX|0250|ASPIRIN 600MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|0.12||||||| 9507435|ERX|0250|ASPIRIN 600MG SUPP|Medicare|MEDICARE ACUTE|0.12||||||| 9507435|ERX|0250|ASPIRIN 600MG SUPP|Blue Cross HMO Specialty|BCBSTX HMO|0.12||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|United Healthcare|UNITED HEALTHCARE|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|United Healthcare|UNITED HEALTHCARE|||||0.46||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Tricare|TRICARE EAST REGION|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|NON CONTRACTED|COMMERCIAL OTHER 1|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Medicare|MEDICARE PART B ONLY IP|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|||||0.46||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Cigna|CIGNA OTHER|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Cigna|CIGNA|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.46||||0.46||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Humana Medicare Advantage|HUMANA MA|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Aetna|AETNA PPO|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Managed Medicaid|MEDICAID AMERIGROUP|0.46||||0.46||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Aetna|AETNA OTHER|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Managed Medicare|HEALTHSPRING MA|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.46||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Blue Cross HMO Specialty|BCBSTX HMO|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Medicare|MEDICARE ACUTE|0.46||||0.46||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|0.46||||0.46||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.46||||0.46||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.46||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Veterans Affairs|VETERANS ADMINISTRATION|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|United Medicare Advantage|UHC MEDICARE GOLD MA|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|United Medicare Advantage|UHC AARP MCR HMO MA|0.46||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.46||||||| 9507468|ERX|0250|PROMETHAZINE 12.5MG SUPP|Managed Medicaid|MEDICAID AMERIGROUP|||||39.75||| 9507468|ERX|0250|PROMETHAZINE 12.5MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|||||39.75||| 9507468|ERX|0250|PROMETHAZINE 12.5MG SUPP|Medicare|MEDICARE ACUTE|39.75||||||| 9507468|ERX|0250|PROMETHAZINE 12.5MG SUPP|Medicaid|MEDICAID|||||39.75||| 9507468|ERX|0250|PROMETHAZINE 12.5MG SUPP|Managed Medicare|HEALTHSPRING MA|39.75||||||| 9507468|ERX|0250|PROMETHAZINE 12.5MG SUPP|NON CONTRACTED|COMMERCIAL OTHER 1|39.75||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Tricare|TRICARE EAST REGION|||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Medicaid|MEDICAID|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Cigna|CIGNA|5.25||||||| 9507500|ERX|0250|OXYCODONE-ASPIRN 4.83-325|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.50||| 9507518|ERX|0250|CODEINE-BUTALBIT-ASPIRIN-|United Medicare Advantage|UHC MEDICARE GOLD MA|18.25||||||| 9507518|ERX|0250|CODEINE-BUTALBIT-ASPIRIN-|Medicare|MEDICARE ACUTE|18.25||||||| 9507559|ERX|0250|PROBENECID 500MG TABLET|Humana Medicare Advantage|HUMANA MA|15.25||||||| 9507559|ERX|0250|PROBENECID 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.25||||||| 9507559|ERX|0250|PROBENECID 500MG TABLET|Medicare|MEDICARE ACUTE|15.25||||15.25||| 9507567|ERX|0250|MEDROXYPROGESTERONE 10MG|NON CONTRACTED|COMMERCIAL OTHER 1|23.50||||||| 9507567|ERX|0250|MEDROXYPROGESTERONE 10MG|Tricare|TRICARE EAST REGION|23.50||||||| 9507567|ERX|0250|MEDROXYPROGESTERONE 10MG|Medicare|MEDICARE ACUTE|23.50||||23.50||| 9507567|ERX|0250|MEDROXYPROGESTERONE 10MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23.50||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Aetna|AETNA PPO|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Aetna|AETNA OTHER|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Cigna|CIGNA|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Humana Medicare Advantage|HUMANA MA|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Workers Compensation|TEXAS MUTUAL INSURANCE|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Medicaid|CRIME VICTIMS COMPENSATION|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Medicaid|MEDICAID|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicare|HEALTHSPRING MA|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Medicare|MEDICARE PART B ONLY IP|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Medicare|MEDICARE ACUTE|0.07||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|United Healthcare|UNITED HEALTHCARE|0.07||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|PHCS|GROUP AND PENSION|||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Tricare|TRICARE EAST REGION|||||0.07||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|0.07||||||| 9507583|ERX|0250|QUINIDINE SULFATE 200MG T|Medicare|MEDICARE PART B ONLY IP|4.50||||||| 9507591|ERX|0250|TRIMETHOPRIM 100MG TABLET|Medicare|MEDICARE ACUTE|10.50||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|9.25||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Medicaid|MEDICAID|9.25||||||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9507609|ERX|0250|MINOXIDIL 2.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|Blue Cross PPO Specialty|BCBSTX OTHER|28.50||||||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|Humana Medicare Advantage|HUMANA MA|28.50||||||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.50||||||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|Blue Cross HMO Specialty|BCBSTX HMO|28.50||||||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|Cigna|CIGNA|28.50||||||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|United Medicare Advantage|UHC MEDICARE GOLD MA|28.50||||||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||28.50||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|United Medicare Advantage|UHC AARP MCR HMO MA|28.50||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Managed Medicaid|MEDICAID AMERIGROUP|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Humana Medicare Advantage|HUMANA MA|1,450.75||||1,450.75||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,450.75||||1,450.75||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Blue Cross HMO Specialty|BCBSTX HMO|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Managed Medicaid|MEDICAID SUPERIOR|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Blue Cross PPO Specialty|BCBSTX PPO|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Aenta Medicare Advantage|AETNA MEDICARE MA|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Workers Compensation|UT EMPLOYEE INJURY|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Veterans Affairs|VETERANS ADMINISTRATION|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|United Medicare Advantage|UHC AARP MCR HMO MA|1,450.75||||1,450.75||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|United Medicare Advantage|UHC MEDICARE GOLD MA|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|United Healthcare|UNITED HEALTHCARE|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Medicare|MEDICARE ACUTE|1,450.75||||1,450.75||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Managed Medicare|HEALTHSPRING MA|1,450.75||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH, 4|Medicaid|MEDICAID|1,450.75||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Medicare|MEDICARE ACUTE|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Medicaid|MEDICAID|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|PHCS|HUMANA|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Cigna|CIGNA OTHER|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Cigna|CIGNA|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.42||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.42||||0.42||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.42||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|226.25||||226.25||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|226.25||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Humana Medicare Advantage|HUMANA MA|226.25||||226.25||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Aetna|AETNA OTHER|226.25||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Aetna|AETNA PPO|226.25||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|226.25||||226.25||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|226.25||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|226.25||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|226.25||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Medicaid|MOLINA HEALTHCARE OF TEXAS|226.25||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Medicaid|MEDICAID|226.25||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Managed Medicare|HEALTHSPRING MA|226.25||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Medicare|MEDICARE ACUTE|226.25||||226.25||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|226.25||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Medicare|MEDICARE ACUTE|419.50||||419.50||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Medicaid|SMITH COUNTY INDIGENT HEALTH|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Rusk State Hospital|RUSK STATE HOSP|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Medicaid|MEDICAID|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|419.50||||419.50||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Managed Medicare|HEALTHSPRING MA|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|419.50||||419.50||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Aetna|AETNA OTHER|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Humana Medicare Advantage|HUMANA MA|419.50||||419.50||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|United Healthcare|UNITED HEALTHCARE|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|419.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|UTMB|UTMB CORRECTIONAL MANAGED CARE|419.50||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Humana Medicare Advantage|HUMANA MA|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Medicaid|MEDICAID|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|United Healthcare|UNITED HEALTHCARE|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Medicare|MEDICARE ACUTE|6.35||||6.35||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Managed Medicare|HEALTHSPRING MA|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.35||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Aetna|AETNA PPO|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Aetna|AETNA OTHER|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.35||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.35||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|PHCS|GROUP AND PENSION|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Healthcare|TML GROUP BENEFITS|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|PHCS|HUMANA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicare|MEDICARE ACUTE|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicare|HEALTHSPRING MA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicaid|MEDICAID HMO|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicaid|SMITH COUNTY INDIGENT HEALTH|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicaid|SUPERIOR HEALTHPLAN CHIP|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicaid|MEDICAID|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Healthcare|UNITED HEALTHCARE|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicare|OTHER INSTITUTIONS|||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Tricare|TRICARE EAST REGION|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|PHCS|HUMANA INSURANCE|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Aetna|AETNA PPO|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Aetna|AETNA QHP HMO|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Aetna|AETNA OTHER|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Cigna|CIGNA OTHER|||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Cigna|CIGNA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Humana Medicare Advantage|HUMANA MA|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|32.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|32.50||||32.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32.50||||32.50||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Managed Medicaid|MEDICAID SUPERIOR|18.25||||18.25||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Cigna|CIGNA OTHER|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Blue Cross HMO Specialty|BCBSTX HMO|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Access Direct Platinum|HEALTHFIRST TPA|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Access Direct Platinum|HEALTHFIRST TPA UMR|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Blue Cross PPO Specialty|BCBSTX PPO|18.25||||18.25||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||18.25||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Workers Compensation|WORKERS COMPENSATION OTHER|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|United Medicare Advantage|UHC AARP MCR HMO MA|18.25||||18.25||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Medicaid|MEDICAID|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Managed Medicare|HEALTHSPRING MA|18.25||||18.25||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|United Healthcare|UNITED HEALTHCARE|18.25||||18.25||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|NON CONTRACTED|COMMERCIAL OTHER 1|18.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Humana Medicare Advantage|HUMANA MA|18.25||||18.25||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Cigna|CIGNA|||||18.25||| 9507765|ERX|0250|IPRATROPIUM 0.06% NASAL,|United Healthcare|UNITED HEALTHCARE|707.25||||||| 9507765|ERX|0250|IPRATROPIUM 0.06% NASAL,|Medicare|MEDICARE ACUTE|707.25||||707.25||| 9507765|ERX|0250|IPRATROPIUM 0.06% NASAL,|Managed Medicare|HEALTHSPRING MA|707.25||||||| 9507765|ERX|0250|IPRATROPIUM 0.06% NASAL,|Medicaid|MEDICAID|707.25||||||| 9507765|ERX|0250|IPRATROPIUM 0.06% NASAL,|Aenta Medicare Advantage|AETNA MEDICARE MA|707.25||||707.25||| 9507765|ERX|0250|IPRATROPIUM 0.06% NASAL,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||707.25||| 9507765|ERX|0250|IPRATROPIUM 0.06% NASAL,|Blue Cross PPO Specialty|BCBSTX PPO|707.25||||||| 9507765|ERX|0250|IPRATROPIUM 0.06% NASAL,|Cigna|CIGNA OTHER|707.25||||||| 9507765|ERX|0250|IPRATROPIUM 0.06% NASAL,|Humana Medicare Advantage|HUMANA MA|707.25||||707.25||| 9507781|ERX|0250|PRAMIPEXOLE 0.125MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9507781|ERX|0250|PRAMIPEXOLE 0.125MG TABLE|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9507781|ERX|0250|PRAMIPEXOLE 0.125MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9507781|ERX|0250|PRAMIPEXOLE 0.125MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9507781|ERX|0250|PRAMIPEXOLE 0.125MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9507781|ERX|0250|PRAMIPEXOLE 0.125MG TABLE|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9507781|ERX|0250|PRAMIPEXOLE 0.125MG TABLE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9507781|ERX|0250|PRAMIPEXOLE 0.125MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Medicaid|SMITH COUNTY JAIL|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||25.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||25.50||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.29||||0.29||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.29||||||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.29||||||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.29||||||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.29||||||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.29||||||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.29||||0.29||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.29||||0.29||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.29||||||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.29||||||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Medicare|MEDICARE ACUTE|0.29||||0.29||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.29||||||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|0.29||||||| 9507807|ERX|0250|PRAMIPEXOLE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.29||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|NON CONTRACTED|COMMERCIAL OTHER 1|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Medicare|MEDICARE ACUTE|71.50||||71.50||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Medicaid|MEDICAID|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||71.50||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|United Medicare Advantage|UHC AARP MCR HMO MA|71.50||||71.50||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Aenta Medicare Advantage|AETNA MEDICARE MA|||||71.50||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Managed Medicare|HEALTHSPRING MA|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Blue Cross PPO Specialty|BCBSTX OTHER|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Blue Cross PPO Specialty|BCBSTX PPO|71.50||||71.50||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Managed Medicaid|MEDICAID SUPERIOR|||||71.50||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Blue Cross HMO Specialty|BCBSTX HMO|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Managed Medicaid|MEDICAID AMERIGROUP|71.50||||71.50||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Aetna|AETNA PPO|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Cigna|CIGNA|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Cigna|CIGNA|71.50||||71.50||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Humana Medicare Advantage|HUMANA MA|71.50||||||| 9507815|ERX|0250|POVIDONE-IODINE 10% OINT,|Workers Compensation|WORKERS COMPENSATION OTHER|71.50||||||| 9507823|ERX|0250|ALPRAZOLAM XR 0.5MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|28.25||||||| 9507856|ERX|0250|DICYCLOMINE 10MG/5ML, 30M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||29.75||| 9507856|ERX|0250|DICYCLOMINE 10MG/5ML, 30M|Medicare|MEDICARE ACUTE|29.75||||29.75||| 9507856|ERX|0250|DICYCLOMINE 10MG/5ML, 30M|Humana Medicare Advantage|HUMANA MA|29.75||||||| 9507872|ERX|0250|PHENOBARBITAL 20MG/5ML, 3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9507872|ERX|0250|PHENOBARBITAL 20MG/5ML, 3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9507872|ERX|0250|PHENOBARBITAL 20MG/5ML, 3|Medicare|MEDICARE ACUTE|15.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|United Healthcare|UNITED HEALTHCARE|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Medicaid|MEDICAID|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Managed Medicare|HEALTHSPRING MA|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.50||||5.50||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Medicare|MEDICARE PART B ONLY IP|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.50||||5.50||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||5.50||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.50||||5.50||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|ChampVA|CHAMPVA CENTER|||||5.50||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Cigna|CIGNA|5.50||||5.50||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.50||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Humana Medicare Advantage|HUMANA MA|5.50||||5.50||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Access Direct Platinum|ANDREWS CENTER|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicare|MEDICARE ACUTE|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicare|HEALTHSPRING MA|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicare|BCBS MEDICARE PPO MA|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicare|JACKSONVILLE ACCESS|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicaid|COUNTY INDIGENT HEALTH OTHER|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicaid|BH TEXAS CHILDRENS MEDICAID|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicaid|MEDICAID HMO|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicaid|MEDICAID|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicaid|SUPERIOR HEALTHPLAN CHIP|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicaid|SMITH COUNTY JAIL|||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicaid|MOLINA HEALTHCARE OF TEXAS|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicare|MEDICARE PART B ONLY IP|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|PHCS|HUMANA|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Rusk State Hospital|RUSK STATE HOSP|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Texas Workforce Commission|DIS DETER SERV (DDS)|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Optum Behavioral Health|BH OPTUM UHC|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Tricare|TRICARE EAST REGION|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|NON CONTRACTED|COMMUNITY HEALTH CENTER|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Healthcare|UNITED HEALTHCARE OTHER|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Healthcare|UNITED HEALTHCARE|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|UTMB|UTMB CORRECTIONAL MANAGED CARE|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID SUPERIOR|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Magellan Behavioral Health|BH MAGELLAN|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Cigna|CIGNA|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Cigna|CIGNA OTHER|||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Humana Medicare Advantage|HUMANA MA|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Cigna Behavioral Health|BH CIGNA|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Blue Cross PPO Specialty|BCBSTX OTHER|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Brinson Benefits|THE HEALTH PLAN SMITH CO|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Aetna|AETNA PPO|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Aetna|BH AETNA|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Blue Cross HMO Specialty|BCBSTX HMO|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Veterans Affairs|VETERANS ADMINISTRATION|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Aenta Medicare Advantage|AETNA MEDICARE MA|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|14.25||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Access Direct Platinum|HEALTHFIRST TPA UMR|14.25||||14.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Access Direct Platinum|HEALTHFIRST TPA|14.25||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|United Healthcare|UNITED HEALTHCARE|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|United Healthcare|UNITED HEALTHCARE|||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|United Healthcare|TML GROUP BENEFITS|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Medicaid|CRIME VICTIMS COMPENSATION|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Medicaid|MEDICAID|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Managed Medicare|HEALTHSPRING MA|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Medicare|MEDICARE ACUTE|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Medicare|MEDICARE PART B ONLY IP|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Workers Compensation|TRAVELERS INSURANCE COMPANY|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Aetna|AETNA PPO|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Aetna|AETNA OTHER|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Cigna|CIGNA OTHER|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Cigna|CIGNA|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Humana Medicare Advantage|HUMANA MA|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|8.50||||||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.50||||8.50||| 9507963|ERX|0250|METHOCARBAMOL 750MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|8.50||||8.50||| 9508003|ERX|0250|PHENOBARBITAL 64.8MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9508003|ERX|0250|PHENOBARBITAL 64.8MG TABL|Medicare|MEDICARE ACUTE|||||2.50||| 9508011|ERX|0250|MEDROXYPROGESTERONE 2.5MG|Aenta Medicare Advantage|AETNA MEDICARE MA|14.25||||||| 9508011|ERX|0250|MEDROXYPROGESTERONE 2.5MG|Humana Medicare Advantage|HUMANA MA|||||14.25||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Magellan Behavioral Health|BH MAGELLAN|5.25||||||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.25||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.25||| 9508037|ERX|0250|SULFASALAZINE 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.25||| 9508052|ERX|0250|TRIHEXYPHENIDYL 2MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||||| 9508052|ERX|0250|TRIHEXYPHENIDYL 2MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.25||| 9508052|ERX|0250|TRIHEXYPHENIDYL 2MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|4.25||||||| 9508060|ERX|0250|TRIHEXYPHENIDYL 5MG TABLE|Humana Medicare Advantage|HUMANA MA|6.75||||||| 9508078|ERX|0250|OLANZAPINE 15MG ODT TABLE|Medicare|MEDICARE ACUTE|213.75||||||| 9508078|ERX|0250|OLANZAPINE 15MG ODT TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|213.75||||||| 9508078|ERX|0250|OLANZAPINE 15MG ODT TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|213.75||||||| 9508094|ERX|0250|BENZOYL PEROXIDE 5% GEL,4|Access Direct Platinum|ANDREWS CENTER|1.63||||||| 9508094|ERX|0250|BENZOYL PEROXIDE 5% GEL,4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.63||||||| 9508094|ERX|0250|BENZOYL PEROXIDE 5% GEL,4|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.63||||||| 9508094|ERX|0250|BENZOYL PEROXIDE 5% GEL,4|Managed Medicaid|MEDICAID AMERIGROUP|1.63||||||| 9508094|ERX|0250|BENZOYL PEROXIDE 5% GEL,4|Managed Medicaid|MEDICAID SUPERIOR|1.63||||||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|PHCS|HUMANA|28.75||||||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|PHCS|GROUP AND PENSION|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Rusk State Hospital|RUSK STATE HOSP|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Healthcare|UNITED HEALTHCARE|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Healthcare|TML GROUP BENEFITS|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|MEDICAID HMO|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|MEDICAID|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicare|MEDICARE ACUTE|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Aetna|AETNA QHP HMO|28.75||||||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Aetna|BOON CHAPMAN|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicare|MEDICARE PART B ONLY IP|28.75||||||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicare|HEALTHSPRING MA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Aetna|AETNA PPO|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Aetna|AETNA OTHER|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Aetna Value Network|AETNA VALUE NETWORK|28.75||||||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|ChampVA|CHAMPVA CENTER|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|CRIME VICTIMS COMPENSATION|28.75||||||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Cigna|CIGNA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Cigna|CIGNA OTHER|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Healthcare|GEHA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Humana Medicare Advantage|HUMANA MA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID SUPERIOR|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Tricare|TRICARE EAST REGION|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Medicare Advantage|UHC AARP MCR HMO MA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Access Direct Platinum|HEALTHFIRST TPA|||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Access Direct Platinum|HEALTHFIRST TPA UMR|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|28.75||||28.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|28.75||||28.75||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|ANDREWS CENTER|0.13||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Workers Compensation|UT EMPLOYEE INJURY|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Cigna|CIGNA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|ChampVA|CHAMPVA CENTER|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Aetna|AETNA OTHER|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Aetna|AETNA PPO|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Aetna|BOON CHAPMAN|0.13||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Aetna|BH AETNA|0.13||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Cigna|CIGNA OTHER|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|SMITH COUNTY JAIL|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|MEDICAID|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|MEDICAID HMO|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|GEHA|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|TML GROUP BENEFITS|0.13||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|GOLDEN RULE|0.13||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Multiplan|WEB TPA|0.13||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|NON CONTRACTED|COMMERCIAL OTHER 4|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|PHCS|GROUP AND PENSION|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|PHCS|HUMANA|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Rusk State Hospital|RUSK STATE HOSP|0.13||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Tricare|TRICARE FOR LIFE|||||0.13||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|PHCS|HUMANA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|PHCS|GROUP AND PENSION|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Tricare|TRICARE EAST REGION|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|United Healthcare|TML GROUP BENEFITS|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Medicaid|MEDICAID|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Medicaid|SMITH COUNTY JAIL|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Aetna|AETNA OTHER|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Aetna|AETNA QHP HMO|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Aetna|AETNA PPO|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Cigna|CIGNA OTHER|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Cigna|CIGNA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Cigna|CIGNA|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9508136|ERX|0250|HEPARIN 1000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Workers Compensation|GALLAGHER BASSETT|||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Cigna|CIGNA|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|ChampVA|CHAMPVA CENTER|||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Aetna|AETNA PPO|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Medicaid|MEDICAID|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Healthcare|TML GROUP BENEFITS|||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|PHCS|GROUP AND PENSION|0.13||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Rusk State Hospital|RUSK STATE HOSP|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Tricare|TRICARE FOR LIFE|0.13||||||| 9508151|ERX|0250|PHENOBARBITAL 65MG/1ML|Medicare|MEDICARE ACUTE|0.21||||||| 9508151|ERX|0250|PHENOBARBITAL 65MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.21||||||| 9508151|ERX|0250|PHENOBARBITAL 65MG/1ML|Aetna Value Network|AETNA VALUE NETWORK|||||0.21||| 9508151|ERX|0250|PHENOBARBITAL 65MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|0.21||||||| 9508151|ERX|0250|PHENOBARBITAL 65MG/1ML|Humana Medicare Advantage|HUMANA MA|0.21||||||| 9508151|ERX|0250|PHENOBARBITAL 65MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.21||||||| 9508151|ERX|0250|PHENOBARBITAL 65MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.21||||||| 9508151|ERX|0250|PHENOBARBITAL 65MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|0.21||||||| 9508169|ERX|0250|PHENOBARBITAL 130MG/1ML|Humana Medicare Advantage|HUMANA MA|55.75||||||| 9508169|ERX|0250|PHENOBARBITAL 130MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|55.75||||||| 9508169|ERX|0250|PHENOBARBITAL 130MG/1ML|Medicare|MEDICARE ACUTE|55.75||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Healthcare|GEHA|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Healthcare|UNITED HEALTHCARE|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Healthcare|UNITED HEALTHCARE OTHER|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Medicaid|MEDICAID|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Medicaid|MOLINA HEALTHCARE OF TEXAS|38.50||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicare|BCBS MEDICARE PPO MA|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicare|HEALTHSPRING MA|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Medicare|MEDICARE ACUTE|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Medicare|MEDICARE PART B ONLY IP|38.50||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Veterans Affairs|VETERANS ADMINISTRATION|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Medicare Advantage|UHC AARP MCR HMO MA|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Workers Compensation|WORKERS COMPENSATION OTHER|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Aenta Medicare Advantage|AETNA MEDICARE MA|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Access Direct Platinum|HEALTHFIRST TPA|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Medicaid|MEDICAID HMO|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38.50||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|ChampVA|CHAMPVA CENTER|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Blue Cross PPO Specialty|BCBSTX OTHER|38.50||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Blue Cross PPO Specialty|BCBSTX PPO|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Aetna|BH AETNA|38.50||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Aetna|BOON CHAPMAN|38.50||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|NON CONTRACTED|COMMERCIAL OTHER 1|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Aetna|AETNA PPO|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Aetna|AETNA OTHER|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Blue Cross HMO Specialty|BCBSTX HMO|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicaid|MEDICAID SUPERIOR|||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicaid|MEDICAID AMERIGROUP|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Cigna|CIGNA|38.50||||38.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Humana Medicare Advantage|HUMANA MA|38.50||||38.50||| 9508185|ERX|0250|CHLORPROMAZINE 25MG/1ML|Humana Medicare Advantage|HUMANA MA|0.99||||||| 9508185|ERX|0250|CHLORPROMAZINE 25MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.99||||||| 9508185|ERX|0250|CHLORPROMAZINE 25MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|0.99||||||| 9508185|ERX|0250|CHLORPROMAZINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|0.99||||||| 9508185|ERX|0250|CHLORPROMAZINE 25MG/1ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.99||||||| 9508185|ERX|0250|CHLORPROMAZINE 25MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.99||||||| 9508185|ERX|0250|CHLORPROMAZINE 25MG/1ML|Medicare|MEDICARE ACUTE|0.99||||||| 9508185|ERX|0250|CHLORPROMAZINE 25MG/1ML|Medicaid|MEDICAID HMO|||||0.99||| 9508185|ERX|0250|CHLORPROMAZINE 25MG/1ML|Medicaid|MEDICAID|0.99||||||| 9508193|ERX|0250|CHLORPROMAZINE 25MG/1ML,|Access Direct Platinum|ANDREWS CENTER|109.75||||||| 9508193|ERX|0250|CHLORPROMAZINE 25MG/1ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|109.75||||||| 9508193|ERX|0250|CHLORPROMAZINE 25MG/1ML,|Aetna|BH AETNA|109.75||||||| 9508193|ERX|0250|CHLORPROMAZINE 25MG/1ML,|Blue Cross PPO Specialty|BCBSTX PPO|109.75||||||| 9508193|ERX|0250|CHLORPROMAZINE 25MG/1ML,|Managed Medicaid|MEDICAID AMERIGROUP|109.75||||||| 9508193|ERX|0250|CHLORPROMAZINE 25MG/1ML,|Managed Medicaid|MEDICAID SUPERIOR|||||109.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Healthcare|UNITED HEALTHCARE|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|PHCS|GROUP AND PENSION|||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Rusk State Hospital|RUSK STATE HOSP|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Tricare|TRICARE EAST REGION|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Multiplan|PACIFICARE|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|NON CONTRACTED|COMMUNITY HEALTH CENTER|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicaid|SMITH COUNTY JAIL|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicaid|MEDICAID|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicare|MEDICARE PART B ONLY IP|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicare|MEDICARE ACUTE|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Cigna|CIGNA OTHER|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Cigna|CIGNA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Humana Medicare Advantage|HUMANA MA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicaid|MEDICAID HMO|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicare|HEALTHSPRING MA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|ChampVA|CHAMPVA CENTER|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Aetna Value Network|AETNA VALUE NETWORK|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Aetna|AETNA QHP HMO|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Aetna|AETNA PPO|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Aetna|BOON CHAPMAN|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Aetna|AETNA OTHER|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|PHCS|HUMANA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Workers Compensation|BROOKSHIRES WORKERS COMP|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Healthcare|TML GROUP BENEFITS|||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Workers Compensation|TEXAS MUTUAL INSURANCE|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Workers Compensation|UT EMPLOYEE INJURY|20.50||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.50||||20.50||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|20.50||||20.50||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|United Medicare Advantage|UHC AARP MCR HMO MA|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Veterans Affairs|VETERANS ADMINISTRATION|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Aetna|AETNA PPO|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Blue Cross HMO Specialty|BCBSTX HMO|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Blue Cross PPO Specialty|BCBSTX PPO|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Managed Medicaid|MEDICAID AMERIGROUP|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Managed Medicaid|MEDICAID SUPERIOR|1.29||||||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Humana Medicare Advantage|HUMANA MA|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Medicare|MEDICARE ACUTE|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Medicaid|MEDICAID|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.29||||||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Managed Medicare|HEALTHSPRING MA|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|PHCS|HUMANA|1.29||||||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Tricare|TRICARE EAST REGION|||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.29||||||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|United Healthcare|UNITED HEALTHCARE OTHER|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|United Healthcare|UNITED HEALTHCARE|1.29||||1.29||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|United Healthcare|UNITED HEALTHCARE|||||1.29||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|United Healthcare|TML GROUP BENEFITS|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|United Healthcare|UNITED HEALTHCARE|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|PHCS|GROUP AND PENSION|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Rusk State Hospital|RUSK STATE HOSP|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Texas Workforce Commission|DIS DETER SERV (DDS)|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Tricare|TRICARE EAST REGION|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|NON CONTRACTED|COMMERCIAL OTHER 2|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicaid|MEDICAID HMO|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicaid|SMITH COUNTY JAIL|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicaid|LAW ENFORCEMENT OTHER|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicaid|MEDICAID|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicare|UTSW MC KIDNEY PROGRAM|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Magellan Behavioral Health|BH MAGELLAN|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Cigna|CIGNA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Cigna|CIGNA OTHER|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicare|OTHER INSTITUTIONS|||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicaid|MEDICAID SUPERIOR|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Blue Cross PPO Specialty|BCBSTX OTHER|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|PHCS|HUMANA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Aetna|AETNA OTHER|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Aetna|AETNA QHP HMO|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Aetna|AETNA PPO|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|United Medicare Advantage|UHC AARP WELLMED HMO MA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Workers Compensation|WORKERS COMPENSATION OTHER|15.50||||||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Access Direct Platinum|HEALTHFIRST TPA|15.50||||15.50||| 9508227|ERX|0250|HEPARIN 1000 UNIT/ML, 10M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||15.50||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Workers Compensation|WORKERS COMPENSATION OTHER|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Aetna|AETNA PPO|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Blue Cross PPO Specialty|BCBSTX OTHER|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|ChampVA|CHAMPVA CENTER|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicaid|MEDICAID SUPERIOR|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicaid|MEDICAID AMERIGROUP|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Cigna|CIGNA OTHER|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Cigna|CIGNA|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Humana Medicare Advantage|HUMANA MA|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Medicare|MEDICARE ACUTE|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Aetna|AETNA OTHER|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Medicaid|MEDICAID|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicare|HEALTHSPRING MA|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Access Direct Platinum|HEALTHFIRST TPA|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicare|BCBS MEDICARE PPO MA|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicare|OTHER INSTITUTIONS|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Multiplan|WEB TPA|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Tricare|TRICARE FOR LIFE|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Rusk State Hospital|RUSK STATE HOSP|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Tricare|TRICARE EAST REGION|236.25||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|United Healthcare|UNITED HEALTHCARE|236.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|United Healthcare|UNITED HEALTHCARE|||||236.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|236.25||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Multiplan|WEB TPA|25.50||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Medicare|MEDICARE ACUTE|25.50||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Cigna|CIGNA OTHER|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Cigna|CIGNA|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Medicaid|MEDICAID|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|PHCS|HUMANA|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|NON CONTRACTED|COMMUNITY HEALTH CENTER|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Texas Workforce Commission|DIS DETER SERV (DDS)|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Optum Behavioral Health|BH OPTUM UHC|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Tricare|TRICARE EAST REGION|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Medicare|MEDICARE ACUTE|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Medicaid|MEDICAID|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Medicaid|BH TEXAS CHILDRENS MEDICAID|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Managed Medicare|JACKSONVILLE ACCESS|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Managed Medicare|HEALTHSPRING MA|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Magellan Behavioral Health|BH MAGELLAN|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Cigna Behavioral Health|BH CIGNA|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Aetna|BH AETNA|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Access Direct Platinum|ANDREWS CENTER|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9508276|ERX|0250|HYDROXYZINE HCL 50MG TABL|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Workers Compensation|ZURICH COMPANY|0.10||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Aetna|AETNA PPO|||||0.10||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.10||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Managed Medicare|BCBS MEDICARE PPO MA|0.10||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Medicare|MEDICARE PART B ONLY IP|0.10||||||| 9508292|ERX|0250|FLUOROURACIL 500MG/10ML|Medicaid|MEDICAID|0.82||||||| 9508292|ERX|0250|FLUOROURACIL 500MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.82||||||| 9508292|ERX|0250|FLUOROURACIL 500MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.82||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|Humana Medicare Advantage|HUMANA MA|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|Tricare|TRICARE EAST REGION|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|Medicare|MEDICARE ACUTE|386.50||||||| 9508300|ERX|0250|VINCRISTINE 2MG/2ML|Medicaid|MEDICAID|386.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Managed Medicare|HEALTHSPRING MA|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Medicaid|MEDICAID|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Medicare|MEDICARE ACUTE|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Cigna|CIGNA|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Humana Medicare Advantage|HUMANA MA|132.50||||||| 9508326|ERX|0250|ETOPOSIDE 100MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|132.50||||||| 9508334|ERX|0250|CISPLATIN 50MG/50ML|Cigna|CIGNA|320.75||||||| 9508334|ERX|0250|CISPLATIN 50MG/50ML|Blue Cross PPO Specialty|BCBSTX OTHER|320.75||||||| 9508334|ERX|0250|CISPLATIN 50MG/50ML|Blue Cross HMO Specialty|BCBSTX HMO|320.75||||||| 9508334|ERX|0250|CISPLATIN 50MG/50ML|Medicare|MEDICARE ACUTE|320.75||||||| 9508359|ERX|0250|SULFA-TRIMETH 80-16MG/ML,|United Healthcare|UNITED HEALTHCARE OTHER|66.25||||||| 9508359|ERX|0250|SULFA-TRIMETH 80-16MG/ML,|Medicaid|MEDICAID|66.25||||||| 9508359|ERX|0250|SULFA-TRIMETH 80-16MG/ML,|Managed Medicare|HEALTHSPRING MA|66.25||||||| 9508359|ERX|0250|SULFA-TRIMETH 80-16MG/ML,|Medicare|MEDICARE ACUTE|66.25||||||| 9508359|ERX|0250|SULFA-TRIMETH 80-16MG/ML,|Veterans Affairs|VETERANS ADMINISTRATION|66.25||||||| 9508359|ERX|0250|SULFA-TRIMETH 80-16MG/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|66.25||||||| 9508359|ERX|0250|SULFA-TRIMETH 80-16MG/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|66.25||||||| 9508359|ERX|0250|SULFA-TRIMETH 80-16MG/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|66.25||||66.25||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Managed Medicaid|MEDICAID AMERIGROUP|||||2.75||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Managed Medicaid|MEDICAID SUPERIOR|||||2.75||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Access Direct Platinum|HEALTHFIRST TPA|2.75||||||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Medicaid|MEDICAID HMO|||||2.75||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|United Healthcare|UNITED HEALTHCARE|||||2.75||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|NON CONTRACTED|COMMERCIAL OTHER 1|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Tricare|TRICARE EAST REGION|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Healthcare|UNITED HEALTHCARE OTHER|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicare|MEDICARE PART B ONLY IP|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicare|MEDICARE ACUTE|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicare|HEALTHSPRING MA|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicare|BCBS MEDICARE PPO MA|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid|MEDICAID HMO|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid|MEDICAID|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Medicare Advantage|UHC MEDICARE GOLD MA|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Medicare Advantage|UHC AARP MCR HMO MA|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Veterans Affairs|VETERANS ADMINISTRATION|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Workers Compensation|UT EMPLOYEE INJURY|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid|SMITH COUNTY JAIL|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Aenta Medicare Advantage|AETNA MEDICARE MA|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Access Direct Platinum|HEALTHFIRST TPA|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Access Direct Platinum|HEALTHFIRST TPA UMR|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Healthcare|UNITED HEALTHCARE|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Blue Cross PPO Specialty|BCBSTX OTHER|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Blue Cross PPO Specialty|BCBSTX PPO|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Aetna|AETNA PPO|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Blue Cross HMO Specialty|BCBSTX HMO|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Humana Medicare Advantage|HUMANA MA|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Cigna|CIGNA|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Cigna|CIGNA OTHER|0.40||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID SUPERIOR|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.40||||0.40||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID AMERIGROUP|0.40||||0.40||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicaid|MEDICAID AMERIGROUP|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Cigna|CIGNA|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Cigna|CIGNA OTHER|||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Blue Cross HMO Specialty|BCBSTX HMO|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Aetna|AETNA PPO|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Aetna|AETNA OTHER|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Blue Cross PPO Specialty|BCBSTX OTHER|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|ChampVA|CHAMPVA CENTER|||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Access Direct Platinum|HEALTHFIRST TPA UMR|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Aenta Medicare Advantage|AETNA MEDICARE MA|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Workers Compensation|WORKERS COMPENSATION OTHER|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Workers Compensation|TEXAS MUTUAL INSURANCE|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Workers Compensation|ZURICH COMPANY|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Access Direct Platinum|HEALTHFIRST TPA|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Veterans Affairs|VETERANS ADMINISTRATION|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Medicare Advantage|UHC MEDICARE GOLD MA|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Medicare Advantage|UHC AARP WELLMED HMO MA|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Brinson Benefits|THE HEALTH PLAN SMITH CO|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Medicare Advantage|UHC AARP MCR HMO MA|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicaid|BH TEXAS CHILDRENS MEDICAID|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicaid|MEDICAID|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Humana Medicare Advantage|HUMANA MA|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicaid|SMITH COUNTY JAIL|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicaid|MEDICAID HMO|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicaid|CRIME VICTIMS COMPENSATION|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicare|HEALTHSPRING MA|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicare|BCBS MEDICARE PPO MA|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicare|MEDICARE PART B ONLY IP|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicare|MEDICARE ACUTE|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Healthcare|UNITED HEALTHCARE|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Healthcare|UNITED HEALTHCARE OTHER|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Healthcare|UNITED HEALTHCARE|4.50||||4.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Healthcare|TML GROUP BENEFITS|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|PHCS|HUMANA|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Rusk State Hospital|RUSK STATE HOSP|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Tricare|TRICARE EAST REGION|4.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|NON CONTRACTED|COMMERCIAL OTHER 1|4.50||||4.50||| 9508391|ERX|0250|PROCHLORPERAZINE 25MG SUP|Medicare|MEDICARE ACUTE|0.41||||||| 9508391|ERX|0250|PROCHLORPERAZINE 25MG SUP|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.41||||||| 9508391|ERX|0250|PROCHLORPERAZINE 25MG SUP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.41||||||| 9508391|ERX|0250|PROCHLORPERAZINE 25MG SUP|Access Direct Platinum|HEALTHFIRST TPA UMR|0.41||||||| 9508391|ERX|0250|PROCHLORPERAZINE 25MG SUP|Blue Cross HMO Specialty|BCBSTX HMO|0.41||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Cigna|CIGNA|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||9.25||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Aetna|AETNA OTHER|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||9.25||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Access Direct Platinum|HEALTHFIRST TPA|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Aetna|AETNA PPO|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||9.25||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Tricare|TRICARE EAST REGION|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|United Healthcare|UNITED HEALTHCARE|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|United Healthcare|TML GROUP BENEFITS|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicare|ETMC AFFILIATE HOSPITALS|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Medicaid|MEDICAID|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Medicaid|CRIME VICTIMS COMPENSATION|9.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|Medicare|MEDICARE ACUTE|14.50||||||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|Medicaid|MEDICAID|14.50||||||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|United Healthcare|UNITED HEALTHCARE OTHER|14.50||||||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||14.50||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|United Medicare Advantage|UHC AARP MCR HMO MA|14.50||||||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|United Medicare Advantage|UHC MEDICARE GOLD MA|14.50||||||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.50||||||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|Blue Cross HMO Specialty|BCBSTX HMO|14.50||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|26.25||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|26.25||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|26.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Cigna|CIGNA OTHER|26.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.25||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|26.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|26.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Workers Compensation|ZURICH COMPANY|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Humana Medicare Advantage|HUMANA MA|26.25||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|26.25||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|26.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.25||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|PHCS|GROUP AND PENSION|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Tricare|TRICARE EAST REGION|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicare|HEALTHSPRING MA|26.25||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|26.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.25||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Medicaid|MEDICAID HMO|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Medicaid|SMITH COUNTY JAIL|||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Medicaid|MEDICAID|26.25||||26.25||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|26.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Medicare|MEDICARE ACUTE|26.25||||26.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Medicaid|SUPERIOR HEALTHPLAN CHIP|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Medicaid|BH TEXAS CHILDRENS MEDICAID|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Medicaid|MEDICAID|58.25||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Managed Medicare|HEALTHSPRING MA|58.25||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|NON CONTRACTED|COMMUNITY HEALTH CENTER|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|58.25||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Managed Medicare|OTHER INSTITUTIONS|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Aetna|BOON CHAPMAN|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Aetna|BH AETNA|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|58.25||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Medicare|MEDICARE ACUTE|58.25||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Cigna|CIGNA OTHER|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Humana Medicare Advantage|HUMANA MA|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Cigna Behavioral Health|BH CIGNA|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||58.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|58.25||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|58.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Cigna|CIGNA|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Cigna Behavioral Health|BH CIGNA|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Humana Medicare Advantage|HUMANA MA|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Aetna|AETNA OTHER|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Aetna|AETNA PPO|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|PHCS|HUMANA|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|PHCS|GROUP AND PENSION|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Aetna|BH AETNA|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Tricare|TRICARE EAST REGION|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|NON CONTRACTED|COMMUNITY HEALTH CENTER|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Healthcare|UNITED HEALTHCARE ERS|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Healthcare|AARP|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Healthcare|UNITED HEALTHCARE|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicare|HEALTHSPRING MA|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicaid|MOLINA HEALTHCARE OF TEXAS|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicaid|MEDICAID|59.25||||59.25||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicaid|BH TEXAS CHILDRENS MEDICAID|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicaid|SUPERIOR HEALTHPLAN CHIP|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|59.25||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicare|MEDICARE ACUTE|59.25||||59.25||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Medicare|MEDICARE ACUTE|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|NON CONTRACTED|COMMUNITY HEALTH CENTER|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Medicaid|MEDICAID HMO|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Aetna|BH AETNA|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Humana Medicare Advantage|HUMANA MA|||||118.75||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118.75||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.75||||||| 9508474|ERX|0250|FLUOXETINE 20MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||685.50||| 9508474|ERX|0250|FLUOXETINE 20MG/5ML|Humana Medicare Advantage|HUMANA MA|685.50||||||| 9508474|ERX|0250|FLUOXETINE 20MG/5ML|Access Direct Platinum|ANDREWS CENTER|685.50||||||| 9508474|ERX|0250|FLUOXETINE 20MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||685.50||| 9508474|ERX|0250|FLUOXETINE 20MG/5ML|Managed Medicare|HEALTHSPRING MA|685.50||||||| 9508474|ERX|0250|FLUOXETINE 20MG/5ML|Medicaid|MEDICAID|685.50||||||| 9508474|ERX|0250|FLUOXETINE 20MG/5ML|Medicare|MEDICARE ACUTE|685.50||||||| 9508482|ERX|0250|PERPHENAZINE 2MG TABLET|Rusk State Hospital|RUSK STATE HOSP|12.25||||||| 9508482|ERX|0250|PERPHENAZINE 2MG TABLET|Medicare|MEDICARE PART B ONLY IP|12.25||||||| 9508482|ERX|0250|PERPHENAZINE 2MG TABLET|Medicare|MEDICARE ACUTE|12.25||||12.25||| 9508482|ERX|0250|PERPHENAZINE 2MG TABLET|Managed Medicare|HEALTHSPRING MA|12.25||||||| 9508482|ERX|0250|PERPHENAZINE 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||||| 9508482|ERX|0250|PERPHENAZINE 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.25||||||| 9508490|ERX|0250|PERPHENAZINE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9508490|ERX|0250|PERPHENAZINE 4MG TABLET|Medicare|MEDICARE ACUTE|15.50||||||| 9508516|ERX|0250|PENICILLIN VK 250MG TABLE|Medicare|MEDICARE ACUTE|5.25||||||| 9508524|ERX|0250|HALOPERIDOL 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.08||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.08||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.08||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.08||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.08||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.08||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.08||||0.08||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.08||||||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.08||||||| 9508540|ERX|0250|HALOPERIDOL 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9508540|ERX|0250|HALOPERIDOL 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9508540|ERX|0250|HALOPERIDOL 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9508540|ERX|0250|HALOPERIDOL 2MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9508540|ERX|0250|HALOPERIDOL 2MG TABLET|Medicare|MEDICARE ACUTE|9.25||||||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|NON CONTRACTED|COMMERCIAL OTHER 4|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|NON CONTRACTED|COMMERCIAL OTHER 1|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|NON CONTRACTED|COMMERCIAL OTHER 2|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|PHCS|HUMANA|62.75||||||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Tricare|TRICARE FOR LIFE|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|United Healthcare|UNITED HEALTHCARE|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|United Healthcare|TML GROUP BENEFITS|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|United Healthcare|UNITED HEALTHCARE OTHER|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|UTMB|UTMB CORRECTIONAL MANAGED CARE|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|MEDICAID BCBSTX|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|SMITH COUNTY JAIL|62.75||||||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|MEDICAID|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|LAW ENFORCEMENT OTHER|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|MEDICAID HMO|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|WELLCARE CHOICE MA|62.75||||||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|OTHER INSTITUTIONS|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|BCBS MEDICARE PPO MA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicare|MEDICARE PART B ONLY IP|62.75||||||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|HEALTHSPRING MA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicare|MEDICARE ACUTE|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Veterans Affairs|VETERANS ADMINISTRATION|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|UHC MEDICARE GOLD MA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|UHC AARP WELLMED HMO MA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|UHC AARP MCR HMO MA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Workers Compensation|WORKERS COMPENSATION OTHER|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Workers Compensation|UT EMPLOYEE INJURY|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Access Direct Platinum|HEALTHFIRST TPA UMR|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Access Direct Platinum|HEALTHFIRST TPA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|United Healthcare|UNITED HEALTHCARE|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Tricare|TRICARE EAST REGION|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Aenta Medicare Advantage|AETNA MEDICARE MA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Cigna|CIGNA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Cigna|CIGNA OTHER|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Humana Medicare Advantage|HUMANA MA|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID AMERIGROUP|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID SUPERIOR|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Aetna|AETNA OTHER|||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Aetna|AETNA PPO|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross HMO Specialty|BCBSTX HMO|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Brinson Benefits|THE HEALTH PLAN SMITH CO|62.75||||||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross PPO Specialty|BCBSTX PPO|62.75||||62.75||| 9508557|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross PPO Specialty|BCBSTX OTHER|||||62.75||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Cigna Behavioral Health|BH CIGNA|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||0.15||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Managed Medicare|OTHER INSTITUTIONS|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Managed Medicare|HOSPICE OF EAST TEXAS|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Medicaid|MEDICAID|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.15||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.15||||||| 9508573|ERX|0250|HALOPERIDOL 10MG TABLET|Medicaid|MEDICAID|0.23||||||| 9508573|ERX|0250|HALOPERIDOL 10MG TABLET|Medicare|MEDICARE ACUTE|0.23||||||| 9508573|ERX|0250|HALOPERIDOL 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.23||||||| 9508573|ERX|0250|HALOPERIDOL 10MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.23||||||| 9508573|ERX|0250|HALOPERIDOL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|0.23||||||| 9508573|ERX|0250|HALOPERIDOL 10MG TABLET|Cigna Behavioral Health|BH CIGNA|0.23||||||| 9508573|ERX|0250|HALOPERIDOL 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.23||||||| 9508573|ERX|0250|HALOPERIDOL 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.23||||||| 9508573|ERX|0250|HALOPERIDOL 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.23||||||| 9508581|ERX|0250|IMIPRAMINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||13.50||| 9508581|ERX|0250|IMIPRAMINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.50||||||| 9508581|ERX|0250|IMIPRAMINE 25MG TABLET|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9508599|ERX|0250|IMIPRAMINE 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.19||||||| 9508599|ERX|0250|IMIPRAMINE 50MG TABLET|Medicare|MEDICARE ACUTE|0.19||||||| 9508599|ERX|0250|IMIPRAMINE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||||| 9508607|ERX|0250|DICLOFENAC SODIUM 25MG TA|Cigna|CIGNA|15.25||||||| 9508607|ERX|0250|DICLOFENAC SODIUM 25MG TA|Humana Medicare Advantage|HUMANA MA|15.25||||||| 9508607|ERX|0250|DICLOFENAC SODIUM 25MG TA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.25||| 9508607|ERX|0250|DICLOFENAC SODIUM 25MG TA|Blue Cross PPO Specialty|BCBSTX PPO|15.25||||||| 9508607|ERX|0250|DICLOFENAC SODIUM 25MG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|15.25||||||| 9508607|ERX|0250|DICLOFENAC SODIUM 25MG TA|United Medicare Advantage|UHC AARP MCR HMO MA|15.25||||||| 9508607|ERX|0250|DICLOFENAC SODIUM 25MG TA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.25||||15.25||| 9508607|ERX|0250|DICLOFENAC SODIUM 25MG TA|Medicare|MEDICARE ACUTE|15.25||||15.25||| 9508607|ERX|0250|DICLOFENAC SODIUM 25MG TA|United Healthcare|UNITED HEALTHCARE|15.25||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|38.50||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicare|HEALTHSPRING MA|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Medicaid|SMITH COUNTY JAIL|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Medicaid|MEDICAID|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Medicare|MEDICARE ACUTE|38.50||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.50||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|38.50||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|ChampVA|CHAMPVA CENTER|||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|38.50||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Aetna|AETNA PPO|||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Aetna|BH AETNA|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.50||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|38.50||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|38.50||||38.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Humana Medicare Advantage|HUMANA MA|38.50||||38.50||| 9508680|ERX|0250|NAFCILLIN 2 G VIAL|Medicaid|MEDICAID|225.75||||||| 9508714|ERX|0250|MENTHOL-LAN-CAL-ZN OX ,11|Humana Medicare Advantage|HUMANA MA|42.75||||||| 9508714|ERX|0250|MENTHOL-LAN-CAL-ZN OX ,11|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42.75||||||| 9508714|ERX|0250|MENTHOL-LAN-CAL-ZN OX ,11|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42.75||||||| 9508714|ERX|0250|MENTHOL-LAN-CAL-ZN OX ,11|Blue Cross PPO Specialty|BCBSTX PPO|42.75||||||| 9508714|ERX|0250|MENTHOL-LAN-CAL-ZN OX ,11|United Medicare Advantage|UHC AARP MCR HMO MA|42.75||||||| 9508714|ERX|0250|MENTHOL-LAN-CAL-ZN OX ,11|Aenta Medicare Advantage|AETNA MEDICARE MA|42.75||||||| 9508714|ERX|0250|MENTHOL-LAN-CAL-ZN OX ,11|Access Direct Platinum|HEALTHFIRST TPA|42.75||||||| 9508714|ERX|0250|MENTHOL-LAN-CAL-ZN OX ,11|Medicare|MEDICARE ACUTE|42.75||||||| 9508714|ERX|0250|MENTHOL-LAN-CAL-ZN OX ,11|Managed Medicare|HEALTHSPRING MA|42.75||||||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Healthcare|TML GROUP BENEFITS|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Healthcare|GOLDEN RULE|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Healthcare|GEHA|156.50||||||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Healthcare|UNITED HEALTHCARE OTHER|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Healthcare|UNITED HEALTHCARE|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|UTMB|UTMB CORRECTIONAL MANAGED CARE|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|PHCS|GROUP AND PENSION|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Rusk State Hospital|RUSK STATE HOSP|156.50||||||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Texas Workforce Commission|DIS DETER SERV (DDS)|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Tricare|TRICARE EAST REGION|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|NON CONTRACTED|COMMERCIAL OTHER 2|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicaid|SMITH COUNTY INDIGENT HEALTH|156.50||||||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicaid|LAW ENFORCEMENT OTHER|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicaid|SMITH COUNTY JAIL|156.50||||||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicaid|COUNTY INDIGENT HEALTH OTHER|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicaid|MEDICAID|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicare|HEALTHSPRING MA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicare|MEDICARE PART B ONLY IP|156.50||||||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicare|MEDICARE ACUTE|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Workers Compensation|TEXAS MUTUAL INSURANCE|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Workers Compensation|WORKERS COMPENSATION OTHER|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|156.50||||||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicare|BCBS MEDICARE PPO MA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Workers Compensation|BROOKSHIRES WORKERS COMP|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Access Direct Platinum|HEALTHFIRST TPA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Access Direct Platinum|HEALTHFIRST TPA UMR|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Aenta Medicare Advantage|AETNA MEDICARE MA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicaid|CRIME VICTIMS COMPENSATION|156.50||||||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Veterans Affairs|VETERANS ADMINISTRATION|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Medicare Advantage|UHC AARP MCR HMO MA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Medicare Advantage|UHC AARP WELLMED HMO MA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|NON CONTRACTED|COMMERCIAL OTHER 1|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Medicare Advantage|UHC MEDICARE GOLD MA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Brinson Benefits|THE HEALTH PLAN SMITH CO|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|ChampVA|CHAMPVA CENTER|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Tricare|TRICARE FOR LIFE|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Blue Cross PPO Specialty|BCBSTX PPO|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Blue Cross PPO Specialty|BCBSTX OTHER|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Aetna|AETNA QHP HMO|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Aetna|AETNA OTHER|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Aetna|BOON CHAPMAN|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Aetna|AETNA PPO|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Blue Cross HMO Specialty|BCBSTX HMO|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Healthcare|UNITED HEALTHCARE ERS|156.50||||||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Aetna Value Network|AETNA VALUE NETWORK|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicaid|MEDICAID AMERIGROUP|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicaid|MEDICAID SUPERIOR|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Magellan Behavioral Health|BH MAGELLAN|||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Humana Medicare Advantage|HUMANA MA|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Cigna|CIGNA OTHER|156.50||||156.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Cigna|CIGNA|156.50||||156.50||| 9508730|ERX|0250|SIMPLE SYRUP, 30ML|Tricare|TRICARE EAST REGION|12.25||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Humana Medicare Advantage|HUMANA MA|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|ChampVA|CHAMPVA CENTER|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Medicare|MEDICARE ACUTE|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Managed Medicare|HEALTHSPRING MA|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Medicaid|MEDICAID|2.75||||||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|PHCS|GROUP AND PENSION|2.75||||||| 9508763|ERX|0250|CHLORPACTIN WCS-90 2GM|Managed Medicare|BCBS MEDICARE PPO MA|1.70||||||| 9508763|ERX|0250|CHLORPACTIN WCS-90 2GM|Medicare|MEDICARE ACUTE|1.70||||||| 9508763|ERX|0250|CHLORPACTIN WCS-90 2GM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.70||||||| 9508763|ERX|0250|CHLORPACTIN WCS-90 2GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.70||||||| 9508763|ERX|0250|CHLORPACTIN WCS-90 2GM|Humana Medicare Advantage|HUMANA MA|1.70||||||| 9508789|ERX|0250|VITAMIN A 10000 UNIT CAPS|ChampVA|CHAMPVA CENTER|2.50||||||| 9508789|ERX|0250|VITAMIN A 10000 UNIT CAPS|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9508789|ERX|0250|VITAMIN A 10000 UNIT CAPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9508789|ERX|0250|VITAMIN A 10000 UNIT CAPS|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9508789|ERX|0250|VITAMIN A 10000 UNIT CAPS|Medicare|MEDICARE ACUTE|2.50||||||| 9508797|ERX|0250|CALAMINE LOTION, 120ML|United Healthcare|UNITED HEALTHCARE|||||20.25||| 9508797|ERX|0250|CALAMINE LOTION, 120ML|Medicare|MEDICARE ACUTE|20.25||||20.25||| 9508797|ERX|0250|CALAMINE LOTION, 120ML|Humana Medicare Advantage|HUMANA MA|20.25||||||| 9508797|ERX|0250|CALAMINE LOTION, 120ML|Cigna|CIGNA|20.25||||||| 9508805|ERX|0250|COLESTIPOL 5 G PACKET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.75||||||| 9508805|ERX|0250|COLESTIPOL 5 G PACKET|Humana Medicare Advantage|HUMANA MA|26.75||||||| 9508805|ERX|0250|COLESTIPOL 5 G PACKET|Managed Medicare|HEALTHSPRING MA|26.75||||||| 9508805|ERX|0250|COLESTIPOL 5 G PACKET|Medicare|MEDICARE ACUTE|26.75||||26.75||| 9508805|ERX|0250|COLESTIPOL 5 G PACKET|Tricare|TRICARE EAST REGION|26.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|PHCS|HUMANA INSURANCE|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Medicaid|MEDICAID|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicare|HEALTHSPRING MA|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Workers Compensation|ZURICH COMPANY|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|PHCS|HUMANA|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Healthcare|GEHA|||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Cigna|CIGNA|||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|7.75||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||7.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.75||||7.75||| 9508839|ERX|0250|CYANOCOBALAMIN 250MCG TAB|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9508839|ERX|0250|CYANOCOBALAMIN 250MCG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9508839|ERX|0250|CYANOCOBALAMIN 250MCG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9508839|ERX|0250|CYANOCOBALAMIN 250MCG TAB|Medicare|MEDICARE ACUTE|||||2.50||| 9508839|ERX|0250|CYANOCOBALAMIN 250MCG TAB|Tricare|TRICARE EAST REGION|2.50||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|United Healthcare|UNITED HEALTHCARE|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|PHCS|HUMANA INSURANCE|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicare|HEALTHSPRING MA|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicaid|MEDICAID HMO|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicare|MEDICARE PART B ONLY IP|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicare|MEDICARE ACUTE|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Access Direct Platinum|ANDREWS CENTER|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Tricare|TRICARE EAST REGION|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Cigna|CIGNA OTHER|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Cigna|CIGNA|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Humana Medicare Advantage|HUMANA MA|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Cigna Behavioral Health|BH CIGNA|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Aetna|AETNA PPO|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.25||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.25||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7.25||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.25||||7.25||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Aetna|AETNA PPO|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Cigna|CIGNA OTHER|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Cigna|CIGNA|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Medicaid|MEDICAID|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Managed Medicare|HEALTHSPRING MA|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|United Healthcare|UNITED HEALTHCARE|0.10||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|United Healthcare|UNITED HEALTHCARE OTHER|0.10||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Tricare|TRICARE EAST REGION|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|NON CONTRACTED|COMMERCIAL OTHER 1|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|United Healthcare|UNITED HEALTHCARE OTHER|46.75||||46.75||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Managed Medicare|HEALTHSPRING MA|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Managed Medicare|BCBS MEDICARE PPO MA|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Medicaid|SMITH COUNTY INDIGENT HEALTH|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Medicaid|CRIME VICTIMS COMPENSATION|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Medicare|MEDICARE ACUTE|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Medicare|MEDICARE PART B ONLY IP|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Access Direct Platinum|HEALTHFIRST TPA|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Medicaid|MEDICAID|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Aenta Medicare Advantage|AETNA MEDICARE MA|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Workers Compensation|TEXAS MUTUAL INSURANCE|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Workers Compensation|WORKERS COMPENSATION OTHER|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Veterans Affairs|VETERANS ADMINISTRATION|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|United Medicare Advantage|UHC MEDICARE GOLD MA|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|United Medicare Advantage|UHC AARP MCR HMO MA|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Humana Medicare Advantage|HUMANA MA|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Managed Medicaid|MEDICAID AMERIGROUP|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Managed Medicaid|MEDICAID SUPERIOR|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Aetna|AETNA PPO|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Blue Cross HMO Specialty|BCBSTX HMO|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|46.75||||||| 9508912|ERX|0250|SENNOSIDES 8.8MG/5ML, 60M|Blue Cross PPO Specialty|BCBSTX PPO|46.75||||||| 9508920|ERX|0250|CAFFEINE 200MG TABLET|Medicare|MEDICARE ACUTE|2.75||||2.75||| 9508938|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|Blue Cross PPO Specialty|BCBSTX PPO|345.75||||||| 9508938|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|345.75||||||| 9508938|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|Humana Medicare Advantage|HUMANA MA|345.75||||345.75||| 9508938|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|United Medicare Advantage|UHC AARP MCR HMO MA|345.75||||||| 9508938|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|United Medicare Advantage|UHC MEDICARE GOLD MA|345.75||||||| 9508938|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|Veterans Affairs|VETERANS ADMINISTRATION|345.75||||||| 9508938|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|Medicare|MEDICARE ACUTE|345.75||||||| 9508946|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|Medicare|MEDICARE ACUTE|394.75||||||| 9508946|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|394.75||||||| 9508946|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|United Medicare Advantage|UHC MEDICARE GOLD MA|394.75||||||| 9508946|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|Humana Medicare Advantage|HUMANA MA|394.75||||||| 9508946|ERX|0258|PERIT.DIALYSIS 1.5% DEX 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|394.75||||||| 9508953|ERX|0258|PERIT.DIALYSIS 1.5% DEX 3|Medicare|MEDICARE ACUTE|454.75||||||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Blue Cross PPO Specialty|BCBSTX PPO|385.75||||||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Blue Cross PPO Specialty|BCBSTX OTHER|385.75||||||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|385.75||||||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Humana Medicare Advantage|HUMANA MA|385.75||||||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Veterans Affairs|VETERANS ADMINISTRATION|385.75||||||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|United Medicare Advantage|UHC AARP MCR HMO MA|385.75||||||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|United Medicare Advantage|UHC MEDICARE GOLD MA|385.75||||385.75||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Tricare|TRICARE EAST REGION|||||385.75||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||385.75||| 9508961|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Medicare|MEDICARE ACUTE|385.75||||385.75||| 9508979|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Medicare|MEDICARE ACUTE|394.75||||394.75||| 9508979|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Tricare|TRICARE EAST REGION|394.75||||||| 9508979|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|394.75||||||| 9508979|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|United Medicare Advantage|UHC MEDICARE GOLD MA|394.75||||||| 9508979|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Managed Medicaid|MEDICAID SUPERIOR|394.75||||||| 9508979|ERX|0258|PERIT.DIALYSIS 2.5% DEX 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|394.75||||||| 9508987|ERX|0258|PERIT.DIALYSIS 2.5% DEX 3|Humana Medicare Advantage|HUMANA MA|454.75||||||| 9508987|ERX|0258|PERIT.DIALYSIS 2.5% DEX 3|Medicare|MEDICARE ACUTE|454.75||||||| 9509001|ERX|0258|PERIT. DIALYSIS 4.25% 200|Medicare|MEDICARE ACUTE|389.25||||||| 9509001|ERX|0258|PERIT. DIALYSIS 4.25% 200|Blue Cross PPO Specialty|BCBSTX OTHER|389.25||||||| 9509019|ERX|0258|PERIT. DIALYSIS 4.25% 250|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|400.50||||||| 9509019|ERX|0258|PERIT. DIALYSIS 4.25% 250|Medicare|MEDICARE ACUTE|400.50||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|United Healthcare|UNITED HEALTHCARE OTHER|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|United Healthcare|UNITED HEALTHCARE|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|UTMB|UTMB CORRECTIONAL MANAGED CARE|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|Medicare|MEDICARE ACUTE|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|Veterans Affairs|VETERANS ADMINISTRATION|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|United Medicare Advantage|UHC MEDICARE GOLD MA|||||130.75||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|Humana Medicare Advantage|HUMANA MA|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|Blue Cross HMO Specialty|BCBSTX HMO|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|Blue Cross PPO Specialty|BCBSTX PPO|130.75||||||| 9509035|ERX|0258|CITRATE DEXTROSE SOLN 500|Aenta Medicare Advantage|AETNA MEDICARE MA|130.75||||||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Blue Cross HMO Specialty|BCBSTX HMO|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Aetna|AETNA PPO|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Blue Cross PPO Specialty|BCBSTX PPO|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Cigna|CIGNA|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Cigna|CIGNA OTHER|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Humana Medicare Advantage|HUMANA MA|3.19||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicaid|MEDICAID AMERIGROUP|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.19||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Veterans Affairs|VETERANS ADMINISTRATION|3.19||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|United Medicare Advantage|UHC AARP MCR HMO MA|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|United Medicare Advantage|UHC MEDICARE GOLD MA|3.19||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Workers Compensation|TEXAS MUTUAL INSURANCE|3.19||||||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicaid|MEDICAID SUPERIOR|3.19||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicaid|SMITH COUNTY JAIL|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicaid|MEDICAID HMO|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicaid|MEDICAID|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicaid|MEDICAID BCBSTX|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicare|HEALTHSPRING MA|3.19||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicare|MEDICARE ACUTE|3.19||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Multiplan|WEB TPA|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|NON CONTRACTED|COMMERCIAL OTHER 2|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Tricare|TRICARE EAST REGION|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Tricare|TRICARE FOR LIFE|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|United Healthcare|UNITED HEALTHCARE|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|United Healthcare|UNITED HEALTHCARE OTHER|||||3.19||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.19||||3.19||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|United Healthcare|GEHA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|United Healthcare|UNITED HEALTHCARE|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|United Healthcare|UNITED HEALTHCARE OTHER|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|United Healthcare|GOLDEN RULE|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|United Healthcare|AARP|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|PHCS|HUMANA INSURANCE|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|PHCS|HUMANA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|NON CONTRACTED|COMMERCIAL OTHER 1|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Medicare|MEDICARE PART B ONLY IP|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Medicare|MEDICARE ACUTE|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicare|HEALTHSPRING MA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Workers Compensation|UT EMPLOYEE INJURY|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Workers Compensation|WORKERS COMPENSATION OTHER|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Aenta Medicare Advantage|AETNA MEDICARE MA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicare|BCBS MEDICARE PPO MA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Access Direct Platinum|HEALTHFIRST TPA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicare|TEXAS COMMUNITY CARE MA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|United Medicare Advantage|UHC AARP MCR HMO MA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Veterans Affairs|VETERANS ADMINISTRATION|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Tricare|TRICARE EAST REGION|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicaid|MEDICAID AMERIGROUP|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicaid|MEDICAID SUPERIOR|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Cigna|CIGNA OTHER|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Cigna|CIGNA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Humana Medicare Advantage|HUMANA MA|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Blue Cross PPO Specialty|BCBSTX OTHER|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Blue Cross PPO Specialty|BCBSTX PPO|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Aetna|AETNA OTHER|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Aetna|AETNA PPO|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||535.25||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Blue Cross HMO Specialty|BCBSTX HMO|||||535.25||| 9509092|ERX|0250|PILOCARPINE 1% EYE DROP,1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||307.75||| 9509092|ERX|0250|PILOCARPINE 1% EYE DROP,1|Medicare|MEDICARE ACUTE|307.75||||||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|Managed Medicare|HEALTHSPRING MA|2.46||||||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|Managed Medicare|BCBS MEDICARE PPO MA|2.46||||||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|Managed Medicare|HOSPICE OF EAST TEXAS|2.46||||||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|Medicare|MEDICARE ACUTE|2.46||||||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|Humana Medicare Advantage|HUMANA MA|2.46||||||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|2.46||||2.46||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Access Direct Platinum|HEALTHFIRST TPA|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Aenta Medicare Advantage|AETNA MEDICARE MA|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Veterans Affairs|VETERANS ADMINISTRATION|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|United Medicare Advantage|UHC MEDICARE GOLD MA|548.75||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|United Medicare Advantage|UHC AARP MCR HMO MA|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Blue Cross HMO Specialty|BCBSTX HMO|548.75||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Cigna|CIGNA|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Humana Medicare Advantage|HUMANA MA|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|NON CONTRACTED|COMMERCIAL OTHER 1|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|United Healthcare|TML GROUP BENEFITS|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|United Healthcare|UNITED HEALTHCARE|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|United Healthcare|GEHA|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Medicare|MEDICARE ACUTE|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Managed Medicare|HEALTHSPRING MA|||||548.75||| 9509183|ERX|0250|TROPICAMIDE 1% EYE DROP,|Managed Medicare|BCBS MEDICARE PPO MA|||||548.75||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Medicaid|MEDICAID|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Medicaid|CRIME VICTIMS COMPENSATION|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Managed Medicare|HEALTHSPRING MA|97.25||||97.25||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Medicare|MEDICARE PART B ONLY IP|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Medicare|MEDICARE ACUTE|97.25||||97.25||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|United Healthcare|UNITED HEALTHCARE OTHER|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|United Healthcare|UNITED HEALTHCARE|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|97.25||||97.25||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Rusk State Hospital|RUSK STATE HOSP|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|NON CONTRACTED|COMMERCIAL OTHER 2|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|NON CONTRACTED|COMMERCIAL OTHER 1|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Magellan Behavioral Health|BH MAGELLAN|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Cigna|CIGNA|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Humana Medicare Advantage|HUMANA MA|97.25||||97.25||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Tricare|TRICARE EAST REGION|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Managed Medicaid|MEDICAID SUPERIOR|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Managed Medicaid|MEDICAID AMERIGROUP|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Blue Cross PPO Specialty|BCBSTX PPO|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Blue Cross PPO Specialty|BCBSTX OTHER|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Aetna|AETNA PPO|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|97.25||||97.25||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Managed Medicare|BCBS MEDICARE PPO MA|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Blue Cross HMO Specialty|BCBSTX HMO|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|United Medicare Advantage|UHC MEDICARE GOLD MA|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|United Medicare Advantage|UHC AARP MCR HMO MA|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Veterans Affairs|VETERANS ADMINISTRATION|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Workers Compensation|WORKERS COMPENSATION OTHER|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Aenta Medicare Advantage|AETNA MEDICARE MA|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|97.25||||97.25||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Access Direct Platinum|HEALTHFIRST TPA UMR|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Access Direct Platinum|HEALTHFIRST TPA|97.25||||||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|97.25||||||| 9509225|ERX|0250|BISMUTH SUBSALIC 262MG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9509225|ERX|0250|BISMUTH SUBSALIC 262MG TA|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9509225|ERX|0250|BISMUTH SUBSALIC 262MG TA|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9509225|ERX|0250|BISMUTH SUBSALIC 262MG TA|Humana Medicare Advantage|HUMANA MA|||||2.50||| 9509225|ERX|0250|BISMUTH SUBSALIC 262MG TA|Medicare|MEDICARE ACUTE|2.50||||||| 9509225|ERX|0250|BISMUTH SUBSALIC 262MG TA|Medicaid|SMITH COUNTY JAIL|2.50||||||| 9509233|ERX|0250|HYALURONATE 10MG/ML, 0.4M|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.21||||||| 9509233|ERX|0250|HYALURONATE 10MG/ML, 0.4M|Medicare|MEDICARE ACUTE|8.21||||8.21||| 9509233|ERX|0250|HYALURONATE 10MG/ML, 0.4M|Managed Medicaid|MEDICAID SUPERIOR|8.21||||||| 9509233|ERX|0250|HYALURONATE 10MG/ML, 0.4M|Blue Cross PPO Specialty|BCBSTX PPO|8.21||||||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Access Direct Platinum|HEALTHFIRST TPA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Veterans Affairs|VETERANS ADMINISTRATION|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Blue Cross HMO Specialty|BCBSTX HMO|1,382.25||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Blue Cross PPO Specialty|BCBSTX PPO|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Cigna|CIGNA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Humana Medicare Advantage|HUMANA MA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Managed Medicare|HEALTHSPRING MA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Managed Medicare|BCBS MEDICARE PPO MA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|Medicare|MEDICARE ACUTE|1,382.25||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|United Healthcare|GEHA|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|United Healthcare|TML GROUP BENEFITS|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|United Healthcare|UNITED HEALTHCARE|||||1,382.25||| 9509241|ERX|0250|CHONDR SU A NA-HYALU SOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,382.25||||||| 9509266|ERX|0250|MEDROXYPROGESTERONE 5MG T|NON CONTRACTED|COMMERCIAL OTHER 1|18.25||||||| 9509266|ERX|0250|MEDROXYPROGESTERONE 5MG T|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9509266|ERX|0250|MEDROXYPROGESTERONE 5MG T|Humana Medicare Advantage|HUMANA MA|||||18.25||| 9509266|ERX|0250|MEDROXYPROGESTERONE 5MG T|Access Direct Platinum|HEALTHFIRST TPA UMR|||||18.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Medicare Advantage|UHC AARP MCR HMO MA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|WORKERS COMPENSATION OTHER|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|GALLAGHER BASSETT|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|TEXAS MUTUAL INSURANCE|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|ZURICH COMPANY|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|UT EMPLOYEE INJURY|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|BROOKSHIRES WORKERS COMP|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST TPA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|ChampVA|CHAMPVA CENTER|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Blue Cross PPO Specialty|BCBSTX PPO|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Blue Cross PPO Specialty|BCBSTX OTHER|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Aetna|AETNA PPO|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Aetna|AETNA QHP HMO|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Aetna|AETNA OTHER|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Aetna Value Network|AETNA VALUE NETWORK|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Blue Cross HMO Specialty|BCBSTX HMO|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicaid|MEDICAID SUPERIOR|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicaid|MEDICAID AMERIGROUP|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Cigna|CIGNA OTHER|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Cigna|CIGNA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Humana Medicare Advantage|HUMANA MA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|MEDICAID HMO|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|MEDICAID BCBSTX|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|MEDICAID|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|LAW ENFORCEMENT OTHER|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|CRIME VICTIMS COMPENSATION|123.25||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Aetna|BOON CHAPMAN|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|SMITH COUNTY JAIL|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|HEALTHSPRING MA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|BCBS MEDICARE PPO MA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|OTHER INSTITUTIONS|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|123.25||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicare|UTSW MC KIDNEY PROGRAM|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicare|MEDICARE PART B ONLY IP|123.25||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicare|MEDICARE ACUTE|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|UNITED HEALTHCARE OTHER|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|UNITED HEALTHCARE ERS|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|UNITED HEALTHCARE|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|GOLDEN RULE|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Veterans Affairs|VETERANS ADMINISTRATION|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|TML GROUP BENEFITS|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|GEHA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|PHCS|HUMANA INSURANCE|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|PHCS|HUMANA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|PHCS|GROUP AND PENSION|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Rusk State Hospital|RUSK STATE HOSP|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Tricare|TRICARE SOUTH PHYSICIAN|||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Texas Workforce Commission|DIS DETER SERV (DDS)|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Tricare|TRICARE EAST REGION|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Tricare|TRICARE FOR LIFE|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Multiplan|WEB TPA|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Multiplan|PACIFICARE|123.25||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|NON CONTRACTED|COMMERCIAL OTHER 2|123.25||||123.25||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|NON CONTRACTED|COMMERCIAL OTHER 1|123.25||||123.25||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Medicare|MEDICARE ACUTE|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Managed Medicare|HEALTHSPRING MA|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Medicaid|MEDICAID|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Humana Medicare Advantage|HUMANA MA|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|102.25||||||| 9509290|ERX|0250|MIDAZOLAM 50MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|102.25||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|0.13||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|UT EMPLOYEE INJURY|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|ZURICH COMPANY|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|GALLAGHER BASSETT|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|BROOKSHIRES WORKERS COMP|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.13||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|ChampVA|CHAMPVA CENTER|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Aetna|BOON CHAPMAN|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Aetna|AETNA OTHER|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Aetna|AETNA QHP HMO|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Aetna Value Network|AETNA VALUE NETWORK|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Cigna|CIGNA OTHER|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Cigna|CIGNA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|SMITH COUNTY JAIL|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|MEDICAID BCBSTX|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|MEDICAID|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Aetna|AETNA PPO|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|MEDICAID HMO|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|LAW ENFORCEMENT OTHER|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|OTHER INSTITUTIONS|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicare|UTSW MC KIDNEY PROGRAM|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Multiplan|PACIFICARE|0.13||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Multiplan|WEB TPA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 2|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|PHCS|HUMANA INSURANCE|0.13||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|PHCS|HUMANA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|PHCS|GROUP AND PENSION|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Rusk State Hospital|RUSK STATE HOSP|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Texas Workforce Commission|DIS DETER SERV (DDS)|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Tricare|TRICARE SOUTH PHYSICIAN|||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Tricare|TRICARE FOR LIFE|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|UNITED HEALTHCARE ERS|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|GEHA|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|TML GROUP BENEFITS|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|GOLDEN RULE|0.13||||0.13||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|28.50||||28.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Healthcare|UNITED HEALTHCARE|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Medicare|MEDICARE PART B ONLY IP|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Medicare|MEDICARE ACUTE|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicare|HEALTHSPRING MA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Medicaid|MEDICAID|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Medicaid|CRIME VICTIMS COMPENSATION|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Cigna|CIGNA OTHER|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Cigna|CIGNA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Humana Medicare Advantage|HUMANA MA|28.50||||28.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|28.50||||28.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|28.50||||28.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.50||||28.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicare|WELLCARE CHOICE MA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Aetna|AETNA PPO|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Aetna|AETNA QHP HMO|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|28.50||||28.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Rusk State Hospital|RUSK STATE HOSP|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|28.50||||28.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Workers Compensation|TEXAS MUTUAL INSURANCE|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Workers Compensation|WORKERS COMPENSATION OTHER|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Access Direct Platinum|HEALTHFIRST TPA|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|28.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|28.50||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Veterans Affairs|VETERANS ADMINISTRATION|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|United Medicare Advantage|UHC MEDICARE GOLD MA|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Blue Cross HMO Specialty|BCBSTX HMO|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Blue Cross PPO Specialty|BCBSTX PPO|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Humana Medicare Advantage|HUMANA MA|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Medicaid|SMITH COUNTY INDIGENT HEALTH|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Medicaid|MEDICAID|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Medicare|MEDICARE ACUTE|1,568.38||||1,568.38||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|NON CONTRACTED|COMMERCIAL OTHER 1|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|United Healthcare|UNITED HEALTHCARE OTHER|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,568.38||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|United Healthcare|UNITED HEALTHCARE|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Rusk State Hospital|RUSK STATE HOSP|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Medicaid|MEDICAID HMO|||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Medicaid|MEDICAID|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicare|HEALTHSPRING MA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Cigna|CIGNA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Cigna|CIGNA OTHER|17.50||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Humana Medicare Advantage|HUMANA MA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Medicare|MEDICARE PART B ONLY IP|17.50||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Aetna|BOON CHAPMAN|17.50||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Aetna|AETNA PPO|||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Aetna|AETNA OTHER|||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Tricare|TRICARE EAST REGION|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|ChampVA|CHAMPVA CENTER|||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|17.50||||17.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|17.50||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Workers Compensation|GALLAGHER BASSETT|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|17.50||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Aetna|AETNA OTHER|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|17.50||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Cigna|CIGNA|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|17.50||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Humana Medicare Advantage|HUMANA MA|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicare|HEALTHSPRING MA|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.50||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Medicaid|MEDICAID|17.50||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|17.50||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Tricare|TRICARE EAST REGION|17.50||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|United Healthcare|UNITED HEALTHCARE|17.50||||17.50||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||17.50||| 9509365|ERX|0250|GELATIN OPHTH 25X50MM|United Healthcare|UNITED HEALTHCARE OTHER|597.50||||||| 9509365|ERX|0250|GELATIN OPHTH 25X50MM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||597.50||| 9509365|ERX|0250|GELATIN OPHTH 25X50MM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||597.50||| 9509365|ERX|0250|GELATIN OPHTH 25X50MM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||597.50||| 9509365|ERX|0250|GELATIN OPHTH 25X50MM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|597.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Aetna|AETNA OTHER|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Aetna|AETNA PPO|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Cigna|CIGNA|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Cigna|CIGNA OTHER|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Cigna|CIGNA|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Humana Medicare Advantage|HUMANA MA|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Medicaid|MEDICAID|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicare|HEALTHSPRING MA|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Medicare|MEDICARE ACUTE|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Medicare|MEDICARE PART B ONLY IP|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|PHCS|GROUP AND PENSION|||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Rusk State Hospital|RUSK STATE HOSP|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Tricare|TRICARE EAST REGION|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|42.50||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Healthcare|UNITED HEALTHCARE|42.50||||42.50||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|42.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Healthcare|GEHA|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Healthcare|UNITED HEALTHCARE|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|PHCS|HUMANA|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|PHCS|GROUP AND PENSION|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Tricare|TRICARE EAST REGION|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Medicare|MEDICARE ACUTE|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Medicare|MEDICARE PART B ONLY IP|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicare|HEALTHSPRING MA|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicare|BCBS MEDICARE PPO MA|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicare|WELLCARE CHOICE MA|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Medicaid|MEDICAID|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Cigna|CIGNA|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Humana Medicare Advantage|HUMANA MA|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Healthcare|UNITED HEALTHCARE OTHER|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Blue Cross PPO Specialty|BCBSTX PPO|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Blue Cross HMO Specialty|BCBSTX HMO|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Aetna|AETNA PPO|38.50||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Medicare Advantage|UHC AARP MCR HMO MA|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Veterans Affairs|VETERANS ADMINISTRATION|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.50||||38.50||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|38.50||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|40.75||||40.75||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Veterans Affairs|VETERANS ADMINISTRATION|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|40.75||||40.75||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Aetna|AETNA PPO|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Blue Cross HMO Specialty|BCBSTX HMO|40.75||||40.75||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Blue Cross PPO Specialty|BCBSTX PPO|40.75||||40.75||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Cigna|CIGNA|||||40.75||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Humana Medicare Advantage|HUMANA MA|40.75||||40.75||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|40.75||||40.75||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Medicaid|MEDICAID|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Managed Medicare|HEALTHSPRING MA|40.75||||40.75||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Managed Medicare|BCBS MEDICARE PPO MA|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|40.75||||40.75||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Medicare|MEDICARE ACUTE|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|Tricare|TRICARE EAST REGION|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|United Healthcare|UNITED HEALTHCARE OTHER|40.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|40.75||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Veterans Affairs|VETERANS ADMINISTRATION|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Workers Compensation|TEXAS MUTUAL INSURANCE|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Workers Compensation|BROOKSHIRES WORKERS COMP|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Cigna|CIGNA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Healthcare|UNITED HEALTHCARE OTHER|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicare|MEDICARE ACUTE|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Healthcare|GEHA|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Aetna Value Network|AETNA VALUE NETWORK|||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Healthcare|GOLDEN RULE|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Tricare|TRICARE FOR LIFE|||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|CRIME VICTIMS COMPENSATION|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicare|BCBS MEDICARE PPO MA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicare|HEALTHSPRING MA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|MEDICAID HMO|||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Tricare|TRICARE EAST REGION|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Cigna|CIGNA OTHER|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicare|MEDICARE PART B ONLY IP|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Aetna|AETNA QHP HMO|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Healthcare|UNITED HEALTHCARE|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Aetna|AETNA PPO|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Healthcare|AARP|||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Humana Medicare Advantage|HUMANA MA|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Healthcare|TML GROUP BENEFITS|||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Aetna|AETNA OTHER|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|MEDICAID|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|PHCS|HUMANA|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|PHCS|GROUP AND PENSION|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|22.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|22.25||||22.25||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Texas Workforce Commission|DIS DETER SERV (DDS)|||||22.25||| 9509530|ERX|0250|NAPHAZOLINE-PHENIR DROP,1|Medicare|MEDICARE ACUTE|62.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Aetna|AETNA PPO|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|PHCS|GROUP AND PENSION|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Healthcare|TML GROUP BENEFITS|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Cigna|CIGNA|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Tricare|TRICARE EAST REGION|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|PHCS|HUMANA|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Aetna|BH AETNA|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Cigna|CIGNA|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Medicaid|MEDICAID|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Tricare|TRICARE FOR LIFE|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.25||||||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Managed Medicare|HEALTHSPRING MA|44.25||||||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Medicare|MEDICARE ACUTE|44.25||||44.25||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|44.25||||||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Medicaid|CRIME VICTIMS COMPENSATION|44.25||||||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Humana Medicare Advantage|HUMANA MA|44.25||||||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.25||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Blue Cross PPO Specialty|BCBSTX PPO|44.25||||44.25||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|44.25||||||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|NON CONTRACTED|COMMUNITY HEALTH CENTER|44.25||||||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|United Medicare Advantage|UHC MEDICARE GOLD MA|44.25||||||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Medicaid|MEDICAID|44.25||||||| 9509571|ERX|0250|BENZOCAINE DENTAL GEL|Managed Medicaid|MEDICAID AMERIGROUP|44.25||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|LAW ENFORCEMENT OTHER|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|NON CONTRACTED|COMMERCIAL OTHER 2|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|MEDICAID HMO|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|OTHER INSTITUTIONS|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|CRIME VICTIMS COMPENSATION|17.50||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|WELLCARE CHOICE MA|17.50||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|SMITH COUNTY JAIL|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicare|MEDICARE PART B ONLY IP|17.50||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|HEALTHSPRING MA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicare|UTSW MC KIDNEY PROGRAM|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|MEDICAID|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aetna|AETNA OTHER|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|UT EMPLOYEE INJURY|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|GALLAGHER BASSETT|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|TEXAS MUTUAL INSURANCE|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|ZURICH COMPANY|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|17.50||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|BROOKSHIRES WORKERS COMP|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|ChampVA|CHAMPVA CENTER|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|MEDICAID BCBSTX|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Tricare|TRICARE FOR LIFE|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Cigna|CIGNA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aetna|AETNA PPO|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aetna Value Network|AETNA VALUE NETWORK|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|TML GROUP BENEFITS|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|GOLDEN RULE|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Cigna|CIGNA OTHER|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|UNITED HEALTHCARE|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aetna|BOON CHAPMAN|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aetna|AETNA QHP HMO|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID SUPERIOR|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|AARP|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|PHCS|HUMANA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|GEHA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Tricare|TRICARE SOUTH PHYSICIAN|||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Tricare|TRICARE EAST REGION|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|UNITED HEALTHCARE ERS|17.50||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Rusk State Hospital|RUSK STATE HOSP|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Humana Medicare Advantage|HUMANA MA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Multiplan|WEB TPA|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|PHCS|HUMANA INSURANCE|17.50||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|PHCS|GROUP AND PENSION|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Multiplan|PACIFICARE|17.50||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.50||||17.50||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Texas Workforce Commission|DIS DETER SERV (DDS)|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|MEDICAID HMO|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|CRIME VICTIMS COMPENSATION|17.50||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicare|HEALTHSPRING MA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|SMITH COUNTY JAIL|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|17.50||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|17.50||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|LAW ENFORCEMENT OTHER|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Multiplan|WEB TPA|17.50||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|PHCS|GROUP AND PENSION|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Texas Workforce Commission|DIS DETER SERV (DDS)|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Tricare|TRICARE EAST REGION|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicaid|MEDICAID SUPERIOR|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Cigna|CIGNA OTHER|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicare|MEDICARE PART B ONLY IP|17.50||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Healthcare|TML GROUP BENEFITS|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Blue Cross PPO Specialty|BCBSTX OTHER|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.50||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Healthcare|UNITED HEALTHCARE|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Aetna Value Network|AETNA VALUE NETWORK|||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Cigna|CIGNA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Humana Medicare Advantage|HUMANA MA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Aetna|AETNA OTHER|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Aetna|BOON CHAPMAN|17.50||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Healthcare|UNITED HEALTHCARE ERS|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Aetna|AETNA PPO|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|ChampVA|CHAMPVA CENTER|17.50||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|17.50||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Rusk State Hospital|RUSK STATE HOSP|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|MEDICAID|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|BROOKSHIRES WORKERS COMP|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|TEXAS MUTUAL INSURANCE|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Access Direct Platinum|HEALTHFIRST TPA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|NON CONTRACTED|COMMERCIAL OTHER 2|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|WORKERS COMPENSATION OTHER|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Healthcare|GEHA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.50||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|UT EMPLOYEE INJURY|||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||17.50||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|GALLAGHER BASSETT|||||17.50||| 9509639|ERX|0250|ALFENTANIL 1000MCG/2ML|Medicare|MEDICARE ACUTE|1.19||||||| 9509639|ERX|0250|ALFENTANIL 1000MCG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|1.19||||||| 9509639|ERX|0250|ALFENTANIL 1000MCG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.19||| 9509639|ERX|0250|ALFENTANIL 1000MCG/2ML|United Healthcare|TML GROUP BENEFITS|1.19||||||| 9509704|ERX|0250|TOLNAFTATE 1% CREAM, 15 G|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|65.50||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Managed Medicare|BCBS MEDICARE PPO MA|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Access Direct Platinum|HEALTHFIRST TPA|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Aetna|AETNA PPO|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Aenta Medicare Advantage|AETNA MEDICARE MA|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Veterans Affairs|VETERANS ADMINISTRATION|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Cigna|CIGNA|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Blue Cross PPO Specialty|BCBSTX PPO|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Blue Cross HMO Specialty|BCBSTX HMO|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Medicare|MEDICARE PART B ONLY IP|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Medicaid|MEDICAID|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Humana Medicare Advantage|HUMANA MA|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|United Medicare Advantage|UHC AARP MCR HMO MA|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|PHCS|GROUP AND PENSION|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|UTMB|UTMB CORRECTIONAL MANAGED CARE|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|NON CONTRACTED|COMMERCIAL OTHER 1|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Medicaid|SMITH COUNTY INDIGENT HEALTH|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Managed Medicare|ETMC AFFILIATE HOSPITALS|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|United Medicare Advantage|UHC AARP WELLMED HMO MA|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|United Healthcare|UNITED HEALTHCARE OTHER|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Medicare|MEDICARE ACUTE|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Access Direct Platinum|HEALTHFIRST TPA UMR|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Managed Medicare|HEALTHSPRING MA|106.25||||106.25||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|United Healthcare|UNITED HEALTHCARE|106.25||||||| 9509712|ERX|0250|UREA 10% CREAM, 142 GM|Tricare|TRICARE EAST REGION|106.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|PHCS|HUMANA|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|UTMB|UTMB CORRECTIONAL MANAGED CARE|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicare|WELLCARE CHOICE MA|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicare|ETMC AFFILIATE HOSPITALS|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Medicaid|COUNTY INDIGENT HEALTH OTHER|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Medicaid|MEDICAID|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicare|BCBS MEDICARE PPO MA|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|84.25||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Medicare|MEDICARE ACUTE|84.25||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Tricare|TRICARE EAST REGION|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|United Healthcare|UNITED HEALTHCARE OTHER|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Medicare|MEDICARE PART B ONLY IP|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|United Healthcare|UNITED HEALTHCARE|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicare|HEALTHSPRING MA|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|United Medicare Advantage|UHC MEDICARE GOLD MA|84.25||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Workers Compensation|TEXAS MUTUAL INSURANCE|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Medicaid|SMITH COUNTY JAIL|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Veterans Affairs|VETERANS ADMINISTRATION|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|United Medicare Advantage|UHC AARP MCR HMO MA|84.25||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Workers Compensation|WORKERS COMPENSATION OTHER|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Brinson Benefits|THE HEALTH PLAN SMITH CO|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Access Direct Platinum|HEALTHFIRST TPA|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Blue Cross PPO Specialty|BCBSTX PPO|84.25||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|84.25||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicaid|MEDICAID UNITED HEALTHCARE|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|84.25||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Blue Cross PPO Specialty|BCBSTX OTHER|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Aenta Medicare Advantage|AETNA MEDICARE MA|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicaid|MEDICAID AMERIGROUP|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Blue Cross HMO Specialty|BCBSTX HMO|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|United Medicare Advantage|UHC AARP WELLMED HMO MA|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Aetna|AETNA PPO|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|84.25||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Managed Medicaid|MEDICAID SUPERIOR|84.25||||||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Humana Medicare Advantage|HUMANA MA|84.25||||84.25||| 9509720|ERX|0250|MICONAZOLE 2% POWDER, 85|Aetna|AETNA QHP HMO|84.25||||||| 9509738|ERX|0250|NA CHLORIDE SPRAY SOLN,17|United Medicare Advantage|UHC MEDICARE GOLD MA|82.25||||||| 9509738|ERX|0250|NA CHLORIDE SPRAY SOLN,17|Medicare|MEDICARE ACUTE|82.25||||||| 9509738|ERX|0250|NA CHLORIDE SPRAY SOLN,17|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|82.25||||||| 9509738|ERX|0250|NA CHLORIDE SPRAY SOLN,17|Humana Medicare Advantage|HUMANA MA|82.25||||||| 9509738|ERX|0250|NA CHLORIDE SPRAY SOLN,17|NON CONTRACTED|COMMERCIAL OTHER 1|||||82.25||| 9509738|ERX|0250|NA CHLORIDE SPRAY SOLN,17|Veterans Affairs|VETERANS ADMINISTRATION|82.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Managed Medicare|HEALTHSPRING MA|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|United Healthcare|GOLDEN RULE|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Medicare|MEDICARE PART B ONLY IP|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Managed Medicaid|MEDICAID SUPERIOR|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Veterans Affairs|VETERANS ADMINISTRATION|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|NON CONTRACTED|COMMERCIAL OTHER 1|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Blue Cross HMO Specialty|BCBSTX HMO|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|United Medicare Advantage|UHC MEDICARE GOLD MA|291.25||||291.25||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|United Medicare Advantage|UHC AARP MCR HMO MA|||||291.25||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Medicare|MEDICARE ACUTE|291.25||||291.25||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Humana Medicare Advantage|HUMANA MA|291.25||||291.25||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Aenta Medicare Advantage|AETNA MEDICARE MA|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Managed Medicare|BCBS MEDICARE PPO MA|291.25||||291.25||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|291.25||||||| 9509779|ERX|0250|PREDNISOLONE 1% EYE DROP,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|291.25||||291.25||| 9509795|ERX|0250|FLUOROMETHOLONE 0.1% DROP|Medicare|MEDICARE ACUTE|2.90||||||| 9509795|ERX|0250|FLUOROMETHOLONE 0.1% DROP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.90||||||| 9509795|ERX|0250|FLUOROMETHOLONE 0.1% DROP|United Medicare Advantage|UHC AARP MCR HMO MA|2.90||||||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|NON CONTRACTED|COMMERCIAL OTHER 1|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Managed Medicaid|MEDICAID SUPERIOR|561.50||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Managed Medicare|HEALTHSPRING MA|561.50||||||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|561.50||||||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Medicaid|MEDICAID|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|United Healthcare|UNITED HEALTHCARE|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Medicare|MEDICARE ACUTE|561.50||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|561.50||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|UTMB|UTMB CORRECTIONAL MANAGED CARE|561.50||||||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|United Healthcare|UNITED HEALTHCARE OTHER|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Medicaid|MEDICAID HMO|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Blue Cross HMO Specialty|BCBSTX HMO|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Aetna|AETNA PPO|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Managed Medicaid|MEDICAID AMERIGROUP|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|561.50||||||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Veterans Affairs|VETERANS ADMINISTRATION|561.50||||||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|United Medicare Advantage|UHC AARP MCR HMO MA|561.50||||||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||561.50||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Humana Medicare Advantage|HUMANA MA|561.50||||561.50||| 9509837|ERX|0250|LANOLIN 50% OINT, 130G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.46||||||| 9509837|ERX|0250|LANOLIN 50% OINT, 130G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.46||||||| 9509837|ERX|0250|LANOLIN 50% OINT, 130G|Medicare|MEDICARE PART B ONLY IP|0.46||||||| 9509878|ERX|0250|TESTOSTERONE CYPION 200MG|Aenta Medicare Advantage|AETNA MEDICARE MA|291.50||||||| 9509878|ERX|0250|TESTOSTERONE CYPION 200MG|Cigna|CIGNA|291.50||||||| 9509878|ERX|0250|TESTOSTERONE CYPION 200MG|United Medicare Advantage|UHC MEDICARE GOLD MA|291.50||||||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|41.25||||||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|41.25||||41.25||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Medicare|MEDICARE ACUTE|41.25||||41.25||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||41.25||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|41.25||||41.25||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|41.25||||||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41.25||||41.25||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|41.25||||||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|41.25||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Cigna|CIGNA|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicaid|MEDICAID|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Cigna|CIGNA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Aetna|AETNA QHP HMO|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Aetna|AETNA PPO|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Aetna Value Network|AETNA VALUE NETWORK|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Cigna|CIGNA OTHER|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|PHCS|GROUP AND PENSION|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|PHCS|HUMANA|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|PHCS|HUMANA INSURANCE|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Tricare|TRICARE FOR LIFE|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Healthcare|GEHA|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Tricare|TRICARE EAST REGION|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Healthcare|TML GROUP BENEFITS|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.50||||||| 9509902|ERX|0250|SILVER NITRATE APPLICATOR|Blue Cross PPO Specialty|BCBSTX PPO|||||0.10||| 9509902|ERX|0250|SILVER NITRATE APPLICATOR|Managed Medicaid|MEDICAID AMERIGROUP|||||0.10||| 9509902|ERX|0250|SILVER NITRATE APPLICATOR|Blue Cross HMO Specialty|BCBSTX HMO|||||0.10||| 9509902|ERX|0250|SILVER NITRATE APPLICATOR|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.10||| 9509902|ERX|0250|SILVER NITRATE APPLICATOR|Medicare|MEDICARE ACUTE|||||0.10||| 9509902|ERX|0250|SILVER NITRATE APPLICATOR|Aetna|AETNA PPO|||||0.10||| 9509902|ERX|0250|SILVER NITRATE APPLICATOR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.10||| 9509902|ERX|0250|SILVER NITRATE APPLICATOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.10||| 9509902|ERX|0250|SILVER NITRATE APPLICATOR|United Healthcare|UNITED HEALTHCARE OTHER|||||0.10||| 9509928|ERX|0250|QUININE SULFATE 324MG CAP|Aetna|AETNA QHP HMO|0.48||||||| 9509928|ERX|0250|QUININE SULFATE 324MG CAP|Medicare|MEDICARE ACUTE|0.48||||||| 9509928|ERX|0250|QUININE SULFATE 324MG CAP|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.48||||||| 9509928|ERX|0250|QUININE SULFATE 324MG CAP|Humana Medicare Advantage|HUMANA MA|0.48||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|United Healthcare|UNITED HEALTHCARE|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Optum Behavioral Health|BH OPTUM UHC|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||12.75||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Medicare|MEDICARE PART B ONLY IP|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Managed Medicare|HEALTHSPRING MA|12.75||||12.75||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.75||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||12.75||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Aetna|BH AETNA|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||12.75||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Veterans Affairs|VETERANS ADMINISTRATION|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Aetna|AETNA OTHER|12.75||||12.75||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||12.75||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Cigna|CIGNA|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||12.75||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Managed Medicaid|MEDICAID AMERIGROUP|12.75||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Managed Medicare|BCBS MEDICARE PPO MA|12.75||||||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|Managed Medicare|OTHER INSTITUTIONS|6,460.75|4474.12|6941.81|3946.31|||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|Managed Medicare|HOSPICE OF EAST TEXAS|5,171.25|4502.28|6941.81|3946.31|||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25,496.36|5855.97|6941.81|3946.31|||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|United Healthcare|GEHA|29,977.82|6941.81|6941.81|3946.31|||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|Blue Cross PPO Specialty|BCBSTX PPO|21,026.65|5421.14|6941.81|3946.31|||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|Managed Medicaid|MEDICAID AMERIGROUP|42,281.67|3946.31|6941.81|3946.31|||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|Medicare|MEDICARE ACUTE|39,992.65|4502.28|6941.81|3946.31|||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|Access Direct Platinum|HEALTHFIRST TPA|35,297.16|5855.97|6941.81|3946.31|||| 9510017|ERX|0250|EFAV-EMTR-TENOF 600-200-3|United Medicare Advantage|UHC MEDICARE GOLD MA|||||565.75||| 9510033|ERX|0250|MULTIVITAMIN,CHILDREN'S T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9510033|ERX|0250|MULTIVITAMIN,CHILDREN'S T|Medicare|MEDICARE ACUTE|2.50||||||| 9510033|ERX|0250|MULTIVITAMIN,CHILDREN'S T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.50||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|110.75||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Managed Medicare|OTHER INSTITUTIONS|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|United Medicare Advantage|UHC AARP WELLMED HMO MA|110.75||||||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|United Medicare Advantage|UHC MEDICARE GOLD MA|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|NON CONTRACTED|COMMERCIAL OTHER 1|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Managed Medicare|HEALTHSPRING MA|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Medicaid|MEDICAID|110.75||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|United Healthcare|UNITED HEALTHCARE|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Medicare|MEDICARE ACUTE|110.75||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Tricare|TRICARE EAST REGION|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Rusk State Hospital|RUSK STATE HOSP|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|United Healthcare|UNITED HEALTHCARE OTHER|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Blue Cross PPO Specialty|BCBSTX PPO|110.75||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Cigna|CIGNA|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Cigna|CIGNA OTHER|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|110.75||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.75||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Humana Medicare Advantage|HUMANA MA|110.75||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Blue Cross HMO Specialty|BCBSTX HMO|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Access Direct Platinum|HEALTHFIRST TPA|110.75||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|110.75||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||110.75||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||110.75||| 9510058|ERX|0250|COENZYME Q10 10MG CAPSULE|Medicare|MEDICARE ACUTE|4.25||||4.25||| 9510058|ERX|0250|COENZYME Q10 10MG CAPSULE|Managed Medicare|HEALTHSPRING MA|4.25||||||| 9510058|ERX|0250|COENZYME Q10 10MG CAPSULE|Humana Medicare Advantage|HUMANA MA|4.25||||||| 9510058|ERX|0250|COENZYME Q10 10MG CAPSULE|United Healthcare|UNITED HEALTHCARE|4.25||||||| 9510066|ERX|0250|COENZYME Q10 30MG CAPSULE|Medicare|MEDICARE ACUTE|0.09||||||| 9510066|ERX|0250|COENZYME Q10 30MG CAPSULE|United Healthcare|UNITED HEALTHCARE|0.09||||||| 9510066|ERX|0250|COENZYME Q10 30MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9510066|ERX|0250|COENZYME Q10 30MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.09||||||| 9510074|ERX|0250|METHYLPHENIDATE ER 18MG T|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|43.50||||||| 9510074|ERX|0250|METHYLPHENIDATE ER 18MG T|Managed Medicaid|MEDICAID AMERIGROUP|43.50||||||| 9510074|ERX|0250|METHYLPHENIDATE ER 18MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.50||||||| 9510082|ERX|0250|METHYLPHENIDATE ER 36MG T|Magellan Behavioral Health|BH MAGELLAN|46.25||||||| 9510082|ERX|0250|METHYLPHENIDATE ER 36MG T|Tricare|TRICARE EAST REGION|46.25||||||| 9510082|ERX|0250|METHYLPHENIDATE ER 36MG T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.25||||||| 9510082|ERX|0250|METHYLPHENIDATE ER 36MG T|Blue Cross PPO Specialty|BCBSTX PPO|46.25||||||| 9510082|ERX|0250|METHYLPHENIDATE ER 36MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.25||||||| 9510082|ERX|0250|METHYLPHENIDATE ER 36MG T|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|46.25||||||| 9510082|ERX|0250|METHYLPHENIDATE ER 36MG T|Medicaid|BH TEXAS CHILDRENS MEDICAID|46.25||||||| 9510082|ERX|0250|METHYLPHENIDATE ER 36MG T|Managed Medicaid|MEDICAID AMERIGROUP|46.25||||||| 9510108|ERX|0250|METHYLPHENIDATE ER 27MG T|Tricare|TRICARE EAST REGION|44.50||||||| 9510108|ERX|0250|METHYLPHENIDATE ER 27MG T|Managed Medicaid|MEDICAID SUPERIOR|44.50||||||| 9510108|ERX|0250|METHYLPHENIDATE ER 27MG T|Managed Medicaid|MEDICAID AMERIGROUP|44.50||||||| 9510108|ERX|0250|METHYLPHENIDATE ER 27MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.50||||||| 9510108|ERX|0250|METHYLPHENIDATE ER 27MG T|Cigna Behavioral Health|BH CIGNA|44.50||||||| 9510108|ERX|0250|METHYLPHENIDATE ER 27MG T|Humana Medicare Advantage|HUMANA MA|44.50||||||| 9510108|ERX|0250|METHYLPHENIDATE ER 27MG T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|44.50||||||| 9510108|ERX|0250|METHYLPHENIDATE ER 27MG T|Medicaid|BH TEXAS CHILDRENS MEDICAID|44.50||||||| 9510108|ERX|0250|METHYLPHENIDATE ER 27MG T|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|44.50||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.42||||0.42||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Medicare|MEDICARE ACUTE|0.42||||0.42||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.42||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|PHCS|HUMANA|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.42||||0.42||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Aetna|AETNA OTHER|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.42||||0.42||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.42||||0.42||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.42||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.42||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|42.50||||42.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Aetna|AETNA PPO|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42.50||||42.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|42.50||||42.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|42.50||||42.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||42.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|42.50||||42.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.50||||42.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|PHCS|HUMANA|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|PHCS|HUMANA INSURANCE|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Managed Medicare|HEALTHSPRING MA|42.50||||42.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Medicare|MEDICARE ACUTE|42.50||||42.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Workers Compensation|ZURICH COMPANY|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Medicaid|MEDICAID|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|42.50||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|42.50||||42.50||| 9510140|ERX|0250|FLAVOXATE 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|23.50||||||| 9510140|ERX|0250|FLAVOXATE 100MG TABLET|Medicaid|MEDICAID|23.50||||||| 9510140|ERX|0250|FLAVOXATE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|23.50||||||| 9510140|ERX|0250|FLAVOXATE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|23.50||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Humana Medicare Advantage|HUMANA MA|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Managed Medicaid|MEDICAID SUPERIOR|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.75||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Veterans Affairs|VETERANS ADMINISTRATION|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Managed Medicaid|MEDICAID AMERIGROUP|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Cigna|CIGNA OTHER|||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|United Medicare Advantage|UHC MEDICARE GOLD MA|||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Aenta Medicare Advantage|AETNA MEDICARE MA|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Blue Cross PPO Specialty|BCBSTX OTHER|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Blue Cross HMO Specialty|BCBSTX HMO|20.75||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.75||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|United Healthcare|TML GROUP BENEFITS|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|United Healthcare|UNITED HEALTHCARE OTHER|20.75||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|NON CONTRACTED|COMMERCIAL OTHER 1|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|United Healthcare|UNITED HEALTHCARE|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Tricare|TRICARE EAST REGION|||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Medicare|MEDICARE ACUTE|20.75||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Medicaid|MEDICAID|20.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Blue Cross PPO Specialty|BCBSTX PPO|20.75||||20.75||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Managed Medicare|HEALTHSPRING MA|20.75||||||| 9510165|ERX|0250|CLOTRIMAZOLE 10MG TROCHE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||25.50||| 9510165|ERX|0250|CLOTRIMAZOLE 10MG TROCHE|Medicare|MEDICARE ACUTE|25.50||||||| 9510165|ERX|0250|CLOTRIMAZOLE 10MG TROCHE|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9510165|ERX|0250|CLOTRIMAZOLE 10MG TROCHE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9510165|ERX|0250|CLOTRIMAZOLE 10MG TROCHE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Humana Medicare Advantage|HUMANA MA|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Veterans Affairs|VETERANS ADMINISTRATION|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|261.50||||261.50||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|United Medicare Advantage|UHC AARP MCR HMO MA|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Blue Cross HMO Specialty|BCBSTX HMO|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|United Healthcare|UNITED HEALTHCARE|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Medicaid|MEDICAID|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Medicare|MEDICARE ACUTE|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Blue Cross PPO Specialty|BCBSTX PPO|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Access Direct Platinum|HEALTHFIRST TPA|261.50||||||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|261.50||||||| 9510207|ERX|0250|PHENYLEPHRINE 10% DROP,5M|Medicare|MEDICARE ACUTE|||||75.75||| 9510215|ERX|0250|GENTAMICIN EYE OINT, 3.5G|Humana Medicare Advantage|HUMANA MA|||||2.02||| 9510215|ERX|0250|GENTAMICIN EYE OINT, 3.5G|Medicare|MEDICARE ACUTE|2.02||||||| 9510215|ERX|0250|GENTAMICIN EYE OINT, 3.5G|United Medicare Advantage|UHC AARP MCR HMO MA|||||2.02||| 9510215|ERX|0250|GENTAMICIN EYE OINT, 3.5G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.02||| 9510215|ERX|0250|GENTAMICIN EYE OINT, 3.5G|Managed Medicare|HEALTHSPRING MA|||||2.02||| 9510215|ERX|0250|GENTAMICIN EYE OINT, 3.5G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.02||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|PHCS|GROUP AND PENSION|||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Managed Medicare|HEALTHSPRING MA|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|United Healthcare|UNITED HEALTHCARE OTHER|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Medicare|MEDICARE ACUTE|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|United Healthcare|UNITED HEALTHCARE|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Tricare|TRICARE EAST REGION|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Access Direct Platinum|HEALTHFIRST TPA UMR|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Aenta Medicare Advantage|AETNA MEDICARE MA|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Veterans Affairs|VETERANS ADMINISTRATION|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Managed Medicare|BCBS MEDICARE PPO MA|||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Access Direct Platinum|HEALTHFIRST TPA|||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|United Medicare Advantage|UHC MEDICARE GOLD MA|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|United Healthcare|UNITED HEALTHCARE|||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|United Medicare Advantage|UHC AARP MCR HMO MA|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Blue Cross HMO Specialty|BCBSTX HMO|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Humana Medicare Advantage|HUMANA MA|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Managed Medicaid|MEDICAID AMERIGROUP|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Blue Cross PPO Specialty|BCBSTX PPO|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Managed Medicaid|MEDICAID SUPERIOR|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Aetna|AETNA PPO|8.71||||||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.71||||8.71||| 9510223|ERX|0250|INDOCYANINE GREEN 25MG VI|Cigna|CIGNA|8.71||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Aetna|BH AETNA|2.50||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Workers Compensation|UT EMPLOYEE INJURY|2.50||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.50||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Medicare|MEDICARE ACUTE|2.50||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Humana Medicare Advantage|HUMANA MA|||||2.50||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9510231|ERX|0250|ASPIRIN-ACETAM-CAFFEINE|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|Medicare|MEDICARE ACUTE|46.50||||||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.50||||||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|NON CONTRACTED|COMMUNITY HEALTH CENTER|46.50||||||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|United Medicare Advantage|UHC MEDICARE GOLD MA|46.50||||46.50||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|Veterans Affairs|VETERANS ADMINISTRATION|46.50||||||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|Magellan Behavioral Health|BH MAGELLAN|46.50||||||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|Humana Medicare Advantage|HUMANA MA|46.50||||||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.50||||||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|Blue Cross PPO Specialty|BCBSTX PPO|46.50||||||| 9510256|ERX|0250|MEDROXYPROGEST DEPO 150MG|Blue Cross PPO Specialty|BCBSTX PPO|701.50||||||| 9510256|ERX|0250|MEDROXYPROGEST DEPO 150MG|Managed Medicaid|MEDICAID AMERIGROUP|701.50||||701.50||| 9510256|ERX|0250|MEDROXYPROGEST DEPO 150MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|701.50||||||| 9510256|ERX|0250|MEDROXYPROGEST DEPO 150MG|Medicare|MEDICARE ACUTE|701.50||||||| 9510256|ERX|0250|MEDROXYPROGEST DEPO 150MG|NON CONTRACTED|COMMUNITY HEALTH CENTER|701.50||||||| 9510272|ERX|0250|NA CHLORIDE 5% DROP,15ML|Veterans Affairs|VETERANS ADMINISTRATION|1.87||||||| 9510272|ERX|0250|NA CHLORIDE 5% DROP,15ML|Medicare|MEDICARE ACUTE|1.87||||||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||174.75||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Aenta Medicare Advantage|AETNA MEDICARE MA|174.75||||174.75||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Humana Medicare Advantage|HUMANA MA|174.75||||174.75||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|174.75||||||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Blue Cross PPO Specialty|BCBSTX PPO|174.75||||||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|174.75||||||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|United Medicare Advantage|UHC MEDICARE GOLD MA|174.75||||174.75||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|174.75||||||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Managed Medicare|HEALTHSPRING MA|174.75||||174.75||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|United Healthcare|UNITED HEALTHCARE OTHER|||||174.75||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Medicare|MEDICARE ACUTE|174.75||||174.75||| 9510306|ERX|0250|TIMOLOL 0.25% EYE DROP, 5|United Medicare Advantage|UHC MEDICARE GOLD MA|||||154.25||| 9510306|ERX|0250|TIMOLOL 0.25% EYE DROP, 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||154.25||| 9510306|ERX|0250|TIMOLOL 0.25% EYE DROP, 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|154.25||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|Medicare|MEDICARE ACUTE|152.50||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|Medicaid|MEDICAID|152.50||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|Medicaid|LAW ENFORCEMENT OTHER|||||152.50||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|NON CONTRACTED|COMMERCIAL OTHER 1|152.50||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|152.50||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|Humana Medicare Advantage|HUMANA MA|152.50||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|152.50||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|Blue Cross HMO Specialty|BCBSTX HMO|152.50||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|Blue Cross PPO Specialty|BCBSTX PPO|152.50||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|United Healthcare|UNITED HEALTHCARE OTHER|152.50||||||| 9510314|ERX|0250|METHYLPREDNISOLONE 500MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|152.50||||||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Veterans Affairs|VETERANS ADMINISTRATION|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Blue Cross HMO Specialty|BCBSTX HMO|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Blue Cross PPO Specialty|BCBSTX PPO|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.10||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Cigna|CIGNA OTHER|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID AMERIGROUP|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID SUPERIOR|0.10||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Humana Medicare Advantage|HUMANA MA|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Healthcare|UNITED HEALTHCARE|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Healthcare|UNITED HEALTHCARE OTHER|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Tricare|TRICARE EAST REGION|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Tricare|TRICARE FOR LIFE|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|NON CONTRACTED|COMMERCIAL OTHER 4|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicaid|SMITH COUNTY JAIL|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicaid|MEDICAID BCBSTX|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicaid|MEDICAID HMO|||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Workers Compensation|TEXAS MUTUAL INSURANCE|0.10||||||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicaid|MEDICAID|0.10||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.10||| 9510355|ERX|0250|LEVOBUNOLOL 0.5% EYE DROP|Humana Medicare Advantage|HUMANA MA|||||170.50||| 9510371|ERX|0250|BACITRAC-POLYMYX EYE OINT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||264.75||| 9510371|ERX|0250|BACITRAC-POLYMYX EYE OINT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|264.75||||||| 9510371|ERX|0250|BACITRAC-POLYMYX EYE OINT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||264.75||| 9510371|ERX|0250|BACITRAC-POLYMYX EYE OINT|Medicaid|SMITH COUNTY JAIL|264.75||||||| 9510371|ERX|0250|BACITRAC-POLYMYX EYE OINT|Workers Compensation|WORKERS COMPENSATION OTHER|264.75||||||| 9510371|ERX|0250|BACITRAC-POLYMYX EYE OINT|Managed Medicaid|MEDICAID SUPERIOR|||||264.75||| 9510371|ERX|0250|BACITRAC-POLYMYX EYE OINT|Blue Cross PPO Specialty|BCBSTX PPO|||||264.75||| 9510371|ERX|0250|BACITRAC-POLYMYX EYE OINT|United Medicare Advantage|UHC MEDICARE GOLD MA|264.75||||264.75||| 9510371|ERX|0250|BACITRAC-POLYMYX EYE OINT|Managed Medicaid|MEDICAID AMERIGROUP|||||264.75||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|Managed Medicaid|MEDICAID AMERIGROUP|||||435.75||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|Blue Cross PPO Specialty|BCBSTX PPO|435.75||||||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|UTMB|UTMB CORRECTIONAL MANAGED CARE|435.75||||||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||435.75||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|Blue Cross PPO Specialty|BCBSTX OTHER|435.75||||||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|Managed Medicaid|MEDICAID SUPERIOR|435.75||||||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|Veterans Affairs|VETERANS ADMINISTRATION|435.75||||||| 9510405|ERX|0250|SULFACETAMIDE 10% DROP,15|Medicare|MEDICARE ACUTE|0.60||||||| 9510405|ERX|0250|SULFACETAMIDE 10% DROP,15|ChampVA|CHAMPVA CENTER|0.60||||||| 9510421|ERX|0250|DEXAMETHASONE 0.1% DROP,5|Humana Medicare Advantage|HUMANA MA|177.50||||||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Aenta Medicare Advantage|AETNA MEDICARE MA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Medicare|MEDICARE ACUTE|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|NON CONTRACTED|COMMERCIAL OTHER 1|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|United Healthcare|UNITED HEALTHCARE|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Managed Medicare|HEALTHSPRING MA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Managed Medicare|BCBS MEDICARE PPO MA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Medicaid|MEDICAID|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Access Direct Platinum|HEALTHFIRST TPA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|United Healthcare|GEHA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Blue Cross PPO Specialty|BCBSTX PPO|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Veterans Affairs|VETERANS ADMINISTRATION|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Blue Cross HMO Specialty|BCBSTX HMO|46.25||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|United Healthcare|TML GROUP BENEFITS|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Managed Medicaid|MEDICAID AMERIGROUP|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Cigna|CIGNA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Humana Medicare Advantage|HUMANA MA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Access Direct Platinum|HEALTHFIRST TPA UMR|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|United Medicare Advantage|UHC AARP MCR HMO MA|||||46.25||| 9510447|ERX|0250|PHENYLEPHRINE 2.5% DROP,2|United Medicare Advantage|UHC MEDICARE GOLD MA|46.25||||46.25||| 9510454|ERX|0250|ATROPINE 1% EYE OINT, 3.5|Veterans Affairs|VETERANS ADMINISTRATION|0.30||||||| 9510454|ERX|0250|ATROPINE 1% EYE OINT, 3.5|Medicare|MEDICARE ACUTE|0.30||||||| 9510462|ERX|0250|GEMCITABINE 1000MG 26.3ML|Medicare|MEDICARE ACUTE|223.15||||223.15||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.50||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|118.50||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Blue Cross PPO Specialty|BCBSTX OTHER|118.50||||||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Blue Cross PPO Specialty|BCBSTX PPO|118.50||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Managed Medicaid|MEDICAID AMERIGROUP|||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Blue Cross HMO Specialty|BCBSTX HMO|||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.50||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|118.50||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Medicaid|MEDICAID|||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|United Healthcare|UNITED HEALTHCARE OTHER|118.50||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Humana Medicare Advantage|HUMANA MA|118.50||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Medicaid|SMITH COUNTY JAIL|||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Veterans Affairs|VETERANS ADMINISTRATION|||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Tricare|TRICARE FOR LIFE|||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Managed Medicare|HEALTHSPRING MA|118.50||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Medicare|MEDICARE ACUTE|118.50||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Tricare|TRICARE EAST REGION|||||118.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|PHCS|GROUP AND PENSION|118.50||||||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Cigna|CIGNA|2.50||||||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Aetna|BH AETNA|2.50||||||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|United Healthcare|GOLDEN RULE|2.50||||||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|United Healthcare|UNITED HEALTHCARE|||||2.50||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.50||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Humana Medicare Advantage|HUMANA MA|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Cigna|CIGNA|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Cigna|CIGNA|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Managed Medicaid|MEDICAID SUPERIOR|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|ChampVA|CHAMPVA CENTER|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Workers Compensation|TEXAS MUTUAL INSURANCE|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Blue Cross HMO Specialty|BCBSTX HMO|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Aetna|AETNA PPO|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Aetna|AETNA OTHER|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Workers Compensation|WORKERS COMPENSATION OTHER|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Blue Cross PPO Specialty|BCBSTX PPO|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Access Direct Platinum|HEALTHFIRST TPA UMR|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|NON CONTRACTED|COMMERCIAL OTHER 2|||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Access Direct Platinum|HEALTHFIRST TPA|||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Aetna|BOON CHAPMAN|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|United Healthcare|UNITED HEALTHCARE|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|United Medicare Advantage|UHC AARP MCR HMO MA|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Veterans Affairs|VETERANS ADMINISTRATION|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|United Healthcare|UNITED HEALTHCARE ERS|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|United Medicare Advantage|UHC MEDICARE GOLD MA|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|United Healthcare|UNITED HEALTHCARE OTHER|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|UTMB|UTMB CORRECTIONAL MANAGED CARE|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Managed Medicaid|MEDICAID AMERIGROUP|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|PHCS|GROUP AND PENSION|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|PHCS|HUMANA|||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Tricare|TRICARE EAST REGION|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Managed Medicare|HEALTHSPRING MA|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Tricare|TRICARE FOR LIFE|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Medicaid|MOLINA HEALTHCARE OF TEXAS|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|NON CONTRACTED|COMMERCIAL OTHER 1|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Aenta Medicare Advantage|AETNA MEDICARE MA|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Medicaid|MEDICAID|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Managed Medicare|BCBS MEDICARE PPO MA|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Medicare|MEDICARE ACUTE|637.75||||637.75||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Medicare|MEDICARE PART B ONLY IP|637.75||||||| 9510520|ERX|0250|THROMBIN (RECOMB) 5,000 U|Blue Cross PPO Specialty|BCBSTX OTHER|||||637.75||| 9510538|ERX|0250|THROMBIN (RECOMB) 20,000|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,355.25||||||| 9510538|ERX|0250|THROMBIN (RECOMB) 20,000|Medicare|MEDICARE ACUTE|3,355.25||||||| 9510538|ERX|0250|THROMBIN (RECOMB) 20,000|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,355.25||||||| 9510538|ERX|0250|THROMBIN (RECOMB) 20,000|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,355.25||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|43.75||||||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Cigna|CIGNA|43.75||||||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|43.75||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Aetna|AETNA OTHER|43.75||||||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.75||||||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|43.75||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|43.75||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43.75||||||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|43.75||||||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Medicare|MEDICARE ACUTE|43.75||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|43.75||||||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|PHCS|HUMANA|43.75||||||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|43.75||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||43.75||| 9510546|ERX|0250|FLECAINIDE 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|43.75||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|United Healthcare|UNITED HEALTHCARE|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|Managed Medicaid|MEDICAID SUPERIOR|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|Blue Cross PPO Specialty|BCBSTX PPO|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|Humana Medicare Advantage|HUMANA MA|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|NON CONTRACTED|COMMERCIAL OTHER 2|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|United Healthcare|UNITED HEALTHCARE OTHER|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|United Medicare Advantage|UHC MEDICARE GOLD MA|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|Medicare|MEDICARE ACUTE|5.14||||||| 9510561|ERX|0250|METHYLPREDNISOLONE 2000MG|Medicaid|MEDICAID|5.14||||||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.50||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|Cigna|CIGNA|2.50||||||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9510579|ERX|0250|VITAMIN B COMP W-C TABLE|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Medicaid|MEDICAID|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Access Direct Platinum|HEALTHFIRST TPA|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Cigna|CIGNA|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Humana Medicare Advantage|HUMANA MA|5.25||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Managed Medicare|HEALTHSPRING MA|||||5.25||| 9510611|ERX|0250|SELEGILINE 5MG CAPSULE|Humana Medicare Advantage|HUMANA MA|27.50||||||| 9510611|ERX|0250|SELEGILINE 5MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.50||| 9510611|ERX|0250|SELEGILINE 5MG CAPSULE|Medicare|MEDICARE ACUTE|27.50||||||| 9510611|ERX|0250|SELEGILINE 5MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||27.50||| 9510611|ERX|0250|SELEGILINE 5MG CAPSULE|Managed Medicare|HEALTHSPRING MA|27.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Medicare|MEDICARE ACUTE|2,779.50||||2,779.50||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|2,779.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|2,779.50||||2,779.50||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|2,779.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,779.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,779.50||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,779.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Cigna|CIGNA|2,779.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|2,779.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Humana Medicare Advantage|HUMANA MA|2,779.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,779.50||||||| 9510660|ERX|0250||Humana Medicare Advantage|HUMANA MA|251.75||||251.75||| 9510660|ERX|0250||Blue Cross HMO Specialty|BCBSTX HMO|251.75||||||| 9510660|ERX|0250||Blue Cross PPO Specialty|BCBSTX PPO|||||251.75||| 9510660|ERX|0250||United Medicare Advantage|UHC MEDICARE GOLD MA|251.75||||251.75||| 9510660|ERX|0250||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||251.75||| 9510660|ERX|0250||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||251.75||| 9510660|ERX|0250||Access Direct Platinum|HEALTHFIRST TPA UMR|||||251.75||| 9510660|ERX|0250||United Healthcare|UNITED HEALTHCARE|||||251.75||| 9510660|ERX|0250||Medicare|MEDICARE ACUTE|||||251.75||| 9510660|ERX|0250||United Healthcare|UNITED HEALTHCARE OTHER|||||251.75||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|United Healthcare|UNITED HEALTHCARE OTHER|0.10||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Managed Medicare|HEALTHSPRING MA|0.10||||||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Medicare|MEDICARE PART B ONLY IP|0.10||||||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|United Healthcare|UNITED HEALTHCARE|0.10||||||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Medicaid|SMITH COUNTY JAIL|||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||0.10||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Aetna|AETNA PPO|9.04||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Managed Medicaid|MEDICAID AMERIGROUP|9.04||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.04||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|United Healthcare|UNITED HEALTHCARE|9.04||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|United Healthcare|UNITED HEALTHCARE OTHER|9.04||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Blue Cross PPO Specialty|BCBSTX PPO|9.04||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.04||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.04||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Blue Cross HMO Specialty|BCBSTX HMO|9.04||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Medicare|MEDICARE ACUTE|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Managed Medicare|BCBS MEDICARE PPO MA|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|United Medicare Advantage|UHC MEDICARE GOLD MA|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Humana Medicare Advantage|HUMANA MA|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Blue Cross PPO Specialty|BCBSTX PPO|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|United Medicare Advantage|UHC AARP MCR HMO MA|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Veterans Affairs|VETERANS ADMINISTRATION|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|UTMB|UTMB CORRECTIONAL MANAGED CARE|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Managed Medicare|HEALTHSPRING MA|44.25||||||| 9510728|ERX|0250|TUBERCULIN,PPD 5 UNIT/ 0.|Managed Medicaid|MEDICAID AMERIGROUP|44.25||||||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Medicare|MEDICARE PART B ONLY IP|4.95||||||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Aetna|AETNA OTHER|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Managed Medicaid|MEDICAID AMERIGROUP|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Managed Medicaid|MEDICAID SUPERIOR|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Humana Medicare Advantage|HUMANA MA|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Aetna|AETNA PPO|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Blue Cross HMO Specialty|BCBSTX HMO|4.95||||||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Blue Cross PPO Specialty|BCBSTX PPO|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Workers Compensation|TEXAS MUTUAL INSURANCE|4.95||||||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Veterans Affairs|VETERANS ADMINISTRATION|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Tricare|TRICARE FOR LIFE|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Rusk State Hospital|RUSK STATE HOSP|4.95||||||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Cigna|CIGNA|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|United Healthcare|TML GROUP BENEFITS|4.95||||||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|United Healthcare|UNITED HEALTHCARE OTHER|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|United Healthcare|UNITED HEALTHCARE|4.95||||||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Medicaid|SMITH COUNTY JAIL|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Medicaid|MEDICAID|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Medicaid|CRIME VICTIMS COMPENSATION|4.95||||||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.95||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Managed Medicare|HEALTHSPRING MA|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|4.95||||||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Managed Medicare|BCBS MEDICARE PPO MA|||||4.95||| 9510736|ERX|0250|METHOHEXITAL 500MG/VIAL|Medicare|MEDICARE ACUTE|4.95||||4.95||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Medicare|MEDICARE ACUTE|216.25||||216.25||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Medicaid|MEDICAID|||||216.25||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Humana Medicare Advantage|HUMANA MA|216.25||||||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Managed Medicaid|MEDICAID AMERIGROUP|||||216.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.25||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Aenta Medicare Advantage|AETNA MEDICARE MA|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Workers Compensation|WORKERS COMPENSATION OTHER|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|18.25||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Blue Cross PPO Specialty|BCBSTX OTHER|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|18.25||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|PHCS|HUMANA|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Tricare|TRICARE EAST REGION|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Medicare|MEDICARE PART B ONLY IP|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Medicaid|MEDICAID|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Medicaid|SMITH COUNTY INDIGENT HEALTH|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Managed Medicare|HEALTHSPRING MA|18.25||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Managed Medicare|BCBS MEDICARE PPO MA|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|United Healthcare|UNITED HEALTHCARE OTHER|18.25||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|NON CONTRACTED|COMMERCIAL OTHER 1|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Humana Medicare Advantage|HUMANA MA|18.25||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Cigna|CIGNA|18.25||||||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.25||||18.25||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.25||||18.25||| 9510785|ERX|0250|OPIUM TINCTURE 10MG/1ML|Cigna|CIGNA OTHER|14.50||||||| 9510785|ERX|0250|OPIUM TINCTURE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.50||||||| 9510785|ERX|0250|OPIUM TINCTURE 10MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|14.50||||||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Medicaid|MEDICAID HMO|||||0.60||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.60||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.60||||||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.60||||||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.60||||0.60||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.60||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|0.60||||0.60||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||0.10||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Humana Medicare Advantage|HUMANA MA|0.10||||0.10||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||0.10||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||0.10||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||0.10||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|United Medicare Advantage|UHC AARP MCR HMO MA|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|United Healthcare|UNITED HEALTHCARE OTHER|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|United Healthcare|UNITED HEALTHCARE|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Rusk State Hospital|RUSK STATE HOSP|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Medicare|MEDICARE PART B ONLY IP|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Managed Medicare|HEALTHSPRING MA|0.10||||0.10||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Managed Medicare|BCBS MEDICARE PPO MA|0.10||||||| 9510835|ERX|0250|CALCIUM ACETATE 667MG CAP|Medicaid|MEDICAID|0.10||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Medicaid|MEDICAID|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Managed Medicare|HEALTHSPRING MA|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Medicare|MEDICARE ACUTE|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Medicare|MEDICARE PART B ONLY IP|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Rusk State Hospital|RUSK STATE HOSP|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Tricare|TRICARE EAST REGION|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|United Healthcare|UNITED HEALTHCARE|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Access Direct Platinum|HEALTHFIRST TPA|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|United Healthcare|UNITED HEALTHCARE|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Aetna|BOON CHAPMAN|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Aetna|AETNA PPO|||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Cigna|CIGNA|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Humana Medicare Advantage|HUMANA MA|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Managed Medicare|WELLCARE CHOICE MA|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|43.25||||43.25||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Cigna|CIGNA OTHER|43.25||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|43.25||||43.25||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Magellan Behavioral Health|BH MAGELLAN|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Cigna|CIGNA|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Aetna|BH AETNA|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Aetna|AETNA PPO|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|ChampVA|CHAMPVA CENTER|||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Veterans Affairs|VETERANS ADMINISTRATION|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Medicare Advantage|UHC MEDICARE GOLD MA|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Workers Compensation|ZURICH COMPANY|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Workers Compensation|WORKERS COMPENSATION OTHER|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicaid|MEDICAID AMERIGROUP|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Access Direct Platinum|HEALTHFIRST TPA UMR|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Workers Compensation|TEXAS MUTUAL INSURANCE|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Medicare Advantage|UHC AARP MCR HMO MA|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Aenta Medicare Advantage|AETNA MEDICARE MA|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Healthcare|UNITED HEALTHCARE|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicaid|MEDICAID SUPERIOR|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Humana Medicare Advantage|HUMANA MA|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Blue Cross HMO Specialty|BCBSTX HMO|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Healthcare|UNITED HEALTHCARE OTHER|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|PHCS|HUMANA|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Tricare|TRICARE FOR LIFE|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Cigna|CIGNA OTHER|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Optum Behavioral Health|BH OPTUM UHC|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Tricare|TRICARE EAST REGION|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|NON CONTRACTED|COMMUNITY HEALTH CENTER|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|NON CONTRACTED|COMMERCIAL OTHER 1|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicare|JACKSONVILLE ACCESS|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicare|HEALTHSPRING MA|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Medicaid|CRIME VICTIMS COMPENSATION|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Medicaid|MEDICAID|13.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|13.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicaid|SMITH COUNTY JAIL|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicaid|MEDICAID HMO|||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicaid|MEDICAID|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicare|HEALTHSPRING MA|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicare|UTSW MC KIDNEY PROGRAM|||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Rusk State Hospital|RUSK STATE HOSP|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Tricare|TRICARE EAST REGION|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Healthcare|UNITED HEALTHCARE|||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Healthcare|UNITED HEALTHCARE|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Healthcare|UNITED HEALTHCARE OTHER|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|NON CONTRACTED|COMMERCIAL OTHER 1|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicare|BCBS MEDICARE PPO MA|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Healthcare|TML GROUP BENEFITS|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicare|OTHER INSTITUTIONS|||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicare|MEDICARE PART B ONLY IP|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Texas Workforce Commission|DIS DETER SERV (DDS)|||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Access Direct Platinum|HEALTHFIRST TPA|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Access Direct Platinum|HEALTHFIRST TPA UMR|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicaid|MOLINA HEALTHCARE OF TEXAS|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Access Direct Platinum|ANDREWS CENTER|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Workers Compensation|WORKERS COMPENSATION OTHER|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Veterans Affairs|VETERANS ADMINISTRATION|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Medicare Advantage|UHC AARP MCR HMO MA|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Aetna|AETNA OTHER|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Aetna|AETNA PPO|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicaid|SUPERIOR HEALTHPLAN CHIP|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross HMO Specialty|BCBSTX HMO|7.50||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID SUPERIOR|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID AMERIGROUP|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Cigna|CIGNA|7.50||||7.50||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Humana Medicare Advantage|HUMANA MA|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Cigna|CIGNA OTHER|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Cigna|CIGNA|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Humana Medicare Advantage|HUMANA MA|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Managed Medicaid|MEDICAID AMERIGROUP|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Blue Cross HMO Specialty|BCBSTX HMO|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|United Medicare Advantage|UHC AARP MCR HMO MA|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Workers Compensation|WORKERS COMPENSATION OTHER|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Access Direct Platinum|HEALTHFIRST TPA UMR|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Brinson Benefits|THE HEALTH PLAN SMITH CO|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Access Direct Platinum|HEALTHFIRST TPA|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Aetna|AETNA PPO|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|United Healthcare|TML GROUP BENEFITS|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Managed Medicaid|MEDICAID SUPERIOR|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|United Healthcare|UNITED HEALTHCARE|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|United Healthcare|UNITED HEALTHCARE OTHER|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|PHCS|HUMANA|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Rusk State Hospital|RUSK STATE HOSP|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Texas Workforce Commission|DIS DETER SERV (DDS)|||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|NON CONTRACTED|COMMERCIAL OTHER 2|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Medicare|MEDICARE PART B ONLY IP|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Managed Medicare|HEALTHSPRING MA|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Managed Medicare|BCBS MEDICARE PPO MA|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Medicaid|SMITH COUNTY JAIL|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Veterans Affairs|VETERANS ADMINISTRATION|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Medicaid|MOLINA HEALTHCARE OF TEXAS|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Medicaid|MEDICAID|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|NON CONTRACTED|COMMERCIAL OTHER 1|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Medicaid|MEDICAID HMO|7.50||||||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Tricare|TRICARE EAST REGION|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||7.50||| 9510934|ERX|0250|SODIUM CHLORIDE 0.9% INH|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|7.50||||||| 9510959|ERX|0250|CLINDAMYCIN 900MG/6ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.50||||||| 9510959|ERX|0250|CLINDAMYCIN 900MG/6ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.50||||||| 9510975|ERX|0250|ISOSORBIDE DINITRATE 30MG|Medicaid|MEDICAID|0.09||||||| 9510975|ERX|0250|ISOSORBIDE DINITRATE 30MG|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9510975|ERX|0250|ISOSORBIDE DINITRATE 30MG|Managed Medicaid|MEDICAID SUPERIOR|0.09||||||| 9510975|ERX|0250|ISOSORBIDE DINITRATE 30MG|Cigna|CIGNA|0.09||||||| 9510975|ERX|0250|ISOSORBIDE DINITRATE 30MG|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9510975|ERX|0250|ISOSORBIDE DINITRATE 30MG|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||||| 9510975|ERX|0250|ISOSORBIDE DINITRATE 30MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.09||||||| 9510975|ERX|0250|ISOSORBIDE DINITRATE 30MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.09||||0.09||| 9510983|ERX|0250|FLUPHENAZINE 2.5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.13||||||| 9510991|ERX|0250|AMILORIDE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|10.50||||||| 9510991|ERX|0250|AMILORIDE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|10.50||||||| 9510991|ERX|0250|AMILORIDE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.50||||||| 9510991|ERX|0250|AMILORIDE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|10.50||||||| 9510991|ERX|0250|AMILORIDE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||||| 9510991|ERX|0250|AMILORIDE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||||| 9510991|ERX|0250|AMILORIDE 5MG TABLET|Medicaid|MEDICAID|10.50||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Humana Medicare Advantage|HUMANA MA|90.25||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Cigna|CIGNA|90.25||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicaid|MEDICAID AMERIGROUP|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicaid|MEDICAID SUPERIOR|90.25||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Blue Cross PPO Specialty|BCBSTX OTHER|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Blue Cross PPO Specialty|BCBSTX PPO|90.25||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|90.25||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Blue Cross HMO Specialty|BCBSTX HMO|90.25||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|90.25||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|90.25||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Workers Compensation|WORKERS COMPENSATION OTHER|90.25||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Workers Compensation|TRAVELERS INSURANCE COMPANY|90.25||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Veterans Affairs|VETERANS ADMINISTRATION|90.25||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|United Medicare Advantage|UHC MEDICARE GOLD MA|90.25||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|United Medicare Advantage|UHC AARP MCR HMO MA|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Tricare|TRICARE EAST REGION|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|United Healthcare|UNITED HEALTHCARE|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Medicare|MEDICARE ACUTE|90.25||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|UTMB|UTMB CORRECTIONAL MANAGED CARE|90.25||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|United Healthcare|UNITED HEALTHCARE OTHER|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Medicaid|MEDICAID HMO|||||90.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|90.25||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicare|HEALTHSPRING MA|||||90.25||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|73.25||||||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|73.25||||||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|73.25||||||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|73.25||||||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|73.25||||||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|Humana Medicare Advantage|HUMANA MA|73.25||||||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|Medicare|MEDICARE ACUTE|73.25||||||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|Medicaid|MEDICAID|73.25||||||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|73.25||||||| 9511023|ERX|0250|HYDROCORTISONE 250MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|73.25||||||| 9511049|ERX|0250|DAPSONE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.75||||||| 9511049|ERX|0250|DAPSONE 100MG TABLET|Tricare|TRICARE FOR LIFE|4.75||||||| 9511049|ERX|0250|DAPSONE 100MG TABLET|Medicare|MEDICARE ACUTE|4.75||||||| 9511049|ERX|0250|DAPSONE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|4.75||||||| 9511056|ERX|0250|DAPSONE 25MG TABLET|Medicare|MEDICARE ACUTE|4.50||||||| 9511056|ERX|0250|DAPSONE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.50||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|United Medicare Advantage|UHC AARP WELLMED HMO MA|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Access Direct Platinum|ANDREWS CENTER|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Blue Cross PPO Specialty|BCBSTX OTHER|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Tricare|TRICARE EAST REGION|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Medicaid|MEDICAID|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|NON CONTRACTED|COMMUNITY HEALTH CENTER|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Medicaid|BH TEXAS CHILDRENS MEDICAID|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Managed Medicare|HEALTHSPRING MA|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Managed Medicaid|MEDICAID SUPERIOR|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Medicare|MEDICARE ACUTE|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Magellan Behavioral Health|BH MAGELLAN|9.25||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Cigna|CIGNA|9.25||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Medicare|MEDICARE ACUTE|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Medicaid|MEDICAID|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|NON CONTRACTED|COMMERCIAL OTHER 1|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Managed Medicare|HEALTHSPRING MA|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.75||||21.75||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Medicare|MEDICARE PART B ONLY IP|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Humana Medicare Advantage|HUMANA MA|21.75||||21.75||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Aetna|AETNA PPO|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Blue Cross HMO Specialty|BCBSTX HMO|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Blue Cross PPO Specialty|BCBSTX OTHER|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Blue Cross PPO Specialty|BCBSTX PPO|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Veterans Affairs|VETERANS ADMINISTRATION|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|United Medicare Advantage|UHC AARP MCR HMO MA|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|21.75||||||| 9511098|ERX|0250|ERGOCALCIFEROL 50000 UNIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Veterans Affairs|VETERANS ADMINISTRATION|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Blue Cross HMO Specialty|BCBSTX HMO|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Blue Cross PPO Specialty|BCBSTX PPO|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Humana Medicare Advantage|HUMANA MA|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|582.75||||582.75||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|United Healthcare|UNITED HEALTHCARE OTHER|||||582.75||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Medicaid|MEDICAID|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Managed Medicare|HEALTHSPRING MA|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|Medicare|MEDICARE ACUTE|582.75||||||| 9511213|ERX|0250|DORNASE ALFA 2.5MG 2.5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|582.75||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Medicare|MEDICARE ACUTE|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Medicaid|MEDICAID|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|PHCS|HUMANA INSURANCE|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|PHCS|GROUP AND PENSION|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Tricare|TRICARE EAST REGION|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|NON CONTRACTED|COMMERCIAL OTHER 1|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|United Healthcare|UNITED HEALTHCARE OTHER|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|United Healthcare|UNITED HEALTHCARE|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Managed Medicaid|MEDICAID AMERIGROUP|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Cigna|CIGNA OTHER|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Aetna|AETNA PPO|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Managed Medicaid|MEDICAID SUPERIOR|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|United Healthcare|TML GROUP BENEFITS|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Blue Cross HMO Specialty|BCBSTX HMO|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Blue Cross PPO Specialty|BCBSTX PPO|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Blue Cross PPO Specialty|BCBSTX OTHER|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Cigna|CIGNA|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Access Direct Platinum|HEALTHFIRST TPA|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Access Direct Platinum|HEALTHFIRST TPA UMR|33.25||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|33.25||||33.25||| 9511254|ERX|0250|AMANTADINE 50MG/5ML, 30ML|United Medicare Advantage|UHC AARP MCR HMO MA|41.25||||41.25||| 9511254|ERX|0250|AMANTADINE 50MG/5ML, 30ML|Veterans Affairs|VETERANS ADMINISTRATION|41.25||||||| 9511254|ERX|0250|AMANTADINE 50MG/5ML, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|41.25||||||| 9511254|ERX|0250|AMANTADINE 50MG/5ML, 30ML|Managed Medicare|HEALTHSPRING MA|41.25||||||| 9511254|ERX|0250|AMANTADINE 50MG/5ML, 30ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|41.25||||||| 9511254|ERX|0250|AMANTADINE 50MG/5ML, 30ML|Medicaid|MEDICAID|41.25||||||| 9511254|ERX|0250|AMANTADINE 50MG/5ML, 30ML|Medicare|MEDICARE ACUTE|41.25||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|United Healthcare|UNITED HEALTHCARE|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|PHCS|HUMANA|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Managed Medicare|HEALTHSPRING MA|0.36||||0.36||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Medicare|MEDICARE ACUTE|0.36||||0.36||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Cigna|CIGNA|0.36||||0.36||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Humana Medicare Advantage|HUMANA MA|0.36||||0.36||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.36||||0.36||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Aetna|AETNA PPO|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.36||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.36||||0.36||| 9511262|ERX|0250|SOTALOL 80MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.36||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.36||||0.36||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Medicare Advantage|UHC AARP MCR HMO MA|105.75||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Veterans Affairs|VETERANS ADMINISTRATION|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Workers Compensation|UT EMPLOYEE INJURY|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Workers Compensation|WORKERS COMPENSATION OTHER|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Blue Cross PPO Specialty|BCBSTX PPO|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Aetna|AETNA OTHER|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Blue Cross HMO Specialty|BCBSTX HMO|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Aetna Value Network|AETNA VALUE NETWORK|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Aetna|AETNA PPO|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicaid|MEDICAID SUPERIOR|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicaid|MEDICAID AMERIGROUP|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|ChampVA|CHAMPVA CENTER|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Blue Cross PPO Specialty|BCBSTX OTHER|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Humana Medicare Advantage|HUMANA MA|105.75||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Cigna|CIGNA|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Cigna|CIGNA OTHER|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicare|OTHER INSTITUTIONS|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Access Direct Platinum|HEALTHFIRST TPA|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicare|HEALTHSPRING MA|105.75||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Workers Compensation|TEXAS MUTUAL INSURANCE|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Aetna|BOON CHAPMAN|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicare|BCBS MEDICARE PPO MA|105.75||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Medicare|MEDICARE ACUTE|105.75||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|PHCS|HUMANA|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Medicaid|MEDICAID|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|PHCS|GROUP AND PENSION|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Tricare|TRICARE EAST REGION|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Tricare|TRICARE FOR LIFE|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|NON CONTRACTED|COMMERCIAL OTHER 1|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Healthcare|TML GROUP BENEFITS|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Healthcare|UNITED HEALTHCARE|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Healthcare|AARP|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Healthcare|GOLDEN RULE|||||105.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Healthcare|UNITED HEALTHCARE OTHER|||||105.75||| 9511288|ERX|0250|ESTRADIOL 0.05MG PATCH|United Healthcare|UNITED HEALTHCARE|||||122.25||| 9511288|ERX|0250|ESTRADIOL 0.05MG PATCH|Medicare|MEDICARE ACUTE|122.25||||||| 9511288|ERX|0250|ESTRADIOL 0.05MG PATCH|Cigna|CIGNA OTHER|122.25||||||| 9511288|ERX|0250|ESTRADIOL 0.05MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||122.25||| 9511288|ERX|0250|ESTRADIOL 0.05MG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||122.25||| 9511296|ERX|0250|ESTRADIOL 0.1MG PATCH|Access Direct Platinum|HEALTHFIRST TPA UMR|||||122.25||| 9511296|ERX|0250|ESTRADIOL 0.1MG PATCH|Aetna|AETNA PPO|||||122.25||| 9511296|ERX|0250|ESTRADIOL 0.1MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||122.25||| 9511296|ERX|0250|ESTRADIOL 0.1MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|122.25||||||| 9511296|ERX|0250|ESTRADIOL 0.1MG PATCH|Medicare|MEDICARE ACUTE|122.25||||||| 9511296|ERX|0250|ESTRADIOL 0.1MG PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|||||122.25||| 9511296|ERX|0250|ESTRADIOL 0.1MG PATCH|United Healthcare|UNITED HEALTHCARE|||||122.25||| 9511304|ERX|0250|ESTRADIOL 0.075MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||122.25||| 9511304|ERX|0250|ESTRADIOL 0.075MG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|122.25||||||| 9511304|ERX|0250|ESTRADIOL 0.075MG PATCH|Medicare|MEDICARE ACUTE|122.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|200.25||||200.25||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Access Direct Platinum|HEALTHFIRST TPA|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Cigna|CIGNA OTHER|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicaid|MEDICAID SUPERIOR|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|200.25||||200.25||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|200.25||||200.25||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Blue Cross PPO Specialty|BCBSTX OTHER|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|United Healthcare|UNITED HEALTHCARE OTHER|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|United Healthcare|UNITED HEALTHCARE|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Medicaid|MEDICAID|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Humana Medicare Advantage|HUMANA MA|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicare|HOSPICE OF EAST TEXAS|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicare|HEALTHSPRING MA|200.25||||200.25||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|200.25||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Medicare|MEDICARE ACUTE|200.25||||200.25||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Blue Cross PPO Specialty|BCBSTX OTHER|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Managed Medicare|HOSPICE OF EAST TEXAS|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Medicaid|MEDICAID|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|UTMB|UTMB CORRECTIONAL MANAGED CARE|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Medicare|MEDICARE ACUTE|365.75||||365.75||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Aetna|BOON CHAPMAN|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Managed Medicare|HEALTHSPRING MA|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Managed Medicaid|MEDICAID SUPERIOR|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Humana Medicare Advantage|HUMANA MA|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Workers Compensation|TEXAS MUTUAL INSURANCE|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|365.75||||365.75||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Access Direct Platinum|HEALTHFIRST TPA|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|United Medicare Advantage|UHC AARP WELLMED HMO MA|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|365.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|365.75||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|557.50||||557.50||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Medicare|MEDICARE ACUTE|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Managed Medicare|HEALTHSPRING MA|557.50||||557.50||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Medicaid|MEDICAID|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Medicare|MEDICARE PART B ONLY IP|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|557.50||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|557.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Medicaid|MEDICAID|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Medicare|MEDICARE ACUTE|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|UTMB|UTMB CORRECTIONAL MANAGED CARE|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Humana Medicare Advantage|HUMANA MA|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Managed Medicaid|MEDICAID SUPERIOR|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|740.50||||||| 9511395|ERX|0250|FENTANYL 100MCG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|740.50||||||| 9511403|ERX|0250|KETOCONAZOLE 200MG TABLET|Medicare|MEDICARE ACUTE|0.54||||||| 9511411|ERX|0250|ITRACONAZOLE 100MG CAPSUL|Medicare|MEDICARE ACUTE|122.50||||||| 9511429|ERX|0250|ITRACONAZOLE 200MG/20ML,1|Managed Medicare|HEALTHSPRING MA|18.53||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Access Direct Platinum|ANDREWS CENTER|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|51.75||||51.75||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|51.75||||51.75||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|51.75||||51.75||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|51.75||||51.75||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Multiplan|WEB TPA|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||51.75||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Medicaid|SMITH COUNTY JAIL|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Medicaid|MEDICAID|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Medicaid|MEDICAID HMO|||||51.75||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Medicare|MEDICARE ACUTE|51.75||||51.75||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|51.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|51.75||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicare|OTHER INSTITUTIONS|||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicare|BCBS MEDICARE PPO MA|181.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicare|HEALTHSPRING MA|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Medicaid|SMITH COUNTY JAIL|181.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Medicaid|MEDICAID|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Medicare|MEDICARE ACUTE|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Medicare|MEDICARE PART B ONLY IP|181.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Healthcare|UNITED HEALTHCARE OTHER|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Healthcare|UNITED HEALTHCARE|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|UTMB|UTMB CORRECTIONAL MANAGED CARE|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|PHCS|GROUP AND PENSION|181.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Tricare|TRICARE EAST REGION|||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Aetna|AETNA QHP HMO|181.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|ChampVA|CHAMPVA CENTER|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Cigna|CIGNA|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Humana Medicare Advantage|HUMANA MA|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Healthcare|GOLDEN RULE|||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicaid|MEDICAID AMERIGROUP|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicaid|MEDICAID SUPERIOR|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Blue Cross HMO Specialty|BCBSTX HMO|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Aetna|AETNA PPO|181.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|181.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Workers Compensation|WORKERS COMPENSATION OTHER|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Rusk State Hospital|RUSK STATE HOSP|||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA UMR|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|NON CONTRACTED|COMMERCIAL OTHER 1|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA|181.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Aenta Medicare Advantage|AETNA MEDICARE MA|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Veterans Affairs|VETERANS ADMINISTRATION|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Medicare Advantage|UHC MEDICARE GOLD MA|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Blue Cross PPO Specialty|BCBSTX PPO|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|181.25||||181.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Medicare Advantage|UHC AARP WELLMED HMO MA|181.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Medicare Advantage|UHC AARP MCR HMO MA|181.25||||181.25||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||44.50||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Humana Medicare Advantage|HUMANA MA|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Medicare|MEDICARE ACUTE|44.50||||44.50||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Managed Medicare|HEALTHSPRING MA|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|44.50||||||| 9511460|ERX|0250|RISPERIDONE 0.25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44.50||||||| 9511478|ERX|0250|RISPERIDONE 1MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|116.25||||||| 9511486|ERX|0250|RISPERIDONE 1MG/ML, 30ML|Medicare|MEDICARE ACUTE|1,741.25||||||| 95115|EAP|0510|IMMUNOTHERAPY ONE INJECTI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||42.50||| 95115|EAP|0510|IMMUNOTHERAPY ONE INJECTI|United Medicare Advantage|UHC AARP MCR HMO MA|||||42.50||| 95115|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||1.02||| 95115|EAP|0510|IMMUNOTHERAPY ONE INJECTI|Blue Cross PPO Specialty|BCBSTX PPO|||||42.50||| 95115|EAP|0510|IMMUNOTHERAPY ONE INJECTI|Blue Cross PPO Specialty|BCBSTX OTHER|||||42.50||| 95115|EAP|0510|IMMUNOTHERAPY ONE INJECTI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||42.50||| 95115|EAP|0510|IMMUNOTHERAPY ONE INJECTI|Medicare|MEDICARE ACUTE|||||42.50||| 95115|EAP|0510|IMMUNOTHERAPY ONE INJECTI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||42.50||| 95115|EAP|0510|IMMUNOTHERAPY ONE INJECTI|Managed Medicare|HEALTHSPRING MA|||||42.50||| 95115|EAP|0510|IMMUNOTHERAPY ONE INJECTI|Humana Medicare Advantage|HUMANA MA|||||42.50||| 9511528|ERX|0250|RISPERIDONE ODT 1MG TABLE|Medicaid|MEDICAID|59.50||||||| 9511536|ERX|0250|RISPERIDONE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|86.75||||||| 9511536|ERX|0250|RISPERIDONE 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|86.75||||||| 9511536|ERX|0250|RISPERIDONE 2MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|86.75||||||| 9511536|ERX|0250|RISPERIDONE 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|86.75||||||| 9511536|ERX|0250|RISPERIDONE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|86.75||||||| 9511536|ERX|0250|RISPERIDONE 2MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|86.75||||||| 9511536|ERX|0250|RISPERIDONE 2MG TABLET|Medicare|MEDICARE ACUTE|86.75||||||| 9511536|ERX|0250|RISPERIDONE 2MG TABLET|Medicaid|MEDICAID|86.75||||||| 9511536|ERX|0250|RISPERIDONE 2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|86.75||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Managed Medicare|HEALTHSPRING MA|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Medicaid|MEDICAID|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Medicare|MEDICARE ACUTE|132.50||||132.50||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Medicare|MEDICARE PART B ONLY IP|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Tricare|TRICARE EAST REGION|||||132.50||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|NON CONTRACTED|COMMERCIAL OTHER 1|||||132.50||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA UMR|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Veterans Affairs|VETERANS ADMINISTRATION|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Humana Medicare Advantage|HUMANA MA|132.50||||132.50||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Managed Medicaid|MEDICAID AMERIGROUP|||||132.50||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|United Medicare Advantage|UHC MEDICARE GOLD MA|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||132.50||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Managed Medicaid|MEDICAID SUPERIOR|||||132.50||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|United Healthcare|UNITED HEALTHCARE|132.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Blue Cross PPO Specialty|BCBSTX PPO|132.50||||132.50||| 9511569|ERX|0250|RISPERIDONE 3MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|102.25||||||| 9511569|ERX|0250|RISPERIDONE 3MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|102.25||||||| 9511569|ERX|0250|RISPERIDONE 3MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|102.25||||||| 9511569|ERX|0250|RISPERIDONE 3MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|102.25||||102.25||| 9511569|ERX|0250|RISPERIDONE 3MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|102.25||||||| 9511569|ERX|0250|RISPERIDONE 3MG TABLET|Medicaid|MEDICAID|102.25||||||| 9511577|ERX|0250|RISPERIDONE 4MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|137.25||||||| 9511577|ERX|0250|RISPERIDONE 4MG TABLET|Medicare|MEDICARE ACUTE|137.25||||||| 9511577|ERX|0250|RISPERIDONE 4MG TABLET|Medicaid|MEDICAID|137.25||||||| 9511577|ERX|0250|RISPERIDONE 4MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|137.25||||||| 9511577|ERX|0250|RISPERIDONE 4MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|137.25||||||| 9511577|ERX|0250|RISPERIDONE 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|137.25||||||| 9511577|ERX|0250|RISPERIDONE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|137.25||||||| 9511585|ERX|0250|GALANTAMINE ER 8MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.70||| 9511585|ERX|0250|GALANTAMINE ER 8MG CAPSUL|Medicare|MEDICARE ACUTE|0.70||||||| 9511585|ERX|0250|GALANTAMINE ER 8MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|0.70||||||| 9511585|ERX|0250|GALANTAMINE ER 8MG CAPSUL|Humana Medicare Advantage|HUMANA MA|0.70||||||| 9511601|ERX|0250|GALANTAMINE 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.35||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|Managed Medicare|HEALTHSPRING MA|90.25||||||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|Medicare|MEDICARE ACUTE|90.25||||90.25||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|90.25||||||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|90.25||||||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|90.25||||90.25||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|90.25||||||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|90.25||||||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|90.25||||||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|Access Direct Platinum|ANDREWS CENTER|90.25||||||| 9511627|ERX|0250|PALIPERIDONE 3MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|90.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Workers Compensation|WORKERS COMPENSATION OTHER|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Cigna|CIGNA|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Cigna|CIGNA|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Humana Medicare Advantage|HUMANA MA|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Aetna|AETNA PPO|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|United Healthcare|UNITED HEALTHCARE|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|United Healthcare|UNITED HEALTHCARE|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|PHCS|HUMANA|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Medicare|MEDICARE ACUTE|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Aetna|AETNA OTHER|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Medicare|MEDICARE PART B ONLY IP|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Medicaid|SMITH COUNTY JAIL|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Medicaid|MEDICAID|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicare|HEALTHSPRING MA|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicare|HOSPICE OF EAST TEXAS|385.25||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|385.25||||385.25||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|385.25||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicare|BCBS MEDICARE PPO MA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicaid|SMITH COUNTY JAIL|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicaid|MEDICAID|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicare|MEDICARE PART B ONLY IP|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|NON CONTRACTED|COMMERCIAL OTHER 1|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|PHCS|GROUP AND PENSION|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|PHCS|HUMANA INSURANCE|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Rusk State Hospital|RUSK STATE HOSP|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Healthcare|UNITED HEALTHCARE OTHER|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Healthcare|TML GROUP BENEFITS|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Healthcare|UNITED HEALTHCARE|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Blue Cross PPO Specialty|BCBSTX PPO|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|ChampVA|CHAMPVA CENTER|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Blue Cross HMO Specialty|BCBSTX HMO|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Aetna|AETNA OTHER|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Aetna|AETNA PPO|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID AMERIGROUP|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicaid|LAW ENFORCEMENT OTHER|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Tricare|TRICARE EAST REGION|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID SUPERIOR|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Cigna|CIGNA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Cigna|CIGNA OTHER|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Cigna|CIGNA|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Humana Medicare Advantage|HUMANA MA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Aenta Medicare Advantage|AETNA MEDICARE MA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA UMR|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Workers Compensation|TEXAS MUTUAL INSURANCE|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicare|MEDICARE ACUTE|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Workers Compensation|UT EMPLOYEE INJURY|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicare|HEALTHSPRING MA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Veterans Affairs|VETERANS ADMINISTRATION|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Medicare Advantage|UHC AARP MCR HMO MA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Medicare Advantage|UHC MEDICARE GOLD MA|2.06||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||2.06||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.06||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Workers Compensation|WORKERS COMPENSATION OTHER|2.06||||2.06||| 9511684|ERX|0250|THEOPHYLLINE ANHYDR XL 20|Managed Medicare|HEALTHSPRING MA|||||14.50||| 9511684|ERX|0250|THEOPHYLLINE ANHYDR XL 20|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.50||||||| 9511684|ERX|0250|THEOPHYLLINE ANHYDR XL 20|Aetna|AETNA PPO|14.50||||||| 9511684|ERX|0250|THEOPHYLLINE ANHYDR XL 20|Blue Cross HMO Specialty|BCBSTX HMO|14.50||||||| 9511684|ERX|0250|THEOPHYLLINE ANHYDR XL 20|Medicare|MEDICARE ACUTE|14.50||||||| 9511692|ERX|0250|THEOPHYLLINE ANHYDR XL 30|Medicare|MEDICARE ACUTE|15.50||||||| 9511692|ERX|0250|THEOPHYLLINE ANHYDR XL 30|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9511692|ERX|0250|THEOPHYLLINE ANHYDR XL 30|Humana Medicare Advantage|HUMANA MA|15.50||||||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|United Medicare Advantage|UHC MEDICARE GOLD MA|||||42.50||| 95117|EAP|0761||Veterans Affairs|VETERANS ADMINISTRATION|||||1.02||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||42.50||| 95117|EAP|0761||Managed Medicaid|MEDICAID SUPERIOR|||||1.02||| 95117|EAP|0761||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.02||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Managed Medicaid|MEDICAID SUPERIOR|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Humana Medicare Advantage|HUMANA MA|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Access Direct Platinum|HEALTHFIRST TPA UMR|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Managed Medicaid|MEDICAID AMERIGROUP|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Veterans Affairs|VETERANS ADMINISTRATION|||||42.50||| 95117|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||1.02||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||42.50||| 95117|EAP|0761||Managed Medicaid|MEDICAID AMERIGROUP|||||1.02||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Blue Cross PPO Specialty|BCBSTX PPO|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||42.50||| 95117|EAP|0761||Blue Cross PPO Specialty|BCBSTX PPO|||||1.02||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Blue Cross HMO Specialty|BCBSTX HMO|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Aetna|AETNA PPO|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|United Healthcare|UNITED HEALTHCARE OTHER|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|United Healthcare|UNITED HEALTHCARE|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|United Medicare Advantage|UHC AARP MCR HMO MA|||||42.50||| 95117|EAP|0761||Tricare|TRICARE EAST REGION|||||1.02||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Medicare|MEDICARE ACUTE|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Medicaid|MEDICAID|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Managed Medicare|HEALTHSPRING MA|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||42.50||| 95117|EAP|0761||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.02||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|NON CONTRACTED|COMMERCIAL OTHER 1|||||42.50||| 95117|EAP|0510|IMMUNOTHERAPY INJECTION|Tricare|TRICARE EAST REGION|||||42.50||| 95117|EAP|0761||Medicare|MEDICARE ACUTE|||||1.02||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Medicare|MEDICARE ACUTE|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Medicare|MEDICARE PART B ONLY IP|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicare|HEALTHSPRING MA|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicare|OTHER INSTITUTIONS|||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Medicaid|SMITH COUNTY JAIL|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Medicaid|SMITH COUNTY INDIGENT HEALTH|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Medicaid|MEDICAID|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|United Healthcare|UNITED HEALTHCARE|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Aetna|AETNA PPO|||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Aetna|AETNA OTHER|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Aetna|BH AETNA|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Tricare|TRICARE EAST REGION|||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|United Healthcare|TML GROUP BENEFITS|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Cigna|CIGNA|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Humana Medicare Advantage|HUMANA MA|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicare|JACKSONVILLE ACCESS|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|United Medicare Advantage|UHC AARP WELLMED HMO MA|38.25||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|38.25||||38.25||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|38.25||||38.25||| 9511775|ERX|0250|ACETAMINOPHEN 650MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.75||| 9511775|ERX|0250|ACETAMINOPHEN 650MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||||| 9511775|ERX|0250|ACETAMINOPHEN 650MG TABLE|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| 9511775|ERX|0250|ACETAMINOPHEN 650MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.75||| 9511775|ERX|0250|ACETAMINOPHEN 650MG TABLE|Managed Medicare|HEALTHSPRING MA|||||2.75||| 9511775|ERX|0250|ACETAMINOPHEN 650MG TABLE|Medicare|MEDICARE ACUTE|2.75||||2.75||| 9511791|ERX|0250|KETOCONAZOLE 2% SHAMPOO,1|Medicare|MEDICARE ACUTE|3.67||||||| 9511791|ERX|0250|KETOCONAZOLE 2% SHAMPOO,1|Veterans Affairs|VETERANS ADMINISTRATION|3.67||||||| 9511791|ERX|0250|KETOCONAZOLE 2% SHAMPOO,1|United Medicare Advantage|UHC MEDICARE GOLD MA|3.67||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aetna|AETNA QHP HMO|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aetna|AETNA PPO|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aetna|AETNA OTHER|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aetna|BH AETNA|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Magellan Behavioral Health|BH MAGELLAN|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Cigna|CIGNA OTHER|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Cigna|CIGNA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Cigna Behavioral Health|BH CIGNA|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|UT EMPLOYEE INJURY|||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|TEXAS MUTUAL INSURANCE|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|WORKERS COMP PHYSICIAN|||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|BROOKSHIRES WORKERS COMP|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|UHC AARP WELLMED HMO MA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Access Direct Platinum|ANDREWS CENTER|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|TML GROUP BENEFITS|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|GEHA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|UNITED HEALTHCARE|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|GOLDEN RULE|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|PHCS|HUMANA INSURANCE|||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|PHCS|GROUP AND PENSION|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|PHCS|HUMANA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Optum Behavioral Health|BH OPTUM UHC|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Rusk State Hospital|RUSK STATE HOSP|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Texas Workforce Commission|DIS DETER SERV (DDS)|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Tricare|TRICARE EAST REGION|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Tricare|TRICARE FOR LIFE|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Multiplan|WEB TPA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Multiplan|NALC|||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 4|||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Cigna|CIGNA|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|NON CONTRACTED|COMMUNITY HEALTH CENTER|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|SMITH COUNTY INDIGENT HEALTH|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|SMITH COUNTY JAIL|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 2|||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|MEDICAID HMO|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|MEDICAID|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|LAW ENFORCEMENT OTHER|||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|CRIME VICTIMS COMPENSATION|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|BH TEXAS CHILDRENS MEDICAID|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|MEDICAID BCBSTX|||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicare|WELLCARE CHOICE MA|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicare|JACKSONVILLE ACCESS|9.25||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross HMO Specialty|BCBSTX HMO|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Aetna|AETNA OTHER|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Aetna|AETNA PPO|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross PPO Specialty|BCBSTX OTHER|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross PPO Specialty|BCBSTX PPO|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicare|MEDICARE PART B ONLY IP|169.50||||||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicare|MEDICARE ACUTE|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicare|BCBS MEDICARE PPO MA|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicare|HEALTHSPRING MA|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicaid|MEDICAID|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicaid|MEDICAID HMO|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|NON CONTRACTED|COMMERCIAL OTHER 2|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|PHCS|GROUP AND PENSION|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Tricare|TRICARE EAST REGION|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Healthcare|UNITED HEALTHCARE OTHER|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Healthcare|TML GROUP BENEFITS|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Healthcare|UNITED HEALTHCARE|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Healthcare|GEHA|169.50||||||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Healthcare|UNITED HEALTHCARE|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|169.50||||||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Veterans Affairs|VETERANS ADMINISTRATION|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Medicare Advantage|UHC MEDICARE GOLD MA|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|NON CONTRACTED|COMMERCIAL OTHER 1|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Medicare Advantage|UHC AARP WELLMED HMO MA|169.50||||||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Medicare Advantage|UHC AARP MCR HMO MA|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Access Direct Platinum|HEALTHFIRST TPA UMR|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Access Direct Platinum|HEALTHFIRST TPA|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Aenta Medicare Advantage|AETNA MEDICARE MA|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Workers Compensation|BROOKSHIRES WORKERS COMP|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Workers Compensation|WORKERS COMPENSATION OTHER|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Humana Medicare Advantage|HUMANA MA|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Cigna|CIGNA|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Cigna|CIGNA|169.50||||||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Cigna|CIGNA OTHER|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicaid|MEDICAID SUPERIOR|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|169.50||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicaid|MEDICAID AMERIGROUP|||||169.50||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|169.50||||169.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|ChampVA|CHAMPVA CENTER|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Aetna|AETNA PPO|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Aetna|AETNA OTHER|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Aetna|BH AETNA|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Cigna Behavioral Health|BH CIGNA|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Cigna|CIGNA OTHER|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Cigna|CIGNA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Workers Compensation|UT EMPLOYEE INJURY|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Workers Compensation|GALLAGHER BASSETT|||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST TPA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|ANDREWS CENTER|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Healthcare|UNITED HEALTHCARE ERS|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Healthcare|TML GROUP BENEFITS|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Healthcare|GOLDEN RULE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|PHCS|GROUP AND PENSION|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Workers Compensation|ZURICH COMPANY|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|PHCS|HUMANA INSURANCE|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|PHCS|HUMANA|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Texas Workforce Commission|DIS DETER SERV (DDS)|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Tricare|TRICARE FOR LIFE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Optum Behavioral Health|BH OPTUM UHC|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Tricare|TRICARE EAST REGION|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Multiplan|NALC|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 2|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|MEDICAID HMO|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Aetna|AETNA QHP HMO|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|SMITH COUNTY JAIL|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|MEDICAID|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|CRIME VICTIMS COMPENSATION|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|BH TEXAS CHILDRENS MEDICAID|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|LAW ENFORCEMENT OTHER|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicare|JACKSONVILLE ACCESS|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicare|WELLCARE CHOICE MA|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9511833|ERX|0250|SALIVA SUBSTITUTE, 60ML|Medicare|MEDICARE ACUTE|54.50||||||| 9511833|ERX|0250|SALIVA SUBSTITUTE, 60ML|Managed Medicare|HEALTHSPRING MA|54.50||||||| 9511833|ERX|0250|SALIVA SUBSTITUTE, 60ML|Medicaid|MEDICAID|54.50||||||| 9511833|ERX|0250|SALIVA SUBSTITUTE, 60ML|PHCS|HUMANA|54.50||||||| 9511833|ERX|0250|SALIVA SUBSTITUTE, 60ML|United Medicare Advantage|UHC MEDICARE GOLD MA|54.50||||||| 9511833|ERX|0250|SALIVA SUBSTITUTE, 60ML|Humana Medicare Advantage|HUMANA MA|54.50||||||| 9511833|ERX|0250|SALIVA SUBSTITUTE, 60ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|54.50||||||| 9511833|ERX|0250|SALIVA SUBSTITUTE, 60ML|Blue Cross HMO Specialty|BCBSTX HMO|54.50||||||| 9511833|ERX|0250|SALIVA SUBSTITUTE, 60ML|Blue Cross PPO Specialty|BCBSTX PPO|54.50||||||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|Medicare|MEDICARE ACUTE|25.50||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.45||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|United Healthcare|UNITED HEALTHCARE|||||0.45||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Medicare|MEDICARE ACUTE|0.45||||0.45||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Managed Medicare|HEALTHSPRING MA|0.45||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.45||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.45||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.45||||0.45||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.45||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.45||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.45||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.45||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Humana Medicare Advantage|HUMANA MA|0.45||||0.45||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Aetna|AETNA PPO|80.50||||80.50||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|80.50||||80.50||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Cigna|CIGNA|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Humana Medicare Advantage|HUMANA MA|80.50||||80.50||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Managed Medicare|HEALTHSPRING MA|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Medicare|MEDICARE ACUTE|80.50||||80.50||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|80.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|80.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Healthcare|GEHA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Healthcare|GOLDEN RULE|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|PHCS|HUMANA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|PHCS|GROUP AND PENSION|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Texas Workforce Commission|DIS DETER SERV (DDS)|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Optum Behavioral Health|BH OPTUM UHC|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Tricare|TRICARE FOR LIFE|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Tricare|TRICARE EAST REGION|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Multiplan|WEB TPA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|NON CONTRACTED|COMMERCIAL OTHER 2|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|MEDICAID HMO|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|MEDICAID BCBSTX|||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|MEDICAID|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|LAW ENFORCEMENT OTHER|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|CRIME VICTIMS COMPENSATION|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|BH TEXAS CHILDRENS MEDICAID|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Workers Compensation|BROOKSHIRES WORKERS COMP|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Workers Compensation|UT EMPLOYEE INJURY|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Workers Compensation|TRAVELERS INSURANCE COMPANY|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Workers Compensation|ZURICH COMPANY|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|SMITH COUNTY JAIL|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Workers Compensation|TEXAS MUTUAL INSURANCE|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Access Direct Platinum|ANDREWS CENTER|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Multiplan|PACIFICARE|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Cigna Behavioral Health|BH CIGNA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Cigna|CIGNA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|PHCS|HUMANA INSURANCE|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Healthcare|TML GROUP BENEFITS|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Cigna|CIGNA OTHER|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|ChampVA|CHAMPVA CENTER|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aetna|AETNA PPO|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aetna|AETNA OTHER|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aetna|AETNA QHP HMO|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aetna|BOON CHAPMAN|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aetna|BH AETNA|2.50||||||| 9511908|ERX|0250|TORSEMIDE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.12||||||| 9511908|ERX|0250|TORSEMIDE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|0.12||||0.12||| 9511908|ERX|0250|TORSEMIDE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.12||||||| 9511908|ERX|0250|TORSEMIDE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.12||||||| 9511908|ERX|0250|TORSEMIDE 10MG TABLET|Medicare|MEDICARE ACUTE|0.12||||0.12||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|PHCS|HUMANA|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|PHCS|HUMANA INSURANCE|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Tricare|TRICARE EAST REGION|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Healthcare|GOLDEN RULE|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Healthcare|UNITED HEALTHCARE|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Healthcare|UNITED HEALTHCARE|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicare|MEDICARE ACUTE|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicaid|MEDICAID HMO|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicaid|MEDICAID|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicare|HEALTHSPRING MA|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicare|MA PART B ONLY IP|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Cigna|CIGNA OTHER|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Cigna|CIGNA|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Cigna|CIGNA|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Aetna|BH AETNA|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Aetna|AETNA PPO|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Aetna|BOON CHAPMAN|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Aetna|AETNA OTHER|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|ChampVA|CHAMPVA CENTER|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.03||||0.03||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Aetna|AETNA QHP HMO|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Aetna|AETNA PPO|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Cigna|CIGNA|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Cigna|CIGNA OTHER|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Medicaid|MEDICAID|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|United Healthcare|UNITED HEALTHCARE|9.25||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|United Healthcare|UNITED HEALTHCARE|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|PHCS|GROUP AND PENSION|||||9.25||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Tricare|TRICARE EAST REGION|9.25||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|4.25||||4.25||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Tricare|TRICARE EAST REGION|||||4.25||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|United Healthcare|UNITED HEALTHCARE|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Medicare|MEDICARE PART B ONLY IP|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Managed Medicare|HEALTHSPRING MA|4.25||||4.25||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.25||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Medicare|MEDICARE ACUTE|4.25||||4.25||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST TPA|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||4.25||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Cigna|CIGNA|4.25||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Humana Medicare Advantage|HUMANA MA|4.25||||4.25||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.25||||4.25||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|4.25||||4.25||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|4.25||||||| 9511973|ERX|0250|CHLOROTHIAZIDE 250MG TABL|Medicaid|MEDICAID|4.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Cigna Behavioral Health|BH CIGNA|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Aetna|BH AETNA|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.50||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Access Direct Platinum|ANDREWS CENTER|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Medicaid|MEDICAID|2.50||||||| 9511981|ERX|0250|DIPHENHYDRAMINE 50MG CAPS|Medicaid|BH TEXAS CHILDRENS MEDICAID|2.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Medicare|MEDICARE ACUTE|8.50||||8.50||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|United Healthcare|UNITED HEALTHCARE OTHER|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Aenta Medicare Advantage|AETNA MEDICARE MA|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|United Medicare Advantage|UHC MEDICARE GOLD MA|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicare|HEALTHSPRING MA|8.50||||8.50||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|United Medicare Advantage|UHC AARP MCR HMO MA|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.50||||8.50||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicaid|MEDICAID SUPERIOR|||||8.50||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.50||||8.50||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicaid|MEDICAID AMERIGROUP|8.50||||8.50||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Cigna|CIGNA|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Humana Medicare Advantage|HUMANA MA|8.50||||8.50||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Blue Cross HMO Specialty|BCBSTX HMO|8.50||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Aetna|AETNA OTHER|||||8.50||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Blue Cross PPO Specialty|BCBSTX PPO|8.50||||8.50||| 9512005|ERX|0250|DIPYRIDAMOLE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|0.07||||||| 9512005|ERX|0250|DIPYRIDAMOLE 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.07||||||| 9512005|ERX|0250|DIPYRIDAMOLE 25MG TABLET|Medicare|MEDICARE ACUTE|0.07||||||| 9512005|ERX|0250|DIPYRIDAMOLE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|0.07||||0.07||| 9512013|ERX|0250|DIPYRIDAMOLE 50MG TABLET|Medicare|MEDICARE ACUTE|9.25||||||| 9512013|ERX|0250|DIPYRIDAMOLE 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||||| 9512013|ERX|0250|DIPYRIDAMOLE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|ChampVA|CHAMPVA CENTER|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Aetna|AETNA QHP HMO|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Aetna Value Network|AETNA VALUE NETWORK|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Cigna|CIGNA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Cigna|CIGNA OTHER|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Cigna|CIGNA|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Access Direct Platinum|HEALTHFIRST TPA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|PHCS|GROUP AND PENSION|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Aetna|AETNA PPO|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|PHCS|HUMANA|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Texas Workforce Commission|DIS DETER SERV (DDS)|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Tricare|TRICARE EAST REGION|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Healthcare|GEHA|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Healthcare|TML GROUP BENEFITS|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Medicaid|MEDICAID|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicaid|MEDICAID|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicaid|LAW ENFORCEMENT OTHER|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|United Healthcare|UNITED HEALTHCARE|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Rusk State Hospital|RUSK STATE HOSP|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicaid|SMITH COUNTY JAIL|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Cigna|CIGNA OTHER|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Cigna|CIGNA|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicare|MEDICARE ACUTE|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Cigna Behavioral Health|BH CIGNA|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Aetna|AETNA QHP HMO|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Aetna|BH AETNA|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Aetna|AETNA OTHER|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.75||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Aetna|AETNA PPO|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Aetna|BOON CHAPMAN|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Aetna|AETNA QHP HMO|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Cigna|CIGNA OTHER|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Humana Medicare Advantage|HUMANA MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|PHCS|HUMANA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Cigna|CIGNA|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Tricare|TRICARE EAST REGION|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Aetna|AETNA OTHER|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Healthcare|UNITED HEALTHCARE|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Healthcare|GOLDEN RULE|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Healthcare|GEHA|||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Healthcare|UNITED HEALTHCARE|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicaid|SMITH COUNTY JAIL|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicaid|MEDICAID|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicare|HEALTHSPRING MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicare|WELLCARE CHOICE MA|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicare|MEDICARE ACUTE|0.03||||0.03||| 9512062|ERX|0250|ISONIAZID 300MG TABLET|Medicare|MEDICARE ACUTE|4.25||||||| 9512062|ERX|0250|ISONIAZID 300MG TABLET|Medicare|MEDICARE PART B ONLY IP|4.25||||||| 9512062|ERX|0250|ISONIAZID 300MG TABLET|Managed Medicare|HEALTHSPRING MA|4.25||||4.25||| 9512062|ERX|0250|ISONIAZID 300MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.25||||||| 9512062|ERX|0250|ISONIAZID 300MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.25||||||| 9512062|ERX|0250|ISONIAZID 300MG TABLET|Humana Medicare Advantage|HUMANA MA|4.25||||||| 9512062|ERX|0250|ISONIAZID 300MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.25||||||| 9512062|ERX|0250|ISONIAZID 300MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.25||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.28||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.28||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Aetna|BH AETNA|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.28||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.28||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Cigna|CIGNA OTHER|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Cigna|CIGNA|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Humana Medicare Advantage|HUMANA MA|0.28||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|PHCS|HUMANA|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|United Healthcare|UNITED HEALTHCARE|||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.28||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|United Healthcare|UNITED HEALTHCARE|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Medicaid|SMITH COUNTY JAIL|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.28||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Medicaid|MEDICAID HMO|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Medicaid|MEDICAID|0.28||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicare|OTHER INSTITUTIONS|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicare|HEALTHSPRING MA|0.28||||0.28||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.28||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Medicare|MEDICARE ACUTE|0.28||||0.28||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Managed Medicare|OTHER INSTITUTIONS|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Managed Medicare|HEALTHSPRING MA|||||28.50||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Medicaid|MEDICAID|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Rusk State Hospital|RUSK STATE HOSP|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Humana Medicare Advantage|HUMANA MA|28.50||||28.50||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.50||||28.50||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|PHCS|HUMANA|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.50||||28.50||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Aetna|AETNA OTHER|||||28.50||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|28.50||||28.50||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.50||||||| 9512088|ERX|0250|MIRTAZAPINE 30MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|28.50||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.25||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||5.25||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Cigna|CIGNA|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|United Healthcare|GOLDEN RULE|||||5.25||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||5.25||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Managed Medicare|HEALTHSPRING MA|5.25||||||| 9512096|ERX|0250|MECLIZINE 12.5MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicare|MEDICARE PART B ONLY IP|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicaid|SMITH COUNTY JAIL|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.25||||||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.25||||||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Tricare|TRICARE EAST REGION|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Healthcare|GOLDEN RULE|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|5.25||||||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Cigna|CIGNA|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicaid|MEDICAID|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Aetna|AETNA PPO|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Aetna|AETNA OTHER|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|ChampVA|CHAMPVA CENTER|||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Aetna|AETNA OTHER|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Aetna|AETNA PPO|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Aetna|AETNA QHP HMO|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Cigna|CIGNA|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Cigna|CIGNA|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Cigna|CIGNA OTHER|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Healthcare|UNITED HEALTHCARE|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Healthcare|UNITED HEALTHCARE|||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|PHCS|HUMANA|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Rusk State Hospital|RUSK STATE HOSP|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicare|HEALTHSPRING MA|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Medicaid|MEDICAID|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Medicaid|SMITH COUNTY JAIL|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.75||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Medicare|MEDICARE PART B ONLY IP|7.75||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Medicaid|MOLINA HEALTHCARE OF TEXAS|9.25||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|United Healthcare|UNITED HEALTHCARE|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|United Healthcare|UNITED HEALTHCARE OTHER|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|United Healthcare|UNITED HEALTHCARE|||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Cigna|CIGNA|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Managed Medicaid|MEDICAID SUPERIOR|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Tricare|TRICARE EAST REGION|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Aetna|AETNA PPO|||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Medicaid|MEDICAID|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Aetna Value Network|AETNA VALUE NETWORK|||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|ChampVA|CHAMPVA CENTER|9.25||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Access Direct Platinum|HEALTHFIRST TPA|||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Veterans Affairs|VETERANS ADMINISTRATION|||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|United Medicare Advantage|UHC AARP WELLMED HMO MA|9.25||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||9.25||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.07||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.07||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.07||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.07||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|0.07||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|0.07||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Medicaid|SMITH COUNTY JAIL|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Medicaid|MEDICAID|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.07||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Medicare|MEDICARE ACUTE|0.07||||0.07||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.07||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Medicaid|MEDICAID|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Tricare|TRICARE EAST REGION|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Cigna|CIGNA|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|United Healthcare|UNITED HEALTHCARE|||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Aetna|BOON CHAPMAN|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Medicare|MEDICARE ACUTE|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Access Direct Platinum|ANDREWS CENTER|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.25||||6.25||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.25||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|6.25||||6.25||| 9512153|ERX|0250|METRONIDAZOLE 250MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||||| 9512153|ERX|0250|METRONIDAZOLE 250MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||||| 9512153|ERX|0250|METRONIDAZOLE 250MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9512153|ERX|0250|METRONIDAZOLE 250MG TABLE|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9512153|ERX|0250|METRONIDAZOLE 250MG TABLE|United Healthcare|UNITED HEALTHCARE|9.25||||||| 9512153|ERX|0250|METRONIDAZOLE 250MG TABLE|Multiplan|NALC|9.25||||||| 9512153|ERX|0250|METRONIDAZOLE 250MG TABLE|Medicare|MEDICARE ACUTE|9.25||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicaid|SMITH COUNTY JAIL|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicaid|MEDICAID|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Healthcare|UNITED HEALTHCARE|0.13||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.13||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Aetna|AETNA PPO|0.13||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.13||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA|0.13||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Veterans Affairs|VETERANS ADMINISTRATION|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|United Medicare Advantage|UHC AARP MCR HMO MA|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Access Direct Platinum|HEALTHFIRST TPA UMR|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Workers Compensation|WORKERS COMPENSATION OTHER|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Aetna|BH AETNA|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Blue Cross HMO Specialty|BCBSTX HMO|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Cigna Behavioral Health|BH CIGNA|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Magellan Behavioral Health|BH MAGELLAN|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Cigna|CIGNA OTHER|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Cigna|CIGNA|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Humana Medicare Advantage|HUMANA MA|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID SUPERIOR|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Access Direct Platinum|ANDREWS CENTER|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID AMERIGROUP|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|United Healthcare|UNITED HEALTHCARE OTHER|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|United Healthcare|UNITED HEALTHCARE|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Texas Workforce Commission|DIS DETER SERV (DDS)|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Tricare|TRICARE EAST REGION|||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Multiplan|WEB TPA|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Medicare|MEDICARE ACUTE|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Medicaid|SMITH COUNTY JAIL|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Medicaid|MEDICAID|0.19||||0.19||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Medicaid|CRIME VICTIMS COMPENSATION|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicare|HEALTHSPRING MA|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicare|BCBS MEDICARE PPO MA|0.19||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.19||||||| 9512187|ERX|0250|CHLORPROMAZINE 50MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.50||||||| 9512187|ERX|0250|CHLORPROMAZINE 50MG TABLE|Medicaid|BH TEXAS CHILDRENS MEDICAID|5.50||||||| 9512187|ERX|0250|CHLORPROMAZINE 50MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.50||||||| 9512187|ERX|0250|CHLORPROMAZINE 50MG TABLE|Access Direct Platinum|ANDREWS CENTER|5.50||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.25||||4.25||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.25||||4.25||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|4.25||||4.25||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Cigna|CIGNA|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||4.25||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||4.25||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Medicare|MEDICARE ACUTE|4.25||||4.25||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Medicaid|MEDICAID|4.25||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|4.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Tricare|TRICARE EAST REGION|9.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Managed Medicare|HEALTHSPRING MA|9.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|9.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Aetna|AETNA PPO|9.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||9.25||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Managed Medicare|JACKSONVILLE ACCESS|0.05||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Aetna|AETNA PPO|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Humana Medicare Advantage|HUMANA MA|0.14||||0.14||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.14||||0.14||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Medicare|MEDICARE ACUTE|0.14||||0.14||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.14||||||| 9512237|ERX|0250|AMITRIPTYLINE 75MG TABLET|Managed Medicare|HEALTHSPRING MA|0.14||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Multiplan|WEB TPA|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|NON CONTRACTED|COMMERCIAL OTHER 1|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|PHCS|GROUP AND PENSION|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|PHCS|HUMANA|||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Tricare|TRICARE FOR LIFE|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Healthcare|GEHA|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Healthcare|UNITED HEALTHCARE ERS|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Healthcare|UNITED HEALTHCARE|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Healthcare|UNITED HEALTHCARE OTHER|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Healthcare|TML GROUP BENEFITS|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|MOLINA HEALTHCARE OF TEXAS|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|SUPERIOR HEALTHPLAN CHIP|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|MEDICAID HMO|||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|MEDICAID|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|COUNTY INDIGENT HEALTH OTHER|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicare|HEALTHSPRING MA|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicare|MEDICARE ACUTE|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicare|MEDICARE PART B ONLY IP|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID AMERIGROUP|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID SUPERIOR|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Cigna|CIGNA|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Cigna|CIGNA OTHER|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicare|BCBS MEDICARE PPO MA|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Humana Medicare Advantage|HUMANA MA|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Brinson Benefits|THE HEALTH PLAN SMITH CO|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|ChampVA|CHAMPVA CENTER|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|LAW ENFORCEMENT OTHER|||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|SMITH COUNTY JAIL|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Blue Cross PPO Specialty|BCBSTX PPO|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Blue Cross PPO Specialty|BCBSTX OTHER|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Aetna|AETNA PPO|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Aetna|BH AETNA|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Aetna|AETNA OTHER|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Aetna|AETNA QHP HMO|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Aetna Value Network|AETNA VALUE NETWORK|||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Tricare|TRICARE EAST REGION|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Blue Cross HMO Specialty|BCBSTX HMO|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Workers Compensation|UT EMPLOYEE INJURY|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Workers Compensation|TEXAS MUTUAL INSURANCE|||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|PHCS|HUMANA INSURANCE|6.25||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Workers Compensation|WORKERS COMPENSATION OTHER|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Workers Compensation|GALLAGHER BASSETT|||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Access Direct Platinum|HEALTHFIRST TPA UMR|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Access Direct Platinum|HEALTHFIRST TPA|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Aenta Medicare Advantage|AETNA MEDICARE MA|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Veterans Affairs|VETERANS ADMINISTRATION|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Medicare Advantage|UHC MEDICARE GOLD MA|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.25||||6.25||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Medicare Advantage|UHC AARP MCR HMO MA|6.25||||6.25||| 9512252|ERX|0250|CHLORPHENIRAMINE 4MG TABL|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9512252|ERX|0250|CHLORPHENIRAMINE 4MG TABL|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9512252|ERX|0250|CHLORPHENIRAMINE 4MG TABL|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.25||||||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Medicare|MEDICARE ACUTE|7.25||||7.25||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.25||||||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.25||||||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|7.25||||||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Aetna|AETNA OTHER|7.25||||||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|7.25||||||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Cigna|CIGNA|7.25||||||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Cigna|CIGNA|7.25||||7.25||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Humana Medicare Advantage|HUMANA MA|7.25||||||| 9512286|ERX|0250|METHYLDOPA 250MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.07||||0.07||| 9512286|ERX|0250|METHYLDOPA 250MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.07||||0.07||| 9512286|ERX|0250|METHYLDOPA 250MG TABLET|Medicare|MEDICARE ACUTE|0.07||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|United Healthcare|GOLDEN RULE|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Medicaid|MEDICAID|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Managed Medicare|HEALTHSPRING MA|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Tricare|TRICARE EAST REGION|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Aetna|AETNA PPO|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Aetna|AETNA OTHER|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Cigna|CIGNA|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Cigna|CIGNA|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Aetna|AETNA PPO|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Medicaid|MEDICAID|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|United Healthcare|UNITED HEALTHCARE|9.25||||9.25||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|United Healthcare|UNITED HEALTHCARE|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|PHCS|HUMANA INSURANCE|9.25||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Tricare|TRICARE EAST REGION|||||9.25||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Optum Behavioral Health|BH OPTUM UHC|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|United Healthcare|UNITED HEALTHCARE|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Medicaid|MEDICAID|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Aetna|BH AETNA|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Magellan Behavioral Health|BH MAGELLAN|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Cigna Behavioral Health|BH CIGNA|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.50||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|5.50||||5.50||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.50||||5.50||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||5.50||| 9512369|ERX|0250|BENZTROPINE 2MG TABLET|Cigna Behavioral Health|BH CIGNA|5.75||||||| 9512369|ERX|0250|BENZTROPINE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|5.75||||||| 9512369|ERX|0250|BENZTROPINE 2MG TABLET|Magellan Behavioral Health|BH MAGELLAN|5.75||||||| 9512369|ERX|0250|BENZTROPINE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||||| 9512369|ERX|0250|BENZTROPINE 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.75||||||| 9512369|ERX|0250|BENZTROPINE 2MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|5.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicare|MEDICARE PART B ONLY IP|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicare|HEALTHSPRING MA|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicaid|MEDICAID|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicaid|MEDICAID HMO|||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|United Healthcare|UNITED HEALTHCARE|||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|United Healthcare|TML GROUP BENEFITS|||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|PHCS|GROUP AND PENSION|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|PHCS|HUMANA INSURANCE|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Rusk State Hospital|RUSK STATE HOSP|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Tricare|TRICARE EAST REGION|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Tricare|TRICARE FOR LIFE|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Access Direct Platinum|ANDREWS CENTER|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Aetna|AETNA PPO|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicare|MEDICARE ACUTE|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|4.75||||4.75||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Magellan Behavioral Health|BH MAGELLAN|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Cigna Behavioral Health|BH CIGNA|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Cigna|CIGNA|4.75||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Humana Medicare Advantage|HUMANA MA|4.75||||4.75||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Cigna Behavioral Health|BH CIGNA|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Cigna|CIGNA|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Cigna|CIGNA OTHER|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Humana Medicare Advantage|HUMANA MA|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Magellan Behavioral Health|BH MAGELLAN|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Aetna|BOON CHAPMAN|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Aetna|AETNA PPO|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Aetna|AETNA OTHER|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Aetna Value Network|AETNA VALUE NETWORK|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|ANDREWS CENTER|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Multiplan|WEB TPA|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Multiplan|NALC|||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Aetna|BH AETNA|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|ChampVA|CHAMPVA CENTER|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|PHCS|HUMANA|||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|PHCS|GROUP AND PENSION|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|PHCS|HUMANA INSURANCE|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Tricare|TRICARE FOR LIFE|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Tricare|TRICARE EAST REGION|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|GEHA|||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|UNITED HEALTHCARE|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|GOLDEN RULE|||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|TML GROUP BENEFITS|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Cigna|CIGNA|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|MEDICAID HMO|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|MEDICAID|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicare|HEALTHSPRING MA|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|5.50||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||5.50||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicaid|MEDICAID HMO|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicaid|BH TEXAS CHILDRENS MEDICAID|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Access Direct Platinum|HEALTHFIRST TPA|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|United Healthcare|UNITED HEALTHCARE|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicaid|MEDICAID|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Workers Compensation|TEXAS MUTUAL INSURANCE|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Aetna|AETNA PPO|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Cigna|CIGNA|5.25||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Cigna|CIGNA OTHER|5.25||||||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|5.25||||||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Tricare|TRICARE EAST REGION|5.25||||||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.25||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|5.75||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Medicare|MEDICARE ACUTE|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Medicaid|MEDICAID|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicare|HEALTHSPRING MA|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|United Healthcare|UNITED HEALTHCARE|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.75||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|5.75||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|PHCS|HUMANA INSURANCE|5.75||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|PHCS|GROUP AND PENSION|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Tricare|TRICARE EAST REGION|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Tricare|TRICARE FOR LIFE|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 4|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|5.75||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Aetna|AETNA OTHER|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Aetna|AETNA PPO|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Aetna|BOON CHAPMAN|5.75||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.75||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.75||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Cigna|CIGNA|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Cigna|CIGNA OTHER|5.75||||5.75||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Humana Medicare Advantage|HUMANA MA|5.75||||5.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Cigna|CIGNA|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Cigna|CIGNA|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Aetna|AETNA OTHER|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Aetna|AETNA PPO|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Aetna|BH AETNA|7.75||||||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|7.75||||||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|7.75||||||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Aetna|AETNA QHP HMO|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|PHCS|HUMANA|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Tricare|TRICARE EAST REGION|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Tricare|TRICARE FOR LIFE|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Cigna|CIGNA OTHER|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.75||||||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|United Healthcare|UNITED HEALTHCARE|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|United Healthcare|TML GROUP BENEFITS|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Managed Medicare|HEALTHSPRING MA|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Medicaid|MEDICAID|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Medicare|UTSW MC KIDNEY PROGRAM|||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9512435|ERX|0250|DIAZEPAM 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|7.75||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicaid|MEDICAID|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicaid|SMITH COUNTY JAIL|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicaid|MEDICAID HMO|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Healthcare|UNITED HEALTHCARE|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|PHCS|HUMANA|||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Access Direct Platinum|ANDREWS CENTER|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Healthcare|UNITED HEALTHCARE|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Aetna|AETNA PPO|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Aetna|BH AETNA|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Aetna|AETNA QHP HMO|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Cigna Behavioral Health|BH CIGNA|5.25||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Cigna|CIGNA|5.25||||5.25||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Cigna|CIGNA OTHER|5.25||||5.25||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Cigna|CIGNA|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Humana Medicare Advantage|HUMANA MA|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|ChampVA|CHAMPVA CENTER|||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Aetna|AETNA QHP HMO|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Aetna|AETNA PPO|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Healthcare|UNITED HEALTHCARE|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicare|HEALTHSPRING MA|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|5.75||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicare|WELLCARE CHOICE MA|||||5.75||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicaid|SMITH COUNTY JAIL|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicaid|MEDICAID|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicare|MEDICARE PART B ONLY IP|5.75||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicare|MEDICARE ACUTE|5.75||||5.75||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicare|MEDICARE ACUTE|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|MEDICAID HMO|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|MEDICAID|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicare|HOSPICE OF EAST TEXAS|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicare|HEALTHSPRING MA|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Healthcare|UNITED HEALTHCARE|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|PHCS|HUMANA INSURANCE|||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|PHCS|HUMANA|||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Tricare|TRICARE EAST REGION|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Multiplan|WEB TPA|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Workers Compensation|ZURICH COMPANY|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Aetna|AETNA PPO|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Aetna|BH AETNA|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.14||||0.14||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Cigna Behavioral Health|BH CIGNA|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Cigna|CIGNA|0.14||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.14||||0.14||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Humana Medicare Advantage|HUMANA MA|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Magellan Behavioral Health|BH MAGELLAN|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Aetna|BH AETNA|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Access Direct Platinum|ANDREWS CENTER|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Cigna Behavioral Health|BH CIGNA|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Multiplan|WEB TPA|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Optum Behavioral Health|BH OPTUM UHC|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Medicaid|MEDICAID HMO|16.75||||||| 9512526|ERX|0250|LORAZEPAM 2MG TABLET|Medicare|MEDICARE ACUTE|16.75||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicare|MEDICARE ACUTE|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicaid|MEDICAID|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicare|HEALTHSPRING MA|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicare|MA PART B ONLY IP|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|United Healthcare|UNITED HEALTHCARE|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|PHCS|GROUP AND PENSION|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Access Direct Platinum|ANDREWS CENTER|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicaid|MEDICAID HMO|||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Aetna|BH AETNA|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|11.50||||11.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Cigna|CIGNA|11.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Cigna|CIGNA OTHER|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Cigna Behavioral Health|BH CIGNA|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Cigna|CIGNA|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Cigna|CIGNA|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Humana Medicare Advantage|HUMANA MA|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|ChampVA|CHAMPVA CENTER|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Aetna|AETNA OTHER|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Workers Compensation|UT EMPLOYEE INJURY|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Multiplan|WEB TPA|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|PHCS|GROUP AND PENSION|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Aetna|AETNA PPO|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|PHCS|HUMANA|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Tricare|TRICARE EAST REGION|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Healthcare|UNITED HEALTHCARE|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Healthcare|UNITED HEALTHCARE|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Healthcare|TML GROUP BENEFITS|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Cigna|CIGNA OTHER|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicare|MA PART B ONLY IP|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicare|HEALTHSPRING MA|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicaid|MOLINA HEALTHCARE OF TEXAS|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicaid|SMITH COUNTY JAIL|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicaid|SUPERIOR HEALTHPLAN CHIP|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicaid|SMITH COUNTY INDIGENT HEALTH|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicaid|MEDICAID|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.50||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicare|MEDICARE ACUTE|11.50||||11.50||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|11.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Medicare|MEDICARE ACUTE|23.50||||23.50||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Managed Medicare|HEALTHSPRING MA|23.50||||23.50||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|23.50||||23.50||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23.50||||23.50||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Humana Medicare Advantage|HUMANA MA|23.50||||23.50||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|United Healthcare|UNITED HEALTHCARE|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Medicaid|MEDICAID|0.10||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Managed Medicare|HEALTHSPRING MA|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.10||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Medicare|MEDICARE PART B ONLY IP|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Managed Medicare|HEALTHSPRING MA|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Medicaid|SMITH COUNTY JAIL|||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|United Healthcare|UNITED HEALTHCARE|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|United Healthcare|UNITED HEALTHCARE|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Aetna|AETNA OTHER|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Tricare|TRICARE EAST REGION|||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Medicare|MEDICARE ACUTE|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.75||||||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Humana Medicare Advantage|HUMANA MA|15.75||||15.75||| 9512583|ERX|0250|GLIMEPIRIDE 4MG TABLET|Cigna|CIGNA|15.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Magellan Behavioral Health|BH MAGELLAN|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Cigna Behavioral Health|BH CIGNA|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Aetna|AETNA PPO|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Aetna|BH AETNA|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Workers Compensation|TRAVELERS INSURANCE COMPANY|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Access Direct Platinum|ANDREWS CENTER|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Healthcare|UNITED HEALTHCARE|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|PHCS|HUMANA|||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Optum Behavioral Health|BH OPTUM UHC|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Cigna|CIGNA|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Tricare|TRICARE EAST REGION|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicaid|MEDICAID|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicare|HEALTHSPRING MA|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|7.75||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|7.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicaid|MEDICAID HMO|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicaid|MEDICAID|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|PHCS|HUMANA|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Rusk State Hospital|RUSK STATE HOSP|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Optum Behavioral Health|BH OPTUM UHC|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Tricare|TRICARE EAST REGION|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Multiplan|WEB TPA|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|United Healthcare|AARP|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Access Direct Platinum|ANDREWS CENTER|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Aetna|AETNA PPO|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Aetna|BH AETNA|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|11.75||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Cigna|CIGNA|||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Cigna|CIGNA OTHER|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|11.75||||11.75||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Magellan Behavioral Health|BH MAGELLAN|11.75||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Cigna|CIGNA OTHER|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Cigna|CIGNA|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Humana Medicare Advantage|HUMANA MA|842.50||||842.50||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Aetna|AETNA OTHER|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|842.50||||842.50||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Medicaid|MEDICAID|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Managed Medicare|HOSPICE OF EAST TEXAS|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Managed Medicare|HEALTHSPRING MA|842.50||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Medicare|MEDICARE ACUTE|842.50||||842.50||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|Medicare|MEDICARE ACUTE|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|ChampVA|CHAMPVA CENTER|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Humana Medicare Advantage|HUMANA MA|5.75||||5.75||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Aetna|BH AETNA|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.75||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.75||||5.75||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Tricare|TRICARE EAST REGION|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|United Healthcare|UNITED HEALTHCARE|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Medicaid|MEDICAID|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Managed Medicare|HEALTHSPRING MA|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|5.75||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Medicare|MEDICARE ACUTE|5.75||||5.75||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Medicare|MEDICARE ACUTE|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Managed Medicare|HEALTHSPRING MA|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Medicaid|MEDICAID|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Tricare|TRICARE EAST REGION|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||7.75||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.75||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|7.75||||7.75||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Aetna|BH AETNA|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||7.75||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Cigna Behavioral Health|BH CIGNA|7.75||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|7.75||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Medicaid|MEDICAID|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Managed Medicare|HEALTHSPRING MA|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|9.25||||||| 9512666|ERX|0250|DOXEPIN 50MG CAPSULE|Medicare|MEDICARE ACUTE|9.25||||||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|9.25||||||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Medicaid|BH TEXAS CHILDRENS MEDICAID|9.25||||||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|9.25||||||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9512724|ERX|0250|FLUPHENAZINE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||||| 9512724|ERX|0250|FLUPHENAZINE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.75||||||| 9512724|ERX|0250|FLUPHENAZINE 5MG TABLET|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9512732|ERX|0250|FLUPHENAZINE 10MG TABLET|Medicare|MEDICARE ACUTE|21.75||||||| 9512732|ERX|0250|FLUPHENAZINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.75||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Access Direct Platinum|HEALTHFIRST TPA UMR|7.50||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Aetna|BH AETNA|7.50||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Humana Medicare Advantage|HUMANA MA|7.50||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|7.50||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Medicaid|MEDICAID|7.50||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Medicare|MEDICARE ACUTE|7.50||||||| 9512765|ERX|0250|CHLORPROMAZINE 10MG TABLE|Medicare|MEDICARE ACUTE|6.75||||||| 9512765|ERX|0250|CHLORPROMAZINE 10MG TABLE|Managed Medicare|HEALTHSPRING MA|||||6.75||| 9512765|ERX|0250|CHLORPROMAZINE 10MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|6.75||||||| 9512765|ERX|0250|CHLORPROMAZINE 10MG TABLE|Humana Medicare Advantage|HUMANA MA|6.75||||||| 9512765|ERX|0250|CHLORPROMAZINE 10MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|6.75||||||| 9512765|ERX|0250|CHLORPROMAZINE 10MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|6.75||||6.75||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|||||5.25||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Cigna|CIGNA|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Humana Medicare Advantage|HUMANA MA|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.25||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Medicaid|MEDICAID|5.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Managed Medicare|HEALTHSPRING MA|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Medicaid|MEDICAID|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|United Healthcare|UNITED HEALTHCARE|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Humana Medicare Advantage|HUMANA MA|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.08||||0.08||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.08||||||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.08||||0.08||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.08||||0.08||| 9512781|ERX|0250|FUROSEMIDE 80MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||0.08||| 9512799|ERX|0250|PROCHLORPERAZINE 5MG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.25||| 9512799|ERX|0250|PROCHLORPERAZINE 5MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|||||9.25||| 9512799|ERX|0250|PROCHLORPERAZINE 5MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.25||| 9512799|ERX|0250|PROCHLORPERAZINE 5MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|||||9.25||| 9512799|ERX|0250|PROCHLORPERAZINE 5MG TABL|Medicare|MEDICARE ACUTE|9.25||||||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|14.25||||||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|United Healthcare|UNITED HEALTHCARE|||||14.25||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|14.25||||||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Medicare|MEDICARE ACUTE|14.25||||14.25||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Humana Medicare Advantage|HUMANA MA|14.25||||14.25||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14.25||||||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.25||||14.25||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Aetna|BOON CHAPMAN|14.25||||||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14.25||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|14.25||||14.25||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Veterans Affairs|VETERANS ADMINISTRATION|14.25||||||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|14.25||||||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||14.25||| 9512823|ERX|0250|LINEZOLID 100MG/5ML, 150M|Veterans Affairs|VETERANS ADMINISTRATION|4,210.25||||||| 9512823|ERX|0250|LINEZOLID 100MG/5ML, 150M|Managed Medicaid|MEDICAID SUPERIOR|4,210.25||||||| 9512823|ERX|0250|LINEZOLID 100MG/5ML, 150M|Medicare|MEDICARE ACUTE|4,210.25||||||| 9512831|ERX|0250|AMITRIPTYLINE 100MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||||| 9512831|ERX|0250|AMITRIPTYLINE 100MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9512831|ERX|0250|AMITRIPTYLINE 100MG TABLE|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9512831|ERX|0250|AMITRIPTYLINE 100MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9512864|ERX|0250|THIORIDAZINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|8.50||||||| 9512906|ERX|0250|TRIFLUOPERAZINE 5MG TABLE|Medicaid|MEDICAID|15.50||||||| 9512955|ERX|0250|LEUCOVORIN 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|140.75||||||| 9512955|ERX|0250|LEUCOVORIN 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|140.75||||||| 9512955|ERX|0250|LEUCOVORIN 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|140.75||||||| 9512955|ERX|0250|LEUCOVORIN 25MG TABLET|Medicare|MEDICARE ACUTE|140.75||||||| 9512955|ERX|0250|LEUCOVORIN 25MG TABLET|Managed Medicare|WELLCARE CHOICE MA|140.75||||||| 9513003|ERX|0250|AMOXICILLIN 250MG CAPSULE|Medicare|MEDICARE ACUTE|5.25||||||| 9513003|ERX|0250|AMOXICILLIN 250MG CAPSULE|Humana Medicare Advantage|HUMANA MA|||||5.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|8.50||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|8.50||||||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|8.50||||||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.50||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|8.50||||||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.50||||||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|8.50||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|8.50||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.50||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Cigna Behavioral Health|BH CIGNA|8.50||||||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Humana Medicare Advantage|HUMANA MA|8.50||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|8.50||||||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.50||||||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicaid|MEDICAID|8.50||||||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicare|HEALTHSPRING MA|8.50||||8.50||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicare|MEDICARE ACUTE|8.50||||8.50||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Workers Compensation|ZURICH COMPANY|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicaid|MEDICAID HMO|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Healthcare|UNITED HEALTHCARE|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicare|MEDICARE ACUTE|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Tricare|TRICARE EAST REGION|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicaid|SMITH COUNTY JAIL|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|PHCS|GROUP AND PENSION|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Aetna|AETNA PPO|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicaid|MEDICAID|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|PHCS|HUMANA|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Cigna|CIGNA OTHER|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|0.22||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Cigna|CIGNA|||||0.22||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Aetna|AETNA OTHER|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|0.22||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.22||||0.22||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.50||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|5.50||||5.50||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Medicaid|BH TEXAS CHILDRENS MEDICAID|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Managed Medicare|HEALTHSPRING MA|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Medicaid|MEDICAID HMO|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.50||||5.50||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Tricare|TRICARE FOR LIFE|||||5.50||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||5.50||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|United Healthcare|UNITED HEALTHCARE|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Tricare|TRICARE EAST REGION|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Medicaid|MEDICAID|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.50||||5.50||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Cigna|CIGNA|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Texas Workforce Commission|DIS DETER SERV (DDS)|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Humana Medicare Advantage|HUMANA MA|5.50||||5.50||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Medicaid|SUPERIOR HEALTHPLAN CHIP|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|5.50||||||| 9513052|ERX|0250|PRAZOSIN 1MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|5.50||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicare|BCBS MEDICARE PPO MA|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicare|MEDICARE PART B ONLY IP|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Access Direct Platinum|HEALTHFIRST TPA UMR|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|PHCS|HUMANA|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicaid|MEDICAID|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Healthcare|TML GROUP BENEFITS|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Tricare|TRICARE EAST REGION|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicaid|CRIME VICTIMS COMPENSATION|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicare|HEALTHSPRING MA|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Healthcare|UNITED HEALTHCARE ERS|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Workers Compensation|WORKERS COMPENSATION OTHER|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Healthcare|GEHA|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Healthcare|UNITED HEALTHCARE OTHER|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Tricare|TRICARE FOR LIFE|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Healthcare|UNITED HEALTHCARE|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Optum Behavioral Health|BH OPTUM UHC|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Cigna|CIGNA|||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Blue Cross PPO Specialty|BCBSTX OTHER|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Workers Compensation|TEXAS MUTUAL INSURANCE|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Aetna|AETNA QHP HMO|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|NON CONTRACTED|COMMERCIAL OTHER 2|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Cigna|CIGNA|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Aetna|AETNA OTHER|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicaid|SMITH COUNTY JAIL|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Veterans Affairs|VETERANS ADMINISTRATION|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID SUPERIOR|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Blue Cross HMO Specialty|BCBSTX HMO|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|0.15||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Aetna|AETNA PPO|0.15||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Workers Compensation|UT EMPLOYEE INJURY|||||0.15||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||0.15||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Tricare|TRICARE EAST REGION|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9513078|ERX|0250|DOXEPIN 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9513094|ERX|0250|ALBUTEROL 4MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.25||||||| 9513094|ERX|0250|ALBUTEROL 4MG TABLET|Humana Medicare Advantage|HUMANA MA|8.25||||||| 9513094|ERX|0250|ALBUTEROL 4MG TABLET|Medicare|MEDICARE ACUTE|8.25||||||| 9513094|ERX|0250|ALBUTEROL 4MG TABLET|Managed Medicare|HEALTHSPRING MA|||||8.25||| 9513094|ERX|0250|ALBUTEROL 4MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||8.25||| 9513094|ERX|0250|ALBUTEROL 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.25||||||| 9513094|ERX|0250|ALBUTEROL 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|8.25||||8.25||| 9513094|ERX|0250|ALBUTEROL 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|8.25||||||| 9513136|ERX|0250|VERAPAMIL 80MG TABLET|Medicare|MEDICARE ACUTE|7.50||||||| 9513136|ERX|0250|VERAPAMIL 80MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||||| 9513136|ERX|0250|VERAPAMIL 80MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9513136|ERX|0250|VERAPAMIL 80MG TABLET|Medicare|MEDICARE PART B ONLY IP|7.50||||||| 9513144|ERX|0250|VERAPAMIL 120MG TABLET|Managed Medicare|HEALTHSPRING MA|9.25||||||| 9513144|ERX|0250|VERAPAMIL 120MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9513144|ERX|0250|VERAPAMIL 120MG TABLET|Medicare|MEDICARE ACUTE|9.25||||||| 9513144|ERX|0250|VERAPAMIL 120MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||||| 9513144|ERX|0250|VERAPAMIL 120MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9513144|ERX|0250|VERAPAMIL 120MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||||| 9513144|ERX|0250|VERAPAMIL 120MG TABLET|PHCS|HUMANA|||||9.25||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|ChampVA|CHAMPVA CENTER|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Humana Medicare Advantage|HUMANA MA|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Managed Medicare|HEALTHSPRING MA|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|United Healthcare|UNITED HEALTHCARE|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Tricare|TRICARE EAST REGION|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Cigna|CIGNA|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.50||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|13.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Medicare|MEDICARE ACUTE|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Medicaid|MEDICAID|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Cigna|CIGNA|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Healthcare|TML GROUP BENEFITS|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|PHCS|GROUP AND PENSION|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Tricare|TRICARE EAST REGION|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicare|HEALTHSPRING MA|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Healthcare|UNITED HEALTHCARE|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Aetna|BH AETNA|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Humana Medicare Advantage|HUMANA MA|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Aetna|AETNA OTHER|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Healthcare|AARP|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Aetna|AETNA PPO|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.50||||11.50||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|11.50||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.50||||11.50||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Aetna|BH AETNA|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Aetna|BOON CHAPMAN|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Cigna|CIGNA OTHER|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Cigna|CIGNA|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|ChampVA|CHAMPVA CENTER|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Humana Medicare Advantage|HUMANA MA|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Aetna|AETNA PPO|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|PHCS|HUMANA|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Healthcare|TML GROUP BENEFITS|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicare|HEALTHSPRING MA|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Tricare|TRICARE EAST REGION|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Healthcare|AARP|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Healthcare|GEHA|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Healthcare|UNITED HEALTHCARE ERS|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Rusk State Hospital|RUSK STATE HOSP|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Medicare|MEDICARE ACUTE|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Healthcare|UNITED HEALTHCARE|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Aetna|AETNA QHP HMO|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Medicaid|MEDICAID|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Cigna|CIGNA|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Healthcare|UNITED HEALTHCARE|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|47.25||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|47.25||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||47.25||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|47.25||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicare|MEDICARE ACUTE|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicaid|MEDICAID|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicaid|MEDICAID HMO|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.08||||0.08||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Humana Medicare Advantage|HUMANA MA|0.08||||0.08||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|United Healthcare|UNITED HEALTHCARE|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Managed Medicare|HEALTHSPRING MA|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Aetna|AETNA PPO|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Medicaid|MEDICAID|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Tricare|TRICARE EAST REGION|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.08||||0.08||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Medicaid|MEDICAID|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Managed Medicare|HEALTHSPRING MA|||||11.50||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|United Healthcare|UNITED HEALTHCARE|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Humana Medicare Advantage|HUMANA MA|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Medicare|MEDICARE PART B ONLY IP|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||11.50||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Medicare|MEDICARE ACUTE|11.50||||11.50||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||11.50||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|11.50||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Aetna|AETNA PPO|11.50||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.25||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.25||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.25||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|Humana Medicare Advantage|HUMANA MA|13.25||||13.25||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|13.25||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|13.25||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.25||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|13.25||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|Medicaid|MEDICAID|13.25||||||| 9513235|ERX|0250|CARBIDOPA-LEVODOPA 10-100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.75||||11.75||| 9513235|ERX|0250|CARBIDOPA-LEVODOPA 10-100|Humana Medicare Advantage|HUMANA MA|11.75||||||| 9513235|ERX|0250|CARBIDOPA-LEVODOPA 10-100|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11.75||| 9513235|ERX|0250|CARBIDOPA-LEVODOPA 10-100|Aenta Medicare Advantage|AETNA MEDICARE MA|11.75||||||| 9513235|ERX|0250|CARBIDOPA-LEVODOPA 10-100|Medicare|MEDICARE ACUTE|11.75||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||12.50||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|12.50||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.50||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|United Healthcare|UNITED HEALTHCARE OTHER|12.50||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Managed Medicare|HEALTHSPRING MA|12.50||||12.50||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||12.50||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Managed Medicare|BCBS MEDICARE PPO MA|12.50||||12.50||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Medicare|MEDICARE PART B ONLY IP|12.50||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|United Medicare Advantage|UHC AARP MCR HMO MA|12.50||||12.50||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.50||||12.50||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Medicaid|MEDICAID|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Medicare|MEDICARE PART B ONLY IP|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Managed Medicare|HEALTHSPRING MA|12.50||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Aetna|AETNA PPO|||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|12.50||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|12.50||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.50||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||||| 9513268|ERX|0250|CARBIDOPA-LEVODOPA 25-250|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||||| 9513268|ERX|0250|CARBIDOPA-LEVODOPA 25-250|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||||| 9513268|ERX|0250|CARBIDOPA-LEVODOPA 25-250|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9513268|ERX|0250|CARBIDOPA-LEVODOPA 25-250|Managed Medicare|HEALTHSPRING MA|0.15||||||| 9513268|ERX|0250|CARBIDOPA-LEVODOPA 25-250|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Medicare|MEDICARE ACUTE|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Healthcare|UNITED HEALTHCARE|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Cigna|CIGNA OTHER|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Healthcare|UNITED HEALTHCARE|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Medicaid|MEDICAID|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Cigna Behavioral Health|BH CIGNA|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Cigna|CIGNA|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicare|HEALTHSPRING MA|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|12.25||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Medicaid|SMITH COUNTY JAIL|||||12.25||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|12.25||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.25||||12.25||| 9513284|ERX|0250|NAPROXEN 375MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||||| 9513284|ERX|0250|NAPROXEN 375MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9513284|ERX|0250|NAPROXEN 375MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||||| 9513284|ERX|0250|NAPROXEN 375MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9513284|ERX|0250|NAPROXEN 375MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9513284|ERX|0250|NAPROXEN 375MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.25||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Tricare|TRICARE EAST REGION|||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Medicare|MEDICARE PART B ONLY IP|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicare|HEALTHSPRING MA|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicare|WELLCARE CHOICE MA|||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Cigna Behavioral Health|BH CIGNA|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.25||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Access Direct Platinum|ANDREWS CENTER|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|17.25||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Humana Medicare Advantage|HUMANA MA|||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Medicaid|MEDICAID|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Medicare|MEDICARE ACUTE|17.25||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||17.25||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|17.25||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicaid|MEDICAID SUPERIOR|||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicare|ETMC AFFILIATE HOSPITALS|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Access Direct Platinum|ANDREWS CENTER|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Cigna|CIGNA|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Workers Compensation|BROOKSHIRES WORKERS COMP|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Workers Compensation|TEXAS MUTUAL INSURANCE|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicare|OTHER INSTITUTIONS|||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicare|JACKSONVILLE ACCESS|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Cigna|CIGNA OTHER|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Access Direct Platinum|HEALTHFIRST TPA UMR|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Healthcare|TML GROUP BENEFITS|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Aetna|AETNA OTHER|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicaid|MEDICAID|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Healthcare|UNITED HEALTHCARE|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Healthcare|UNITED HEALTHCARE OTHER|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|PHCS|HUMANA|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicaid|SMITH COUNTY JAIL|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Healthcare|GEHA|9.25||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Aetna|AETNA PPO|9.25||||||| 9513318|ERX|0250|IRINOTECAN 100MG/5ML|Medicaid|MEDICAID|6,302.50||||||| 9513318|ERX|0250|IRINOTECAN 100MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|6,302.50||||||| 9513326|ERX|0250|NORTRIPTYLINE 10MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||||| 9513326|ERX|0250|NORTRIPTYLINE 10MG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|0.08||||||| 9513326|ERX|0250|NORTRIPTYLINE 10MG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|0.08||||||| 9513326|ERX|0250|NORTRIPTYLINE 10MG CAPSUL|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9513326|ERX|0250|NORTRIPTYLINE 10MG CAPSUL|Managed Medicare|HEALTHSPRING MA|0.08||||||| 9513326|ERX|0250|NORTRIPTYLINE 10MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.08||||||| 9513334|ERX|0250|NORTRIPTYLINE 50MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|21.25||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Medicaid|MEDICAID|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Medicare|MEDICARE ACUTE|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.07||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Aetna|AETNA PPO|||||0.07||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||0.07||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Access Direct Platinum|ANDREWS CENTER|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Cigna|CIGNA|||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Medicare|MEDICARE ACUTE|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Tricare|TRICARE EAST REGION|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|10.50||||10.50||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|Medicaid|MEDICAID|10.50||||||| 9513375|ERX|0250|GLIPIZIDE 10MG TABLET|PHCS|HUMANA|10.50||||10.50||| 9513391|ERX|0250|CAPTOPRIL 12.5MG TABLET|Medicare|MEDICARE ACUTE|11.75||||||| 9513391|ERX|0250|CAPTOPRIL 12.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|11.75||||||| 9513391|ERX|0250|CAPTOPRIL 12.5MG TABLET|Humana Medicare Advantage|HUMANA MA|11.75||||||| 9513409|ERX|0250|CAPTOPRIL 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||||| 9513409|ERX|0250|CAPTOPRIL 25MG TABLET|Medicare|MEDICARE ACUTE|12.25||||||| 9513409|ERX|0250|CAPTOPRIL 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|12.25||||||| 9513425|ERX|0250|IRINOTECAN 40MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|2,521.50||||||| 9513425|ERX|0250|IRINOTECAN 40MG/2ML|Medicaid|MEDICAID|2,521.50||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.25||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.25||||12.25||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|12.25||||12.25||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||12.25||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Veterans Affairs|VETERANS ADMINISTRATION|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Humana Medicare Advantage|HUMANA MA|12.25||||12.25||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Aetna|BH AETNA|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Aetna|AETNA OTHER|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||12.25||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Access Direct Platinum|HEALTHFIRST TPA|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|United Healthcare|UNITED HEALTHCARE|||||12.25||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Tricare|TRICARE EAST REGION|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Medicare|MEDICARE ACUTE|12.25||||12.25||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Cigna|CIGNA|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Medicare|MEDICARE PART B ONLY IP|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Blue Cross HMO Specialty|BCBSTX HMO|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Cigna|CIGNA OTHER|||||12.25||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Managed Medicare|BCBS MEDICARE PPO MA|12.25||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Managed Medicare|HEALTHSPRING MA|12.25||||12.25||| 9513441|ERX|0250|GLYBURIDE 2.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||5.50||| 9513441|ERX|0250|GLYBURIDE 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|5.50||||||| 9513441|ERX|0250|GLYBURIDE 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|5.50||||5.50||| 9513441|ERX|0250|GLYBURIDE 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||||| 9513441|ERX|0250|GLYBURIDE 2.5MG TABLET|Medicare|MEDICARE ACUTE|5.50||||||| 9513441|ERX|0250|GLYBURIDE 2.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.09||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.09||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.09||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||0.09||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.09||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.09||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.09||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|||||0.09||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Medicaid|MEDICAID|0.09||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|PHCS|HUMANA|||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Healthcare|UNITED HEALTHCARE|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Aetna|AETNA QHP HMO|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Aetna|AETNA PPO|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Medicaid|MEDICAID|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||7.50||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.50||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|7.50||||||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||14.50||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Humana Medicare Advantage|HUMANA MA|14.50||||14.50||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|14.50||||||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|14.50||||||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.50||||14.50||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|14.50||||||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Medicare|MEDICARE ACUTE|14.50||||14.50||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Managed Medicare|HEALTHSPRING MA|||||14.50||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|United Healthcare|UNITED HEALTHCARE|14.50||||||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14.50||||14.50||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.50||||||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|Medicare|MEDICARE PART B ONLY IP|14.50||||||| 9513482|ERX|0250|VERAPAMIL SR 120MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|14.50||||||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Aetna|AETNA OTHER|15.50||||||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.50||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|15.50||||||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||15.50||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|United Healthcare|UNITED HEALTHCARE|15.50||||||| 9513508|ERX|0250|CARBIDOPA-LEVO SR 50-200M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||25.50||| 9513508|ERX|0250|CARBIDOPA-LEVO SR 50-200M|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9513508|ERX|0250|CARBIDOPA-LEVO SR 50-200M|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9513508|ERX|0250|CARBIDOPA-LEVO SR 50-200M|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9513508|ERX|0250|CARBIDOPA-LEVO SR 50-200M|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9513508|ERX|0250|CARBIDOPA-LEVO SR 50-200M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||12.25||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|Managed Medicare|HEALTHSPRING MA|12.25||||||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.25||||||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|12.25||||||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|12.25||||||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|Medicare|MEDICARE ACUTE|12.25||||12.25||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|Humana Medicare Advantage|HUMANA MA|12.25||||12.25||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|12.25||||||| 9513516|ERX|0250|DILTIAZEM SR 60MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|12.25||||||| 9513524|ERX|0250|DILTIAZEM SR 90MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|13.25||||||| 9513524|ERX|0250|DILTIAZEM SR 90MG CAPSULE|Humana Medicare Advantage|HUMANA MA|13.25||||||| 9513524|ERX|0250|DILTIAZEM SR 90MG CAPSULE|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9513532|ERX|0250|CROMOLYN 4% SPRAY|Managed Medicare|HEALTHSPRING MA|||||96.25||| 9513532|ERX|0250|CROMOLYN 4% SPRAY|Medicare|MEDICARE ACUTE|96.25||||96.25||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Managed Medicare|HEALTHSPRING MA|15.50||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|United Healthcare|UNITED HEALTHCARE|8.50||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.50||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Managed Medicare|HEALTHSPRING MA|8.50||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.50||||8.50||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|8.50||||8.50||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Aetna|BH AETNA|8.50||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Medicare|MEDICARE ACUTE|8.50||||8.50||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.50||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Humana Medicare Advantage|HUMANA MA|8.50||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|8.50||||8.50||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.50||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|8.50||||8.50||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.50||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.50||||||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|10.50||||10.50||| 9513565|ERX|0250|LABETALOL 200MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|10.50||||10.50||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|10.50||||||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.50||||||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Humana Medicare Advantage|HUMANA MA|10.50||||10.50||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|10.50||||10.50||| 9513565|ERX|0250|LABETALOL 200MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|10.50||||||| 9513565|ERX|0250|LABETALOL 200MG TABLET|United Healthcare|UNITED HEALTHCARE|10.50||||||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Managed Medicare|HEALTHSPRING MA|10.50||||||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Medicare|MEDICARE ACUTE|10.50||||10.50||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10.50||||||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10.50||||||| 9513565|ERX|0250|LABETALOL 200MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||10.50||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Medicare|MEDICARE PART B ONLY IP|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|United Healthcare|UNITED HEALTHCARE|||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Managed Medicare|HEALTHSPRING MA|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Aetna|AETNA OTHER|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Aetna|AETNA PPO|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Blue Cross HMO Specialty|BCBSTX HMO|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Blue Cross PPO Specialty|BCBSTX PPO|0.08||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Humana Medicare Advantage|HUMANA MA|0.08||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|United Healthcare|UNITED HEALTHCARE OTHER|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|PHCS|HUMANA|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Managed Medicaid|MEDICAID SUPERIOR|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.08||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.08||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|United Medicare Advantage|UHC AARP MCR HMO MA|0.08||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Veterans Affairs|VETERANS ADMINISTRATION|0.08||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.08||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.08||||0.08||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.08||| 9513581|ERX|0250|ENALAPRIL 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||||| 9513581|ERX|0250|ENALAPRIL 2.5MG TABLET|Medicaid|MEDICAID|12.75||||||| 9513581|ERX|0250|ENALAPRIL 2.5MG TABLET|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9513581|ERX|0250|ENALAPRIL 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9513581|ERX|0250|ENALAPRIL 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9513581|ERX|0250|ENALAPRIL 2.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|12.75||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||15.50||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||15.50||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Cigna|CIGNA|15.50||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Medicaid|SMITH COUNTY JAIL|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Medicaid|MEDICAID|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||||| 9513607|ERX|0250|ENALAPRIL 10MG TABLET|PHCS|HUMANA|15.50||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Healthcare|UNITED HEALTHCARE|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Tricare|TRICARE EAST REGION|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Healthcare|TML GROUP BENEFITS|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|PHCS|HUMANA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|PHCS|GROUP AND PENSION|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Rusk State Hospital|RUSK STATE HOSP|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Healthcare|GEHA|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicare|MEDICARE ACUTE|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|SMITH COUNTY JAIL|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|LAW ENFORCEMENT OTHER|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|ChampVA|CHAMPVA CENTER|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Aetna|BH AETNA|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Aetna Value Network|AETNA VALUE NETWORK|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Aetna|AETNA OTHER|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Aetna|AETNA QHP HMO|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|MEDICAID|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Magellan Behavioral Health|BH MAGELLAN|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Cigna|CIGNA OTHER|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Cigna|CIGNA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Aetna|AETNA PPO|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Cigna|CIGNA|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Optum Behavioral Health|BH OPTUM UHC|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Access Direct Platinum|ANDREWS CENTER|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|22.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22.25||||22.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|22.25||||22.25||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Workers Compensation|GALLAGHER BASSETT|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Aetna|AETNA OTHER|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Workers Compensation|BROOKSHIRES WORKERS COMP|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Cigna|CIGNA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Cigna Behavioral Health|BH CIGNA|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Access Direct Platinum|HEALTHFIRST TPA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Aetna|BOON CHAPMAN|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Aetna|AETNA PPO|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Aetna|AETNA QHP HMO|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicare|UTSW MC KIDNEY PROGRAM|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Cigna|CIGNA OTHER|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|CRIME VICTIMS COMPENSATION|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicare|JACKSONVILLE ACCESS|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|SMITH COUNTY JAIL|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|MEDICAID HMO|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|PHCS|HUMANA INSURANCE|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|BH TEXAS CHILDRENS MEDICAID|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|PHCS|HUMANA|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|PHCS|GROUP AND PENSION|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Tricare|TRICARE EAST REGION|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Tricare|TRICARE FOR LIFE|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|MEDICAID|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||2.50||| 9513656|ERX|0250|CARBIDOPA-LEVO SR 25-100M|Medicare|MEDICARE ACUTE|14.25||||14.25||| 9513656|ERX|0250|CARBIDOPA-LEVO SR 25-100M|Blue Cross PPO Specialty|BCBSTX PPO|14.25||||||| 9513656|ERX|0250|CARBIDOPA-LEVO SR 25-100M|United Medicare Advantage|UHC MEDICARE GOLD MA|14.25||||14.25||| 9513656|ERX|0250|CARBIDOPA-LEVO SR 25-100M|Managed Medicare|HEALTHSPRING MA|||||14.25||| 9513656|ERX|0250|CARBIDOPA-LEVO SR 25-100M|Humana Medicare Advantage|HUMANA MA|14.25||||14.25||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Access Direct Platinum|HEALTHFIRST TPA|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19.25||||19.25||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Veterans Affairs|VETERANS ADMINISTRATION|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Cigna|CIGNA|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Humana Medicare Advantage|HUMANA MA|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Aetna|AETNA OTHER|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.25||||19.25||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Aetna|AETNA PPO|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Blue Cross HMO Specialty|BCBSTX HMO|||||19.25||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.25||||19.25||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|United Healthcare|UNITED HEALTHCARE|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Medicare|MEDICARE ACUTE|19.25||||19.25||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Medicaid|MEDICAID|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Managed Medicare|HEALTHSPRING MA|19.25||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|19.25||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicaid|MEDICAID HMO|||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicaid|LAW ENFORCEMENT OTHER|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicaid|MEDICAID|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicare|MEDICARE ACUTE|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Tricare|TRICARE EAST REGION|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Multiplan|WEB TPA|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|PHCS|HUMANA|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Tricare|TRICARE FOR LIFE|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Aetna|AETNA OTHER|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Aetna|AETNA QHP HMO|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Aetna|AETNA PPO|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Cigna|CIGNA|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Cigna|CIGNA|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Cigna|CIGNA OTHER|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Aetna|BH AETNA|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.14||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.14||||0.14||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.14||||0.14||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|PHCS|HUMANA|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Tricare|TRICARE EAST REGION|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicaid|MEDICAID|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicaid|SMITH COUNTY JAIL|||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicaid|MEDICAID HMO|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Access Direct Platinum|ANDREWS CENTER|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Workers Compensation|TRAVELERS INSURANCE COMPANY|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Cigna Behavioral Health|BH CIGNA|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Cigna|CIGNA|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Aetna|BOON CHAPMAN|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Aetna|AETNA PPO|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Aetna|BH AETNA|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Aetna|AETNA OTHER|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Healthcare|UNITED HEALTHCARE|15.50||||15.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Healthcare|UNITED HEALTHCARE|15.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Healthcare|TML GROUP BENEFITS|15.50||||||| 9513698|ERX|0250|FLUVOXAMINE 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|26.75||||||| 9513698|ERX|0250|FLUVOXAMINE 50MG TABLET|Medicare|MEDICARE ACUTE|26.75||||||| 9513698|ERX|0250|FLUVOXAMINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|||||26.75||| 9513698|ERX|0250|FLUVOXAMINE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.75||||||| 9513698|ERX|0250|FLUVOXAMINE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||26.75||| 9513714|ERX|0250|SULFASALAZINE 500MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.10||| 9513714|ERX|0250|SULFASALAZINE 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||||| 9513714|ERX|0250|SULFASALAZINE 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.10||| 9513714|ERX|0250|SULFASALAZINE 500MG TABLE|Medicare|MEDICARE ACUTE|0.10||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Rusk State Hospital|RUSK STATE HOSP|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Tricare|TRICARE EAST REGION|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|NON CONTRACTED|COMMERCIAL OTHER 1|169.50||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|United Healthcare|UNITED HEALTHCARE OTHER|169.50||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|United Healthcare|UNITED HEALTHCARE|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Managed Medicare|BCBS MEDICARE PPO MA|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Managed Medicare|HEALTHSPRING MA|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicaid|SMITH COUNTY JAIL|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicare|MEDICARE PART B ONLY IP|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicare|MEDICARE ACUTE|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Managed Medicaid|MEDICAID SUPERIOR|169.50||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|169.50||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Cigna|CIGNA|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Cigna|CIGNA OTHER|||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Humana Medicare Advantage|HUMANA MA|169.50||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Blue Cross PPO Specialty|BCBSTX PPO|169.50||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|ChampVA|CHAMPVA CENTER|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicaid|MEDICAID HMO|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Aetna|AETNA PPO|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|169.50||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|169.50||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Aetna|AETNA OTHER|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Blue Cross HMO Specialty|BCBSTX HMO|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Workers Compensation|WORKERS COMPENSATION OTHER|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Workers Compensation|TEXAS MUTUAL INSURANCE|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Aenta Medicare Advantage|AETNA MEDICARE MA|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Access Direct Platinum|HEALTHFIRST TPA UMR|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Veterans Affairs|VETERANS ADMINISTRATION|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|United Medicare Advantage|UHC MEDICARE GOLD MA|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||169.50||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicaid|CRIME VICTIMS COMPENSATION|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|United Medicare Advantage|UHC AARP MCR HMO MA|169.50||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicaid|MEDICAID|169.50||||||| 9513755|ERX|0250|BISOPROLOL-HCTZ 10-6.25MG|Veterans Affairs|VETERANS ADMINISTRATION|31.25||||||| 9513755|ERX|0250|BISOPROLOL-HCTZ 10-6.25MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||31.25||| 9513755|ERX|0250|BISOPROLOL-HCTZ 10-6.25MG|Blue Cross HMO Specialty|BCBSTX HMO|31.25||||||| 9513755|ERX|0250|BISOPROLOL-HCTZ 10-6.25MG|Humana Medicare Advantage|HUMANA MA|31.25||||||| 9513755|ERX|0250|BISOPROLOL-HCTZ 10-6.25MG|Blue Cross PPO Specialty|BCBSTX PPO|||||31.25||| 9513755|ERX|0250|BISOPROLOL-HCTZ 10-6.25MG|Medicare|MEDICARE ACUTE|31.25||||||| 9513763|ERX|0250|BISOPROLOL-HCTZ 2.5-6.25M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.25||||||| 9513763|ERX|0250|BISOPROLOL-HCTZ 2.5-6.25M|United Healthcare|UNITED HEALTHCARE OTHER|31.25||||||| 9513763|ERX|0250|BISOPROLOL-HCTZ 2.5-6.25M|Managed Medicare|HEALTHSPRING MA|31.25||||||| 9513763|ERX|0250|BISOPROLOL-HCTZ 2.5-6.25M|Medicare|MEDICARE ACUTE|31.25||||31.25||| 9513763|ERX|0250|BISOPROLOL-HCTZ 2.5-6.25M|United Medicare Advantage|UHC MEDICARE GOLD MA|31.25||||||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|31.25||||||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|Humana Medicare Advantage|HUMANA MA|31.25||||||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.25||||||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|United Medicare Advantage|UHC AARP MCR HMO MA|31.25||||||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|United Medicare Advantage|UHC MEDICARE GOLD MA|31.25||||||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|Medicare|MEDICARE ACUTE|31.25||||31.25||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|31.25||||||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|United Healthcare|UNITED HEALTHCARE|31.25||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|31.25||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|United Healthcare|TML GROUP BENEFITS|||||31.25||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||31.25||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Medicare|MEDICARE ACUTE|31.25||||31.25||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|31.25||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|31.25||||31.25||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||31.25||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31.25||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|31.25||||31.25||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||31.25||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|31.25||||31.25||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.25||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|31.25||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|31.25||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|31.25||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|31.25||||31.25||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|31.25||||||| 9513797|ERX|0250|NORETHINDRONE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||28.50||| 9513797|ERX|0250|NORETHINDRONE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|28.50||||||| 9513797|ERX|0250|NORETHINDRONE 5MG TABLET|Medicaid|MEDICAID HMO|28.50||||||| 9513805|ERX|0250|DISULFIRAM 250MG TABLET|Optum Behavioral Health|BH OPTUM UHC|36.75||||||| 9513888|ERX|0250|BETHANECHOL 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9513888|ERX|0250|BETHANECHOL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9513888|ERX|0250|BETHANECHOL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9513904|ERX|0250|ACETAZOLAMIDE 500MG CAPSU|Medicaid|CRIME VICTIMS COMPENSATION|0.41||||||| 9513904|ERX|0250|ACETAZOLAMIDE 500MG CAPSU|NON CONTRACTED|COMMERCIAL OTHER 1|0.41||||||| 9513904|ERX|0250|ACETAZOLAMIDE 500MG CAPSU|Blue Cross PPO Specialty|BCBSTX PPO|0.41||||||| 9513904|ERX|0250|ACETAZOLAMIDE 500MG CAPSU|Humana Medicare Advantage|HUMANA MA|0.41||||||| 9513904|ERX|0250|ACETAZOLAMIDE 500MG CAPSU|Aenta Medicare Advantage|AETNA MEDICARE MA|0.41||||||| 9513904|ERX|0250|ACETAZOLAMIDE 500MG CAPSU|Medicare|MEDICARE ACUTE|0.41||||0.41||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Veterans Affairs|VETERANS ADMINISTRATION|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA|||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID SUPERIOR|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID AMERIGROUP|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Cigna|CIGNA OTHER|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Cigna|CIGNA|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Humana Medicare Advantage|HUMANA MA|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Aetna|AETNA OTHER|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Aetna|AETNA PPO|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Aetna|AETNA QHP HMO|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Aetna Value Network|AETNA VALUE NETWORK|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Cigna|CIGNA|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross PPO Specialty|BCBSTX OTHER|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross HMO Specialty|BCBSTX HMO|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE OTHER|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Healthcare|GEHA|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|PHCS|HUMANA|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|PHCS|GROUP AND PENSION|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicare|HEALTHSPRING MA|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicaid|MEDICAID|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicare|BCBS MEDICARE PPO MA|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Tricare|TRICARE EAST REGION|467.75||||467.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicare|MEDICARE PART B ONLY IP|467.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicare|MEDICARE ACUTE|467.75||||467.75||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Medicaid|MEDICAID|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Medicaid|SMITH COUNTY JAIL|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Managed Medicare|HEALTHSPRING MA|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|3.74||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|United Healthcare|UNITED HEALTHCARE|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|3.74||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Medicare|MEDICARE PART B ONLY IP|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Cigna|CIGNA|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Medicare|MEDICARE ACUTE|3.74||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Humana Medicare Advantage|HUMANA MA|3.74||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Tricare|TRICARE EAST REGION|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.74||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|3.74||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|3.74||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|3.74||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.74||||3.74||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|3.74||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.74||||3.74||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|6.72||||6.72||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.72||||6.72||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|6.72||||6.72||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||6.72||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Humana Medicare Advantage|HUMANA MA|6.72||||6.72||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.72||||6.72||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|6.72||||6.72||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|United Healthcare|UNITED HEALTHCARE|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Tricare|TRICARE EAST REGION|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Managed Medicare|HEALTHSPRING MA|6.72||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Medicare|MEDICARE ACUTE|6.72||||6.72||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Medicaid|MEDICAID|6.72||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.32||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Medicaid|MEDICAID HMO|||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Medicaid|SMITH COUNTY JAIL|2.32||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|NON CONTRACTED|COMMERCIAL OTHER 2|2.32||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|PHCS|HUMANA|2.32||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|PHCS|GROUP AND PENSION|2.32||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Tricare|TRICARE EAST REGION|2.32||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicare|BCBS MEDICARE PPO MA|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|United Healthcare|UNITED HEALTHCARE OTHER|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.32||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|ChampVA|CHAMPVA CENTER|2.32||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Medicaid|MEDICAID|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Humana Medicare Advantage|HUMANA MA|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Cigna|CIGNA|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Medicare|MEDICARE ACUTE|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicare|HEALTHSPRING MA|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|2.32||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Veterans Affairs|VETERANS ADMINISTRATION|2.32||||2.32||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|2.32||||2.32||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Veterans Affairs|VETERANS ADMINISTRATION|460.75||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|460.75||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|460.75||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Cigna|CIGNA OTHER|460.75||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Humana Medicare Advantage|HUMANA MA|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Aetna|AETNA PPO|||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|United Healthcare|UNITED HEALTHCARE OTHER|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Managed Medicare|HEALTHSPRING MA|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Tricare|TRICARE EAST REGION|460.75||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Managed Medicare|BCBS MEDICARE PPO MA|||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Medicaid|MEDICAID|460.75||||460.75||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|460.75||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Medicare|MEDICARE ACUTE|460.75||||460.75||| 9513987|ERX|0250|TRIAMCINOLONE 0.1% DENT ,|Medicare|MEDICARE ACUTE|292.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Blue Cross PPO Specialty|BCBSTX PPO|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Humana Medicare Advantage|HUMANA MA|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Managed Medicaid|MEDICAID SUPERIOR|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Blue Cross HMO Specialty|BCBSTX HMO|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Aenta Medicare Advantage|AETNA MEDICARE MA|33.50||||33.50||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||33.50||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|United Medicare Advantage|UHC AARP MCR HMO MA|33.50||||33.50||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|NON CONTRACTED|COMMERCIAL OTHER 1|||||33.50||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Tricare|TRICARE EAST REGION|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|UTMB|UTMB CORRECTIONAL MANAGED CARE|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Medicaid|SMITH COUNTY INDIGENT HEALTH|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Managed Medicare|HEALTHSPRING MA|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Medicare|MEDICARE PART B ONLY IP|33.50||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Medicare|MEDICARE ACUTE|33.50||||33.50||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Medicare|MEDICARE ACUTE|69.75||||69.75||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Managed Medicare|HEALTHSPRING MA|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Medicaid|MEDICAID|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|United Medicare Advantage|UHC AARP MCR HMO MA|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|United Medicare Advantage|UHC MEDICARE GOLD MA|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Access Direct Platinum|HEALTHFIRST TPA|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Managed Medicaid|MEDICAID UNITED HEALTHCARE|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||69.75||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Cigna|CIGNA|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Humana Medicare Advantage|HUMANA MA|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|69.75||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Blue Cross PPO Specialty|BCBSTX PPO|||||69.75||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||7.75||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|7.75||||7.75||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|United Healthcare|UNITED HEALTHCARE|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Medicaid|MEDICAID|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Managed Medicare|OTHER INSTITUTIONS|||||7.75||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Managed Medicare|HEALTHSPRING MA|7.75||||7.75||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Medicare|MEDICARE PART B ONLY IP|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|7.75||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Medicare|MEDICARE PART B ONLY IP|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Medicare|MEDICARE ACUTE|8.50||||8.50||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Managed Medicare|BCBS MEDICARE PPO MA|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Managed Medicare|HEALTHSPRING MA|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Medicaid|SMITH COUNTY JAIL|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Tricare|TRICARE EAST REGION|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|United Healthcare|UNITED HEALTHCARE|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|8.50||||8.50||| 9514050|ERX|0250|RENAL VITAMIN TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.50||||8.50||| 9514050|ERX|0250|RENAL VITAMIN TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Medicaid|MEDICAID|8.50||||8.50||| 9514050|ERX|0250|RENAL VITAMIN TABLET|PHCS|GROUP AND PENSION|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Veterans Affairs|VETERANS ADMINISTRATION|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Access Direct Platinum|HEALTHFIRST TPA|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.50||||8.50||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Aetna|AETNA PPO|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Aetna|AETNA OTHER|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Managed Medicaid|MEDICAID AMERIGROUP|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.50||||8.50||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Humana Medicare Advantage|HUMANA MA|8.50||||8.50||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.50||||8.50||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Blue Cross HMO Specialty|BCBSTX HMO|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.50||||||| 9514050|ERX|0250|RENAL VITAMIN TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.50||||8.50||| 9514068|ERX|0250|NALTREXONE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.47||||||| 9514068|ERX|0250|NALTREXONE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|0.47||||||| 9514068|ERX|0250|NALTREXONE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.47||| 9514068|ERX|0250|NALTREXONE 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.47||||||| 9514068|ERX|0250|NALTREXONE 50MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.47||||||| 9514068|ERX|0250|NALTREXONE 50MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.47||||||| 9514068|ERX|0250|NALTREXONE 50MG TABLET|Medicare|MEDICARE ACUTE|0.47||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicare|BCBS MEDICARE PPO MA|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicare|HEALTHSPRING MA|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|United Healthcare|TML GROUP BENEFITS|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|United Healthcare|UNITED HEALTHCARE ERS|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|United Healthcare|UNITED HEALTHCARE|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Medicaid|MEDICAID|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|NON CONTRACTED|COMMERCIAL OTHER 1|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|United Medicare Advantage|UHC MEDICARE GOLD MA|5.75||||5.75||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Workers Compensation|WORKERS COMPENSATION OTHER|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.75||||5.75||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Aenta Medicare Advantage|AETNA MEDICARE MA|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Medicare|MEDICARE ACUTE|5.75||||5.75||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Tricare|TRICARE EAST REGION|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicaid|MEDICAID AMERIGROUP|5.75||||5.75||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|United Healthcare|UNITED HEALTHCARE OTHER|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Magellan Behavioral Health|BH MAGELLAN|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Cigna|CIGNA|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Humana Medicare Advantage|HUMANA MA|5.75||||5.75||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicaid|MEDICAID SUPERIOR|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.75||||5.75||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Aetna|AETNA OTHER|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Access Direct Platinum|HEALTHFIRST TPA UMR|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.75||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.75||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||5.75||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Blue Cross HMO Specialty|BCBSTX HMO|5.75||||5.75||| 9514084|ERX|0250|PEG 3350, 4L|Blue Cross HMO Specialty|BCBSTX HMO|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Blue Cross PPO Specialty|BCBSTX PPO|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Aetna|AETNA PPO|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Humana Medicare Advantage|HUMANA MA|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|Cigna|CIGNA|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Cigna|CIGNA OTHER|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|Managed Medicaid|MEDICAID AMERIGROUP|||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|Access Direct Platinum|HEALTHFIRST TPA UMR|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Managed Medicaid|MEDICAID SUPERIOR|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Access Direct Platinum|HEALTHFIRST TPA|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Aenta Medicare Advantage|AETNA MEDICARE MA|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Managed Medicaid|MEDICAID UNITED HEALTHCARE|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Workers Compensation|ZURICH COMPANY|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|ChampVA|CHAMPVA CENTER|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Workers Compensation|WORKERS COMPENSATION OTHER|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Veterans Affairs|VETERANS ADMINISTRATION|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|United Medicare Advantage|UHC AARP WELLMED HMO MA|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|United Medicare Advantage|UHC AARP MCR HMO MA|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|United Medicare Advantage|UHC MEDICARE GOLD MA|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|UTMB|UTMB CORRECTIONAL MANAGED CARE|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|United Healthcare|UNITED HEALTHCARE|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|Medicare|MEDICARE PART B ONLY IP|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Tricare|TRICARE EAST REGION|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Medicare|MEDICARE ACUTE|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|United Healthcare|UNITED HEALTHCARE OTHER|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Managed Medicare|HEALTHSPRING MA|198.75||||198.75||| 9514084|ERX|0250|PEG 3350, 4L|Managed Medicare|BCBS MEDICARE PPO MA|198.75||||||| 9514084|ERX|0250|PEG 3350, 4L|Medicaid|MEDICAID|198.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Managed Medicare|OTHER INSTITUTIONS|||||772.75||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Managed Medicare|HEALTHSPRING MA|772.75||||772.75||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Managed Medicare|BCBS MEDICARE PPO MA|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Medicare|MEDICARE PART B ONLY IP|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|United Healthcare|UNITED HEALTHCARE OTHER|772.75||||772.75||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|United Healthcare|UNITED HEALTHCARE|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Medicare|MEDICARE ACUTE|772.75||||772.75||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Rusk State Hospital|RUSK STATE HOSP|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Tricare|TRICARE EAST REGION|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|United Medicare Advantage|UHC MEDICARE GOLD MA|772.75||||772.75||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|772.75||||772.75||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|United Medicare Advantage|UHC AARP MCR HMO MA|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Access Direct Platinum|HEALTHFIRST TPA UMR|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Veterans Affairs|VETERANS ADMINISTRATION|772.75||||772.75||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Aenta Medicare Advantage|AETNA MEDICARE MA|772.75||||772.75||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Humana Medicare Advantage|HUMANA MA|772.75||||772.75||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|772.75||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Blue Cross PPO Specialty|BCBSTX PPO|772.75||||772.75||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Brinson Benefits|THE HEALTH PLAN SMITH CO|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|ChampVA|CHAMPVA CENTER|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Aetna|BH AETNA|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Cigna|CIGNA|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Cigna|CIGNA OTHER|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Aetna|AETNA OTHER|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Workers Compensation|TEXAS MUTUAL INSURANCE|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Workers Compensation|BROOKSHIRES WORKERS COMP|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Aetna|AETNA PPO|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Access Direct Platinum|HEALTHFIRST TPA|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|PHCS|GROUP AND PENSION|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|PHCS|HUMANA INSURANCE|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Rusk State Hospital|RUSK STATE HOSP|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Optum Behavioral Health|BH OPTUM UHC|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Tricare|TRICARE EAST REGION|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Aetna|BOON CHAPMAN|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Magellan Behavioral Health|BH MAGELLAN|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|PHCS|HUMANA|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Multiplan|WEB TPA|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Healthcare|TML GROUP BENEFITS|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Healthcare|GOLDEN RULE|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicaid|LAW ENFORCEMENT OTHER|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicaid|MEDICAID HMO|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicaid|MEDICAID|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicaid|SMITH COUNTY JAIL|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicaid|SMITH COUNTY INDIGENT HEALTH|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicare|OTHER INSTITUTIONS|||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicare|ETMC AFFILIATE HOSPITALS|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicare|JACKSONVILLE ACCESS|25.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9514159|ERX|0250|LOXAPINE 5MG CAPSULE|Medicare|MEDICARE ACUTE|20.75||||||| 9514159|ERX|0250|LOXAPINE 5MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|20.75||||||| 9514159|ERX|0250|LOXAPINE 5MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.75||||||| 9514167|ERX|0250|LOXAPINE 10MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9514167|ERX|0250|LOXAPINE 10MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||||| 9514175|ERX|0250|LOXAPINE 25MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|32.50||||||| 9514175|ERX|0250|LOXAPINE 25MG CAPSULE|Medicare|MEDICARE ACUTE|32.50||||||| 9514175|ERX|0250|LOXAPINE 25MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|32.50||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Aetna|AETNA PPO|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Aetna|AETNA OTHER|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Aetna|AETNA QHP HMO|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Blue Cross PPO Specialty|BCBSTX PPO|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Blue Cross HMO Specialty|BCBSTX HMO|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Brinson Benefits|THE HEALTH PLAN SMITH CO|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|ChampVA|CHAMPVA CENTER|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Cigna|CIGNA OTHER|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Cigna|CIGNA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Humana Medicare Advantage|HUMANA MA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID SUPERIOR|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID AMERIGROUP|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST TPA UMR|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST TPA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Aenta Medicare Advantage|AETNA MEDICARE MA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|TEXAS MUTUAL INSURANCE|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|UT EMPLOYEE INJURY|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Veterans Affairs|VETERANS ADMINISTRATION|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Medicare Advantage|UHC MEDICARE GOLD MA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|WORKERS COMPENSATION OTHER|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|BROOKSHIRES WORKERS COMP|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Medicare Advantage|UHC AARP WELLMED HMO MA|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Medicare Advantage|UHC AARP MCR HMO MA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Healthcare|TML GROUP BENEFITS|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Healthcare|UNITED HEALTHCARE|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Healthcare|GEHA|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Healthcare|AARP|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Healthcare|UNITED HEALTHCARE OTHER|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|PHCS|GROUP AND PENSION|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|PHCS|HUMANA INSURANCE|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|PHCS|HUMANA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Rusk State Hospital|RUSK STATE HOSP|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Tricare|TRICARE FOR LIFE|||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|NON CONTRACTED|COMMERCIAL OTHER 4|||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Cigna Behavioral Health|BH CIGNA|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicare|HEALTHSPRING MA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|NON CONTRACTED|COMMERCIAL OTHER 2|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|SUPERIOR HEALTHPLAN CHIP|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicare|BCBS MEDICARE PPO MA|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|SMITH COUNTY INDIGENT HEALTH|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|MEDICAID HMO|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Blue Cross PPO Specialty|BCBSTX OTHER|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Aetna|BOON CHAPMAN|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|LAW ENFORCEMENT OTHER|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Tricare|TRICARE EAST REGION|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|SMITH COUNTY JAIL|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|CRIME VICTIMS COMPENSATION|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|MEDICAID|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicare|MEDICARE PART B ONLY IP|21.25||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|NON CONTRACTED|COMMERCIAL OTHER 1|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicare|MEDICARE ACUTE|21.25||||21.25||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|21.25||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|CRIME VICTIMS COMPENSATION|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|SMITH COUNTY JAIL|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|MEDICAID|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|LAW ENFORCEMENT OTHER|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Multiplan|PACIFICARE|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|NON CONTRACTED|COMMUNITY HEALTH CENTER|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|PHCS|GROUP AND PENSION|||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|PHCS|HUMANA INSURANCE|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Rusk State Hospital|RUSK STATE HOSP|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Tricare|TRICARE EAST REGION|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Tricare|TRICARE FOR LIFE|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Healthcare|UNITED HEALTHCARE ERS|||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Healthcare|UNITED HEALTHCARE|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Workers Compensation|WORKERS COMPENSATION OTHER|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Workers Compensation|WORKERS COMP PHYSICIAN|||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Workers Compensation|BROOKSHIRES WORKERS COMP|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Workers Compensation|ZURICH COMPANY|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Workers Compensation|TEXAS MUTUAL INSURANCE|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Access Direct Platinum|HEALTHFIRST TPA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|SUPERIOR HEALTHPLAN CHIP|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicaid|MEDICAID SUPERIOR|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Workers Compensation|GALLAGHER BASSETT|||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Brinson Benefits|THE HEALTH PLAN SMITH CO|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|ChampVA|CHAMPVA CENTER|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Cigna|CIGNA|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Blue Cross PPO Specialty|BCBSTX OTHER|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Aetna|AETNA PPO|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Workers Compensation|UT EMPLOYEE INJURY|||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Aetna|BOON CHAPMAN|15.50||||15.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Aetna|AETNA OTHER|15.50||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross PPO Specialty|BCBSTX OTHER|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Aetna|AETNA PPO|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Aetna|AETNA OTHER|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Aetna|BOON CHAPMAN|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Aetna|AETNA QHP HMO|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|ChampVA|CHAMPVA CENTER|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Brinson Benefits|THE HEALTH PLAN SMITH CO|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Magellan Behavioral Health|BH MAGELLAN|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Cigna|CIGNA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicaid|MEDICAID SUPERIOR|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Access Direct Platinum|HEALTHFIRST TPA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Workers Compensation|WORKERS COMP PHYSICIAN|||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Workers Compensation|ZURICH COMPANY|||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Workers Compensation|BROOKSHIRES WORKERS COMP|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Medicare Advantage|UHC AARP WELLMED HMO MA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Healthcare|UNITED HEALTHCARE|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Workers Compensation|WORKERS COMPENSATION OTHER|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Healthcare|TML GROUP BENEFITS|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Healthcare|GOLDEN RULE|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Healthcare|GEHA|||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|PHCS|GROUP AND PENSION|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|PHCS|HUMANA INSURANCE|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|PHCS|HUMANA|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Rusk State Hospital|RUSK STATE HOSP|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Texas Workforce Commission|DIS DETER SERV (DDS)|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Tricare|TRICARE FOR LIFE|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Cigna|CIGNA OTHER|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Workers Compensation|TEXAS MUTUAL INSURANCE|||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Tricare|TRICARE EAST REGION|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Multiplan|WEB TPA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|NON CONTRACTED|COMMERCIAL OTHER 2|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicare|OTHER INSTITUTIONS|||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|SMITH COUNTY JAIL|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Aetna Value Network|AETNA VALUE NETWORK|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|LAW ENFORCEMENT OTHER|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|MOLINA HEALTHCARE OF TEXAS|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|MEDICAID|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|SUPERIOR HEALTHPLAN CHIP|15.50||||15.50||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|MEDICAID HMO|15.50||||15.50||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Managed Medicare|HEALTHSPRING MA|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|NON CONTRACTED|COMMERCIAL OTHER 1|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Tricare|TRICARE EAST REGION|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|UTMB|UTMB CORRECTIONAL MANAGED CARE|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|United Medicare Advantage|UHC MEDICARE GOLD MA|441.75||||441.75||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Veterans Affairs|VETERANS ADMINISTRATION|||||441.75||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|United Medicare Advantage|UHC AARP MCR HMO MA|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Access Direct Platinum|HEALTHFIRST TPA|||||441.75||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Cigna|CIGNA|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Blue Cross PPO Specialty|BCBSTX PPO|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Blue Cross PPO Specialty|BCBSTX OTHER|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Blue Cross HMO Specialty|BCBSTX HMO|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Medicaid|MEDICAID|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Aetna|AETNA PPO|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Humana Medicare Advantage|HUMANA MA|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Managed Medicaid|MEDICAID AMERIGROUP|441.75||||441.75||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|441.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|441.75||||441.75||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Medicare|MEDICARE ACUTE|441.75||||441.75||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Managed Medicaid|MEDICAID SUPERIOR|441.75||||||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||49.75||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|49.75||||||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|49.75||||||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|49.75||||||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|49.75||||||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|49.75||||||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|||||49.75||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Medicaid|SMITH COUNTY JAIL|49.75||||||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Medicare|MEDICARE ACUTE|49.75||||49.75||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|49.75||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|United Healthcare|UNITED HEALTHCARE OTHER|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|United Healthcare|UNITED HEALTHCARE|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Tricare|TRICARE EAST REGION|||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Medicare|MEDICARE ACUTE|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Medicare|MEDICARE PART B ONLY IP|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Medicaid|MEDICAID|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicare|HEALTHSPRING MA|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Veterans Affairs|VETERANS ADMINISTRATION|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|United Medicare Advantage|UHC AARP MCR HMO MA|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Workers Compensation|UT EMPLOYEE INJURY|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Access Direct Platinum|HEALTHFIRST TPA UMR|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|United Medicare Advantage|UHC MEDICARE GOLD MA|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Humana Medicare Advantage|HUMANA MA|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Medicaid|SMITH COUNTY JAIL|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Cigna|CIGNA|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicaid|MEDICAID AMERIGROUP|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|NON CONTRACTED|COMMERCIAL OTHER 1|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Blue Cross PPO Specialty|BCBSTX OTHER|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Blue Cross PPO Specialty|BCBSTX PPO|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Blue Cross HMO Specialty|BCBSTX HMO|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Magellan Behavioral Health|BH MAGELLAN|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Aetna|AETNA PPO|0.21||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicaid|MEDICAID SUPERIOR|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Aenta Medicare Advantage|AETNA MEDICARE MA|0.21||||0.21||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.21||||0.21||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30.75||||30.75||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Blue Cross PPO Specialty|BCBSTX PPO|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Managed Medicaid|MEDICAID AMERIGROUP|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Humana Medicare Advantage|HUMANA MA|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Workers Compensation|UT EMPLOYEE INJURY|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|United Medicare Advantage|UHC AARP MCR HMO MA|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Managed Medicare|HEALTHSPRING MA|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Veterans Affairs|VETERANS ADMINISTRATION|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Medicaid|LAW ENFORCEMENT OTHER|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Medicare|MEDICARE ACUTE|30.75||||30.75||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|NON CONTRACTED|COMMERCIAL OTHER 1|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||30.75||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Rusk State Hospital|RUSK STATE HOSP|30.75||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Tricare|TRICARE EAST REGION|30.75||||||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|26.75||||||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|Medicare|MEDICARE ACUTE|26.75||||26.75||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|Medicaid|MEDICAID|26.75||||||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|26.75||||||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.75||||||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|26.75||||||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|26.75||||||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.75||||||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|26.75||||||| 9514324|ERX|0250|METOLAZONE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|26.75||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Cigna|CIGNA|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Medicaid|MEDICAID|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|PHCS|HUMANA|||||25.50||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Medicare|MEDICARE ACUTE|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Medicaid|MEDICAID|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.23||||0.23||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.23||||0.23||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.23||||0.23||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Medicaid|SMITH COUNTY JAIL|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.23||||0.23||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Aetna|AETNA OTHER|0.23||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.23||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Aetna|AETNA OTHER|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Aetna|BH AETNA|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Cigna|CIGNA OTHER|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Cigna|CIGNA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Cigna|CIGNA|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicaid|LAW ENFORCEMENT OTHER|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicaid|SMITH COUNTY JAIL|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicaid|MEDICAID|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Aetna|AETNA QHP HMO|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Aetna|AETNA PPO|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|PHCS|HUMANA|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Tricare|TRICARE EAST REGION|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Healthcare|TML GROUP BENEFITS|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|PHCS|GROUP AND PENSION|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Medicare|MEDICARE ACUTE|16.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Rusk State Hospital|RUSK STATE HOSP|16.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|16.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Medicaid|MEDICAID|16.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Managed Medicare|HEALTHSPRING MA|16.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|16.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|16.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|16.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.50||||16.50||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|16.50||||||| 9514381|ERX|0250|MINOXIDIL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.50||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.20||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.20||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.20||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.20||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.20||||0.20||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.20||||0.20||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.20||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.20||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.20||||0.20||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.20||||0.20||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.20||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Medicaid|MEDICAID HMO|0.20||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.20||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Medicare|MEDICARE ACUTE|0.20||||0.20||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Medicaid|MEDICAID|0.20||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Medicare|MEDICARE ACUTE|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Medicaid|SMITH COUNTY JAIL|||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Medicaid|MEDICAID|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicare|HOSPICE OF EAST TEXAS|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Aetna|AETNA OTHER|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Aetna|AETNA PPO|31.50||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|31.50||||31.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|31.50||||||| 9514449|ERX|0250|CYCLOPHOSPHAMIDE 25MG TAB|Medicare|MEDICARE ACUTE|25.50||||||| 9514456|ERX|0250|ANAGRELIDE 0.5MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|0.67||||||| 9514456|ERX|0250|ANAGRELIDE 0.5MG CAPSULE|Medicare|MEDICARE ACUTE|0.67||||||| 9514464|ERX|0250|CARBAMAZEPINE 200MG CAPSU|Access Direct Platinum|ANDREWS CENTER|19.75||||||| 9514472|ERX|0250|CARBAMAZEPINE XR 300MG CA|Access Direct Platinum|ANDREWS CENTER|19.75||||||| 9514480|ERX|0250|MESALAMINE 250MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|0.15||||||| 9514480|ERX|0250|MESALAMINE 250MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.15||||||| 9514480|ERX|0250|MESALAMINE 250MG CAPSULE|Medicare|MEDICARE ACUTE|0.15||||||| 9514480|ERX|0250|MESALAMINE 250MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9514498|ERX|0250|LANTHANUM CARBONATE 500MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|55.75||||||| 9514498|ERX|0250|LANTHANUM CARBONATE 500MG|Medicare|MEDICARE ACUTE|55.75||||55.75||| 9514498|ERX|0250|LANTHANUM CARBONATE 500MG|Medicaid|SMITH COUNTY JAIL|||||55.75||| 9514506|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Optum Behavioral Health|BH OPTUM UHC|0.53||||||| 9514506|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|NON CONTRACTED|COMMERCIAL OTHER 1|0.53||||||| 9514506|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Blue Cross PPO Specialty|BCBSTX PPO|0.53||||||| 9514506|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.53||||||| 9514506|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Managed Medicaid|MEDICAID AMERIGROUP|0.53||||||| 9514506|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.53||||||| 9514514|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Blue Cross PPO Specialty|BCBSTX PPO|0.53||||||| 9514514|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Medicaid|MEDICAID|0.53||||||| 9514514|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Medicare|MEDICARE ACUTE|0.53||||||| 9514514|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|United Medicare Advantage|UHC MEDICARE GOLD MA|0.53||||||| 9514514|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.53||| 9514514|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.53||||0.53||| 9514514|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.53||||||| 9514514|ERX|0250|AMPHETAMINE/DEXTR0AM XR 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.53||||||| 9514522|ERX|0250|AMPHETAMINE/DEXTR0AM XR 2|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.53||||||| 9514522|ERX|0250|AMPHETAMINE/DEXTR0AM XR 2|Blue Cross PPO Specialty|BCBSTX PPO|0.53||||||| 9514522|ERX|0250|AMPHETAMINE/DEXTR0AM XR 2|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.53||||||| 9514530|ERX|0250|MINERAL OIL, 25ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.29||| 9514530|ERX|0250|MINERAL OIL, 25ML|Humana Medicare Advantage|HUMANA MA|0.29||||||| 9514530|ERX|0250|MINERAL OIL, 25ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.29||| 9514530|ERX|0250|MINERAL OIL, 25ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.29||| 9514530|ERX|0250|MINERAL OIL, 25ML|Veterans Affairs|VETERANS ADMINISTRATION|0.29||||||| 9514530|ERX|0250|MINERAL OIL, 25ML|Aetna|AETNA PPO|0.29||||||| 9514530|ERX|0250|MINERAL OIL, 25ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.29||| 9514530|ERX|0250|MINERAL OIL, 25ML|Blue Cross HMO Specialty|BCBSTX HMO|0.29||||||| 9514530|ERX|0250|MINERAL OIL, 25ML|Blue Cross PPO Specialty|BCBSTX PPO|0.29||||0.29||| 9514530|ERX|0250|MINERAL OIL, 25ML|United Healthcare|UNITED HEALTHCARE|0.29||||0.29||| 9514530|ERX|0250|MINERAL OIL, 25ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.29||||||| 9514530|ERX|0250|MINERAL OIL, 25ML|Tricare|TRICARE EAST REGION|0.29||||||| 9514530|ERX|0250|MINERAL OIL, 25ML|Medicare|MEDICARE ACUTE|0.29||||0.29||| 9514530|ERX|0250|MINERAL OIL, 25ML|Managed Medicare|HEALTHSPRING MA|||||0.29||| 9514530|ERX|0250|MINERAL OIL, 25ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.29||| 9514530|ERX|0250|MINERAL OIL, 25ML|Medicaid|CRIME VICTIMS COMPENSATION|0.29||||||| 9514530|ERX|0250|MINERAL OIL, 25ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.29||||||| 9514548|ERX|0250|OXANDROLONE 2.5MG TABLET|Medicare|MEDICARE ACUTE|76.25||||||| 9514571|ERX|0250|PERMETHRIN 1% RINSE, 59ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||94.75||| 9514571|ERX|0250|PERMETHRIN 1% RINSE, 59ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|94.75||||||| 9514571|ERX|0250|PERMETHRIN 1% RINSE, 59ML|Managed Medicaid|MEDICAID AMERIGROUP|94.75||||||| 9514571|ERX|0250|PERMETHRIN 1% RINSE, 59ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|94.75||||||| 9514571|ERX|0250|PERMETHRIN 1% RINSE, 59ML|United Medicare Advantage|UHC MEDICARE GOLD MA|94.75||||||| 9514571|ERX|0250|PERMETHRIN 1% RINSE, 59ML|Medicaid|MEDICAID|94.75||||||| 9514571|ERX|0250|PERMETHRIN 1% RINSE, 59ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|94.75||||||| 9514571|ERX|0250|PERMETHRIN 1% RINSE, 59ML|Medicare|MEDICARE ACUTE|94.75||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Access Direct Platinum|ANDREWS CENTER|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Multiplan|WEB TPA|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Aetna|BH AETNA|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Aetna|AETNA QHP HMO|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Cigna Behavioral Health|BH CIGNA|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Cigna|CIGNA|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9514605|ERX|0250|CLOBETASOL 0.05% OINT, 15|Humana Medicare Advantage|HUMANA MA|431.25||||431.25||| 9514605|ERX|0250|CLOBETASOL 0.05% OINT, 15|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|431.25||||431.25||| 9514605|ERX|0250|CLOBETASOL 0.05% OINT, 15|United Medicare Advantage|UHC MEDICARE GOLD MA|431.25||||||| 9514605|ERX|0250|CLOBETASOL 0.05% OINT, 15|United Medicare Advantage|UHC AARP MCR HMO MA|431.25||||||| 9514605|ERX|0250|CLOBETASOL 0.05% OINT, 15|Medicare|MEDICARE ACUTE|431.25||||||| 9514613|ERX|0250|AMPHETAMINE-DEXTR0AM 10MG|Tricare|TRICARE EAST REGION|25.50||||||| 9514613|ERX|0250|AMPHETAMINE-DEXTR0AM 10MG|Medicaid|BH TEXAS CHILDRENS MEDICAID|25.50||||||| 9514613|ERX|0250|AMPHETAMINE-DEXTR0AM 10MG|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9514613|ERX|0250|AMPHETAMINE-DEXTR0AM 10MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9514613|ERX|0250|AMPHETAMINE-DEXTR0AM 10MG|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9514613|ERX|0250|AMPHETAMINE-DEXTR0AM 10MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9514621|ERX|0250|AMPHETAMINE-DEXTR0AM 5MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9514621|ERX|0250|AMPHETAMINE-DEXTR0AM 5MG|Optum Behavioral Health|BH OPTUM UHC|25.50||||||| 9514639|ERX|0250|AMPHETAMINE-DEXTR0AM 20MG|Tricare|TRICARE EAST REGION|25.50||||||| 9514639|ERX|0250|AMPHETAMINE-DEXTR0AM 20MG|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9514639|ERX|0250|AMPHETAMINE-DEXTR0AM 20MG|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9514639|ERX|0250|AMPHETAMINE-DEXTR0AM 20MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9514647|ERX|0250|IFOSFAMIDE 1000MG/20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|349.95||||||| 9514647|ERX|0250|IFOSFAMIDE 1000MG/20ML|Medicare|MEDICARE ACUTE|349.95||||||| 9514647|ERX|0250|IFOSFAMIDE 1000MG/20ML|United Healthcare|UNITED HEALTHCARE OTHER|349.95||||||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Managed Medicare|HEALTHSPRING MA|1.84||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Medicare|MEDICARE ACUTE|1.84||||||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Cigna|CIGNA|1.84||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.84||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Aetna|BH AETNA|1.84||||||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Humana Medicare Advantage|HUMANA MA|1.84||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Aetna|AETNA PPO|1.84||||||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.84||||||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|1.84||||||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|1.84||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|1.84||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|1.84||||||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.84||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.84||||1.84||| 9514662|ERX|0250|SUMATRIPTAN 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.84||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.50||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|46.50||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|United Medicare Advantage|UHC AARP MCR HMO MA|46.50||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Blue Cross PPO Specialty|BCBSTX PPO|46.50||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Blue Cross HMO Specialty|BCBSTX HMO|46.50||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.50||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Aetna|AETNA QHP HMO|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Aetna|AETNA OTHER|||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Access Direct Platinum|HEALTHFIRST TPA|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Cigna|CIGNA|||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Humana Medicare Advantage|HUMANA MA|46.50||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|United Healthcare|UNITED HEALTHCARE|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Medicare|MEDICARE PART B ONLY IP|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Medicare|MEDICARE ACUTE|46.50||||46.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Medicaid|MEDICAID|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Managed Medicare|HEALTHSPRING MA|46.50||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Managed Medicare|OTHER INSTITUTIONS|||||46.50||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|88.75||||88.75||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Managed Medicare|HEALTHSPRING MA|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Medicaid|MEDICAID|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|United Healthcare|UNITED HEALTHCARE OTHER|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|United Healthcare|UNITED HEALTHCARE|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Humana Medicare Advantage|HUMANA MA|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Managed Medicaid|MEDICAID SUPERIOR|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Aetna|AETNA PPO|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|88.75||||88.75||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Medicare|MEDICARE ACUTE|88.75||||88.75||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Managed Medicare|OTHER INSTITUTIONS|||||88.75||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Blue Cross PPO Specialty|BCBSTX PPO|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Blue Cross HMO Specialty|BCBSTX HMO|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|United Medicare Advantage|UHC AARP MCR HMO MA|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|88.75||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|88.75||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Aetna|AETNA PPO|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Cigna|CIGNA|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Humana Medicare Advantage|HUMANA MA|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|United Healthcare|UNITED HEALTHCARE|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Medicare|MEDICARE ACUTE|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Managed Medicare|BCBS MEDICARE PPO MA|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Managed Medicare|HEALTHSPRING MA|47.19||||||| 9514696|ERX|0250|MILRINONE 10MG/10ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||47.19||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Managed Medicare|BCBS MEDICARE PPO MA|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Medicare|MEDICARE ACUTE|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Medicaid|MEDICAID|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|NON CONTRACTED|COMMERCIAL OTHER 1|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|United Healthcare|UNITED HEALTHCARE OTHER|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|United Healthcare|UNITED HEALTHCARE|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Humana Medicare Advantage|HUMANA MA|63.89||||63.89||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Blue Cross PPO Specialty|BCBSTX PPO|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Veterans Affairs|VETERANS ADMINISTRATION|63.89||||||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|63.89||||63.89||| 9514704|ERX|0250|MILRINONE 20MG/20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|63.89||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Workers Compensation|TEXAS MUTUAL INSURANCE|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Workers Compensation|UT EMPLOYEE INJURY|||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|ChampVA|CHAMPVA CENTER|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Aetna|AETNA OTHER|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Aetna|BOON CHAPMAN|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Aetna|AETNA PPO|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Aetna Value Network|AETNA VALUE NETWORK|||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Cigna|CIGNA|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Cigna|CIGNA OTHER|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Cigna|CIGNA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Humana Medicare Advantage|HUMANA MA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Healthcare|GEHA|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Healthcare|UNITED HEALTHCARE|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Healthcare|TML GROUP BENEFITS|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|PHCS|GROUP AND PENSION|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|PHCS|HUMANA|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Rusk State Hospital|RUSK STATE HOSP|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Tricare|TRICARE EAST REGION|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Access Direct Platinum|HEALTHFIRST TPA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 4|||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicare|MEDICARE PART B ONLY IP|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicare|MEDICARE ACUTE|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicare|HEALTHSPRING MA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|CRIME VICTIMS COMPENSATION|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|SMITH COUNTY JAIL|18.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|MEDICAID HMO|||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|MEDICAID|18.75||||18.75||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|18.75||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicaid|MEDICAID|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicaid|CRIME VICTIMS COMPENSATION|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicare|WELLCARE CHOICE MA|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicare|HEALTHSPRING MA|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicare|MEDICARE PART B ONLY IP|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicare|MEDICARE ACUTE|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|PHCS|GROUP AND PENSION|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Rusk State Hospital|RUSK STATE HOSP|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Tricare|TRICARE SOUTH PHYSICIAN|||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|United Healthcare|TML GROUP BENEFITS|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|United Healthcare|UNITED HEALTHCARE|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Cigna|CIGNA|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Cigna|CIGNA OTHER|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Humana Medicare Advantage|HUMANA MA|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Aetna|AETNA OTHER|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Aetna|AETNA QHP HMO|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|United Healthcare|UNITED HEALTHCARE|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Tricare|TRICARE EAST REGION|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Aetna|AETNA PPO|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|ChampVA|CHAMPVA CENTER|||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.50||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|||||46.50||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|46.50||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Workers Compensation|TEXAS MUTUAL INSURANCE|46.50||||||| 9514746|ERX|0250|LEUCOVORIN 100MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|61.50||||||| 9514746|ERX|0250|LEUCOVORIN 100MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|61.50||||||| 9514746|ERX|0250|LEUCOVORIN 100MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|61.50||||||| 9514746|ERX|0250|LEUCOVORIN 100MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|61.50||||||| 9514746|ERX|0250|LEUCOVORIN 100MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|61.50||||||| 9514746|ERX|0250|LEUCOVORIN 100MG/10ML|Medicare|MEDICARE ACUTE|61.50||||||| 9514746|ERX|0250|LEUCOVORIN 100MG/10ML|Managed Medicare|WELLCARE CHOICE MA|61.50||||||| 9514746|ERX|0250|LEUCOVORIN 100MG/10ML|Medicaid|MEDICAID|61.50||||||| 9514753|ERX|0250|LEUCOVORIN 350MG/17.5ML|Medicaid|MEDICAID|162.50||||||| 9514753|ERX|0250|LEUCOVORIN 350MG/17.5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|162.50||||||| 9514753|ERX|0250|LEUCOVORIN 350MG/17.5ML|Blue Cross PPO Specialty|BCBSTX PPO|162.50||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Veterans Affairs|VETERANS ADMINISTRATION|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|United Medicare Advantage|UHC AARP MCR HMO MA|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|United Medicare Advantage|UHC MEDICARE GOLD MA|127.25||||127.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Cigna|CIGNA|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Humana Medicare Advantage|HUMANA MA|127.25||||127.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Managed Medicaid|MEDICAID SUPERIOR|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|127.25||||127.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|ChampVA|CHAMPVA CENTER|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|127.25||||127.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Blue Cross PPO Specialty|BCBSTX PPO|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Blue Cross HMO Specialty|BCBSTX HMO|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Aetna|AETNA OTHER|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127.25||||127.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|United Healthcare|UNITED HEALTHCARE OTHER|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Workers Compensation|WORKERS COMPENSATION OTHER|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|United Healthcare|UNITED HEALTHCARE|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|United Healthcare|TML GROUP BENEFITS|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||127.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Medicare|MEDICARE ACUTE|127.25||||127.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Managed Medicare|WELLCARE CHOICE MA|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|127.25||||127.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Managed Medicare|HEALTHSPRING MA|127.25||||127.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Managed Medicare|BCBS MEDICARE PPO MA|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|127.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Medicaid|MEDICAID|127.25||||||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Medicaid|SMITH COUNTY JAIL|192.50||||||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Medicaid|MEDICAID|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicare|BCBS MEDICARE PPO MA|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Medicare|MEDICARE ACUTE|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE OTHER|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Aetna|AETNA PPO|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Aetna|AETNA OTHER|192.50||||||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Tricare|TRICARE EAST REGION|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|192.50||||||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Cigna|CIGNA OTHER|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Cigna|CIGNA|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Medicare Advantage|UHC AARP MCR HMO MA|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Veterans Affairs|VETERANS ADMINISTRATION|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|192.50||||192.50||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA|||||192.50||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|128.75||||128.75||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Aenta Medicare Advantage|AETNA MEDICARE MA|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|United Medicare Advantage|UHC MEDICARE GOLD MA|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|128.75||||128.75||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|United Medicare Advantage|UHC AARP MCR HMO MA|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Cigna|CIGNA|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Humana Medicare Advantage|HUMANA MA|128.75||||128.75||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Veterans Affairs|VETERANS ADMINISTRATION|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Blue Cross PPO Specialty|BCBSTX PPO|128.75||||128.75||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|128.75||||128.75||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|UTMB|UTMB CORRECTIONAL MANAGED CARE|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|United Healthcare|UNITED HEALTHCARE OTHER|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|United Healthcare|UNITED HEALTHCARE|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|NON CONTRACTED|COMMERCIAL OTHER 1|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Tricare|TRICARE EAST REGION|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Medicare|MEDICARE ACUTE|128.75||||128.75||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Managed Medicare|HEALTHSPRING MA|128.75||||||| 9514787|ERX|0250|ADENOSINE 3MG/ML, 2ML VIA|Medicaid|MEDICAID|128.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicaid|MEDICAID|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicaid|CRIME VICTIMS COMPENSATION|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|HEALTHSPRING MA|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|WELLCARE CHOICE MA|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicare|MEDICARE ACUTE|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|PHCS|GROUP AND PENSION|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|PHCS|HUMANA|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Tricare|TRICARE EAST REGION|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Healthcare|UNITED HEALTHCARE|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Healthcare|TML GROUP BENEFITS|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Aetna|AETNA PPO|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Aetna|AETNA OTHER|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicare|MEDICARE PART B ONLY IP|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Cigna|CIGNA|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Humana Medicare Advantage|HUMANA MA|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicaid|SMITH COUNTY JAIL|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.31||||0.31||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.31||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Access Direct Platinum|HEALTHFIRST TPA|0.31||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|United Medicare Advantage|UHC AARP MCR HMO MA|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Cigna|CIGNA|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Managed Medicaid|MEDICAID SUPERIOR|61.50||||61.50||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|61.50||||61.50||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|61.50||||61.50||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|61.50||||61.50||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||61.50||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Aetna|AETNA PPO|61.50||||61.50||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|United Healthcare|UNITED HEALTHCARE|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Tricare|TRICARE EAST REGION|||||61.50||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Medicare|MEDICARE ACUTE|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Medicaid|SMITH COUNTY JAIL|61.50||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Medicaid|MEDICAID|61.50||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Managed Medicare|HEALTHSPRING MA|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Medicaid|MEDICAID|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Medicare|MEDICARE ACUTE|1.67||||1.67||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Tricare|TRICARE EAST REGION|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|United Healthcare|UNITED HEALTHCARE|||||1.67||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Aetna|AETNA PPO|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Medicaid|SMITH COUNTY JAIL|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|1.67||||1.67||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Cigna|CIGNA|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Cigna|CIGNA OTHER|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Humana Medicare Advantage|HUMANA MA|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.67||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|1.67||||1.67||| 9514852|ERX|0250|PACLITAXEL 100MG/16.7ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|165.25||||||| 9514852|ERX|0250|PACLITAXEL 100MG/16.7ML|Humana Medicare Advantage|HUMANA MA|165.25||||||| 9514852|ERX|0250|PACLITAXEL 100MG/16.7ML|Blue Cross PPO Specialty|BCBSTX PPO|165.25||||||| 9514852|ERX|0250|PACLITAXEL 100MG/16.7ML|Medicaid|MEDICAID|165.25||||||| 9514860|ERX|0250|PACLITAXEL 300MG/50ML|NON CONTRACTED|COMMERCIAL OTHER 1|548.25||||||| 9514860|ERX|0250|PACLITAXEL 300MG/50ML|Medicare|MEDICARE ACUTE|548.25||||||| 9514860|ERX|0250|PACLITAXEL 300MG/50ML|Medicaid|MEDICAID|548.25||||||| 9514860|ERX|0250|PACLITAXEL 300MG/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|548.25||||||| 9514860|ERX|0250|PACLITAXEL 300MG/50ML|Blue Cross PPO Specialty|BCBSTX PPO|548.25||||||| 9514860|ERX|0250|PACLITAXEL 300MG/50ML|Humana Medicare Advantage|HUMANA MA|548.25||||||| 9514860|ERX|0250|PACLITAXEL 300MG/50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|548.25||||||| 9514878|ERX|0250|CYTARABINE 100MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|46.50||||||| 9514878|ERX|0250|CYTARABINE 100MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.50||||||| 9514878|ERX|0250|CYTARABINE 100MG/5ML|Cigna|CIGNA|46.50||||||| 9514878|ERX|0250|CYTARABINE 100MG/5ML|Humana Medicare Advantage|HUMANA MA|46.50||||||| 9514878|ERX|0250|CYTARABINE 100MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|46.50||||||| 9514878|ERX|0250|CYTARABINE 100MG/5ML|Medicare|MEDICARE ACUTE|46.50||||||| 9514878|ERX|0250|CYTARABINE 100MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|46.50||||||| 9514910|ERX|0250|CYTARABINE 1000MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|2.57||||||| 9514910|ERX|0250|CYTARABINE 1000MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|2.57||||||| 9514928|ERX|0250|CYTARABINE 2 G/20ML|Veterans Affairs|VETERANS ADMINISTRATION|513.50||||||| 9514928|ERX|0250|CYTARABINE 2 G/20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|513.50||||||| 9514928|ERX|0250|CYTARABINE 2 G/20ML|Blue Cross PPO Specialty|BCBSTX PPO|513.50||||||| 9514928|ERX|0250|CYTARABINE 2 G/20ML|Blue Cross HMO Specialty|BCBSTX HMO|513.50||||||| 9514928|ERX|0250|CYTARABINE 2 G/20ML|Medicare|MEDICARE ACUTE|513.50||||||| 9514928|ERX|0250|CYTARABINE 2 G/20ML|NON CONTRACTED|COMMERCIAL OTHER 1|513.50||||||| 9514936|ERX|0250|LEVOCARNITINE 200MG/ML, 5|Blue Cross PPO Specialty|BCBSTX PPO|410.75||||||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|UTMB|UTMB CORRECTIONAL MANAGED CARE|170.75||||||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|United Healthcare|UNITED HEALTHCARE|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|PHCS|GROUP AND PENSION|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Tricare|TRICARE EAST REGION|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Managed Medicare|HEALTHSPRING MA|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Managed Medicare|BCBS MEDICARE PPO MA|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Medicaid|MEDICAID|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Medicare|MEDICARE ACUTE|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Aenta Medicare Advantage|AETNA MEDICARE MA|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Medicare|MEDICARE PART B ONLY IP|170.75||||||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Access Direct Platinum|HEALTHFIRST TPA|170.75||||||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Access Direct Platinum|HEALTHFIRST TPA UMR|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|United Medicare Advantage|UHC MEDICARE GOLD MA|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|United Medicare Advantage|UHC AARP MCR HMO MA|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Veterans Affairs|VETERANS ADMINISTRATION|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Cigna|CIGNA|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Cigna|CIGNA|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Humana Medicare Advantage|HUMANA MA|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Managed Medicaid|MEDICAID UNITED HEALTHCARE|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|NON CONTRACTED|COMMERCIAL OTHER 1|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|United Healthcare|UNITED HEALTHCARE OTHER|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Managed Medicaid|MEDICAID SUPERIOR|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Managed Medicaid|MEDICAID AMERIGROUP|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Aetna|AETNA QHP HMO|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Aetna|BOON CHAPMAN|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Aetna|AETNA PPO|||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|ChampVA|CHAMPVA CENTER|170.75||||||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Blue Cross PPO Specialty|BCBSTX PPO|170.75||||170.75||| 9514944|ERX|0250|POLYMYXIN B 500000 UNIT V|Blue Cross HMO Specialty|BCBSTX HMO|170.75||||170.75||| 9514951|ERX|0250|METHOTREXATE 1000MG/40ML|Blue Cross HMO Specialty|BCBSTX HMO|513.50||||||| 9514951|ERX|0250|METHOTREXATE 1000MG/40ML|Blue Cross PPO Specialty|BCBSTX PPO|513.50||||||| 9514951|ERX|0250|METHOTREXATE 1000MG/40ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|513.50||||||| 9514951|ERX|0250|METHOTREXATE 1000MG/40ML|Medicare|MEDICARE ACUTE|513.50||||||| 9514951|ERX|0250|METHOTREXATE 1000MG/40ML|NON CONTRACTED|COMMERCIAL OTHER 1|513.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Medicare|MEDICARE ACUTE|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Medicaid|MEDICAID|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Humana Medicare Advantage|HUMANA MA|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|140.50||||140.50||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|140.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|140.50||||||| 9514977|ERX|0250|OCTREOTIDE 100MCG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|247.50||||||| 9514977|ERX|0250|OCTREOTIDE 100MCG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|247.50||||||| 9514977|ERX|0250|OCTREOTIDE 100MCG/1ML|Humana Medicare Advantage|HUMANA MA|247.50||||||| 9514977|ERX|0250|OCTREOTIDE 100MCG/1ML|Access Direct Platinum|HEALTHFIRST TPA|247.50||||||| 9514977|ERX|0250|OCTREOTIDE 100MCG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|247.50||||||| 9514977|ERX|0250|OCTREOTIDE 100MCG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|247.50||||||| 9514977|ERX|0250|OCTREOTIDE 100MCG/1ML|Medicare|MEDICARE ACUTE|247.50||||||| 9514977|ERX|0250|OCTREOTIDE 100MCG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|247.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|United Healthcare|UNITED HEALTHCARE|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Medicaid|MEDICAID|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Managed Medicare|HEALTHSPRING MA|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Medicare|MEDICARE PART B ONLY IP|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Medicare|MEDICARE ACUTE|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|954.50||||954.50||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Access Direct Platinum|HEALTHFIRST TPA|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Cigna|CIGNA OTHER|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Humana Medicare Advantage|HUMANA MA|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Managed Medicaid|MEDICAID SUPERIOR|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|954.50||||954.50||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Aetna|AETNA PPO|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|954.50||||954.50||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|954.50||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|954.50||||954.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|46.50||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|46.50||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Humana Medicare Advantage|HUMANA MA|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.50||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Medicare|MEDICARE ACUTE|46.50||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Managed Medicare|HEALTHSPRING MA|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Medicaid|MEDICAID|46.50||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Medicaid|SMITH COUNTY JAIL|||||46.50||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|United Healthcare|UNITED HEALTHCARE|||||46.50||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|PHCS|HUMANA INSURANCE|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Medicaid|MEDICAID|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Medicare|MEDICARE ACUTE|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Humana Medicare Advantage|HUMANA MA|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|513.50||||||| 9515016|ERX|0250|PAMIDRONATE 30MG/10ML|Blue Cross PPO Specialty|BCBSTX OTHER|513.50||||||| 9515024|ERX|0250|DOXORUBICIN 10MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|155.25||||||| 9515024|ERX|0250|DOXORUBICIN 10MG/5ML|Medicare|MEDICARE ACUTE|155.25||||||| 9515024|ERX|0250|DOXORUBICIN 10MG/5ML|Medicaid|MEDICAID|155.25||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|United Healthcare|UNITED HEALTHCARE OTHER|623.75||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|NON CONTRACTED|COMMERCIAL OTHER 1|623.75||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Tricare|TRICARE EAST REGION|623.75||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Managed Medicare|HEALTHSPRING MA|||||623.75||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Medicaid|MEDICAID|623.75||||623.75||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Medicare|MEDICARE ACUTE|623.75||||623.75||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|623.75||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Blue Cross HMO Specialty|BCBSTX HMO|623.75||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Blue Cross PPO Specialty|BCBSTX PPO|623.75||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|623.75||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Humana Medicare Advantage|HUMANA MA|623.75||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|623.75||||||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||623.75||| 9515032|ERX|0250|DOXORUBICIN 50MG/25ML|Managed Medicaid|MEDICAID AMERIGROUP|623.75||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Humana Medicare Advantage|HUMANA MA|4.62||||4.62||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Cigna|CIGNA|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|4.62||||4.62||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Medicare|MEDICARE ACUTE|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Medicaid|MEDICAID|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Managed Medicare|HEALTHSPRING MA|4.62||||4.62||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|4.62||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|United Healthcare|UNITED HEALTHCARE|4.62||||||| 9515065|ERX|0250|FLUPHENAZINE DEC 25MG/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.50||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|United Healthcare|UNITED HEALTHCARE OTHER|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|United Healthcare|UNITED HEALTHCARE|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Tricare|TRICARE EAST REGION|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|NON CONTRACTED|COMMERCIAL OTHER 1|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicare|HOSPICE OF EAST TEXAS|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicare|HEALTHSPRING MA|21.75||||21.75||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Medicaid|MEDICAID|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Medicare|MEDICARE ACUTE|21.75||||21.75||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Workers Compensation|WORKERS COMPENSATION OTHER|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Workers Compensation|UT EMPLOYEE INJURY|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Medicare|MEDICARE PART B ONLY IP|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Workers Compensation|TEXAS MUTUAL INSURANCE|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicare|BCBS MEDICARE PPO MA|21.75||||21.75||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Access Direct Platinum|HEALTHFIRST TPA|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Veterans Affairs|VETERANS ADMINISTRATION|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|United Medicare Advantage|UHC AARP MCR HMO MA|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Blue Cross HMO Specialty|BCBSTX HMO|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Blue Cross PPO Specialty|BCBSTX OTHER|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Blue Cross PPO Specialty|BCBSTX PPO|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Aetna|AETNA PPO|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.75||||21.75||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Humana Medicare Advantage|HUMANA MA|21.75||||21.75||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.75||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.75||||21.75||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicaid|MEDICAID AMERIGROUP|21.75||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Managed Medicaid|MEDICAID SUPERIOR|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Humana Medicare Advantage|HUMANA MA|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Aetna|AETNA PPO|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Access Direct Platinum|HEALTHFIRST TPA|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Medicare|MEDICARE ACUTE|0.74||||0.74||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Medicare|MEDICARE PART B ONLY IP|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.74||||0.74||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Medicaid|MEDICAID|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Medicaid|CRIME VICTIMS COMPENSATION|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|Managed Medicare|HEALTHSPRING MA|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|0.74||||||| 9515107|ERX|0250|BUMETANIDE 2.5MG/10ML|United Healthcare|UNITED HEALTHCARE|0.74||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Tricare|TRICARE FOR LIFE|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Managed Medicare|HEALTHSPRING MA|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Medicare|MEDICARE ACUTE|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Aetna Value Network|AETNA VALUE NETWORK|||||118.50||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Cigna|CIGNA|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Humana Medicare Advantage|HUMANA MA|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|118.50||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Cigna|CIGNA|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Humana Medicare Advantage|HUMANA MA|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Blue Cross HMO Specialty|BCBSTX HMO|||||143.50||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Blue Cross PPO Specialty|BCBSTX PPO|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Veterans Affairs|VETERANS ADMINISTRATION|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Medicare|MEDICARE ACUTE|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Managed Medicare|HEALTHSPRING MA|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Managed Medicare|BCBS MEDICARE PPO MA|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|United Healthcare|UNITED HEALTHCARE OTHER|143.50||||||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|United Healthcare|TML GROUP BENEFITS|143.50||||||| 9515149|ERX|0250|CAFFEINE-NA BENZOATE 500M|Access Direct Platinum|HEALTHFIRST TPA UMR|127.25||||||| 9515149|ERX|0250|CAFFEINE-NA BENZOATE 500M|Blue Cross PPO Specialty|BCBSTX PPO|127.25||||||| 9515149|ERX|0250|CAFFEINE-NA BENZOATE 500M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127.25||||||| 9515149|ERX|0250|CAFFEINE-NA BENZOATE 500M|Managed Medicaid|MEDICAID AMERIGROUP|127.25||||||| 9515198|ERX|0250|BLEOMYCIN 15 UNIT 5ML|Cigna|CIGNA|2,403.75||||2,403.75||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Tricare|TRICARE EAST REGION|128.75||||||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|128.75||||||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Managed Medicare|HEALTHSPRING MA|||||128.75||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Medicare|MEDICARE PART B ONLY IP|128.75||||||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Medicare|MEDICARE ACUTE|128.75||||128.75||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|128.75||||||| 9515255|ERX|0250|CINACALCET 30MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|128.75||||128.75||| 9515255|ERX|0250|CINACALCET 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|128.75||||||| 9515255|ERX|0250|CINACALCET 30MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|128.75||||||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|128.75||||||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|128.75||||128.75||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|128.75||||||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|128.75||||128.75||| 9515255|ERX|0250|CINACALCET 30MG TABLET|Humana Medicare Advantage|HUMANA MA|128.75||||128.75||| 9515388|ERX|0250|PILOCARPINE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9515388|ERX|0250|PILOCARPINE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9515388|ERX|0250|PILOCARPINE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9515388|ERX|0250|PILOCARPINE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9515388|ERX|0250|PILOCARPINE 5MG TABLET|Medicare|MEDICARE ACUTE|25.50||||||| 9515388|ERX|0250|PILOCARPINE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|||||25.50||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Healthcare|UNITED HEALTHCARE OTHER|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Healthcare|TML GROUP BENEFITS|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Healthcare|GOLDEN RULE|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Rusk State Hospital|RUSK STATE HOSP|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Tricare|TRICARE EAST REGION|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Medicaid|MEDICAID|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicare|BCBS MEDICARE PPO MA|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicare|HEALTHSPRING MA|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Medicare|MEDICARE PART B ONLY IP|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Medicaid|SMITH COUNTY JAIL|||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Access Direct Platinum|HEALTHFIRST TPA UMR|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Aenta Medicare Advantage|AETNA MEDICARE MA|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|PHCS|HUMANA INSURANCE|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Medicare Advantage|UHC AARP MCR HMO MA|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Medicare Advantage|UHC MEDICARE GOLD MA|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Aetna|AETNA PPO|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Healthcare|UNITED HEALTHCARE|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Blue Cross HMO Specialty|BCBSTX HMO|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Blue Cross PPO Specialty|BCBSTX OTHER|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Cigna|CIGNA OTHER|16.75||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Cigna|CIGNA|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||16.75||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicaid|MEDICAID AMERIGROUP|16.75||||16.75||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Managed Medicaid|MEDICAID SUPERIOR|17.25||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Humana Medicare Advantage|HUMANA MA|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Blue Cross HMO Specialty|BCBSTX HMO|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Blue Cross PPO Specialty|BCBSTX PPO|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|United Medicare Advantage|UHC AARP MCR HMO MA|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|United Medicare Advantage|UHC MEDICARE GOLD MA|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Veterans Affairs|VETERANS ADMINISTRATION|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Blue Cross PPO Specialty|BCBSTX OTHER|17.25||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Aenta Medicare Advantage|AETNA MEDICARE MA|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Access Direct Platinum|HEALTHFIRST TPA|17.25||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Medicare|MEDICARE PART B ONLY IP|17.25||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Medicare|MEDICARE ACUTE|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Managed Medicare|OTHER INSTITUTIONS|||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.25||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Managed Medicare|HEALTHSPRING MA|17.25||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Medicaid|MEDICAID|17.25||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Rusk State Hospital|RUSK STATE HOSP|17.25||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|NON CONTRACTED|COMMERCIAL OTHER 1|||||17.25||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.25||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|United Healthcare|UNITED HEALTHCARE OTHER|17.25||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|United Healthcare|GOLDEN RULE|17.25||||||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|United Healthcare|UNITED HEALTHCARE|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|14.25||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Medicaid|MEDICAID|14.25||||||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|14.25||||||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Medicare|MEDICARE ACUTE|14.25||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|14.25||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|14.25||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Humana Medicare Advantage|HUMANA MA|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||14.25||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||14.25||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Managed Medicaid|MEDICAID AMERIGROUP|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Cigna|CIGNA OTHER|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Humana Medicare Advantage|HUMANA MA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Blue Cross HMO Specialty|BCBSTX HMO|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Blue Cross PPO Specialty|BCBSTX PPO|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Aetna|AETNA PPO|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Aetna|AETNA OTHER|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|United Medicare Advantage|UHC AARP MCR HMO MA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Veterans Affairs|VETERANS ADMINISTRATION|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Aenta Medicare Advantage|AETNA MEDICARE MA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|United Medicare Advantage|UHC MEDICARE GOLD MA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Access Direct Platinum|HEALTHFIRST TPA UMR|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Access Direct Platinum|HEALTHFIRST TPA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Workers Compensation|WORKERS COMPENSATION OTHER|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Medicare|MEDICARE ACUTE|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Medicare|MEDICARE PART B ONLY IP|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Managed Medicare|BCBS MEDICARE PPO MA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Cigna|CIGNA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Managed Medicare|HEALTHSPRING MA|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Managed Medicaid|MEDICAID SUPERIOR|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Medicaid|SMITH COUNTY JAIL|||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Medicaid|MEDICAID|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|PHCS|HUMANA|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|PHCS|GROUP AND PENSION|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Tricare|TRICARE EAST REGION|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|Tricare|TRICARE FOR LIFE|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|NON CONTRACTED|COMMERCIAL OTHER 1|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.47||||||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|United Healthcare|UNITED HEALTHCARE OTHER|||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|United Healthcare|UNITED HEALTHCARE|0.47||||0.47||| 9515479|ERX|0250|NITROGLYCERIN 0.4MG TAB,#|United Healthcare|UNITED HEALTHCARE|||||0.47||| 9515495|ERX|0250|PREDNISOLONE 5MG/5ML, 30M|Medicare|MEDICARE ACUTE|44.50||||44.50||| 9515495|ERX|0250|PREDNISOLONE 5MG/5ML, 30M|United Medicare Advantage|UHC AARP MCR HMO MA|44.50||||||| 9515495|ERX|0250|PREDNISOLONE 5MG/5ML, 30M|Aetna|AETNA PPO|44.50||||||| 9515495|ERX|0250|PREDNISOLONE 5MG/5ML, 30M|Managed Medicaid|MEDICAID SUPERIOR|||||44.50||| 9515495|ERX|0250|PREDNISOLONE 5MG/5ML, 30M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.50||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Humana Medicare Advantage|HUMANA MA|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|United Healthcare|UNITED HEALTHCARE|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Tricare|TRICARE EAST REGION|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Medicaid|MEDICAID|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Managed Medicare|HEALTHSPRING MA|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|18.75||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Medicare|MEDICARE ACUTE|18.75||||18.75||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Medicare|MEDICARE PART B ONLY IP|18.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Medicare|MEDICARE PART B ONLY IP|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Managed Medicare|OTHER INSTITUTIONS|||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Managed Medicare|BCBS MEDICARE PPO MA|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Managed Medicare|HEALTHSPRING MA|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|NON CONTRACTED|COMMERCIAL OTHER 1|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Rusk State Hospital|RUSK STATE HOSP|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Optum Behavioral Health|BH OPTUM UHC|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Tricare|TRICARE EAST REGION|||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|United Healthcare|UNITED HEALTHCARE|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|United Medicare Advantage|UHC AARP MCR HMO MA|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Veterans Affairs|VETERANS ADMINISTRATION|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Workers Compensation|WORKERS COMPENSATION OTHER|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Aetna|BOON CHAPMAN|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Blue Cross HMO Specialty|BCBSTX HMO|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Managed Medicaid|MEDICAID SUPERIOR|12.75||||12.75||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Humana Medicare Advantage|HUMANA MA|12.75||||12.75||| 9515677|ERX|0250|MESALAMINE 1000MG SUPP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|122.25||||||| 9515677|ERX|0250|MESALAMINE 1000MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|122.25||||||| 9515677|ERX|0250|MESALAMINE 1000MG SUPP|United Healthcare|UNITED HEALTHCARE OTHER|122.25||||||| 9515677|ERX|0250|MESALAMINE 1000MG SUPP|Managed Medicare|HEALTHSPRING MA|122.25||||122.25||| 9515677|ERX|0250|MESALAMINE 1000MG SUPP|Managed Medicare|ETMC REHABILITATION HOSPITAL|122.25||||||| 9515677|ERX|0250|MESALAMINE 1000MG SUPP|Medicare|MEDICARE ACUTE|122.25||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Medicare|MEDICARE ACUTE|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Medicaid|MEDICAID|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Managed Medicare|HEALTHSPRING MA|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|NON CONTRACTED|COMMERCIAL OTHER 1|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|United Healthcare|UNITED HEALTHCARE OTHER|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Blue Cross PPO Specialty|BCBSTX PPO|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Humana Medicare Advantage|HUMANA MA|486.75||||||| 9515685|ERX|0250|CARBOPLATIN 450MG/45ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|486.75||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Cigna|CIGNA OTHER|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Cigna|CIGNA|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Humana Medicare Advantage|HUMANA MA|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Aetna|AETNA QHP HMO|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Aetna|AETNA PPO|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Aetna Value Network|AETNA VALUE NETWORK|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Cigna|CIGNA|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|United Healthcare|UNITED HEALTHCARE|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|United Healthcare|UNITED HEALTHCARE|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|United Healthcare|GEHA|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|PHCS|HUMANA|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Tricare|TRICARE EAST REGION|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Managed Medicare|HEALTHSPRING MA|24.25||||24.25||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|24.25||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Medicare|MEDICARE ACUTE|24.25||||24.25||| 9515701|ERX|0250|OXYCODONE SR 20MG TABLET|Medicare|MEDICARE ACUTE|0.37||||||| 9515701|ERX|0250|OXYCODONE SR 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.37||||||| 9515701|ERX|0250|OXYCODONE SR 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.37||| 9515701|ERX|0250|OXYCODONE SR 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.37||||||| 9515701|ERX|0250|OXYCODONE SR 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.37||||||| 9515701|ERX|0250|OXYCODONE SR 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.37||||||| 9515701|ERX|0250|OXYCODONE SR 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.37||||||| 9515701|ERX|0250|OXYCODONE SR 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.37||||||| 9515719|ERX|0250|OXYCODONE SR 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|65.75||||||| 9515719|ERX|0250|OXYCODONE SR 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|65.75||||||| 9515719|ERX|0250|OXYCODONE SR 40MG TABLET|Tricare|TRICARE EAST REGION|65.75||||||| 9515719|ERX|0250|OXYCODONE SR 40MG TABLET|Medicare|MEDICARE ACUTE|65.75||||||| 9515735|ERX|0250|MAGNESIUM LACTATE 84MG TA|Medicare|MEDICARE ACUTE|0.05||||||| 9515735|ERX|0250|MAGNESIUM LACTATE 84MG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||||| 9515735|ERX|0250|MAGNESIUM LACTATE 84MG TA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||||| 9515735|ERX|0250|MAGNESIUM LACTATE 84MG TA|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||||| 9515735|ERX|0250|MAGNESIUM LACTATE 84MG TA|Humana Medicare Advantage|HUMANA MA|0.05||||||| 9515735|ERX|0250|MAGNESIUM LACTATE 84MG TA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9515743|ERX|0250|CILOSTAZOL 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9515743|ERX|0250|CILOSTAZOL 50MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9515743|ERX|0250|CILOSTAZOL 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||25.50||| 9515743|ERX|0250|CILOSTAZOL 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9515743|ERX|0250|CILOSTAZOL 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9515743|ERX|0250|CILOSTAZOL 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9515743|ERX|0250|CILOSTAZOL 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||25.50||| 9515743|ERX|0250|CILOSTAZOL 50MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9515743|ERX|0250|CILOSTAZOL 50MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Optum Behavioral Health|BH OPTUM UHC|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Tricare|TRICARE EAST REGION|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Medicaid|MEDICAID|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Medicare|MEDICARE ACUTE|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Managed Medicare|HEALTHSPRING MA|||||21.75||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Access Direct Platinum|ANDREWS CENTER|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.75||||21.75||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Aetna|BH AETNA|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Magellan Behavioral Health|BH MAGELLAN|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|||||21.75||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.75||||21.75||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|21.75||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|21.75||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.50||||1.50||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Cigna Behavioral Health|BH CIGNA|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Aetna|AETNA OTHER|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Aetna|BH AETNA|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|1.50||||1.50||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.50||||1.50||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|1.50||||1.50||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Access Direct Platinum|ANDREWS CENTER|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|1.50||||1.50||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Medicaid|MEDICAID|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Medicare|MEDICARE ACUTE|1.50||||1.50||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|United Healthcare|UNITED HEALTHCARE|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|Tricare|TRICARE EAST REGION|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|1.50||||||| 9515768|ERX|0250|ARIPIPRAZOLE 5MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Optum Behavioral Health|BH OPTUM UHC|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Tricare|TRICARE FOR LIFE|||||1.50||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Medicare|MEDICARE ACUTE|1.50||||1.50||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Medicaid|MEDICAID|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.50||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Access Direct Platinum|ANDREWS CENTER|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|1.50||||1.50||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.50||||1.50||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Tricare|TRICARE EAST REGION|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Aetna|BH AETNA|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Magellan Behavioral Health|BH MAGELLAN|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|1.50||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|1.50||||1.50||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Humana Medicare Advantage|HUMANA MA|1.50||||1.50||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Magellan Behavioral Health|BH MAGELLAN|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||1.50||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Access Direct Platinum|ANDREWS CENTER|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Managed Medicare|HEALTHSPRING MA|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Medicaid|MEDICAID|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Medicare|MEDICARE PART B ONLY IP|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Medicare|MEDICARE ACUTE|1.50||||1.50||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Optum Behavioral Health|BH OPTUM UHC|1.50||||||| 9515784|ERX|0250|ARIPIPRAZOLE 15MG TABLET|Tricare|TRICARE EAST REGION|1.50||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Multiplan|WEB TPA|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Texas Workforce Commission|DIS DETER SERV (DDS)|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Medicaid|MEDICAID|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Managed Medicare|HEALTHSPRING MA|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Access Direct Platinum|HEALTHFIRST TPA|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Medicare|MEDICARE ACUTE|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Aetna|AETNA PPO|||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Humana Medicare Advantage|HUMANA MA|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|239.25||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|239.25||||||| 9515800|ERX|0250|CARBOPLATIN 50MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|75.50||||||| 9515800|ERX|0250|CARBOPLATIN 50MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|75.50||||||| 9515800|ERX|0250|CARBOPLATIN 50MG/5ML|Medicaid|MEDICAID|75.50||||||| 9515800|ERX|0250|CARBOPLATIN 50MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|75.50||||||| 9515800|ERX|0250|CARBOPLATIN 50MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|75.50||||||| 9515818|ERX|0250|ARIPIPRAZOLE 20MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|212.25||||||| 9515818|ERX|0250|ARIPIPRAZOLE 20MG TABLET|Medicare|MEDICARE ACUTE|212.25||||||| 9515818|ERX|0250|ARIPIPRAZOLE 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|212.25||||||| 9515818|ERX|0250|ARIPIPRAZOLE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|212.25||||||| 9515818|ERX|0250|ARIPIPRAZOLE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|212.25||||||| 9515818|ERX|0250|ARIPIPRAZOLE 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|212.25||||||| 9515818|ERX|0250|ARIPIPRAZOLE 20MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|212.25||||||| 9515818|ERX|0250|ARIPIPRAZOLE 20MG TABLET|Magellan Behavioral Health|BH MAGELLAN|212.25||||||| 9515818|ERX|0250|ARIPIPRAZOLE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Magellan Behavioral Health|BH MAGELLAN|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Access Direct Platinum|ANDREWS CENTER|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Medicaid|MEDICAID|212.25||||||| 9515826|ERX|0250|ARIPIPRAZOLE 30MG TABLET|Medicare|MEDICARE ACUTE|212.25||||||| 9515834|ERX|0250|ARIPIPRAZOLE 1MG/ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|165.25||||||| 9515883|ERX|0250|CARBOPLATIN 150MG/15ML|United Healthcare|UNITED HEALTHCARE OTHER|162.25||||||| 9515883|ERX|0250|CARBOPLATIN 150MG/15ML|Medicare|MEDICARE ACUTE|162.25||||||| 9515883|ERX|0250|CARBOPLATIN 150MG/15ML|Medicaid|MEDICAID|162.25||||||| 9515883|ERX|0250|CARBOPLATIN 150MG/15ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|162.25||||||| 9515883|ERX|0250|CARBOPLATIN 150MG/15ML|Blue Cross PPO Specialty|BCBSTX PPO|162.25||||||| 9515883|ERX|0250|CARBOPLATIN 150MG/15ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|162.25||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.30||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.30||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Managed Medicare|HOSPICE OF EAST TEXAS|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Medicaid|MEDICAID|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|Medicare|MEDICARE ACUTE|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.30||||||| 9515917|ERX|0250|GLYCOPYRROLATE 1MG TABLET|United Healthcare|UNITED HEALTHCARE|0.30||||||| 9515925|ERX|0250|NITROGLYCERIN SPRAY|Medicare|MEDICARE ACUTE|17.83||||17.83||| 9515925|ERX|0250|NITROGLYCERIN SPRAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.83||||||| 9515925|ERX|0250|NITROGLYCERIN SPRAY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.83||||||| 9515925|ERX|0250|NITROGLYCERIN SPRAY|Humana Medicare Advantage|HUMANA MA|17.83||||||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Access Direct Platinum|HEALTHFIRST TPA|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Cigna|CIGNA|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|38.25||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Cigna|CIGNA OTHER|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Aetna|AETNA PPO|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.25||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Tricare|TRICARE EAST REGION|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|United Healthcare|UNITED HEALTHCARE|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|MEDICAID HMO|||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|MEDICAID|38.25||||38.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicare|MEDICARE ACUTE|38.25||||||| 9516006|ERX|0250|DEXAMETHASONE 0.5MG/5ML,3|Managed Medicaid|MEDICAID SUPERIOR|||||82.75||| 9516006|ERX|0250|DEXAMETHASONE 0.5MG/5ML,3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||82.75||| 9516006|ERX|0250|DEXAMETHASONE 0.5MG/5ML,3|Managed Medicaid|MEDICAID AMERIGROUP|||||82.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Medicare|MEDICARE ACUTE|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Medicaid|MEDICAID|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Healthcare|UNITED HEALTHCARE|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Healthcare|TML GROUP BENEFITS|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicare|HEALTHSPRING MA|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Cigna|CIGNA|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Humana Medicare Advantage|HUMANA MA|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|47.75||||47.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|47.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|47.75||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Cigna|CIGNA|||||25.50||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Aetna|AETNA OTHER|25.50||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||25.50||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Medicaid|MEDICAID|25.50||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|||||25.50||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9516063|ERX|0250|METHIMAZOLE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|12.75||||||| 9516063|ERX|0250|METHIMAZOLE 5MG TABLET|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9516063|ERX|0250|METHIMAZOLE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|12.75||||12.75||| 9516063|ERX|0250|METHIMAZOLE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|12.75||||12.75||| 9516063|ERX|0250|METHIMAZOLE 5MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||12.75||| 9516063|ERX|0250|METHIMAZOLE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|12.75||||||| 9516063|ERX|0250|METHIMAZOLE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||12.75||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|18.75||||||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.75||||||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|18.75||||||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|18.75||||||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||18.75||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|18.75||||||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.75||||||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|Medicare|MEDICARE ACUTE|18.75||||18.75||| 9516089|ERX|0250|LIOTHYRONINE 5MCG TABLET|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9516089|ERX|0250|LIOTHYRONINE 5MCG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||||| 9516089|ERX|0250|LIOTHYRONINE 5MCG TABLET|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9516097|ERX|0250|LIOTHYRONINE 25MCG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9516097|ERX|0250|LIOTHYRONINE 25MCG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9516097|ERX|0250|LIOTHYRONINE 25MCG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9516097|ERX|0250|LIOTHYRONINE 25MCG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9516097|ERX|0250|LIOTHYRONINE 25MCG TABLET|Medicare|MEDICARE ACUTE|15.50||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.35||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Tricare|TRICARE FOR LIFE|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|PHCS|HUMANA|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|United Healthcare|UNITED HEALTHCARE|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Managed Medicare|HEALTHSPRING MA|0.35||||0.35||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Medicaid|MEDICAID HMO|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Medicaid|MEDICAID|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Medicare|MEDICARE ACUTE|0.35||||0.35||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Aetna|AETNA PPO|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.35||||0.35||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Humana Medicare Advantage|HUMANA MA|0.35||||0.35||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Tricare|TRICARE EAST REGION|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Cigna|CIGNA OTHER|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Cigna|CIGNA|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.35||||0.35||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.35||||0.35||| 9516139|ERX|0250|METAXALONE 800MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.35||||0.35||| 9516139|ERX|0250|METAXALONE 800MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.35||||||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.35||||0.35||| 9516139|ERX|0250|METAXALONE 800MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.35||||||| 9516204|ERX|0250|NADOLOL 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32.25||||||| 9516204|ERX|0250|NADOLOL 40MG TABLET|Humana Medicare Advantage|HUMANA MA|32.25||||||| 9516204|ERX|0250|NADOLOL 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|32.25||||||| 9516204|ERX|0250|NADOLOL 40MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||32.25||| 9516204|ERX|0250|NADOLOL 40MG TABLET|Medicare|MEDICARE PART B ONLY IP|32.25||||||| 9516204|ERX|0250|NADOLOL 40MG TABLET|Medicare|MEDICARE ACUTE|32.25||||||| 9516204|ERX|0250|NADOLOL 40MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|32.25||||32.25||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Healthcare|UNITED HEALTHCARE|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Healthcare|TML GROUP BENEFITS|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Healthcare|GEHA|||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Rusk State Hospital|RUSK STATE HOSP|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|PHCS|HUMANA INSURANCE|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Optum Behavioral Health|BH OPTUM UHC|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Tricare|TRICARE EAST REGION|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Tricare|TRICARE FOR LIFE|||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|NON CONTRACTED|COMMUNITY HEALTH CENTER|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|SMITH COUNTY JAIL|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|MEDICAID HMO|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|MEDICAID|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|HOSPICE OF EAST TEXAS|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|OTHER INSTITUTIONS|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|MA PART B ONLY IP|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|HEALTHSPRING MA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicare|MEDICARE PART B ONLY IP|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicare|MEDICARE ACUTE|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|WELLCARE CHOICE MA|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|ANDREWS CENTER|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Workers Compensation|UT EMPLOYEE INJURY|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Workers Compensation|TEXAS MUTUAL INSURANCE|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Multiplan|WEB TPA|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Aetna|BOON CHAPMAN|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Aetna|BH AETNA|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|PHCS|HUMANA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Aetna|AETNA QHP HMO|26.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Aetna|AETNA OTHER|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Aetna|AETNA PPO|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Aetna Value Network|AETNA VALUE NETWORK|||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|ChampVA|CHAMPVA CENTER|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Humana Medicare Advantage|HUMANA MA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Cigna|CIGNA OTHER|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Cigna|CIGNA|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|26.75||||26.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|26.75||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Humana Medicare Advantage|HUMANA MA|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Blue Cross PPO Specialty|BCBSTX PPO|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Blue Cross HMO Specialty|BCBSTX HMO|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|United Medicare Advantage|UHC AARP MCR HMO MA|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Medicare|MEDICARE ACUTE|513.50||||513.50||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Managed Medicare|HEALTHSPRING MA|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|513.50||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Medicaid|MEDICAID|513.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Multiplan|WEB TPA|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Rusk State Hospital|RUSK STATE HOSP|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|PHCS|GROUP AND PENSION|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|PHCS|HUMANA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Texas Workforce Commission|DIS DETER SERV (DDS)|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Healthcare|TML GROUP BENEFITS|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Healthcare|GEHA|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicaid|MEDICAID HMO|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicaid|MEDICAID|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|HOSPICE OF EAST TEXAS|0.13||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Workers Compensation|ZURICH COMPANY|0.13||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Workers Compensation|GALLAGHER BASSETT|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Workers Compensation|BROOKSHIRES WORKERS COMP|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|OTHER INSTITUTIONS|0.13||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Healthcare|UNITED HEALTHCARE ERS|0.13||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Aetna|BOON CHAPMAN|0.13||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Aetna|AETNA QHP HMO|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Aetna|AETNA PPO|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Aetna|AETNA OTHER|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Aetna Value Network|AETNA VALUE NETWORK|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Tricare|TRICARE FOR LIFE|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|ChampVA|CHAMPVA CENTER|0.13||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Cigna|CIGNA|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Cigna|CIGNA OTHER|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Cigna|CIGNA|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Humana Medicare Advantage|HUMANA MA|17.50||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Blue Cross HMO Specialty|BCBSTX HMO|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|United Medicare Advantage|UHC AARP MCR HMO MA|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Veterans Affairs|VETERANS ADMINISTRATION|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.50||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Access Direct Platinum|HEALTHFIRST TPA UMR|17.50||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Aenta Medicare Advantage|AETNA MEDICARE MA|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Medicare|MEDICARE PART B ONLY IP|17.50||||||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Managed Medicaid|MEDICAID SUPERIOR|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Managed Medicare|BCBS MEDICARE PPO MA|17.50||||||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Managed Medicare|HEALTHSPRING MA|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Medicaid|MEDICAID HMO|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|United Healthcare|UNITED HEALTHCARE|17.50||||||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|United Healthcare|TML GROUP BENEFITS|17.50||||||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Rusk State Hospital|RUSK STATE HOSP|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|Tricare|TRICARE EAST REGION|||||17.50||| 9516329|ERX|0250|GLYCOPYRROLATE 0.2MG/ML,|NON CONTRACTED|COMMERCIAL OTHER 1|17.50||||17.50||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Texas Workforce Commission|DIS DETER SERV (DDS)|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Tricare|TRICARE EAST REGION|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Healthcare|UNITED HEALTHCARE|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Healthcare|TML GROUP BENEFITS|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Healthcare|GEHA|||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|MEDICAID|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|SMITH COUNTY JAIL|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|MEDICAID HMO|||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicare|HEALTHSPRING MA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicare|MEDICARE PART B ONLY IP|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicare|MEDICARE ACUTE|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Workers Compensation|ZURICH COMPANY|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|CRIME VICTIMS COMPENSATION|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Access Direct Platinum|HEALTHFIRST TPA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aetna|BOON CHAPMAN|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aetna|AETNA QHP HMO|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Healthcare|UNITED HEALTHCARE|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aetna|AETNA PPO|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aetna|AETNA OTHER|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Rusk State Hospital|RUSK STATE HOSP|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|ChampVA|CHAMPVA CENTER|0.29||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Cigna|CIGNA OTHER|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Cigna|CIGNA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Humana Medicare Advantage|HUMANA MA|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.29||||0.29||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|0.29||||0.29||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Humana Medicare Advantage|HUMANA MA|2.42||||||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Blue Cross HMO Specialty|BCBSTX HMO|2.42||||||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.42||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.42||||2.42||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|United Medicare Advantage|UHC AARP MCR HMO MA|2.42||||||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.42||||||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Medicare|MEDICARE ACUTE|2.42||||2.42||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.42||||||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Managed Medicare|HEALTHSPRING MA|||||2.42||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Medicaid|MEDICAID|2.42||||||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.42||||||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Rusk State Hospital|RUSK STATE HOSP|2.42||||||| 9516386|ERX|0250|TIMOLOL GEL 0.5% EYE DROP|Medicare|MEDICARE ACUTE|318.75||||||| 9516394|ERX|0250|GENTAMICIN EYE DROP, 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|102.75||||||| 9516394|ERX|0250|GENTAMICIN EYE DROP, 5ML|Blue Cross PPO Specialty|BCBSTX PPO|102.75||||||| 9516394|ERX|0250|GENTAMICIN EYE DROP, 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||102.75||| 9516394|ERX|0250|GENTAMICIN EYE DROP, 5ML|Humana Medicare Advantage|HUMANA MA|102.75||||||| 9516394|ERX|0250|GENTAMICIN EYE DROP, 5ML|Medicare|MEDICARE ACUTE|102.75||||||| 9516410|ERX|0250|CIPROFLOXACIN 0.3% DROP,5|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||88.75||| 9516410|ERX|0250|CIPROFLOXACIN 0.3% DROP,5|United Healthcare|UNITED HEALTHCARE OTHER|88.75||||||| 9516410|ERX|0250|CIPROFLOXACIN 0.3% DROP,5|Medicaid|LAW ENFORCEMENT OTHER|88.75||||||| 9516410|ERX|0250|CIPROFLOXACIN 0.3% DROP,5|Medicaid|MEDICAID|88.75||||||| 9516410|ERX|0250|CIPROFLOXACIN 0.3% DROP,5|Medicare|MEDICARE ACUTE|88.75||||||| 9516410|ERX|0250|CIPROFLOXACIN 0.3% DROP,5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|88.75||||||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|United Medicare Advantage|UHC AARP MCR HMO MA|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Aetna|AETNA PPO|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Aetna|AETNA OTHER|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Blue Cross PPO Specialty|BCBSTX PPO|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Blue Cross HMO Specialty|BCBSTX HMO|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Cigna|CIGNA|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Cigna|CIGNA|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Humana Medicare Advantage|HUMANA MA|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Managed Medicaid|MEDICAID SUPERIOR|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|United Medicare Advantage|UHC MEDICARE GOLD MA|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Access Direct Platinum|HEALTHFIRST TPA UMR|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Medicare|MEDICARE PART B ONLY IP|0.37||||||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Managed Medicare|BCBS MEDICARE PPO MA|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Managed Medicare|HEALTHSPRING MA|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Medicaid|MEDICAID|0.37||||||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|NON CONTRACTED|COMMERCIAL OTHER 1|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Tricare|TRICARE EAST REGION|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|Texas Workforce Commission|DIS DETER SERV (DDS)|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|United Healthcare|UNITED HEALTHCARE|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|United Healthcare|UNITED HEALTHCARE OTHER|||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|United Healthcare|UNITED HEALTHCARE|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|United Healthcare|TML GROUP BENEFITS|0.37||||0.37||| 9516428|ERX|0250|OPIUM-BELLAD 16.2-60MG SU|United Healthcare|GOLDEN RULE|||||0.37||| 9516436|ERX|0250|FENT 5MCG/ML-BUPIV0.125%|United Healthcare|UNITED HEALTHCARE OTHER|191.50||||||| 9516436|ERX|0250|FENT 5MCG/ML-BUPIV0.125%|Medicaid|COUNTY INDIGENT HEALTH OTHER|191.50||||||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Managed Medicaid|MEDICAID AMERIGROUP|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Cigna|CIGNA|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Humana Medicare Advantage|HUMANA MA|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Blue Cross HMO Specialty|BCBSTX HMO|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Blue Cross PPO Specialty|BCBSTX PPO|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|United Medicare Advantage|UHC AARP MCR HMO MA|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Medicare|MEDICARE ACUTE|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Managed Medicare|BCBS MEDICARE PPO MA|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||145.75||| 9516444|ERX|0250|CEFAZOLIN 2 G/100ML D5W|Tricare|TRICARE EAST REGION|||||145.75||| 9516469|ERX|0250|NEOMYC-POLYMYX-HC ,10ML|Veterans Affairs|VETERANS ADMINISTRATION|||||807.50||| 9516469|ERX|0250|NEOMYC-POLYMYX-HC ,10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||807.50||| 9516477|ERX|0250|NEOMYC-POLYMYX-HC EAR,10M|Medicaid|MEDICAID|||||807.50||| 9516477|ERX|0250|NEOMYC-POLYMYX-HC EAR,10M|Aenta Medicare Advantage|AETNA MEDICARE MA|807.50||||||| 9516477|ERX|0250|NEOMYC-POLYMYX-HC EAR,10M|United Medicare Advantage|UHC AARP MCR HMO MA|807.50||||||| 9516493|ERX|0250|TRIFLURIDINE 1% EYE DROP,|Medicare|MEDICARE ACUTE|14.12||||14.12||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Blue Cross PPO Specialty|BCBSTX PPO|||||42.50||| 95165|EAP|0761||Blue Cross PPO Specialty|BCBSTX PPO|||||1.02||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Blue Cross HMO Specialty|BCBSTX HMO|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Humana Medicare Advantage|HUMANA MA|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Cigna|CIGNA|||||42.50||| 95165|EAP|0761||Cigna|CIGNA|||||1.02||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Aetna|AETNA PPO|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Managed Medicaid|MEDICAID SUPERIOR|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Managed Medicaid|MEDICAID AMERIGROUP|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Access Direct Platinum|HEALTHFIRST TPA UMR|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Tricare|TRICARE EAST REGION|||||42.50||| 95165|EAP|0510|ANTIGEN THERAPY SERVICES|Medicare|MEDICARE ACUTE|||||42.50||| 95165|EAP|0761||Medicare|MEDICARE ACUTE|||||1.02||| 9516501|ERX|0250|NEOMYC-POLYMYX-GRAMIC,10M|Medicare|MEDICARE ACUTE|4.91||||||| 9516501|ERX|0250|NEOMYC-POLYMYX-GRAMIC,10M|ChampVA|CHAMPVA CENTER|4.91||||||| 9516501|ERX|0250|NEOMYC-POLYMYX-GRAMIC,10M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.91||||||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|21.75||||21.75||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21.75||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|21.75||||||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|21.75||||||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.75||||||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|Humana Medicare Advantage|HUMANA MA|21.75||||||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|Aetna|AETNA PPO|21.75||||||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.75||||||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|21.75||||||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|21.75||||||| 9516568|ERX|0250|RAMIPRIL 1.25MG CAPSULE|Medicare|MEDICARE ACUTE|21.75||||21.75||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||26.25||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Managed Medicare|HEALTHSPRING MA|||||26.25||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Medicaid|SMITH COUNTY INDIGENT HEALTH|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Medicare|MEDICARE ACUTE|26.25||||26.25||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|26.25||||26.25||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Aetna|AETNA PPO|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Humana Medicare Advantage|HUMANA MA|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|26.25||||26.25||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.25||||26.25||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|26.25||||26.25||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|26.25||||||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|26.25||||26.25||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Aetna|AETNA PPO|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||25.50||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Medicaid|MEDICAID|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9516600|ERX|0250|SILVER SULFADIAZINE 1% ,4|Medicare|MEDICARE ACUTE|605.75||||||| 9516600|ERX|0250|SILVER SULFADIAZINE 1% ,4|Workers Compensation|WORKERS COMPENSATION OTHER|605.75||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Managed Medicaid|MEDICAID SUPERIOR|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.50||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Optum Behavioral Health|BH OPTUM UHC|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Medicaid|MEDICAID HMO|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Medicaid|MEDICAID|15.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Medicaid|BH TEXAS CHILDRENS MEDICAID|15.50||||15.50||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Medicaid|MEDICAID|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|United Healthcare|TML GROUP BENEFITS|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|United Healthcare|UNITED HEALTHCARE|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|United Healthcare|UNITED HEALTHCARE|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|PHCS|GROUP AND PENSION|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA UMR|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Medicaid|MEDICAID HMO|||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Managed Medicaid|MEDICAID SUPERIOR|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Cigna|CIGNA|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Cigna|CIGNA OTHER|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Aetna|AETNA PPO|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Aetna Value Network|AETNA VALUE NETWORK|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|38.50||||38.50||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|38.50||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|38.50||||38.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Blue Cross HMO Specialty|BCBSTX HMO|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Blue Cross PPO Specialty|BCBSTX PPO|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Brinson Benefits|THE HEALTH PLAN SMITH CO|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|ChampVA|CHAMPVA CENTER|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Aetna|AETNA PPO|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Aetna|AETNA OTHER|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Cigna|CIGNA OTHER|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Cigna|CIGNA|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Humana Medicare Advantage|HUMANA MA|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicaid|MEDICAID SUPERIOR|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicaid|MEDICAID AMERIGROUP|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Veterans Affairs|VETERANS ADMINISTRATION|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Medicare Advantage|UHC AARP WELLMED HMO MA|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Medicare Advantage|UHC AARP MCR HMO MA|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Medicare Advantage|UHC MEDICARE GOLD MA|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Workers Compensation|WORKERS COMPENSATION OTHER|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Aenta Medicare Advantage|AETNA MEDICARE MA|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Access Direct Platinum|HEALTHFIRST TPA UMR|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Access Direct Platinum|HEALTHFIRST TPA|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Rusk State Hospital|RUSK STATE HOSP|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|PHCS|HUMANA|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|PHCS|HUMANA INSURANCE|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Tricare|TRICARE EAST REGION|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Cigna|CIGNA|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Aetna|BOON CHAPMAN|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|NON CONTRACTED|COMMERCIAL OTHER 1|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|NON CONTRACTED|COMMERCIAL OTHER 2|||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Healthcare|UNITED HEALTHCARE|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Healthcare|UNITED HEALTHCARE OTHER|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicare|MEDICARE PART B ONLY IP|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicare|MEDICARE ACUTE|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicaid|SMITH COUNTY INDIGENT HEALTH|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicaid|COUNTY INDIGENT HEALTH OTHER|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicaid|MEDICAID|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicaid|MOLINA HEALTHCARE OF TEXAS|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicaid|CRIME VICTIMS COMPENSATION|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicare|MA PART B ONLY IP|97.25||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicare|HEALTHSPRING MA|97.25||||97.25||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicare|BCBS MEDICARE PPO MA|97.25||||||| 9516683|ERX|0250|PYRAZINAMIDE 500MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9516683|ERX|0250|PYRAZINAMIDE 500MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9516683|ERX|0250|PYRAZINAMIDE 500MG TABLET|Medicare|MEDICARE ACUTE|15.50||||||| 9516683|ERX|0250|PYRAZINAMIDE 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9516683|ERX|0250|PYRAZINAMIDE 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9516683|ERX|0250|PYRAZINAMIDE 500MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9516691|ERX|0250|POLYMYXIN B-TMP EYE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|||||355.50||| 9516691|ERX|0250|POLYMYXIN B-TMP EYE DROP,|Humana Medicare Advantage|HUMANA MA|355.50||||||| 9516691|ERX|0250|POLYMYXIN B-TMP EYE DROP,|Medicare|MEDICARE PART B ONLY IP|355.50||||||| 9516691|ERX|0250|POLYMYXIN B-TMP EYE DROP,|Medicare|MEDICARE ACUTE|355.50||||||| 9516709|ERX|0250|TENOFOVIR 300MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|236.25||||||| 9516709|ERX|0250|TENOFOVIR 300MG TABLET|Medicare|MEDICARE PART B ONLY IP|236.25||||||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Workers Compensation|WORKERS COMPENSATION OTHER|||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Workers Compensation|UT EMPLOYEE INJURY|||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|United Medicare Advantage|UHC AARP MCR HMO MA|359.25||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|United Medicare Advantage|UHC MEDICARE GOLD MA|||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|359.25||||||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Managed Medicaid|MEDICAID SUPERIOR|||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Managed Medicaid|MEDICAID AMERIGROUP|||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|359.25||||||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Humana Medicare Advantage|HUMANA MA|359.25||||||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Blue Cross PPO Specialty|BCBSTX PPO|359.25||||||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Medicaid|MEDICAID HMO|||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Managed Medicare|HEALTHSPRING MA|||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|359.25||||||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Medicare|MEDICARE ACUTE|359.25||||||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|NON CONTRACTED|COMMERCIAL OTHER 1|||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|UTMB|UTMB CORRECTIONAL MANAGED CARE|359.25||||359.25||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|United Healthcare|UNITED HEALTHCARE|||||359.25||| 9516766|ERX|0250|DILTIAZEM XL 300MG CAPSUL|Medicare|MEDICARE ACUTE|27.25||||||| 9516766|ERX|0250|DILTIAZEM XL 300MG CAPSUL|Managed Medicare|HEALTHSPRING MA|27.25||||||| 9516766|ERX|0250|DILTIAZEM XL 300MG CAPSUL|Medicaid|MEDICAID|27.25||||||| 9516766|ERX|0250|DILTIAZEM XL 300MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.25||||||| 9516766|ERX|0250|DILTIAZEM XL 300MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|27.25||||||| 9516766|ERX|0250|DILTIAZEM XL 300MG CAPSUL|Humana Medicare Advantage|HUMANA MA|27.25||||||| 9516766|ERX|0250|DILTIAZEM XL 300MG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.25||||||| 9516766|ERX|0250|DILTIAZEM XL 300MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|27.25||||||| 9516766|ERX|0250|DILTIAZEM XL 300MG CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27.25||||||| 9516774|ERX|0250|PERMETHRIN 5% CREAM, 60 G|Managed Medicaid|MEDICAID AMERIGROUP|647.50||||||| 9516774|ERX|0250|PERMETHRIN 5% CREAM, 60 G|Humana Medicare Advantage|HUMANA MA|647.50||||||| 9516774|ERX|0250|PERMETHRIN 5% CREAM, 60 G|Medicaid|MEDICAID|647.50||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.68||||0.68||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Medicare|MEDICARE ACUTE|0.68||||0.68||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.68||||0.68||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.68||||0.68||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.68||||0.68||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.68||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.68||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.68||||0.68||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.68||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.68||||||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.31||||0.31||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.31||||||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.31||||||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.31||||0.31||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.31||||0.31||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.31||||0.31||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.31||||||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|0.31||||||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|Medicare|MEDICARE ACUTE|0.31||||0.31||| 9516857|ERX|0250|TALC AEROSOL 4 G KIT|Managed Medicare|HEALTHSPRING MA|883.75||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.35||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.35||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.35||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.35||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.35||||0.35||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Humana Medicare Advantage|HUMANA MA|0.35||||0.35||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.35||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.35||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Medicare|MEDICARE ACUTE|0.35||||0.35||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.35||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Managed Medicare|HEALTHSPRING MA|0.35||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Managed Medicare|BCBS MEDICARE PPO MA|0.35||||||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Tricare|TRICARE EAST REGION|||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|NON CONTRACTED|COMMERCIAL OTHER 1|5,067.50||||||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|United Healthcare|UNITED HEALTHCARE OTHER|5,067.50||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Medicaid|MEDICAID|||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Managed Medicare|HEALTHSPRING MA|5,067.50||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Medicare|MEDICARE ACUTE|5,067.50||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Aetna|AETNA PPO|||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Aetna|AETNA OTHER|5,067.50||||||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,067.50||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,067.50||||||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|United Healthcare|UNITED HEALTHCARE|||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Blue Cross PPO Specialty|BCBSTX PPO|5,067.50||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Cigna|CIGNA|5,067.50||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Cigna|CIGNA|||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Humana Medicare Advantage|HUMANA MA|5,067.50||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Veterans Affairs|VETERANS ADMINISTRATION|5,067.50||||||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|United Medicare Advantage|UHC AARP MCR HMO MA|5,067.50||||5,067.50||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,067.50||||||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|United Medicare Advantage|UHC MEDICARE GOLD MA|5,067.50||||||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,067.50||||||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5,067.50||||||| 9516881|ERX|0250|ISOSULFAN BLUE 10MG/ML, 5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5,067.50||||5,067.50||| 9516972|ERX|0250|BRIMONIDINE 0.15% DROP,5M|Aenta Medicare Advantage|AETNA MEDICARE MA|5.81||||||| 9516972|ERX|0250|BRIMONIDINE 0.15% DROP,5M|United Medicare Advantage|UHC MEDICARE GOLD MA|5.81||||||| 9516972|ERX|0250|BRIMONIDINE 0.15% DROP,5M|Medicare|MEDICARE PART B ONLY IP|5.81||||||| 9516972|ERX|0250|BRIMONIDINE 0.15% DROP,5M|Medicare|MEDICARE ACUTE|5.81||||5.81||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|United Healthcare|UNITED HEALTHCARE OTHER|360.50||||||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Medicaid|CRIME VICTIMS COMPENSATION|360.50||||||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Medicare|MEDICARE PART B ONLY IP|360.50||||||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Medicare|MEDICARE ACUTE|360.50||||||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Managed Medicaid|MEDICAID SUPERIOR|360.50||||360.50||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|360.50||||360.50||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Managed Medicaid|MEDICAID AMERIGROUP|||||360.50||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Blue Cross PPO Specialty|BCBSTX OTHER|360.50||||||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|360.50||||||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Aetna|AETNA PPO|360.50||||||| 9517020|ERX|0250|AMOX-CLAV 400-57MG/5ML,50|Access Direct Platinum|HEALTHFIRST TPA|360.50||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Aetna Value Network|AETNA VALUE NETWORK|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|ChampVA|CHAMPVA CENTER|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Blue Cross HMO Specialty|BCBSTX HMO|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX PPO|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Humana Medicare Advantage|HUMANA MA|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Cigna|CIGNA|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Cigna|CIGNA|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Managed Medicaid|MEDICAID SUPERIOR|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Managed Medicaid|MEDICAID AMERIGROUP|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Medicare|MEDICARE ACUTE|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Medicaid|MEDICAID|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|United Healthcare|UNITED HEALTHCARE OTHER|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|United Healthcare|TML GROUP BENEFITS|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Aetna|AETNA OTHER|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|58.25||||58.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|58.25||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Aetna|AETNA PPO|||||58.25||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Aetna|AETNA PPO|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Medicaid|SMITH COUNTY JAIL|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE OTHER|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|PHCS|HUMANA|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Managed Medicare|WELLCARE CHOICE MA|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Medicare|MEDICARE ACUTE|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX OTHER|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Veterans Affairs|VETERANS ADMINISTRATION|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|PHCS|HUMANA INSURANCE|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Cigna|CIGNA OTHER|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Medicare|MEDICARE PART B ONLY IP|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Cigna|CIGNA|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|United Medicare Advantage|UHC AARP MCR HMO MA|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Managed Medicare|MA PART B ONLY IP|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Cigna|CIGNA|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Medicaid|CRIME VICTIMS COMPENSATION|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|PHCS|GROUP AND PENSION|||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|140.75||||140.75||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Tricare|TRICARE EAST REGION|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|ChampVA|CHAMPVA CENTER|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Rusk State Hospital|RUSK STATE HOSP|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Aetna|BOON CHAPMAN|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Medicaid|MEDICAID|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Aetna|AETNA OTHER|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Managed Medicare|BCBS MEDICARE PPO MA|140.75||||||| 9517046|ERX|0250|THIAMINE 100MG/ML, 2ML|Workers Compensation|WORKERS COMPENSATION OTHER|140.75||||140.75||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Managed Medicare|BCBS MEDICARE PPO MA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Medicaid|SMITH COUNTY INDIGENT HEALTH|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|United Medicare Advantage|UHC MEDICARE GOLD MA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|United Medicare Advantage|UHC AARP MCR HMO MA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Veterans Affairs|VETERANS ADMINISTRATION|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|United Medicare Advantage|UHC AARP WELLMED HMO MA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|United Healthcare|UNITED HEALTHCARE|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Aenta Medicare Advantage|AETNA MEDICARE MA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Aetna|AETNA QHP HMO|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Aetna|BOON CHAPMAN|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Aetna|AETNA OTHER|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Blue Cross PPO Specialty|BCBSTX PPO|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Humana Medicare Advantage|HUMANA MA|13.25||||13.25||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Managed Medicare|HEALTHSPRING MA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Access Direct Platinum|HEALTHFIRST TPA UMR|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Aetna|AETNA PPO|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Medicaid|MEDICAID|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Access Direct Platinum|HEALTHFIRST TPA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|NON CONTRACTED|COMMERCIAL OTHER 1|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Blue Cross PPO Specialty|BCBSTX OTHER|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Cigna|CIGNA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Blue Cross HMO Specialty|BCBSTX HMO|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|United Healthcare|UNITED HEALTHCARE OTHER|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|PHCS|GROUP AND PENSION|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Tricare|TRICARE EAST REGION|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Cigna|CIGNA OTHER|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Managed Medicaid|MEDICAID SUPERIOR|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Managed Medicaid|MEDICAID AMERIGROUP|13.25||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.25||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aetna Value Network|AETNA VALUE NETWORK|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aetna|AETNA PPO|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Workers Compensation|UT EMPLOYEE INJURY|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aetna|AETNA QHP HMO|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aetna|AETNA OTHER|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aetna|BOON CHAPMAN|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicare|HEALTHSPRING MA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|UNITED HEALTHCARE|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Texas Workforce Commission|DIS DETER SERV (DDS)|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|PHCS|HUMANA INSURANCE|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|PHCS|HUMANA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|GOLDEN RULE|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Multiplan|WEB TPA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Tricare|TRICARE FOR LIFE|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|TML GROUP BENEFITS|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Tricare|TRICARE EAST REGION|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|MEDICAID BCBSTX|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|SMITH COUNTY JAIL|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicare|MEDICARE ACUTE|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicare|MEDICARE PART B ONLY IP|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|MEDICAID|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Cigna|CIGNA OTHER|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|MEDICAID HMO|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|ChampVA|CHAMPVA CENTER|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|PHCS|GROUP AND PENSION|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Cigna|CIGNA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|46.50||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Humana Medicare Advantage|HUMANA MA|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|46.50||||46.50||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|46.50||||46.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Workers Compensation|UT EMPLOYEE INJURY|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Workers Compensation|TEXAS MUTUAL INSURANCE|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|61.50||||||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|61.50||||||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Workers Compensation|BROOKSHIRES WORKERS COMP|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|61.50||||||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aetna|BOON CHAPMAN|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aetna Value Network|AETNA VALUE NETWORK|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aetna|AETNA PPO|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|ChampVA|CHAMPVA CENTER|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Humana Medicare Advantage|HUMANA MA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicare|MEDICARE PART B ONLY IP|61.50||||||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Cigna|CIGNA OTHER|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Cigna|CIGNA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicare|MEDICARE ACUTE|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|61.50||||||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aetna|AETNA OTHER|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|SMITH COUNTY JAIL|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aetna|AETNA QHP HMO|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|LAW ENFORCEMENT OTHER|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|MEDICAID|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|MEDICAID HMO|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|PHCS|HUMANA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Rusk State Hospital|RUSK STATE HOSP|61.50||||||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicare|HEALTHSPRING MA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Texas Workforce Commission|DIS DETER SERV (DDS)|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Healthcare|TML GROUP BENEFITS|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Tricare|TRICARE EAST REGION|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Healthcare|UNITED HEALTHCARE|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|PHCS|GROUP AND PENSION|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Tricare|TRICARE FOR LIFE|||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Healthcare|GEHA|61.50||||61.50||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|61.50||||61.50||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Cigna|CIGNA|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Humana Medicare Advantage|HUMANA MA|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Aetna|AETNA OTHER|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Aetna|AETNA PPO|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Workers Compensation|TEXAS MUTUAL INSURANCE|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Cigna|CIGNA|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicare|HEALTHSPRING MA|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Healthcare|UNITED HEALTHCARE ERS|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Cigna|CIGNA OTHER|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.74||||||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 4|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicaid|MEDICAID HMO|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicare|MEDICARE ACUTE|0.74||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Healthcare|GOLDEN RULE|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicaid|MEDICAID|||||0.74||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Tricare|TRICARE FOR LIFE|||||0.74||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|61.25||||||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Blue Cross HMO Specialty|BCBSTX HMO|61.25||||||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Access Direct Platinum|HEALTHFIRST TPA|61.25||||||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Aetna Value Network|AETNA VALUE NETWORK|||||61.25||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Blue Cross PPO Specialty|BCBSTX OTHER|61.25||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicare|MEDICARE PART B ONLY IP|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicare|HEALTHSPRING MA|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicaid|MEDICAID|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicaid|CRIME VICTIMS COMPENSATION|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicare|MEDICARE ACUTE|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicare|MA PART B ONLY IP|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|PHCS|HUMANA INSURANCE|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Humana Medicare Advantage|HUMANA MA|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Tricare|TRICARE EAST REGION|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Cigna|CIGNA|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicaid|MEDICAID AMERIGROUP|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE OTHER|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Cigna|CIGNA OTHER|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Aetna|AETNA PPO|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicaid|MEDICAID SUPERIOR|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Veterans Affairs|VETERANS ADMINISTRATION|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|ChampVA|CHAMPVA CENTER|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|PHCS|HUMANA|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Cigna|CIGNA|228.75||||228.75||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Blue Cross HMO Specialty|BCBSTX HMO|228.75||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|228.75||||228.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Aetna|AETNA OTHER|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Cigna|CIGNA|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Aetna|AETNA PPO|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Blue Cross PPO Specialty|BCBSTX OTHER|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Aetna|AETNA QHP HMO|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Humana Medicare Advantage|HUMANA MA|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Tricare|TRICARE EAST REGION|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|PHCS|GROUP AND PENSION|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Cigna|CIGNA OTHER|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Medicare|MEDICARE ACUTE|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Medicaid|MEDICAID|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|78.75||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Managed Medicare|HEALTHSPRING MA|78.75||||78.75||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|United Healthcare|UNITED HEALTHCARE|78.75||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|United Healthcare|UNITED HEALTHCARE OTHER|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|United Healthcare|UNITED HEALTHCARE|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Medicaid|MEDICAID|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Medicare|MEDICARE ACUTE|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Tricare|TRICARE EAST REGION|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Managed Medicare|BCBS MEDICARE PPO MA|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|PHCS|GROUP AND PENSION|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Managed Medicare|HEALTHSPRING MA|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Cigna|CIGNA OTHER|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Blue Cross HMO Specialty|BCBSTX HMO|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Managed Medicaid|MEDICAID AMERIGROUP|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|NON CONTRACTED|COMMERCIAL OTHER 1|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Cigna|CIGNA|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Blue Cross PPO Specialty|BCBSTX PPO|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|United Medicare Advantage|UHC AARP MCR HMO MA|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Aetna|AETNA QHP HMO|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Veterans Affairs|VETERANS ADMINISTRATION|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Blue Cross PPO Specialty|BCBSTX OTHER|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Access Direct Platinum|HEALTHFIRST TPA UMR|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Aetna|AETNA OTHER|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Humana Medicare Advantage|HUMANA MA|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|United Medicare Advantage|UHC MEDICARE GOLD MA|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.16||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Aenta Medicare Advantage|AETNA MEDICARE MA|2.16||||||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Aetna|AETNA PPO|||||39.75||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|39.75||||||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|United Healthcare|UNITED HEALTHCARE|||||39.75||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|39.75||||||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|39.75||||39.75||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||39.75||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|39.75||||||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Medicaid|MEDICAID|||||39.75||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Medicare|MEDICARE ACUTE|39.75||||39.75||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Humana Medicare Advantage|HUMANA MA|39.75||||39.75||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|39.75||||||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|39.75||||||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||39.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|PHCS|GROUP AND PENSION|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Rusk State Hospital|RUSK STATE HOSP|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicare|MEDICARE ACUTE|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicaid|CRIME VICTIMS COMPENSATION|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicare|BCBS MEDICARE PPO MA|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicare|HEALTHSPRING MA|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicare|MEDICARE PART B ONLY IP|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Healthcare|UNITED HEALTHCARE|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Healthcare|UNITED HEALTHCARE OTHER|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Tricare|TRICARE EAST REGION|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Cigna|CIGNA|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Healthcare|TML GROUP BENEFITS|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Humana Medicare Advantage|HUMANA MA|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicaid|MEDICAID|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Cigna|CIGNA OTHER|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicare|WELLCARE CHOICE MA|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|PHCS|HUMANA|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicaid|MEDICAID SUPERIOR|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Medicare Advantage|UHC AARP MCR HMO MA|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Blue Cross PPO Specialty|BCBSTX PPO|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicaid|MEDICAID AMERIGROUP|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Aetna|BOON CHAPMAN|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Aetna|AETNA OTHER|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Aetna|AETNA PPO|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Aetna|AETNA QHP HMO|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Veterans Affairs|VETERANS ADMINISTRATION|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Workers Compensation|TEXAS MUTUAL INSURANCE|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Workers Compensation|WORKERS COMPENSATION OTHER|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Blue Cross HMO Specialty|BCBSTX HMO|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Access Direct Platinum|HEALTHFIRST TPA UMR|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Access Direct Platinum|HEALTHFIRST TPA|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Aetna Value Network|AETNA VALUE NETWORK|899.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Blue Cross PPO Specialty|BCBSTX OTHER|899.75||||899.75||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|899.75||||899.75||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Cigna|CIGNA|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Aetna|AETNA PPO|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Rusk State Hospital|RUSK STATE HOSP|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Veterans Affairs|VETERANS ADMINISTRATION|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Medicaid|MEDICAID|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|United Healthcare|TML GROUP BENEFITS|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Managed Medicare|BCBS MEDICARE PPO MA|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Managed Medicare|OTHER INSTITUTIONS|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Medicare|MEDICARE ACUTE|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Medicare|MEDICARE PART B ONLY IP|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.52||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.52||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE OTHER|||||0.52||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE|0.52||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Blue Cross PPO Specialty|BCBSTX OTHER|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Blue Cross HMO Specialty|BCBSTX HMO|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Aetna|BOON CHAPMAN|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Aetna|AETNA QHP HMO|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Veterans Affairs|VETERANS ADMINISTRATION|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Workers Compensation|WORKERS COMPENSATION OTHER|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Medicare Advantage|UHC AARP MCR HMO MA|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Access Direct Platinum|HEALTHFIRST TPA UMR|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Blue Cross PPO Specialty|BCBSTX PPO|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Aetna|AETNA PPO|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Access Direct Platinum|HEALTHFIRST TPA|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Aenta Medicare Advantage|AETNA MEDICARE MA|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Medicare|MEDICARE ACUTE|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicare|BCBS MEDICARE PPO MA|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicare|HEALTHSPRING MA|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Medicaid|MEDICAID|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Medicaid|CRIME VICTIMS COMPENSATION|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Medicaid|COUNTY INDIGENT HEALTH OTHER|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Rusk State Hospital|RUSK STATE HOSP|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|PHCS|HUMANA|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Tricare|TRICARE EAST REGION|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|NON CONTRACTED|COMMERCIAL OTHER 1|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Healthcare|UNITED HEALTHCARE|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Medicare|MEDICARE PART B ONLY IP|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Healthcare|AARP|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Cigna|CIGNA|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Humana Medicare Advantage|HUMANA MA|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Healthcare|UNITED HEALTHCARE OTHER|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicaid|MEDICAID SUPERIOR|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Medicaid|MOLINA HEALTHCARE OF TEXAS|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.50||||16.50||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Cigna|CIGNA OTHER|16.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicaid|MEDICAID AMERIGROUP|16.50||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Workers Compensation|TEXAS MUTUAL INSURANCE|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Aetna|AETNA QHP HMO|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|ChampVA|CHAMPVA CENTER|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Aetna|AETNA OTHER|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Aetna|AETNA PPO|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Healthcare|UNITED HEALTHCARE ERS|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Cigna|CIGNA OTHER|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Cigna|CIGNA|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Cigna|CIGNA|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Humana Medicare Advantage|HUMANA MA|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Healthcare|GEHA|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Tricare|TRICARE EAST REGION|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Workers Compensation|BROOKSHIRES WORKERS COMP|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Workers Compensation|GALLAGHER BASSETT|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|PHCS|GROUP AND PENSION|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Rusk State Hospital|RUSK STATE HOSP|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Tricare|TRICARE FOR LIFE|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicaid|MEDICAID|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Healthcare|UNITED HEALTHCARE|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Texas Workforce Commission|DIS DETER SERV (DDS)|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicare|HEALTHSPRING MA|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicare|MEDICARE ACUTE|129.25||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicare|MEDICARE PART B ONLY IP|129.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicaid|MEDICAID HMO|||||129.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||129.25||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Medicaid|MEDICAID|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Multiplan|WEB TPA|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|38.50||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|38.50||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.60||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.60||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.60||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|0.60||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Aetna Value Network|AETNA VALUE NETWORK|||||0.60||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|0.60||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|0.60||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|0.60||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|0.60||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|0.60||||0.60||| 9517327|ERX|0250|AMPICILLIN 1000MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.87||| 9517327|ERX|0250|AMPICILLIN 1000MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||0.87||| 9517327|ERX|0250|AMPICILLIN 1000MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|0.87||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|30.25||||30.25||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Veterans Affairs|VETERANS ADMINISTRATION|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA|||||30.25||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Blue Cross HMO Specialty|BCBSTX HMO|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Aetna|AETNA QHP HMO|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Aetna|AETNA PPO|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Cigna|CIGNA|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Humana Medicare Advantage|HUMANA MA|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Cigna|CIGNA OTHER|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|United Healthcare|UNITED HEALTHCARE OTHER|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|30.25||||30.25||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Tricare|TRICARE EAST REGION|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|30.25||||30.25||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Medicare|MEDICARE ACUTE|30.25||||30.25||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Aetna|AETNA OTHER|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX PPO|30.25||||30.25||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Managed Medicaid|MEDICAID AMERIGROUP|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|30.25||||30.25||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Managed Medicare|HEALTHSPRING MA|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Managed Medicare|BCBS MEDICARE PPO MA|30.25||||30.25||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|Medicaid|MEDICAID|30.25||||||| 9517368|ERX|0250|HEPARIN 10,000 UNIT/1ML|PHCS|GROUP AND PENSION|30.25||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicare|WELLCARE CHOICE MA|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicaid|SMITH COUNTY JAIL|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicaid|MEDICAID|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicaid|MEDICAID HMO|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicare|MEDICARE ACUTE|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicare|HEALTHSPRING MA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Healthcare|UNITED HEALTHCARE|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Healthcare|TML GROUP BENEFITS|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|PHCS|HUMANA|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Tricare|TRICARE EAST REGION|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Healthcare|UNITED HEALTHCARE|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Cigna|CIGNA|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Rusk State Hospital|RUSK STATE HOSP|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Cigna|CIGNA OTHER|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Aetna|AETNA PPO|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Aetna|BOON CHAPMAN|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Aetna|AETNA OTHER|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicare|MEDICARE PART B ONLY IP|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Workers Compensation|UT EMPLOYEE INJURY|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Humana Medicare Advantage|HUMANA MA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Workers Compensation|BROOKSHIRES WORKERS COMP|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Workers Compensation|GALLAGHER BASSETT|||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|ChampVA|CHAMPVA CENTER|||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|169.50||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|169.50||||169.50||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|PHCS|GROUP AND PENSION|169.50||||||| 9517384|ERX|0250|MESNA 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.20||||||| 9517384|ERX|0250|MESNA 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.20||||||| 9517384|ERX|0250|MESNA 100MG/ML, 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|15.20||||||| 9517384|ERX|0250|MESNA 100MG/ML, 10ML|Medicare|MEDICARE ACUTE|15.20||||||| 9517384|ERX|0250|MESNA 100MG/ML, 10ML|Medicaid|MEDICAID|15.20||||||| 9517384|ERX|0250|MESNA 100MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE OTHER|15.20||||||| 9517392|ERX|0250|PENTAMIDINE NEB 300MG VIA|Medicare|MEDICARE ACUTE|||||1,014.50||| 9517392|ERX|0250|PENTAMIDINE NEB 300MG VIA|Managed Medicare|HEALTHSPRING MA|1,014.50||||||| 9517418|ERX|0250|ESZOPICLONE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|54.25||||||| 9517418|ERX|0250|ESZOPICLONE 1MG TABLET|Multiplan|WEB TPA|54.25||||||| 9517434|ERX|0250|ESZOPICLONE 3MG TABLET|Aetna|BH AETNA|54.25||||||| 9517434|ERX|0250|ESZOPICLONE 3MG TABLET|Humana Medicare Advantage|HUMANA MA|54.25||||||| 9517442|ERX|0250|LEVALBUTEROL 45MCG INH,15|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|561.75||||||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Medicare|MEDICARE ACUTE|0.46||||||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Medicaid|MEDICAID HMO|||||0.46||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|United Healthcare|UNITED HEALTHCARE OTHER|0.46||||||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Tricare|TRICARE EAST REGION|||||0.46||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Veterans Affairs|VETERANS ADMINISTRATION|0.46||||||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.46||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.46||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.46||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Managed Medicare|HEALTHSPRING MA|0.46||||||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Blue Cross PPO Specialty|BCBSTX PPO|0.46||||0.46||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Cigna|CIGNA|0.46||||||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Humana Medicare Advantage|HUMANA MA|0.46||||||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Managed Medicaid|MEDICAID SUPERIOR|0.46||||0.46||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Medicaid|MEDICAID|0.46||||||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Cigna|CIGNA OTHER|||||0.46||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.46||||0.46||| 9517459|ERX|0250|LEVALBUTEROL NEB 0.31MG/3|Managed Medicaid|MEDICAID AMERIGROUP|||||0.46||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97.50||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Managed Medicaid|MEDICAID SUPERIOR|||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Humana Medicare Advantage|HUMANA MA|97.50||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Blue Cross PPO Specialty|BCBSTX PPO|97.50||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Access Direct Platinum|HEALTHFIRST TPA|||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|97.50||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Cigna|CIGNA|||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|97.50||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|97.50||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|United Medicare Advantage|UHC MEDICARE GOLD MA|97.50||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|United Medicare Advantage|UHC AARP MCR HMO MA|97.50||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Veterans Affairs|VETERANS ADMINISTRATION|97.50||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Managed Medicare|HEALTHSPRING MA|97.50||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|United Healthcare|UNITED HEALTHCARE|97.50||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Medicaid|MEDICAID|97.50||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Medicare|MEDICARE ACUTE|97.50||||97.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Managed Medicaid|MEDICAID AMERIGROUP|||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|United Healthcare|UNITED HEALTHCARE OTHER|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Medicare|MEDICARE ACUTE|97.50||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Medicaid|MEDICAID|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Managed Medicare|HEALTHSPRING MA|97.50||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Tricare|TRICARE EAST REGION|97.50||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Veterans Affairs|VETERANS ADMINISTRATION|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Texas Workforce Commission|DIS DETER SERV (DDS)|||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|United Medicare Advantage|UHC MEDICARE GOLD MA|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|97.50||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|United Medicare Advantage|UHC AARP MCR HMO MA|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Humana Medicare Advantage|HUMANA MA|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Blue Cross PPO Specialty|BCBSTX PPO|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|NON CONTRACTED|COMMERCIAL OTHER 1|97.50||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Managed Medicaid|MEDICAID SUPERIOR|97.50||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97.50||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Blue Cross HMO Specialty|BCBSTX HMO|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Managed Medicaid|MEDICAID AMERIGROUP|||||97.50||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|97.50||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Aenta Medicare Advantage|AETNA MEDICARE MA|97.50||||||| 9517483|ERX|0250|MODAFINIL 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|79.75||||||| 9517483|ERX|0250|MODAFINIL 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|79.75||||||| 9517483|ERX|0250|MODAFINIL 100MG TABLET|Humana Medicare Advantage|HUMANA MA|79.75||||||| 9517483|ERX|0250|MODAFINIL 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|79.75||||||| 9517483|ERX|0250|MODAFINIL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|79.75||||||| 9517483|ERX|0250|MODAFINIL 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|79.75||||||| 9517483|ERX|0250|MODAFINIL 100MG TABLET|Medicare|MEDICARE ACUTE|79.75||||||| 9517491|ERX|0250|MODAFINIL 200MG TABLET|Managed Medicare|HEALTHSPRING MA|110.50||||110.50||| 9517491|ERX|0250|MODAFINIL 200MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|110.50||||||| 9517491|ERX|0250|MODAFINIL 200MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.50||||110.50||| 9517491|ERX|0250|MODAFINIL 200MG TABLET|Humana Medicare Advantage|HUMANA MA|110.50||||110.50||| 9517491|ERX|0250|MODAFINIL 200MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||110.50||| 9517491|ERX|0250|MODAFINIL 200MG TABLET|Medicare|MEDICARE ACUTE|110.50||||||| 9517491|ERX|0250|MODAFINIL 200MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|110.50||||||| 9517491|ERX|0250|MODAFINIL 200MG TABLET|Tricare|TRICARE EAST REGION|110.50||||||| 9517491|ERX|0250|MODAFINIL 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|110.50||||||| 9517509|ERX|0250|TIAGABINE 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|41.25||||||| 9517525|ERX|0250|MEPERIDINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.19||| 9517525|ERX|0250|MEPERIDINE 50MG TABLET|Medicare|MEDICARE ACUTE|||||0.19||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|20.75||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.75||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.75||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|20.75||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Humana Medicare Advantage|HUMANA MA|20.75||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.75||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|20.75||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|20.75||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.75||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|20.75||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Medicaid|MEDICAID|||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|20.75||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Medicare|MEDICARE ACUTE|20.75||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Tricare|TRICARE EAST REGION|||||20.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Managed Medicare|HEALTHSPRING MA|||||20.75||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Medicare|MEDICARE PART B ONLY IP|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicare|HEALTHSPRING MA|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicare|BCBS MEDICARE PPO MA|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Medicaid|MEDICAID|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|United Healthcare|UNITED HEALTHCARE|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|United Healthcare|TML GROUP BENEFITS|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Blue Cross PPO Specialty|BCBSTX PPO|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|NON CONTRACTED|COMMERCIAL OTHER 1|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicaid|MEDICAID AMERIGROUP|||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Tricare|TRICARE EAST REGION|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Blue Cross HMO Specialty|BCBSTX HMO|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Aetna|AETNA PPO|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Blue Cross PPO Specialty|BCBSTX OTHER|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Cigna|CIGNA|||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Humana Medicare Advantage|HUMANA MA|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Veterans Affairs|VETERANS ADMINISTRATION|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|United Medicare Advantage|UHC MEDICARE GOLD MA|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Workers Compensation|WORKERS COMPENSATION OTHER|||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Access Direct Platinum|HEALTHFIRST TPA UMR|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Aenta Medicare Advantage|AETNA MEDICARE MA|18.25||||18.25||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Workers Compensation|TRAVELERS INSURANCE COMPANY|18.25||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|United Medicare Advantage|UHC AARP MCR HMO MA|18.25||||18.25||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Workers Compensation|WORKERS COMPENSATION OTHER|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Workers Compensation|TEXAS MUTUAL INSURANCE|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Workers Compensation|UT EMPLOYEE INJURY|||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Humana Medicare Advantage|HUMANA MA|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Cigna|CIGNA|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Access Direct Platinum|HEALTHFIRST TPA UMR|||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicaid|MEDICAID AMERIGROUP|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Aetna|AETNA PPO|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicaid|MEDICAID SUPERIOR|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Cigna|CIGNA OTHER|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Brinson Benefits|THE HEALTH PLAN SMITH CO|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Blue Cross PPO Specialty|BCBSTX OTHER|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Blue Cross PPO Specialty|BCBSTX PPO|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Cigna|CIGNA|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|PHCS|HUMANA|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Tricare|TRICARE EAST REGION|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Tricare|TRICARE FOR LIFE|||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|United Healthcare|UNITED HEALTHCARE OTHER|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Veterans Affairs|VETERANS ADMINISTRATION|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicaid|MEDICAID HMO|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicaid|COUNTY INDIGENT HEALTH OTHER|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|United Healthcare|UNITED HEALTHCARE|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicaid|SMITH COUNTY JAIL|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|United Healthcare|UNITED HEALTHCARE|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicaid|MEDICAID|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicare|HEALTHSPRING MA|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicare|MEDICARE ACUTE|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicare|MEDICARE PART B ONLY IP|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicare|BCBS MEDICARE PPO MA|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|82.75||||82.75||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|UTMB|UTMB CORRECTIONAL MANAGED CARE|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicaid|CRIME VICTIMS COMPENSATION|82.75||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Blue Cross HMO Specialty|BCBSTX HMO|82.75||||82.75||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicare|HEALTHSPRING MA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicaid|SMITH COUNTY JAIL|||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Healthcare|UNITED HEALTHCARE|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|PHCS|HUMANA|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|PHCS|GROUP AND PENSION|||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Tricare|TRICARE EAST REGION|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Healthcare|UNITED HEALTHCARE|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|ChampVA|CHAMPVA CENTER|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Aetna|AETNA PPO|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Aetna|AETNA OTHER|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicare|MEDICARE ACUTE|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Healthcare|TML GROUP BENEFITS|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Cigna|CIGNA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Cigna|CIGNA|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicaid|MEDICAID|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Humana Medicare Advantage|HUMANA MA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.53||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.53||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||0.53||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.53||||0.53||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|Humana Medicare Advantage|HUMANA MA|0.12||||0.12||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.12||||||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.12||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.12||||0.12||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.12||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|Managed Medicaid|MEDICAID AMERIGROUP|0.12||||||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|Blue Cross PPO Specialty|BCBSTX PPO|0.12||||0.12||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|Blue Cross HMO Specialty|BCBSTX HMO|||||0.12||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|Medicare|MEDICARE PART B ONLY IP|0.12||||||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|Medicare|MEDICARE ACUTE|0.12||||0.12||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|Managed Medicare|HEALTHSPRING MA|||||0.12||| 9517616|ERX|0250|MTH-ME BLUE-SALICY-NAPHOS|United Healthcare|UNITED HEALTHCARE|||||0.12||| 9517640|ERX|0250|PHENOBARBITAL 32.4MG TABL|Medicare|MEDICARE ACUTE|2.50||||||| 9517640|ERX|0250|PHENOBARBITAL 32.4MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9517640|ERX|0250|PHENOBARBITAL 32.4MG TABL|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9517640|ERX|0250|PHENOBARBITAL 32.4MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.50||| 9517640|ERX|0250|PHENOBARBITAL 32.4MG TABL|Medicaid|MEDICAID|2.50||||||| 9517640|ERX|0250|PHENOBARBITAL 32.4MG TABL|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9517640|ERX|0250|PHENOBARBITAL 32.4MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|16.50||||16.50||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.50||||16.50||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Aetna|AETNA OTHER|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.50||||16.50||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|United Healthcare|UNITED HEALTHCARE|16.50||||16.50||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Medicare|MEDICARE ACUTE|16.50||||16.50||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|16.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|16.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Medicaid|SMITH COUNTY JAIL|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Medicaid|MEDICAID|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||7.50||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||7.50||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Cigna|CIGNA|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||7.50||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Humana Medicare Advantage|HUMANA MA|7.50||||7.50||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|7.50||||7.50||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Managed Medicare|HEALTHSPRING MA|7.50||||7.50||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Magellan Behavioral Health|BH MAGELLAN|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.50||||7.50||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|United Healthcare|UNITED HEALTHCARE|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.50||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|7.50||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Medicaid|MEDICAID|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Medicaid|SMITH COUNTY INDIGENT HEALTH|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Medicare|MEDICARE ACUTE|8.25||||8.25||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Aenta Medicare Advantage|AETNA MEDICARE MA|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.25||||8.25||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Veterans Affairs|VETERANS ADMINISTRATION|8.25||||8.25||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|United Medicare Advantage|UHC AARP MCR HMO MA|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|United Medicare Advantage|UHC MEDICARE GOLD MA|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Humana Medicare Advantage|HUMANA MA|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Managed Medicaid|MEDICAID AMERIGROUP|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Aetna|AETNA PPO|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Blue Cross PPO Specialty|BCBSTX PPO|8.25||||8.25||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Blue Cross HMO Specialty|BCBSTX HMO|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Blue Cross PPO Specialty|BCBSTX OTHER|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|PHCS|HUMANA|8.25||||8.25||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|NON CONTRACTED|COMMERCIAL OTHER 1|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Managed Medicare|BCBS MEDICARE PPO MA|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Managed Medicare|HEALTHSPRING MA|8.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Medicaid|LAW ENFORCEMENT OTHER|8.25||||||| 9517699|ERX|0250|POTASSIUM CHLORIDE 8 MEQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||||| 9517699|ERX|0250|POTASSIUM CHLORIDE 8 MEQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11.50||| 9517699|ERX|0250|POTASSIUM CHLORIDE 8 MEQ|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||||| 9517699|ERX|0250|POTASSIUM CHLORIDE 8 MEQ|Humana Medicare Advantage|HUMANA MA|11.50||||11.50||| 9517699|ERX|0250|POTASSIUM CHLORIDE 8 MEQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||11.50||| 9517699|ERX|0250|POTASSIUM CHLORIDE 8 MEQ|Medicare|MEDICARE PART B ONLY IP|11.50||||||| 9517699|ERX|0250|POTASSIUM CHLORIDE 8 MEQ|Medicare|MEDICARE ACUTE|11.50||||11.50||| 9517707|ERX|0250|METHACHOLINE 100MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||513.50||| 9517707|ERX|0250|METHACHOLINE 100MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||513.50||| 9517707|ERX|0250|METHACHOLINE 100MG VIAL|Managed Medicare|HEALTHSPRING MA|||||513.50||| 9517707|ERX|0250|METHACHOLINE 100MG VIAL|Medicare|MEDICARE ACUTE|||||513.50||| 9517723|ERX|0250|OXALIPLATIN 100MG/20ML|Medicaid|MEDICAID|877.20||||||| 9517723|ERX|0250|OXALIPLATIN 100MG/20ML|Blue Cross PPO Specialty|BCBSTX PPO|877.20||||||| 9517723|ERX|0250|OXALIPLATIN 100MG/20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|877.20||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Cigna|CIGNA|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Aetna|AETNA QHP HMO|||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Aetna|AETNA PPO|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Tricare|TRICARE EAST REGION|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Managed Medicare|OTHER INSTITUTIONS|||||25.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Managed Medicare|HEALTHSPRING MA|30.75||||30.75||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Medicaid|SMITH COUNTY JAIL|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Medicare|MEDICARE ACUTE|30.75||||30.75||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|PHCS|HUMANA|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|United Healthcare|UNITED HEALTHCARE|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Managed Medicare|BCBS MEDICARE PPO MA|30.75||||30.75||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|30.75||||30.75||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Blue Cross PPO Specialty|BCBSTX OTHER|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Humana Medicare Advantage|HUMANA MA|30.75||||30.75||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Cigna|CIGNA|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30.75||||30.75||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30.75||||30.75||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Aenta Medicare Advantage|AETNA MEDICARE MA|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|30.75||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|30.75||||||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UMR|43.75||||||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Aenta Medicare Advantage|AETNA MEDICARE MA|43.75||||||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|43.75||||||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|43.75||||||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Humana Medicare Advantage|HUMANA MA|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|43.75||||||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Workers Compensation|WORKERS COMPENSATION OTHER|43.75||||||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|United Healthcare|UNITED HEALTHCARE OTHER|||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|United Healthcare|UNITED HEALTHCARE|43.75||||||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Medicare|MEDICARE PART B ONLY IP|43.75||||||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Medicare|MEDICARE ACUTE|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Managed Medicare|HEALTHSPRING MA|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|43.75||||43.75||| 9517772|ERX|0250|DILTIAZEM XL 240MG CAPSUL|Medicaid|COUNTY INDIGENT HEALTH OTHER|43.75||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|48.50||||48.50||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Managed Medicare|HEALTHSPRING MA|48.50||||48.50||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Medicare|MEDICARE PART B ONLY IP|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Medicare|MEDICARE ACUTE|48.50||||48.50||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|United Healthcare|UNITED HEALTHCARE|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|48.50||||48.50||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Humana Medicare Advantage|HUMANA MA|48.50||||48.50||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|48.50||||48.50||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|48.50||||48.50||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|48.50||||48.50||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|48.50||||48.50||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Tricare|TRICARE EAST REGION|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|48.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|48.50||||||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.37||||0.37||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.37||||||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|0.37||||||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|Humana Medicare Advantage|HUMANA MA|0.37||||||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.37||||0.37||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|United Healthcare|UNITED HEALTHCARE OTHER|0.37||||||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.37||||||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|Managed Medicare|HEALTHSPRING MA|0.37||||0.37||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.37||||||| 9517822|ERX|0250|INDOMETHACIN SR 75MG CAPS|Medicare|MEDICARE ACUTE|26.50||||||| 9517822|ERX|0250|INDOMETHACIN SR 75MG CAPS|United Healthcare|UNITED HEALTHCARE|26.50||||||| 9517822|ERX|0250|INDOMETHACIN SR 75MG CAPS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.50||||||| 9517822|ERX|0250|INDOMETHACIN SR 75MG CAPS|Veterans Affairs|VETERANS ADMINISTRATION|26.50||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Aetna|BOON CHAPMAN|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Cigna|CIGNA|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Humana Medicare Advantage|HUMANA MA|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|PHCS|GROUP AND PENSION|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Aetna|AETNA PPO|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Tricare|TRICARE EAST REGION|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Aetna|BH AETNA|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Multiplan|NALC|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|United Healthcare|UNITED HEALTHCARE|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Medicaid|SMITH COUNTY JAIL|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Medicaid|MEDICAID|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicare|HEALTHSPRING MA|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Medicare|MEDICARE PART B ONLY IP|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Medicare|MEDICARE ACUTE|0.03||||0.03||| 9517848|ERX|0250|TRIAMTERENE 50MG CAPSULE|Medicare|MEDICARE ACUTE|15.50||||||| 9517848|ERX|0250|TRIAMTERENE 50MG CAPSULE|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9517855|ERX|0250|BIVALIRUDIN 250MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|2,006.40||||||| 9517855|ERX|0250|BIVALIRUDIN 250MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|2,006.40||||||| 9517855|ERX|0250|BIVALIRUDIN 250MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|2,006.40||||||| 9517855|ERX|0250|BIVALIRUDIN 250MG VIAL|Medicare|MEDICARE ACUTE|2,006.40||||||| 9517855|ERX|0250|BIVALIRUDIN 250MG VIAL|Humana Medicare Advantage|HUMANA MA|2,006.40||||||| 9517855|ERX|0250|BIVALIRUDIN 250MG VIAL|Cigna|CIGNA|2,006.40||||||| 9517855|ERX|0250|BIVALIRUDIN 250MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,006.40||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.36||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.36||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Medicare|MEDICARE ACUTE|0.36||||0.36||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.36||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|0.36||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.36||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.36||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.36||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.36||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.36||||||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||15.50||| 9517897|ERX|0250|RIFAXIMIN 200MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|50.25||||||| 9517897|ERX|0250|RIFAXIMIN 200MG TABLET|Cigna|CIGNA|50.25||||||| 9517897|ERX|0250|RIFAXIMIN 200MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|50.25||||||| 9517897|ERX|0250|RIFAXIMIN 200MG TABLET|Medicare|MEDICARE ACUTE|50.25||||||| 9517897|ERX|0250|RIFAXIMIN 200MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|50.25||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|United Medicare Advantage|UHC MEDICARE GOLD MA|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|United Medicare Advantage|UHC AARP MCR HMO MA|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Aenta Medicare Advantage|AETNA MEDICARE MA|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Access Direct Platinum|HEALTHFIRST TPA|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Blue Cross PPO Specialty|BCBSTX PPO|1.70||||1.70||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.70||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Humana Medicare Advantage|HUMANA MA|1.70||||1.70||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Cigna|CIGNA|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.70||||1.70||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Blue Cross HMO Specialty|BCBSTX HMO|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.70||||1.70||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Managed Medicaid|MEDICAID AMERIGROUP|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Veterans Affairs|VETERANS ADMINISTRATION|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Medicaid|MEDICAID|1.70||||1.70||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Managed Medicare|HEALTHSPRING MA|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Managed Medicare|BCBS MEDICARE PPO MA|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.70||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Medicare|MEDICARE PART B ONLY IP|1.70||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Medicare|MEDICARE ACUTE|1.70||||1.70||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.70||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|United Healthcare|UNITED HEALTHCARE|1.70||||||| 9517921|ERX|0250|PROPAFENONE 225MG CAPSULE|Medicare|MEDICARE ACUTE|65.75||||65.75||| 9517921|ERX|0250|PROPAFENONE 225MG CAPSULE|Cigna|CIGNA|65.75||||||| 9517921|ERX|0250|PROPAFENONE 225MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||65.75||| 9517921|ERX|0250|PROPAFENONE 225MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||65.75||| 9517921|ERX|0250|PROPAFENONE 225MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|65.75||||||| 9517939|ERX|0250|PROPAFENONE 325MG CAPSULE|Humana Medicare Advantage|HUMANA MA|||||83.25||| 9517939|ERX|0250|PROPAFENONE 325MG CAPSULE|Cigna|CIGNA|83.25||||||| 9517939|ERX|0250|PROPAFENONE 325MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|83.25||||||| 9517939|ERX|0250|PROPAFENONE 325MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|83.25||||||| 9517939|ERX|0250|PROPAFENONE 325MG CAPSULE|Medicare|MEDICARE ACUTE|83.25||||||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Managed Medicare|HEALTHSPRING MA|0.41||||0.41||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.41||||||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Medicare|MEDICARE ACUTE|0.41||||0.41||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.41||||||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.41||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.41||||||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Humana Medicare Advantage|HUMANA MA|0.41||||||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.41||||0.41||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.41||||||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.41||||0.41||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.41||||||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Humana Medicare Advantage|HUMANA MA|12.75||||12.75||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Aetna|BH AETNA|12.75||||||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||12.75||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||12.75||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|United Healthcare|UNITED HEALTHCARE|||||12.75||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|United Healthcare|GOLDEN RULE|12.75||||||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Blue Cross HMO Specialty|BCBSTX HMO|12.75||||||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.75||||||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Managed Medicare|BCBS MEDICARE PPO MA|||||12.75||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.75||||||| 9517954|ERX|0250|OMEGA-3 ACID ETHYL ESTERS|Managed Medicare|HEALTHSPRING MA|12.75||||||| 9518028|ERX|0250|CAPSAICIN 0.025% CREAM, 6|Medicare|MEDICARE ACUTE|127.75||||127.75||| 9518028|ERX|0250|CAPSAICIN 0.025% CREAM, 6|Veterans Affairs|VETERANS ADMINISTRATION|||||127.75||| 9518069|ERX|0250|PHENYLEPHRINE 0.5% NASAL,|Blue Cross PPO Specialty|BCBSTX PPO|46.75||||||| 9518069|ERX|0250|PHENYLEPHRINE 0.5% NASAL,|Humana Medicare Advantage|HUMANA MA|||||46.75||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Tricare|TRICARE EAST REGION|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|United Healthcare|UNITED HEALTHCARE|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|United Healthcare|TML GROUP BENEFITS|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Medicaid|SMITH COUNTY JAIL|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Medicaid|MEDICAID HMO|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Medicaid|MEDICAID|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Cigna|CIGNA OTHER|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Cigna|CIGNA|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Aetna|BOON CHAPMAN|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Aetna|AETNA OTHER|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Aetna|AETNA PPO|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|ChampVA|CHAMPVA CENTER|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||9.25||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|9.25||||||| 9518077|ERX|0250|OXYCODONE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9518093|ERX|0250|PRIMIDONE 250MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.50||||||| 9518093|ERX|0250|PRIMIDONE 250MG TABLET|Medicare|MEDICARE ACUTE|31.50||||||| 9518093|ERX|0250|PRIMIDONE 250MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|31.50||||||| 9518093|ERX|0250|PRIMIDONE 250MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|31.50||||||| 9518101|ERX|0250|PSEUDOEPHEDRINE 30MG TABL|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9518101|ERX|0250|PSEUDOEPHEDRINE 30MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.50||| 9518101|ERX|0250|PSEUDOEPHEDRINE 30MG TABL|Cigna|CIGNA OTHER|||||2.50||| 9518101|ERX|0250|PSEUDOEPHEDRINE 30MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|||||2.50||| 9518101|ERX|0250|PSEUDOEPHEDRINE 30MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|||||2.50||| 9518101|ERX|0250|PSEUDOEPHEDRINE 30MG TABL|Medicaid|MEDICAID|2.50||||||| 9518101|ERX|0250|PSEUDOEPHEDRINE 30MG TABL|Medicare|MEDICARE ACUTE|2.50||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Aetna|AETNA OTHER|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Aetna|BH AETNA|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|PHCS|GROUP AND PENSION|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Tricare|TRICARE EAST REGION|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Tricare|TRICARE FOR LIFE|||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Medicare|MEDICARE ACUTE|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Medicaid|MEDICAID|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.36||||0.36||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.36||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|||||0.36||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Managed Medicare|BCBS MEDICARE PPO MA|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Managed Medicare|HEALTHSPRING MA|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Medicare|MEDICARE ACUTE|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|PHCS|GROUP AND PENSION|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Managed Medicare|OTHER INSTITUTIONS|||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|United Healthcare|UNITED HEALTHCARE|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|ChampVA|CHAMPVA CENTER|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Blue Cross PPO Specialty|BCBSTX PPO|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Blue Cross PPO Specialty|BCBSTX OTHER|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Blue Cross HMO Specialty|BCBSTX HMO|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Aetna|AETNA OTHER|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Aetna|AETNA PPO|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Cigna|CIGNA|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|United Healthcare|UNITED HEALTHCARE OTHER|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Tricare|TRICARE EAST REGION|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|NON CONTRACTED|COMMERCIAL OTHER 1|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Cigna|CIGNA OTHER|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Medicaid|MEDICAID|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Humana Medicare Advantage|HUMANA MA|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Aetna|AETNA QHP HMO|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Managed Medicaid|MEDICAID SUPERIOR|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Managed Medicaid|MEDICAID AMERIGROUP|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|United Medicare Advantage|UHC AARP MCR HMO MA|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|106.50||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Veterans Affairs|VETERANS ADMINISTRATION|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Workers Compensation|WORKERS COMPENSATION OTHER|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||106.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|106.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|106.50||||||| 9518168|ERX|0250|CEFUROXIME 750MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|79.75||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.25||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|United Healthcare|UNITED HEALTHCARE|||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Tricare|TRICARE EAST REGION|38.25||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Medicare|MEDICARE ACUTE|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Managed Medicare|HEALTHSPRING MA|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|38.25||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Medicaid|MEDICAID|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.25||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|United Healthcare|GOLDEN RULE|38.25||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Humana Medicare Advantage|HUMANA MA|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Aetna|AETNA PPO|38.25||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|38.25||||38.25||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|38.25||||||| 9518200|ERX|0250|AMPICILLIN 250MG/5ML,100M|Medicare|MEDICARE ACUTE|76.25||||||| 9518200|ERX|0250|AMPICILLIN 250MG/5ML,100M|Blue Cross PPO Specialty|BCBSTX PPO|76.25||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|PHCS|GROUP AND PENSION|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|United Healthcare|UNITED HEALTHCARE|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Managed Medicare|HEALTHSPRING MA|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Medicaid|MEDICAID|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Medicare|MEDICARE ACUTE|1,440.75||||1,440.75||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Medicare|MEDICARE PART B ONLY IP|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Tricare|TRICARE EAST REGION|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Managed Medicare|BCBS MEDICARE PPO MA|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Cigna|CIGNA|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Humana Medicare Advantage|HUMANA MA|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,440.75||||1,440.75||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Aetna|AETNA OTHER|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Aetna|AETNA PPO|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Blue Cross PPO Specialty|BCBSTX OTHER|1,440.75||||||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|1,440.75||||1,440.75||| 9518242|ERX|0250|NICARDIPINE 25MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|1,440.75||||||| 9518275|ERX|0250|ASCORBIC ACID 500 MG/ML 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|452.40||||||| 9518275|ERX|0250|ASCORBIC ACID 500 MG/ML 5|Humana Medicare Advantage|HUMANA MA|452.40||||||| 9518291|ERX|0250|PENTOBARBITAL 50MG/1ML|Medicaid|MEDICAID|74.25||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Workers Compensation|UT EMPLOYEE INJURY|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Aenta Medicare Advantage|AETNA MEDICARE MA|26.50||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Access Direct Platinum|HEALTHFIRST TPA UMR|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Veterans Affairs|VETERANS ADMINISTRATION|26.50||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|United Medicare Advantage|UHC MEDICARE GOLD MA|26.50||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.50||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|United Medicare Advantage|UHC AARP MCR HMO MA|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Cigna|CIGNA|||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Humana Medicare Advantage|HUMANA MA|26.50||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Blue Cross PPO Specialty|BCBSTX PPO|26.50||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Blue Cross HMO Specialty|BCBSTX HMO|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Aetna|AETNA PPO|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.50||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Access Direct Platinum|HEALTHFIRST TPA|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|United Healthcare|UNITED HEALTHCARE OTHER|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|United Healthcare|UNITED HEALTHCARE|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|United Healthcare|TML GROUP BENEFITS|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|NON CONTRACTED|COMMERCIAL OTHER 1|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Tricare|TRICARE EAST REGION|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Medicare|MEDICARE PART B ONLY IP|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Medicare|MEDICARE ACUTE|26.50||||26.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Managed Medicare|BCBS MEDICARE PPO MA|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Medicaid|MEDICAID|26.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Managed Medicare|HEALTHSPRING MA|26.50||||26.50||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Rusk State Hospital|RUSK STATE HOSP|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Medicaid|MEDICAID|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Medicare|MEDICARE ACUTE|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Optum Behavioral Health|BH OPTUM UHC|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Aetna|BH AETNA|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Magellan Behavioral Health|BH MAGELLAN|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|513.50||||||| 9518317|ERX|0250|BENZTROPINE 1MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|513.50||||||| 9518333|ERX|0250|CHLOROTHIAZIDE 500MG VIAL|Medicare|MEDICARE ACUTE|536.43||||||| 9518333|ERX|0250|CHLOROTHIAZIDE 500MG VIAL|Medicaid|MEDICAID|536.43||||||| 9518333|ERX|0250|CHLOROTHIAZIDE 500MG VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|536.43||||||| 9518374|ERX|0250|DOCUSATE SODIUM 50MG CAPS|Access Direct Platinum|ANDREWS CENTER|5.25||||||| 9518374|ERX|0250|DOCUSATE SODIUM 50MG CAPS|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||||| 9518374|ERX|0250|DOCUSATE SODIUM 50MG CAPS|Medicare|MEDICARE ACUTE|5.25||||||| 9518374|ERX|0250|DOCUSATE SODIUM 50MG CAPS|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||||| 9518374|ERX|0250|DOCUSATE SODIUM 50MG CAPS|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.25||||||| 9518374|ERX|0250|DOCUSATE SODIUM 50MG CAPS|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||||| 9518374|ERX|0250|DOCUSATE SODIUM 50MG CAPS|Managed Medicaid|MEDICAID SUPERIOR|5.25||||||| 9518374|ERX|0250|DOCUSATE SODIUM 50MG CAPS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Medicare|MEDICARE PART B ONLY IP|0.03||||||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Medicare|MEDICARE ACUTE|0.03||||0.03||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||0.03||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.03||||||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.03||||||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Humana Medicare Advantage|HUMANA MA|0.03||||0.03||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.03||||||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.03||||||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.03||||||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.03||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Workers Compensation|ZURICH COMPANY|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Workers Compensation|TRAVELERS INSURANCE COMPANY|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Cigna Behavioral Health|BH CIGNA|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Cigna|CIGNA OTHER|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Cigna|CIGNA|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Magellan Behavioral Health|BH MAGELLAN|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Aetna|BH AETNA|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Aetna|AETNA OTHER|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Aetna|AETNA PPO|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|United Healthcare|UNITED HEALTHCARE|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|United Healthcare|UNITED HEALTHCARE|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|United Healthcare|TML GROUP BENEFITS|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Multiplan|WEB TPA|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Rusk State Hospital|RUSK STATE HOSP|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|PHCS|GROUP AND PENSION|||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|PHCS|HUMANA|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Optum Behavioral Health|BH OPTUM UHC|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Tricare|TRICARE FOR LIFE|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Tricare|TRICARE EAST REGION|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid|MEDICAID HMO|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Access Direct Platinum|ANDREWS CENTER|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid|LAW ENFORCEMENT OTHER|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid|MEDICAID|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||5.25||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|5.25||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Medicaid|SUPERIOR HEALTHPLAN CHIP|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Medicaid|MOLINA HEALTHCARE OF TEXAS|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Medicare|MEDICARE ACUTE|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Medicaid|MEDICAID|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Medicaid|COUNTY INDIGENT HEALTH OTHER|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Managed Medicare|HEALTHSPRING MA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|PHCS|GROUP AND PENSION|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|PHCS|HUMANA|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Tricare|TRICARE FOR LIFE|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|NON CONTRACTED|COMMERCIAL OTHER 1|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|United Healthcare|UNITED HEALTHCARE OTHER|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|United Healthcare|TML GROUP BENEFITS|||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|United Healthcare|UNITED HEALTHCARE|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Aetna|AETNA PPO|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Aetna|AETNA OTHER|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Blue Cross PPO Specialty|BCBSTX PPO|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Blue Cross PPO Specialty|BCBSTX OTHER|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|United Healthcare|UNITED HEALTHCARE ERS|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Blue Cross HMO Specialty|BCBSTX HMO|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Tricare|TRICARE EAST REGION|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|ChampVA|CHAMPVA CENTER|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Humana Medicare Advantage|HUMANA MA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Medicare|MEDICARE PART B ONLY IP|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Managed Medicare|BCBS MEDICARE PPO MA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Cigna|CIGNA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Cigna|CIGNA OTHER|||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Managed Medicaid|MEDICAID SUPERIOR|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Managed Medicaid|MEDICAID AMERIGROUP|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|United Medicare Advantage|UHC AARP MCR HMO MA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|United Medicare Advantage|UHC MEDICARE GOLD MA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|United Medicare Advantage|UHC AARP WELLMED HMO MA|8.50||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Veterans Affairs|VETERANS ADMINISTRATION|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Access Direct Platinum|HEALTHFIRST TPA UMR|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Access Direct Platinum|HEALTHFIRST TPA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Aenta Medicare Advantage|AETNA MEDICARE MA|8.50||||8.50||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Workers Compensation|WORKERS COMPENSATION OTHER|8.50||||8.50||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|13.25||||13.25||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|13.25||||13.25||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|13.25||||13.25||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.25||||13.25||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Managed Medicaid|MEDICAID AMERIGROUP|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Cigna|CIGNA|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|13.25||||13.25||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|13.25||||13.25||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|United Healthcare|UNITED HEALTHCARE|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Managed Medicare|BCBS MEDICARE PPO MA|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Humana Medicare Advantage|HUMANA MA|13.25||||13.25||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Managed Medicare|OTHER INSTITUTIONS|||||13.25||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Managed Medicare|HEALTHSPRING MA|13.25||||13.25||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Medicaid|MEDICAID|13.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9518457|ERX|0250|METHYL SALIC/MENTHOL ,120|Medicare|MEDICARE ACUTE|0.54||||0.54||| 9518457|ERX|0250|METHYL SALIC/MENTHOL ,120|Medicaid|MEDICAID|0.54||||||| 9518457|ERX|0250|METHYL SALIC/MENTHOL ,120|Managed Medicare|HEALTHSPRING MA|0.54||||||| 9518457|ERX|0250|METHYL SALIC/MENTHOL ,120|Blue Cross PPO Specialty|BCBSTX PPO|0.54||||||| 9518457|ERX|0250|METHYL SALIC/MENTHOL ,120|Humana Medicare Advantage|HUMANA MA|0.54||||||| 9518457|ERX|0250|METHYL SALIC/MENTHOL ,120|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.54||||||| 9518457|ERX|0250|METHYL SALIC/MENTHOL ,120|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.54||||0.54||| 9518457|ERX|0250|METHYL SALIC/MENTHOL ,120|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.54||||||| 9518481|ERX|0250|MESALAMINE 4 G KIT, 60ML|Managed Medicare|HEALTHSPRING MA|2.79||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Workers Compensation|WORKERS COMPENSATION OTHER|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.25||||0.25||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|United Medicare Advantage|UHC AARP MCR HMO MA|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Cigna|CIGNA|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Humana Medicare Advantage|HUMANA MA|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Aetna|AETNA PPO|||||0.25||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.25||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Blue Cross PPO Specialty|BCBSTX PPO|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Blue Cross HMO Specialty|BCBSTX HMO|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Tricare|TRICARE EAST REGION|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Managed Medicare|HEALTHSPRING MA|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Medicaid|MEDICAID|0.25||||||| 9518499|ERX|0250|PENTAZOCINE-NALOXONE TABL|Medicare|MEDICARE ACUTE|0.25||||0.25||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Managed Medicare|BCBS MEDICARE PPO MA|||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Managed Medicare|HEALTHSPRING MA|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|United Healthcare|UNITED HEALTHCARE OTHER|0.15||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|United Healthcare|UNITED HEALTHCARE|||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|ChampVA|CHAMPVA CENTER|||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Aetna|AETNA PPO|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Managed Medicaid|MEDICAID SUPERIOR|||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Managed Medicaid|MEDICAID AMERIGROUP|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Medicaid|MEDICAID|0.15||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Veterans Affairs|VETERANS ADMINISTRATION|||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Blue Cross HMO Specialty|BCBSTX HMO|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.15||||0.15||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.15||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Cigna|CIGNA|||||0.15||| 9518523|ERX|0250|RASAGILINE 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|98.25||||98.25||| 9518523|ERX|0250|RASAGILINE 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|98.25||||||| 9518523|ERX|0250|RASAGILINE 0.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|98.25||||||| 9518523|ERX|0250|RASAGILINE 0.5MG TABLET|Medicare|MEDICARE ACUTE|98.25||||||| 9518549|ERX|0250|ALBUTEROL 4MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.25||||||| 9518549|ERX|0250|ALBUTEROL 4MG TABLET|Medicare|MEDICARE ACUTE|20.25||||||| 9518549|ERX|0250|ALBUTEROL 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|20.25||||||| 9518580|ERX|0250|ETHAMBUTOL 400MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.23||||||| 9518580|ERX|0250|ETHAMBUTOL 400MG TABLET|Humana Medicare Advantage|HUMANA MA|0.23||||||| 9518580|ERX|0250|ETHAMBUTOL 400MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.23||||||| 9518580|ERX|0250|ETHAMBUTOL 400MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.23||||0.23||| 9518580|ERX|0250|ETHAMBUTOL 400MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.23||||||| 9518580|ERX|0250|ETHAMBUTOL 400MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.23||||||| 9518580|ERX|0250|ETHAMBUTOL 400MG TABLET|Managed Medicare|HEALTHSPRING MA|0.23||||||| 9518580|ERX|0250|ETHAMBUTOL 400MG TABLET|Medicare|MEDICARE ACUTE|0.23||||||| 9518580|ERX|0250|ETHAMBUTOL 400MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.23||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Medicare|MEDICARE ACUTE|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Medicaid|MEDICAID|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Multiplan|WEB TPA|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Humana Medicare Advantage|HUMANA MA|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.25||||||| 9518598|ERX|0250|LITHIUM 300MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.25||||0.25||| 9518606|ERX|0250|ELECTROLYTE,ORAL 240ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9518606|ERX|0250|ELECTROLYTE,ORAL 240ML|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9518606|ERX|0250|ELECTROLYTE,ORAL 240ML|Managed Medicaid|MEDICAID SUPERIOR|25.50||||25.50||| 9518606|ERX|0250|ELECTROLYTE,ORAL 240ML|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||25.50||| 9518606|ERX|0250|ELECTROLYTE,ORAL 240ML|Cigna|CIGNA OTHER|25.50||||25.50||| 9518606|ERX|0250|ELECTROLYTE,ORAL 240ML|Medicaid|MEDICAID HMO|||||25.50||| 9518606|ERX|0250|ELECTROLYTE,ORAL 240ML|Medicaid|MEDICAID|||||25.50||| 9518606|ERX|0250|ELECTROLYTE,ORAL 240ML|Medicare|MEDICARE ACUTE|25.50||||||| 9518622|ERX|0250|MINERAL OIL-PETROLATUM 1|Medicare|MEDICARE ACUTE|0.72||||||| 9518622|ERX|0250|MINERAL OIL-PETROLATUM 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.72||||||| 9518622|ERX|0250|MINERAL OIL-PETROLATUM 1|Managed Medicaid|MEDICAID SUPERIOR|0.72||||||| 9518622|ERX|0250|MINERAL OIL-PETROLATUM 1|Managed Medicaid|MEDICAID AMERIGROUP|0.72||||||| 9518622|ERX|0250|MINERAL OIL-PETROLATUM 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.72||||||| 9518630|ERX|0250|MINERAL OIL-PET OINT, 396|Blue Cross PPO Specialty|BCBSTX PPO|133.75||||||| 9518630|ERX|0250|MINERAL OIL-PET OINT, 396|Medicare|MEDICARE ACUTE|133.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Medicare|MEDICARE ACUTE|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Access Direct Platinum|HEALTHFIRST TPA UMR|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Managed Medicaid|MEDICAID AMERIGROUP|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29.75||||29.75||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Managed Medicaid|MEDICAID SUPERIOR|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Blue Cross PPO Specialty|BCBSTX PPO|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Blue Cross HMO Specialty|BCBSTX HMO|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Aenta Medicare Advantage|AETNA MEDICARE MA|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|United Medicare Advantage|UHC MEDICARE GOLD MA|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Access Direct Platinum|HEALTHFIRST TPA|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Medicaid|MEDICAID|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Medicaid|CRIME VICTIMS COMPENSATION|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|United Healthcare|UNITED HEALTHCARE|||||29.75||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|United Healthcare|UNITED HEALTHCARE OTHER|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Humana Medicare Advantage|HUMANA MA|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Access Direct Platinum|ANDREWS CENTER|29.75||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Managed Medicare|HEALTHSPRING MA|29.75||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Veterans Affairs|VETERANS ADMINISTRATION|||||2.50||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Managed Medicare|BCBS MEDICARE PPO MA|||||2.50||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|NON CONTRACTED|COMMERCIAL OTHER 1|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Tricare|TRICARE EAST REGION|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Healthcare|UNITED HEALTHCARE OTHER|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Healthcare|TML GROUP BENEFITS|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Healthcare|GEHA|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Medicaid|MEDICAID|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Medicaid|CRIME VICTIMS COMPENSATION|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicare|HOSPICE OF EAST TEXAS|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Healthcare|UNITED HEALTHCARE|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicare|HEALTHSPRING MA|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Medicare|MEDICARE ACUTE|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Medicare Advantage|UHC AARP WELLMED HMO MA|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Medicare Advantage|UHC MEDICARE GOLD MA|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Medicare Advantage|UHC AARP MCR HMO MA|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Veterans Affairs|VETERANS ADMINISTRATION|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Workers Compensation|TRAVELERS INSURANCE COMPANY|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Aenta Medicare Advantage|AETNA MEDICARE MA|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Medicaid|MOLINA HEALTHCARE OF TEXAS|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Workers Compensation|WORKERS COMPENSATION OTHER|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Access Direct Platinum|HEALTHFIRST TPA UMR|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicare|ETMC AFFILIATE HOSPITALS|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Access Direct Platinum|HEALTHFIRST TPA|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Cigna|CIGNA OTHER|||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Cigna|CIGNA|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Humana Medicare Advantage|HUMANA MA|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicaid|MEDICAID SUPERIOR|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|UTMB|UTMB CORRECTIONAL MANAGED CARE|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Aetna|BOON CHAPMAN|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Aetna|AETNA PPO|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Blue Cross HMO Specialty|BCBSTX HMO|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Blue Cross PPO Specialty|BCBSTX OTHER|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicaid|MEDICAID AMERIGROUP|10.50||||10.50||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|ChampVA|CHAMPVA CENTER|10.50||||||| 9518697|ERX|0250|FLUOCINONIDE 0.05% CREAM,|Humana Medicare Advantage|HUMANA MA|519.75||||||| 9518697|ERX|0250|FLUOCINONIDE 0.05% CREAM,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||519.75||| 9518697|ERX|0250|FLUOCINONIDE 0.05% CREAM,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|519.75||||||| 9518697|ERX|0250|FLUOCINONIDE 0.05% CREAM,|Medicare|MEDICARE ACUTE|519.75||||||| 9518697|ERX|0250|FLUOCINONIDE 0.05% CREAM,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|519.75||||||| 9518721|ERX|0250|METHOTREXATE PF 50MG/2ML|United Healthcare|UNITED HEALTHCARE|43.50||||||| 9518721|ERX|0250|METHOTREXATE PF 50MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|43.50||||43.50||| 9518721|ERX|0250|METHOTREXATE PF 50MG/2ML|Medicare|MEDICARE ACUTE|43.50||||||| 9518721|ERX|0250|METHOTREXATE PF 50MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43.50||||||| 9518721|ERX|0250|METHOTREXATE PF 50MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|43.50||||||| 9518721|ERX|0250|METHOTREXATE PF 50MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|43.50||||||| 9518721|ERX|0250|METHOTREXATE PF 50MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.50||||||| 9518762|ERX|0250|VECURONIUM 20MG VIAL|Medicare|MEDICARE ACUTE|85.50||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Cigna|CIGNA OTHER|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Managed Medicaid|MEDICAID SUPERIOR|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Managed Medicaid|MEDICAID AMERIGROUP|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Aetna Value Network|AETNA VALUE NETWORK|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Aetna|AETNA QHP HMO|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Aetna|AETNA PPO|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Aetna|AETNA OTHER|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Blue Cross HMO Specialty|BCBSTX HMO|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Blue Cross PPO Specialty|BCBSTX PPO|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|United Medicare Advantage|UHC AARP MCR HMO MA|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Humana Medicare Advantage|HUMANA MA|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Veterans Affairs|VETERANS ADMINISTRATION|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Cigna|CIGNA|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Workers Compensation|WORKERS COMPENSATION OTHER|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Access Direct Platinum|HEALTHFIRST TPA|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Access Direct Platinum|HEALTHFIRST TPA UMR|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Tricare|TRICARE EAST REGION|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|NON CONTRACTED|COMMERCIAL OTHER 1|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|United Healthcare|UNITED HEALTHCARE OTHER|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|United Healthcare|UNITED HEALTHCARE|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Managed Medicare|HEALTHSPRING MA|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Managed Medicare|BCBS MEDICARE PPO MA|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Medicaid|SMITH COUNTY JAIL|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Medicaid|MEDICAID|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Medicare|MEDICARE ACUTE|0.45||||0.45||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|United Healthcare|GEHA|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Medicare|MEDICARE PART B ONLY IP|0.45||||||| 9518770|ERX|0258|SODIUM CHLORIDE 0.9%,100M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.45||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Medicare|MEDICARE ACUTE|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Medicaid|MEDICAID|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Managed Medicare|HEALTHSPRING MA|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|United Healthcare|UNITED HEALTHCARE|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|NON CONTRACTED|COMMERCIAL OTHER 2|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|ChampVA|CHAMPVA CENTER|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Aetna|BOON CHAPMAN|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Humana Medicare Advantage|HUMANA MA|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Managed Medicaid|MEDICAID SUPERIOR|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|563.50||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|563.50||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Humana Medicare Advantage|HUMANA MA|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Managed Medicaid|MEDICAID AMERIGROUP|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|ChampVA|CHAMPVA CENTER|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Blue Cross HMO Specialty|BCBSTX HMO|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Blue Cross PPO Specialty|BCBSTX PPO|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Veterans Affairs|VETERANS ADMINISTRATION|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|1.56||||1.56||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|United Medicare Advantage|UHC AARP MCR HMO MA|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Access Direct Platinum|HEALTHFIRST TPA|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|NON CONTRACTED|COMMERCIAL OTHER 1|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|United Healthcare|UNITED HEALTHCARE OTHER|1.56||||1.56||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|United Healthcare|UNITED HEALTHCARE|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Managed Medicare|HEALTHSPRING MA|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Medicaid|MEDICAID|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Medicaid|CRIME VICTIMS COMPENSATION|1.56||||||| 9518804|ERX|0250|HYDROMORPHONE PCA 1MG/ML,|Medicare|MEDICARE ACUTE|1.56||||||| 9518820|ERX|0250|RIVASTIGMINE 9.5MG PATCH|Medicare|MEDICARE ACUTE|60.75||||||| 9518820|ERX|0250|RIVASTIGMINE 9.5MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|60.75||||||| 9518820|ERX|0250|RIVASTIGMINE 9.5MG PATCH|Humana Medicare Advantage|HUMANA MA|||||60.75||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Blue Cross PPO Specialty|BCBSTX OTHER|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|ChampVA|CHAMPVA CENTER|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Aetna|BOON CHAPMAN|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Aetna|AETNA OTHER|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Aetna|AETNA QHP HMO|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Managed Medicaid|MEDICAID SUPERIOR|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Managed Medicaid|MEDICAID AMERIGROUP|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Workers Compensation|WORKERS COMPENSATION OTHER|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Workers Compensation|TEXAS MUTUAL INSURANCE|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Workers Compensation|BROOKSHIRES WORKERS COMP|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Aenta Medicare Advantage|AETNA MEDICARE MA|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Access Direct Platinum|HEALTHFIRST TPA UMR|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Access Direct Platinum|HEALTHFIRST TPA|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Medicare Advantage|UHC AARP MCR HMO MA|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Healthcare|GEHA|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Cigna|CIGNA OTHER|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Healthcare|UNITED HEALTHCARE OTHER|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Healthcare|UNITED HEALTHCARE|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Healthcare|UNITED HEALTHCARE|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Workers Compensation|UT EMPLOYEE INJURY|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Rusk State Hospital|RUSK STATE HOSP|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Cigna|CIGNA|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|PHCS|HUMANA INSURANCE|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|PHCS|HUMANA|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|PHCS|GROUP AND PENSION|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Tricare|TRICARE EAST REGION|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Texas Workforce Commission|DIS DETER SERV (DDS)|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Aetna|AETNA PPO|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|NON CONTRACTED|COMMERCIAL OTHER 1|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicaid|MEDICAID HMO|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicaid|SMITH COUNTY JAIL|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicaid|MEDICAID|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Blue Cross HMO Specialty|BCBSTX HMO|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicaid|CRIME VICTIMS COMPENSATION|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicare|MEDICARE PART B ONLY IP|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Managed Medicare|HEALTHSPRING MA|0.05||||0.05||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Managed Medicare|BCBS MEDICARE PPO MA|0.05||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.05||||||| 9518929|ERX|0258|DEXTROSE 5%-WATER,VISIV 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Blue Cross PPO Specialty|BCBSTX PPO|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|NON CONTRACTED|COMMERCIAL OTHER 1|||||127.50||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|United Healthcare|UNITED HEALTHCARE|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Blue Cross HMO Specialty|BCBSTX HMO|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|United Healthcare|TML GROUP BENEFITS|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|UTMB|UTMB CORRECTIONAL MANAGED CARE|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Medicare|MEDICARE ACUTE|127.50||||127.50||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Medicaid|MOLINA HEALTHCARE OF TEXAS|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Medicaid|MEDICAID|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Managed Medicare|WELLCARE CHOICE MA|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||127.50||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Managed Medicare|HEALTHSPRING MA|127.50||||127.50||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Managed Medicare|BCBS MEDICARE PPO MA|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|United Medicare Advantage|UHC MEDICARE GOLD MA|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|United Medicare Advantage|UHC AARP MCR HMO MA|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Veterans Affairs|VETERANS ADMINISTRATION|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Humana Medicare Advantage|HUMANA MA|127.50||||127.50||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Cigna|CIGNA|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Managed Medicaid|MEDICAID SUPERIOR|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127.50||||||| 9518937|ERX|0258|DEXTROSE 5%-WATER,VISIV 2|Aetna|AETNA OTHER|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|Medicaid|MEDICAID|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|Medicare|MEDICARE ACUTE|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|NON CONTRACTED|COMMERCIAL OTHER 1|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|Blue Cross HMO Specialty|BCBSTX HMO|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|Blue Cross PPO Specialty|BCBSTX PPO|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|Managed Medicaid|MEDICAID AMERIGROUP|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|Humana Medicare Advantage|HUMANA MA|127.50||||||| 9518945|ERX|0258|NA CHLORIDE 0.9%,250ML VI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|127.50||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|4.75||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|4.75||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.75||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Aenta Medicare Advantage|AETNA MEDICARE MA|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Cigna|CIGNA|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Cigna|CIGNA OTHER|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.75||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Aetna|AETNA QHP HMO|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Humana Medicare Advantage|HUMANA MA|4.75||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Aetna|AETNA PPO|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.75||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Blue Cross PPO Specialty|BCBSTX OTHER|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|United Healthcare|UNITED HEALTHCARE|4.75||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|United Healthcare|UNITED HEALTHCARE OTHER|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|United Healthcare|GOLDEN RULE|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|NON CONTRACTED|COMMERCIAL OTHER 1|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Medicaid|MEDICAID|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Managed Medicare|BCBS MEDICARE PPO MA|4.75||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Managed Medicare|HEALTHSPRING MA|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Medicare|MEDICARE PART B ONLY IP|4.75||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Medicare|MEDICARE ACUTE|4.75||||4.75||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Medicare|MEDICARE ACUTE|11.75||||||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|11.75||||11.75||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.75||||||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.75||||||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|11.75||||||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.75||||||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|11.75||||||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Humana Medicare Advantage|HUMANA MA|11.75||||11.75||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Access Direct Platinum|ANDREWS CENTER|11.75||||||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|||||11.75||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|11.75||||||| 9518960|ERX|0250|HEMATINIC COMBO CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|||||11.75||| 9519000|ERX|0250|ZOLPIDEM CR 12.5MG TABLET|Medicare|MEDICARE ACUTE|50.25||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Access Direct Platinum|HEALTHFIRST TPA|||||2.50||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.50||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|United Healthcare|UNITED HEALTHCARE OTHER|||||2.50||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Medicaid|MEDICAID|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|213.25||||||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Medicare|MEDICARE PART B ONLY IP|213.25||||||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Medicare|MEDICARE ACUTE|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Medicaid|MEDICAID|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|213.25||||||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Managed Medicare|HEALTHSPRING MA|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|213.25||||||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|United Healthcare|UNITED HEALTHCARE|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|United Healthcare|UNITED HEALTHCARE|||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|PHCS|HUMANA|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Tricare|TRICARE EAST REGION|213.25||||||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|213.25||||||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|213.25||||||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Aetna|AETNA OTHER|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Aetna|AETNA PPO|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|213.25||||||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Cigna|CIGNA|213.25||||||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Humana Medicare Advantage|HUMANA MA|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|213.25||||213.25||| 9519026|ERX|0250|CLOPIDOGREL 300MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|213.25||||213.25||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|United Medicare Advantage|UHC AARP MCR HMO MA|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Veterans Affairs|VETERANS ADMINISTRATION|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Access Direct Platinum|HEALTHFIRST TPA|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Humana Medicare Advantage|HUMANA MA|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Blue Cross HMO Specialty|BCBSTX HMO|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Blue Cross PPO Specialty|BCBSTX PPO|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|NON CONTRACTED|COMMERCIAL OTHER 1|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|United Healthcare|UNITED HEALTHCARE OTHER|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Managed Medicare|HEALTHSPRING MA|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Medicare|MEDICARE ACUTE|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Medicaid|MEDICAID|4.62||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Medicaid|CRIME VICTIMS COMPENSATION|4.62||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Medicaid|MEDICAID|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Medicare|MEDICARE ACUTE|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Managed Medicare|HEALTHSPRING MA|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|United Healthcare|UNITED HEALTHCARE OTHER|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Rusk State Hospital|RUSK STATE HOSP|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Blue Cross HMO Specialty|BCBSTX HMO|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Blue Cross PPO Specialty|BCBSTX PPO|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Aetna|AETNA OTHER|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Aetna|BOON CHAPMAN|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Managed Medicaid|MEDICAID SUPERIOR|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Humana Medicare Advantage|HUMANA MA|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|United Medicare Advantage|UHC AARP MCR HMO MA|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|4.56||||||| 9519042|ERX|0258|CLINIMIX E 5/15 2000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.56||||||| 9519067|ERX|0258|CLINIMIX 5/15 1000ML|Humana Medicare Advantage|HUMANA MA|3.71||||||| 9519067|ERX|0258|CLINIMIX 5/15 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|3.71||||||| 9519067|ERX|0258|CLINIMIX 5/15 1000ML|Medicare|MEDICARE ACUTE|3.71||||||| 9519067|ERX|0258|CLINIMIX 5/15 1000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.71||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|PHCS|GROUP AND PENSION|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|United Healthcare|UNITED HEALTHCARE OTHER|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Medicaid|MEDICAID|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Managed Medicare|HEALTHSPRING MA|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|United Medicare Advantage|UHC AARP MCR HMO MA|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Workers Compensation|WORKERS COMPENSATION OTHER|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Aenta Medicare Advantage|AETNA MEDICARE MA|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Access Direct Platinum|HEALTHFIRST TPA UMR|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Aetna|AETNA PPO|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Blue Cross HMO Specialty|BCBSTX HMO|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.75||||12.75||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Managed Medicaid|MEDICAID SUPERIOR|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Managed Medicaid|MEDICAID AMERIGROUP|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Cigna|CIGNA OTHER|12.75||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Humana Medicare Advantage|HUMANA MA|12.75||||12.75||| 9519091|ERX|0250|LUBIPROSTONE 8MCG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.31||||0.31||| 9519091|ERX|0250|LUBIPROSTONE 8MCG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.31||||||| 9519091|ERX|0250|LUBIPROSTONE 8MCG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|0.31||||||| 9519091|ERX|0250|LUBIPROSTONE 8MCG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.31||||||| 9519091|ERX|0250|LUBIPROSTONE 8MCG CAPSULE|Medicare|MEDICARE ACUTE|0.31||||0.31||| 9519091|ERX|0250|LUBIPROSTONE 8MCG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.31||||||| 9519091|ERX|0250|LUBIPROSTONE 8MCG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.31||| 9519109|ERX|0250|ESTRADIOL 0.025MG PATCH|Cigna|CIGNA OTHER|76.50||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|NON CONTRACTED|COMMERCIAL OTHER 1|6.25||||6.25||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Rusk State Hospital|RUSK STATE HOSP|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|United Healthcare|UNITED HEALTHCARE OTHER|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|United Healthcare|UNITED HEALTHCARE|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Medicaid|COUNTY INDIGENT HEALTH OTHER|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Medicaid|MEDICAID|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Medicaid|CRIME VICTIMS COMPENSATION|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Managed Medicare|HEALTHSPRING MA|6.25||||6.25||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Managed Medicare|BCBS MEDICARE PPO MA|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Medicare|MEDICARE PART B ONLY IP|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Medicare|MEDICARE ACUTE|6.25||||6.25||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Access Direct Platinum|HEALTHFIRST TPA|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Aenta Medicare Advantage|AETNA MEDICARE MA|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Workers Compensation|WORKERS COMPENSATION OTHER|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Workers Compensation|TEXAS MUTUAL INSURANCE|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Veterans Affairs|VETERANS ADMINISTRATION|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|United Healthcare|TML GROUP BENEFITS|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|United Medicare Advantage|UHC AARP WELLMED HMO MA|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|United Medicare Advantage|UHC MEDICARE GOLD MA|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|United Medicare Advantage|UHC AARP MCR HMO MA|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Tricare|TRICARE EAST REGION|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Blue Cross HMO Specialty|BCBSTX HMO|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Blue Cross PPO Specialty|BCBSTX PPO|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Aetna|AETNA QHP HMO|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Aetna|AETNA PPO|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Aetna|AETNA OTHER|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.25||||6.25||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Managed Medicaid|MEDICAID SUPERIOR|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Managed Medicaid|MEDICAID AMERIGROUP|6.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Humana Medicare Advantage|HUMANA MA|6.25||||6.25||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Cigna|CIGNA|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Humana Medicare Advantage|HUMANA MA|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Managed Medicaid|MEDICAID SUPERIOR|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Aetna|BOON CHAPMAN|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Veterans Affairs|VETERANS ADMINISTRATION|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Medicare|MEDICARE PART B ONLY IP|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Medicare|MEDICARE ACUTE|0.28||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Managed Medicare|HEALTHSPRING MA|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Managed Medicare|BCBS MEDICARE PPO MA|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Medicaid|MEDICAID|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|United Healthcare|UNITED HEALTHCARE OTHER|||||0.28||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|United Healthcare|UNITED HEALTHCARE|0.28||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Tricare|TRICARE EAST REGION|0.28||||||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|United Healthcare|UNITED HEALTHCARE|1.45||||||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|Medicaid|MEDICAID HMO|1.45||||||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|Managed Medicare|HOSPICE OF EAST TEXAS|1.45||||||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|Managed Medicare|HEALTHSPRING MA|1.45||||||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|Medicare|MEDICARE ACUTE|1.45||||1.45||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|1.45||||||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|1.45||||||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|1.45||||||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||1.45||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.45||||||| 9519158|ERX|0250|FENTANYL 12MCG PATCH|Humana Medicare Advantage|HUMANA MA|1.45||||1.45||| 9519174|ERX|0250|CEFOTAXIME 1 GM/100ML NS|Medicare|MEDICARE ACUTE|60.25||||60.25||| 9519182|ERX|0250|CEFOTAXIME 2 GM/100ML NS|Medicare|MEDICARE ACUTE|89.25||||||| 9519257|ERX|0250|CEFEPIME NOT FOR ORDER EN|NON CONTRACTED|COMMERCIAL OTHER 1|255.75||||||| 9519265|ERX|0250|CEFEPIME 2G NOT 4 ORDER E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.27||||||| 9519265|ERX|0250|CEFEPIME 2G NOT 4 ORDER E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.27||||||| 9519265|ERX|0250|CEFEPIME 2G NOT 4 ORDER E|Medicare|MEDICARE ACUTE|4.27||||||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Medicare|MEDICARE ACUTE|118.50||||118.50||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||118.50||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Access Direct Platinum|HEALTHFIRST TPA UMR|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Access Direct Platinum|HEALTHFIRST TPA|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Cigna|CIGNA|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Humana Medicare Advantage|HUMANA MA|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Managed Medicaid|MEDICAID SUPERIOR|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Managed Medicaid|MEDICAID AMERIGROUP|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Blue Cross PPO Specialty|BCBSTX PPO|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Blue Cross PPO Specialty|BCBSTX OTHER|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|United Healthcare|UNITED HEALTHCARE|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Tricare|TRICARE EAST REGION|||||216.25||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Managed Medicare|HEALTHSPRING MA|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Medicaid|MOLINA HEALTHCARE OF TEXAS|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Medicaid|MEDICAID|216.25||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Medicare|MEDICARE ACUTE|216.25||||216.25||| 9519299|ERX|0250|AMPICILLIN 500MG/ 100ML N|Medicare|MEDICARE ACUTE|0.60||||||| 9519299|ERX|0250|AMPICILLIN 500MG/ 100ML N|Blue Cross PPO Specialty|BCBSTX PPO|0.60||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Aenta Medicare Advantage|AETNA MEDICARE MA|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Access Direct Platinum|HEALTHFIRST TPA UMR|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Access Direct Platinum|HEALTHFIRST TPA|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|United Medicare Advantage|UHC MEDICARE GOLD MA|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|United Medicare Advantage|UHC AARP MCR HMO MA|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Managed Medicaid|MEDICAID AMERIGROUP|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Humana Medicare Advantage|HUMANA MA|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Cigna|CIGNA OTHER|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Managed Medicaid|MEDICAID SUPERIOR|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Aetna|AETNA PPO|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Aetna|AETNA OTHER|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|ChampVA|CHAMPVA CENTER|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Blue Cross HMO Specialty|BCBSTX HMO|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Blue Cross PPO Specialty|BCBSTX OTHER|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Veterans Affairs|VETERANS ADMINISTRATION|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Blue Cross PPO Specialty|BCBSTX PPO|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|NON CONTRACTED|COMMERCIAL OTHER 1|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Texas Workforce Commission|DIS DETER SERV (DDS)|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Tricare|TRICARE EAST REGION|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Tricare|TRICARE FOR LIFE|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|UTMB|UTMB CORRECTIONAL MANAGED CARE|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|United Healthcare|UNITED HEALTHCARE OTHER|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|United Healthcare|UNITED HEALTHCARE|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|United Healthcare|UNITED HEALTHCARE|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Managed Medicare|HEALTHSPRING MA|634.75||||634.75||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Managed Medicare|BCBS MEDICARE PPO MA|634.75||||||| 9519307|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Medicare|MEDICARE ACUTE|634.75||||634.75||| 9519315|ERX|0250|CEFUROXIME 1.5 G/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|0.87||||||| 9519315|ERX|0250|CEFUROXIME 1.5 G/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.87||||||| 9519315|ERX|0250|CEFUROXIME 1.5 G/100ML NS|Humana Medicare Advantage|HUMANA MA|0.87||||||| 9519315|ERX|0250|CEFUROXIME 1.5 G/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.87||||||| 9519315|ERX|0250|CEFUROXIME 1.5 G/100ML NS|United Medicare Advantage|UHC AARP MCR HMO MA|0.87||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Medicare|MEDICARE ACUTE|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Managed Medicare|HEALTHSPRING MA|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Medicaid|MEDICAID|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|United Healthcare|UNITED HEALTHCARE|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Cigna|CIGNA OTHER|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Cigna|CIGNA|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Humana Medicare Advantage|HUMANA MA|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Aetna|AETNA PPO|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Aetna|AETNA OTHER|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.75||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|21.75||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|||||21.75||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|21.75||||21.75||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Blue Cross PPO Specialty|BCBSTX PPO|709.75||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|709.75||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Humana Medicare Advantage|HUMANA MA|709.75||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Managed Medicaid|MEDICAID SUPERIOR|709.75||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|United Medicare Advantage|UHC AARP MCR HMO MA|709.75||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Workers Compensation|WORKERS COMPENSATION OTHER|709.75||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Aenta Medicare Advantage|AETNA MEDICARE MA|709.75||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Managed Medicare|BCBS MEDICARE PPO MA|709.75||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Medicare|MEDICARE ACUTE|709.75||||709.75||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Tricare|TRICARE EAST REGION|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|NON CONTRACTED|COMMERCIAL OTHER 1|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|United Healthcare|UNITED HEALTHCARE OTHER|394.25||||394.25||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|United Healthcare|UNITED HEALTHCARE|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|United Healthcare|TML GROUP BENEFITS|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Medicare|MEDICARE ACUTE|394.25||||394.25||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Medicaid|MEDICAID|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Medicaid|CRIME VICTIMS COMPENSATION|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Medicaid|COUNTY INDIGENT HEALTH OTHER|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Medicaid|SMITH COUNTY JAIL|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Managed Medicare|BCBS MEDICARE PPO MA|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||394.25||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Access Direct Platinum|HEALTHFIRST TPA UMR|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Access Direct Platinum|HEALTHFIRST TPA|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Aenta Medicare Advantage|AETNA MEDICARE MA|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Workers Compensation|WORKERS COMPENSATION OTHER|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Managed Medicare|HEALTHSPRING MA|394.25||||394.25||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Veterans Affairs|VETERANS ADMINISTRATION|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|United Medicare Advantage|UHC AARP WELLMED HMO MA|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|United Medicare Advantage|UHC AARP MCR HMO MA|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|United Medicare Advantage|UHC MEDICARE GOLD MA|394.25||||394.25||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Managed Medicaid|MEDICAID UNITED HEALTHCARE|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Managed Medicaid|MEDICAID SUPERIOR|394.25||||394.25||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Medicare|MEDICARE PART B ONLY IP|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|UTMB|UTMB CORRECTIONAL MANAGED CARE|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|394.25||||394.25||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Managed Medicaid|MEDICAID AMERIGROUP|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Cigna|CIGNA OTHER|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Cigna|CIGNA|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Humana Medicare Advantage|HUMANA MA|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Aetna|AETNA PPO|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Aetna|AETNA OTHER|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Aetna|BOON CHAPMAN|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|394.25||||394.25||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Blue Cross HMO Specialty|BCBSTX HMO|394.25||||394.25||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Blue Cross PPO Specialty|BCBSTX OTHER|394.25||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Blue Cross PPO Specialty|BCBSTX PPO|394.25||||394.25||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|Blue Cross PPO Specialty|BCBSTX PPO|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|Humana Medicare Advantage|HUMANA MA|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|United Medicare Advantage|UHC AARP MCR HMO MA|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|Managed Medicare|HEALTHSPRING MA|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|Medicaid|MEDICAID|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|Medicare|MEDICARE ACUTE|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|UTMB|UTMB CORRECTIONAL MANAGED CARE|225.75||||||| 9519364|ERX|0250|NAFCILLIN 2 GM/100ML MB+|NON CONTRACTED|COMMERCIAL OTHER 1|225.75||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|NON CONTRACTED|COMMERCIAL OTHER 1|||||118.50||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|UTMB|UTMB CORRECTIONAL MANAGED CARE|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|United Healthcare|UNITED HEALTHCARE OTHER|118.50||||118.50||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Medicare|MEDICARE PART B ONLY IP|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Managed Medicare|HEALTHSPRING MA|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Managed Medicare|BCBS MEDICARE PPO MA|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Aenta Medicare Advantage|AETNA MEDICARE MA|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|118.50||||118.50||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Access Direct Platinum|HEALTHFIRST TPA UMR|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Workers Compensation|WORKERS COMPENSATION OTHER|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Veterans Affairs|VETERANS ADMINISTRATION|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Medicare|MEDICARE ACUTE|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|United Medicare Advantage|UHC MEDICARE GOLD MA|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|United Medicare Advantage|UHC AARP MCR HMO MA|||||118.50||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Managed Medicaid|MEDICAID SUPERIOR|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Cigna|CIGNA|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Humana Medicare Advantage|HUMANA MA|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Aetna|AETNA PPO|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||118.50||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Blue Cross HMO Specialty|BCBSTX HMO|118.50||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Blue Cross PPO Specialty|BCBSTX PPO|118.50||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Blue Cross HMO Specialty|BCBSTX HMO|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Blue Cross PPO Specialty|BCBSTX OTHER|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Blue Cross PPO Specialty|BCBSTX PPO|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Brinson Benefits|THE HEALTH PLAN SMITH CO|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|ChampVA|CHAMPVA CENTER|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Aetna|AETNA OTHER|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Humana Medicare Advantage|HUMANA MA|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Cigna|CIGNA OTHER|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Managed Medicaid|MEDICAID SUPERIOR|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|United Medicare Advantage|UHC MEDICARE GOLD MA|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|United Medicare Advantage|UHC AARP MCR HMO MA|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Veterans Affairs|VETERANS ADMINISTRATION|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Workers Compensation|WORKERS COMPENSATION OTHER|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Workers Compensation|UT EMPLOYEE INJURY|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Workers Compensation|BROOKSHIRES WORKERS COMP|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Access Direct Platinum|HEALTHFIRST TPA UMR|||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Managed Medicaid|MEDICAID AMERIGROUP|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Access Direct Platinum|HEALTHFIRST TPA|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Aenta Medicare Advantage|AETNA MEDICARE MA|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicaid|COUNTY INDIGENT HEALTH OTHER|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicaid|SMITH COUNTY INDIGENT HEALTH|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Cigna|CIGNA|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicaid|MEDICAID|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicaid|CRIME VICTIMS COMPENSATION|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Aetna|AETNA PPO|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicaid|SMITH COUNTY JAIL|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicaid|MOLINA HEALTHCARE OF TEXAS|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicaid|LAW ENFORCEMENT OTHER|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Managed Medicare|HEALTHSPRING MA|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Managed Medicare|BCBS MEDICARE PPO MA|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicare|MEDICARE PART B ONLY IP|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicare|MEDICARE ACUTE|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|UTMB|UTMB CORRECTIONAL MANAGED CARE|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|United Healthcare|UNITED HEALTHCARE OTHER|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|United Healthcare|UNITED HEALTHCARE|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|United Healthcare|GEHA|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|United Healthcare|TML GROUP BENEFITS|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Rusk State Hospital|RUSK STATE HOSP|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|PHCS|HUMANA|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Tricare|TRICARE EAST REGION|199.75||||199.75||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|NON CONTRACTED|COMMERCIAL OTHER 2|199.75||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|NON CONTRACTED|COMMERCIAL OTHER 1|199.75||||199.75||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Rusk State Hospital|RUSK STATE HOSP|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|PHCS|GROUP AND PENSION|||||58.25||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Medicare|MEDICARE PART B ONLY IP|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Managed Medicare|BCBS MEDICARE PPO MA|58.25||||58.25||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Managed Medicare|HEALTHSPRING MA|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Medicaid|MEDICAID|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Medicare|MEDICARE ACUTE|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Veterans Affairs|VETERANS ADMINISTRATION|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|United Medicare Advantage|UHC AARP MCR HMO MA|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|58.25||||58.25||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Humana Medicare Advantage|HUMANA MA|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Aetna|AETNA PPO|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|58.25||||||| 9519398|ERX|0250|VANCOMYCIN 500MG/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|58.25||||||| 9519448|ERX|0250|SORAFENIB 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.71||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Managed Medicare|HEALTHSPRING MA|32.25||||32.25||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|32.25||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Medicare|MEDICARE ACUTE|32.25||||32.25||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|32.25||||32.25||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|32.25||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|PHCS|HUMANA|||||32.25||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|32.25||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|32.25||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|32.25||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|32.25||||32.25||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|32.25||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32.25||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|32.25||||32.25||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32.25||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Cigna|CIGNA|||||32.25||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Cigna|CIGNA|32.25||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Humana Medicare Advantage|HUMANA MA|32.25||||32.25||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Humana Medicare Advantage|HUMANA MA|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Cigna|CIGNA|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Blue Cross PPO Specialty|BCBSTX PPO|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|United Healthcare|UNITED HEALTHCARE OTHER|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Medicare|MEDICARE ACUTE|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Medicaid|MEDICAID|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|127.50||||||| 9519463|ERX|0250|NA CHLORIDE 0.9%,500ML VI|Managed Medicare|HEALTHSPRING MA|127.50||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicare|ETMC REHABILITATION HOSPITAL|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicare|BCBS MEDICARE PPO MA|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Medicaid|MEDICAID|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Medicare|MEDICARE PART B ONLY IP|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Medicare|MEDICARE ACUTE|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|PHCS|HUMANA|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Tricare|TRICARE EAST REGION|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|United Healthcare|UNITED HEALTHCARE|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Veterans Affairs|VETERANS ADMINISTRATION|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|United Medicare Advantage|UHC MEDICARE GOLD MA|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|United Medicare Advantage|UHC AARP MCR HMO MA|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Workers Compensation|WORKERS COMPENSATION OTHER|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Workers Compensation|UT EMPLOYEE INJURY|||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|United Healthcare|UNITED HEALTHCARE OTHER|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Aenta Medicare Advantage|AETNA MEDICARE MA|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Access Direct Platinum|HEALTHFIRST TPA UMR|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|NON CONTRACTED|COMMERCIAL OTHER 1|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Access Direct Platinum|HEALTHFIRST TPA|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicare|HEALTHSPRING MA|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross HMO Specialty|BCBSTX HMO|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross PPO Specialty|BCBSTX PPO|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross PPO Specialty|BCBSTX OTHER|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Aetna|BH AETNA|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Aetna|AETNA PPO|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Aetna|AETNA OTHER|||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicaid|MEDICAID SUPERIOR|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.25||||6.25||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Cigna|CIGNA OTHER|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Cigna|CIGNA|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Cigna Behavioral Health|BH CIGNA|6.25||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Humana Medicare Advantage|HUMANA MA|6.25||||6.25||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Humana Medicare Advantage|HUMANA MA|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Managed Medicaid|MEDICAID SUPERIOR|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Blue Cross HMO Specialty|BCBSTX HMO|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Blue Cross PPO Specialty|BCBSTX PPO|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Access Direct Platinum|HEALTHFIRST TPA UMR|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Veterans Affairs|VETERANS ADMINISTRATION|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|United Medicare Advantage|UHC AARP MCR HMO MA|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Medicaid|MEDICAID|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Medicare|MEDICARE ACUTE|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|257.25||||||| 9519497|ERX|0258|LORAZEPAM 100MG/D5W 100ML|Managed Medicare|BCBS MEDICARE PPO MA|257.25||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Medicaid|MEDICAID|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Managed Medicare|HEALTHSPRING MA|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Medicare|MEDICARE ACUTE|1.18||||1.18||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|NON CONTRACTED|COMMERCIAL OTHER 1|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.18||||1.18||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|United Medicare Advantage|UHC MEDICARE GOLD MA|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|United Medicare Advantage|UHC AARP MCR HMO MA|1.18||||1.18||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.18||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Access Direct Platinum|HEALTHFIRST TPA|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Blue Cross HMO Specialty|BCBSTX HMO|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Blue Cross PPO Specialty|BCBSTX PPO|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Managed Medicaid|MEDICAID SUPERIOR|1.18||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Humana Medicare Advantage|HUMANA MA|1.18||||1.18||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Cigna|CIGNA|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Cigna|CIGNA OTHER|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Humana Medicare Advantage|HUMANA MA|830.75||||830.75||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Managed Medicaid|MEDICAID SUPERIOR|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Managed Medicaid|MEDICAID AMERIGROUP|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Blue Cross PPO Specialty|BCBSTX PPO|830.75||||830.75||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Blue Cross PPO Specialty|BCBSTX OTHER|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Aetna|AETNA PPO|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Aetna|AETNA OTHER|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Workers Compensation|WORKERS COMPENSATION OTHER|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Aenta Medicare Advantage|AETNA MEDICARE MA|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Blue Cross HMO Specialty|BCBSTX HMO|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Access Direct Platinum|HEALTHFIRST TPA UMR|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Veterans Affairs|VETERANS ADMINISTRATION|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|United Medicare Advantage|UHC AARP MCR HMO MA|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|United Medicare Advantage|UHC MEDICARE GOLD MA|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|United Healthcare|UNITED HEALTHCARE|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|United Healthcare|UNITED HEALTHCARE OTHER|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Tricare|TRICARE EAST REGION|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|NON CONTRACTED|COMMERCIAL OTHER 1|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Medicare|MEDICARE ACUTE|830.75||||830.75||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Managed Medicare|BCBS MEDICARE PPO MA|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Managed Medicare|HEALTHSPRING MA|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Managed Medicare|ETMC AFFILIATE HOSPITALS|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|830.75||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Medicaid|MEDICAID|830.75||||||| 9519521|ERX|0250|KETOTIFEN 0.025% OPTH 5ML|Medicare|MEDICARE ACUTE|86.50||||||| 9519521|ERX|0250|KETOTIFEN 0.025% OPTH 5ML|Veterans Affairs|VETERANS ADMINISTRATION|86.50||||||| 9519521|ERX|0250|KETOTIFEN 0.025% OPTH 5ML|Humana Medicare Advantage|HUMANA MA|86.50||||||| 9519521|ERX|0250|KETOTIFEN 0.025% OPTH 5ML|Cigna|CIGNA OTHER|||||86.50||| 9519588|ERX|0250|CEFUROXIME 750MG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|88.50||||||| 9519588|ERX|0250|CEFUROXIME 750MG/100ML NS|Blue Cross PPO Specialty|BCBSTX OTHER|88.50||||||| 9519588|ERX|0250|CEFUROXIME 750MG/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|88.50||||||| 9519588|ERX|0250|CEFUROXIME 750MG/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|88.50||||||| 9519588|ERX|0250|CEFUROXIME 750MG/100ML NS|United Healthcare|UNITED HEALTHCARE|88.50||||||| 9519588|ERX|0250|CEFUROXIME 750MG/100ML NS|Medicare|MEDICARE ACUTE|88.50||||||| 9519604|ERX|0250|DOBUTAMINE STRESS 250MG/2|Humana Medicare Advantage|HUMANA MA|||||48.50||| 9519604|ERX|0250|DOBUTAMINE STRESS 250MG/2|Blue Cross PPO Specialty|BCBSTX PPO|48.50||||||| 9519612|ERX|0250|TOLVAPTAN 30MG TABLET|Managed Medicare|HEALTHSPRING MA|2,317.50||||||| 9519612|ERX|0250|TOLVAPTAN 30MG TABLET|Medicare|MEDICARE ACUTE|2,317.50||||||| 9519612|ERX|0250|TOLVAPTAN 30MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,317.50||||||| 9519620|ERX|0250|BETAXOLOL 0.25% DROP,10ML|Medicare|MEDICARE ACUTE|928.75||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|9.68||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|9.68||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.68||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|Humana Medicare Advantage|HUMANA MA|9.68||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|Aetna|AETNA PPO|9.68||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.68||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|United Healthcare|UNITED HEALTHCARE OTHER|9.68||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.68||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|Managed Medicare|HEALTHSPRING MA|9.68||||||| 9519661|ERX|0250|TOLVAPTAN 15MG (1/2 TABLE|Medicare|MEDICARE ACUTE|9.68||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Medicare|MEDICARE ACUTE|158.50||||158.50||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Medicaid|MEDICAID|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Managed Medicare|HEALTHSPRING MA|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Blue Cross PPO Specialty|BCBSTX OTHER|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Aetna|AETNA PPO|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Cigna|CIGNA|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Humana Medicare Advantage|HUMANA MA|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|158.50||||158.50||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|158.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|158.50||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Multiplan|WEB TPA|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|61.25||||||| 9519703|ERX|0250|GENTAMICIN PF 20MG VIAL|Medicaid|MEDICAID|61.25||||||| 9519729|ERX|0250|DESVENLAFAXINE 50MG TABLE|Medicare|MEDICARE ACUTE|47.25||||||| 9519729|ERX|0250|DESVENLAFAXINE 50MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|47.25||||||| 9519729|ERX|0250|DESVENLAFAXINE 50MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47.25||||||| 9519729|ERX|0250|DESVENLAFAXINE 50MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|47.25||||||| 9519729|ERX|0250|DESVENLAFAXINE 50MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|47.25||||||| 9519737|ERX|0250|QUETIAPINE XR 200MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|83.75||||||| 9519737|ERX|0250|QUETIAPINE XR 200MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|83.75||||||| 9519737|ERX|0250|QUETIAPINE XR 200MG TABLE|Aetna|BH AETNA|83.75||||||| 9519737|ERX|0250|QUETIAPINE XR 200MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|83.75||||||| 9519745|ERX|0250|QUETIAPINE XR 300MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|1.10||||||| 9519745|ERX|0250|QUETIAPINE XR 300MG TABLE|Medicaid|MEDICAID|1.10||||||| 9519745|ERX|0250|QUETIAPINE XR 300MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|1.10||||||| 9519745|ERX|0250|QUETIAPINE XR 300MG TABLE|Magellan Behavioral Health|BH MAGELLAN|1.10||||||| 9519745|ERX|0250|QUETIAPINE XR 300MG TABLE|Humana Medicare Advantage|HUMANA MA|1.10||||||| 9519745|ERX|0250|QUETIAPINE XR 300MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.10||| 9519745|ERX|0250|QUETIAPINE XR 300MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.10||||||| 9519745|ERX|0250|QUETIAPINE XR 300MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.10||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.25||||17.25||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Access Direct Platinum|HEALTHFIRST TPA|17.25||||17.25||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||17.25||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Managed Medicaid|MEDICAID SUPERIOR|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Cigna|CIGNA|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.25||||17.25||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Aetna|AETNA PPO|||||17.25||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|17.25||||17.25||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|17.25||||17.25||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Medicare|MEDICARE ACUTE|||||17.25||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Medicaid|MEDICAID|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|United Healthcare|UNITED HEALTHCARE|||||17.25||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|PHCS|GROUP AND PENSION|17.25||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|17.25||||||| 9519760|ERX|0250|QUETIAPINE XR 400MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|1.29||||||| 9519760|ERX|0250|QUETIAPINE XR 400MG TABLE|Medicaid|MEDICAID|1.29||||||| 9519760|ERX|0250|QUETIAPINE XR 400MG TABLE|Magellan Behavioral Health|BH MAGELLAN|1.29||||||| 9519760|ERX|0250|QUETIAPINE XR 400MG TABLE|Humana Medicare Advantage|HUMANA MA|1.29||||||| 9519760|ERX|0250|QUETIAPINE XR 400MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.29||||||| 9519760|ERX|0250|QUETIAPINE XR 400MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|1.29||||||| 9519778|ERX|0250|ASENAPINE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|86.25||||||| 9519778|ERX|0250|ASENAPINE 5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|86.25||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Medicare|MEDICARE ACUTE|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Medicaid|MEDICAID|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Multiplan|WEB TPA|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST TPA|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||0.13||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID SUPERIOR|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Cigna|CIGNA|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Humana Medicare Advantage|HUMANA MA|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Aetna|AETNA QHP HMO|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9519802|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||||| 9519836|ERX|0250|DIALYSIS W- DEX 1.5 % 100|Humana Medicare Advantage|HUMANA MA|13.25||||||| 9519836|ERX|0250|DIALYSIS W- DEX 1.5 % 100|Medicare|MEDICARE ACUTE|13.25||||||| 9519844|ERX|0250|URSODIOL 250MG TABLET|Medicaid|SMITH COUNTY JAIL|0.37||||||| 9519844|ERX|0250|URSODIOL 250MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.37||||||| 9519844|ERX|0250|URSODIOL 250MG TABLET|Medicare|MEDICARE ACUTE|0.37||||||| 9519844|ERX|0250|URSODIOL 250MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.37||||||| 9519844|ERX|0250|URSODIOL 250MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.37||||||| 9519844|ERX|0250|URSODIOL 250MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.37||||||| 9519844|ERX|0250|URSODIOL 250MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.37||||||| 9519844|ERX|0250|URSODIOL 250MG TABLET|Humana Medicare Advantage|HUMANA MA|0.37||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Cigna|CIGNA|||||25.50||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Aetna|AETNA PPO|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Aetna Value Network|AETNA VALUE NETWORK|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Access Direct Platinum|HEALTHFIRST TPA|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Medicaid|MEDICAID HMO|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Medicaid|MEDICAID|25.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|25.50||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Managed Medicare|HEALTHSPRING MA|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Medicaid|MEDICAID|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Medicare|MEDICARE ACUTE|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|United Healthcare|UNITED HEALTHCARE|||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|United Healthcare|TML GROUP BENEFITS|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|United Healthcare|GOLDEN RULE|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Tricare|TRICARE EAST REGION|||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Aetna|AETNA QHP HMO|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Aetna|AETNA PPO|||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|48.25||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|48.25||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||48.25||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|48.25||||48.25||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Humana Medicare Advantage|HUMANA MA|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|579.25||||579.25||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Aetna|BOON CHAPMAN|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|579.25||||579.25||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|579.25||||579.25||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|579.25||||579.25||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Texas Workforce Commission|DIS DETER SERV (DDS)|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|United Healthcare|UNITED HEALTHCARE|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Medicare|MEDICARE ACUTE|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Medicaid|SUPERIOR HEALTHPLAN CHIP|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Medicaid|MEDICAID|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|579.25||||||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Managed Medicare|HEALTHSPRING MA|579.25||||579.25||| 9519877|ERX|0250|ALVIMOPAN 12MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|579.25||||||| 9519885|ERX|0250|CETIRIZINE SYRUP 30MG/30M|Medicare|MEDICARE ACUTE|26.50||||||| 9519885|ERX|0250|CETIRIZINE SYRUP 30MG/30M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26.50||||||| 9519885|ERX|0250|CETIRIZINE SYRUP 30MG/30M|Blue Cross PPO Specialty|BCBSTX PPO|26.50||||||| 9519885|ERX|0250|CETIRIZINE SYRUP 30MG/30M|Managed Medicaid|MEDICAID AMERIGROUP|||||26.50||| 9519901|ERX|0250|MONTELUKAST CHEWABLE 4MG|Managed Medicaid|MEDICAID AMERIGROUP|||||49.25||| 9519901|ERX|0250|MONTELUKAST CHEWABLE 4MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|49.25||||||| 9519901|ERX|0250|MONTELUKAST CHEWABLE 4MG|Tricare|TRICARE EAST REGION|49.25||||||| 9519901|ERX|0250|MONTELUKAST CHEWABLE 4MG|Medicaid|SUPERIOR HEALTHPLAN CHIP|49.25||||||| 9519901|ERX|0250|MONTELUKAST CHEWABLE 4MG|Medicare|MEDICARE ACUTE|49.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Medicare|MEDICARE PART B ONLY IP|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Managed Medicare|BCBS MEDICARE PPO MA|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Managed Medicare|HEALTHSPRING MA|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|United Healthcare|UNITED HEALTHCARE OTHER|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|United Healthcare|UNITED HEALTHCARE|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|NON CONTRACTED|COMMERCIAL OTHER 1|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Veterans Affairs|VETERANS ADMINISTRATION|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|United Medicare Advantage|UHC AARP MCR HMO MA|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Workers Compensation|WORKERS COMPENSATION OTHER|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|United Healthcare|GEHA|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Access Direct Platinum|HEALTHFIRST TPA UMR|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Medicaid|MEDICAID|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Aetna|AETNA PPO|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Aetna|AETNA OTHER|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Blue Cross PPO Specialty|BCBSTX OTHER|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Blue Cross HMO Specialty|BCBSTX HMO|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Blue Cross PPO Specialty|BCBSTX PPO|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Cigna|CIGNA OTHER|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Cigna|CIGNA|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Humana Medicare Advantage|HUMANA MA|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Managed Medicaid|MEDICAID SUPERIOR|13.25||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.25||||13.25||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Managed Medicaid|MEDICAID AMERIGROUP|13.25||||13.25||| 9519927|ERX|0250|RIFAMPIN 150MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.16||||||| 9519935|ERX|0250|DOFETILIDE 125MCG CAPSULE|Managed Medicare|HEALTHSPRING MA|37.75||||||| 9519935|ERX|0250|DOFETILIDE 125MCG CAPSULE|Medicare|MEDICARE PART B ONLY IP|37.75||||||| 9519935|ERX|0250|DOFETILIDE 125MCG CAPSULE|Medicare|MEDICARE ACUTE|37.75||||37.75||| 9519935|ERX|0250|DOFETILIDE 125MCG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37.75||||||| 9519935|ERX|0250|DOFETILIDE 125MCG CAPSULE|Humana Medicare Advantage|HUMANA MA|37.75||||||| 9519935|ERX|0250|DOFETILIDE 125MCG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|37.75||||37.75||| 9519935|ERX|0250|DOFETILIDE 125MCG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Aetna|AETNA PPO|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|37.75||||37.75||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Humana Medicare Advantage|HUMANA MA|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|37.75||||37.75||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37.75||||37.75||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|United Healthcare|UNITED HEALTHCARE|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Medicare|MEDICARE PART B ONLY IP|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Medicare|MEDICARE ACUTE|37.75||||37.75||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||37.75||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|37.75||||||| 9519943|ERX|0250|DOFETILIDE 250MCG CAPSULE|Managed Medicare|HEALTHSPRING MA|37.75||||||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|26.50||||26.50||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|26.50||||||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Medicare|MEDICARE ACUTE|26.50||||26.50||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||26.50||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.50||||||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|26.50||||26.50||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.50||||||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.50||||||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|26.50||||26.50||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.50||||||| 9519968|ERX|0250|CINACALCET 60MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|216.25||||||| 9519968|ERX|0250|CINACALCET 60MG TABLET|Humana Medicare Advantage|HUMANA MA|216.25||||||| 9519968|ERX|0250|CINACALCET 60MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|216.25||||||| 9519968|ERX|0250|CINACALCET 60MG TABLET|Medicare|MEDICARE PART B ONLY IP|216.25||||||| 9519968|ERX|0250|CINACALCET 60MG TABLET|Medicare|MEDICARE ACUTE|216.25||||216.25||| 9519968|ERX|0250|CINACALCET 60MG TABLET|Managed Medicare|HEALTHSPRING MA|216.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Tricare|TRICARE EAST REGION|||||13.25||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|13.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Medicaid|MEDICAID|13.25||||13.25||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|13.25||||13.25||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|13.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|13.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|13.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.25||||13.25||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.25||||13.25||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Aetna|AETNA OTHER|13.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||13.25||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|13.25||||||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|13.25||||13.25||| 9519976|ERX|0250|GLIMEPIRIDE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.25||||||| 9519984|ERX|0250|ALBENDAZOLE 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|281.75||||||| 9519984|ERX|0250|ALBENDAZOLE 200MG TABLET|Medicare|MEDICARE ACUTE|281.75||||||| 9519992|ERX|0250|CARMUSTINE 7.7MG WAFER|Medicare|MEDICARE ACUTE|7,693.50||||||| 9519992|ERX|0250|CARMUSTINE 7.7MG WAFER|Blue Cross PPO Specialty|BCBSTX PPO|7,693.50||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Medicare Advantage|UHC AARP WELLMED HMO MA|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Medicare Advantage|UHC AARP MCR HMO MA|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Veterans Affairs|VETERANS ADMINISTRATION|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Access Direct Platinum|HEALTHFIRST TPA UMR|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Cigna|CIGNA OTHER|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Cigna|CIGNA|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Magellan Behavioral Health|BH MAGELLAN|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Humana Medicare Advantage|HUMANA MA|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicaid|MEDICAID SUPERIOR|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicaid|MEDICAID AMERIGROUP|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Aetna|BH AETNA|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Aetna|AETNA QHP HMO|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Access Direct Platinum|ANDREWS CENTER|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Aetna|AETNA PPO|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|ChampVA|CHAMPVA CENTER|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Blue Cross HMO Specialty|BCBSTX HMO|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Blue Cross PPO Specialty|BCBSTX PPO|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Healthcare|UNITED HEALTHCARE OTHER|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Healthcare|UNITED HEALTHCARE|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|NON CONTRACTED|COMMERCIAL OTHER 1|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicare|BCBS MEDICARE PPO MA|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicare|HEALTHSPRING MA|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicare|OTHER INSTITUTIONS|||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.25||||13.25||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Medicaid|SMITH COUNTY INDIGENT HEALTH|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Medicaid|MEDICAID|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Medicare|MEDICARE PART B ONLY IP|13.25||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Medicare|MEDICARE ACUTE|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Medicaid|CRIME VICTIMS COMPENSATION|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|PHCS|GROUP AND PENSION|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|PHCS|HUMANA|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Texas Workforce Commission|DIS DETER SERV (DDS)|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Tricare|TRICARE EAST REGION|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|United Healthcare|UNITED HEALTHCARE|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|United Healthcare|TML GROUP BENEFITS|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|United Healthcare|GEHA|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|ChampVA|CHAMPVA CENTER|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Aetna|BOON CHAPMAN|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Aetna|AETNA QHP HMO|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Aetna|AETNA PPO|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Aetna|AETNA OTHER|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Multiplan|WEB TPA|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Aetna Value Network|AETNA VALUE NETWORK|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Cigna|CIGNA|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Cigna|CIGNA OTHER|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Cigna|CIGNA|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Cigna Behavioral Health|BH CIGNA|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Workers Compensation|TEXAS MUTUAL INSURANCE|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.43||||||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Workers Compensation|BROOKSHIRES WORKERS COMP|||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Medicaid|MEDICAID|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|0.43||||0.43||| 9520040|ERX|0250|CELECOXIB 200MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.43||||0.43||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Veterans Affairs|VETERANS ADMINISTRATION|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Workers Compensation|WORKERS COMPENSATION OTHER|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Workers Compensation|UT EMPLOYEE INJURY|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Workers Compensation|TRAVELERS INSURANCE COMPANY|7.50||||||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Workers Compensation|TEXAS MUTUAL INSURANCE|7.50||||||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Cigna|CIGNA|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Cigna|CIGNA|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Humana Medicare Advantage|HUMANA MA|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Managed Medicaid|MEDICAID SUPERIOR|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Managed Medicaid|MEDICAID AMERIGROUP|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Aetna|AETNA PPO|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Aetna|AETNA OTHER|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Blue Cross HMO Specialty|BCBSTX HMO|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|United Healthcare|UNITED HEALTHCARE OTHER|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|United Healthcare|UNITED HEALTHCARE|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|United Healthcare|TML GROUP BENEFITS|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|PHCS|HUMANA|7.50||||||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Tricare|TRICARE EAST REGION|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Managed Medicare|HEALTHSPRING MA|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Managed Medicare|BCBS MEDICARE PPO MA|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Medicaid|SMITH COUNTY JAIL|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Medicaid|MEDICAID HMO|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Medicaid|LAW ENFORCEMENT OTHER|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Medicaid|MEDICAID|7.50||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||7.50||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Medicare|MEDICARE ACUTE|0.52||||0.52||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Medicaid|MEDICAID HMO|0.52||||||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Managed Medicare|HEALTHSPRING MA|||||0.52||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Blue Cross PPO Specialty|BCBSTX PPO|0.52||||0.52||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.52||||||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Managed Medicaid|MEDICAID SUPERIOR|0.52||||0.52||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Humana Medicare Advantage|HUMANA MA|0.52||||||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.52||||||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.52||| 9520099|ERX|0250|LIDOCAINE 4% CREAM, 5 GRA|Veterans Affairs|VETERANS ADMINISTRATION|0.52||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|709.50||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|709.50||||709.50||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|United Medicare Advantage|UHC AARP MCR HMO MA|709.50||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|United Medicare Advantage|UHC AARP WELLMED HMO MA|709.50||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|Veterans Affairs|VETERANS ADMINISTRATION|709.50||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||709.50||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|Humana Medicare Advantage|HUMANA MA|709.50||||709.50||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|709.50||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|709.50||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|709.50||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|NON CONTRACTED|COMMUNITY HEALTH CENTER|709.50||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|Medicaid|SMITH COUNTY JAIL|709.50||||||| 9520107|ERX|0250|DICLOFENAC 1% GEL, 100 GM|Medicare|MEDICARE ACUTE|709.50||||709.50||| 9520115|ERX|0250|VIT E-LIDO-ALO VER-COLAGN|Medicare|MEDICARE ACUTE|129.50||||||| 9520115|ERX|0250|VIT E-LIDO-ALO VER-COLAGN|Blue Cross HMO Specialty|BCBSTX HMO|129.50||||||| 9520115|ERX|0250|VIT E-LIDO-ALO VER-COLAGN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|129.50||||||| 9520115|ERX|0250|VIT E-LIDO-ALO VER-COLAGN|Managed Medicaid|MEDICAID AMERIGROUP|129.50||||||| 9520115|ERX|0250|VIT E-LIDO-ALO VER-COLAGN|Humana Medicare Advantage|HUMANA MA|129.50||||129.50||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Workers Compensation|BROOKSHIRES WORKERS COMP|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Aenta Medicare Advantage|AETNA MEDICARE MA|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Access Direct Platinum|HEALTHFIRST TPA UMR|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Access Direct Platinum|HEALTHFIRST TPA|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|United Medicare Advantage|UHC MEDICARE GOLD MA|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|United Medicare Advantage|UHC AARP MCR HMO MA|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Veterans Affairs|VETERANS ADMINISTRATION|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Humana Medicare Advantage|HUMANA MA|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Managed Medicaid|MEDICAID UNITED HEALTHCARE|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Managed Medicaid|MEDICAID SUPERIOR|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Managed Medicaid|MEDICAID AMERIGROUP|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Aetna|AETNA OTHER|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Blue Cross PPO Specialty|BCBSTX PPO|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|UTMB|UTMB CORRECTIONAL MANAGED CARE|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|NON CONTRACTED|COMMERCIAL OTHER 1|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Managed Medicare|HEALTHSPRING MA|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Managed Medicare|BCBS MEDICARE PPO MA|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Medicaid|MEDICAID|67.75||||||| 9520123|ERX|0250|NA HYPOCHL 0.125% SOLN,47|Medicare|MEDICARE ACUTE|67.75||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Medicare|MEDICARE ACUTE|11.50||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|United Healthcare|UNITED HEALTHCARE OTHER|11.50||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Blue Cross PPO Specialty|BCBSTX OTHER|11.50||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Managed Medicaid|MEDICAID SUPERIOR|11.50||||11.50||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Managed Medicaid|MEDICAID AMERIGROUP|11.50||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.50||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.50||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.50||||||| 9520131|ERX|0250|PETROLATUM LIP THERAPY, 1|Workers Compensation|WORKERS COMPENSATION OTHER|11.50||||||| 9520149|ERX|0250|POLYETHYLENE GLYCOL 3350,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||187.50||| 9520149|ERX|0250|POLYETHYLENE GLYCOL 3350,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||187.50||| 9520149|ERX|0250|POLYETHYLENE GLYCOL 3350,|Humana Medicare Advantage|HUMANA MA|187.50||||||| 9520149|ERX|0250|POLYETHYLENE GLYCOL 3350,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|187.50||||||| 9520149|ERX|0250|POLYETHYLENE GLYCOL 3350,|Managed Medicare|HEALTHSPRING MA|||||187.50||| 9520149|ERX|0250|POLYETHYLENE GLYCOL 3350,|Managed Medicare|BCBS MEDICARE PPO MA|187.50||||||| 9520149|ERX|0250|POLYETHYLENE GLYCOL 3350,|Medicare|MEDICARE ACUTE|187.50||||||| 9520156|ERX|0250|VERAPAMIL 40MG TABLET|Medicaid|MEDICAID|0.12||||||| 9520156|ERX|0250|VERAPAMIL 40MG TABLET|Managed Medicare|HEALTHSPRING MA|0.12||||0.12||| 9520156|ERX|0250|VERAPAMIL 40MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.12||||||| 9520156|ERX|0250|VERAPAMIL 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.12||| 9520156|ERX|0250|VERAPAMIL 40MG TABLET|Humana Medicare Advantage|HUMANA MA|||||0.12||| 9520156|ERX|0250|VERAPAMIL 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.12||||0.12||| 9520198|ERX|0250|CLOTRIMAZOLE 3 DAY VAG CR|Humana Medicare Advantage|HUMANA MA|92.50||||||| 9520198|ERX|0250|CLOTRIMAZOLE 3 DAY VAG CR|Blue Cross PPO Specialty|BCBSTX PPO|92.50||||||| 9520206|ERX|0250|EXEMESTANE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|117.75||||||| 9520214|ERX|0250|METRONIDAZOLE 0.75% GEL,4|Medicare|MEDICARE ACUTE|371.75||||||| 9520214|ERX|0250|METRONIDAZOLE 0.75% GEL,4|Medicaid|MEDICAID|371.75||||||| 9520214|ERX|0250|METRONIDAZOLE 0.75% GEL,4|Humana Medicare Advantage|HUMANA MA|371.75||||||| 9520214|ERX|0250|METRONIDAZOLE 0.75% GEL,4|Aenta Medicare Advantage|AETNA MEDICARE MA|||||371.75||| 9520214|ERX|0250|METRONIDAZOLE 0.75% GEL,4|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|371.75||||||| 9520248|ERX|0250|BRIMONIDINE 0.1% EYE DROP|United Medicare Advantage|UHC AARP MCR HMO MA|550.75||||||| 9520248|ERX|0250|BRIMONIDINE 0.1% EYE DROP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|550.75||||||| 9520248|ERX|0250|BRIMONIDINE 0.1% EYE DROP|Aenta Medicare Advantage|AETNA MEDICARE MA|550.75||||||| 9520248|ERX|0250|BRIMONIDINE 0.1% EYE DROP|Humana Medicare Advantage|HUMANA MA|550.75||||550.75||| 9520248|ERX|0250|BRIMONIDINE 0.1% EYE DROP|Managed Medicare|HEALTHSPRING MA|550.75||||||| 9520248|ERX|0250|BRIMONIDINE 0.1% EYE DROP|Medicare|MEDICARE PART B ONLY IP|550.75||||||| 9520248|ERX|0250|BRIMONIDINE 0.1% EYE DROP|Medicare|MEDICARE ACUTE|550.75||||550.75||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|Medicare|MEDICARE ACUTE|31.50||||||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|Managed Medicare|HEALTHSPRING MA|31.50||||||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|31.50||||||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|31.50||||||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|31.50||||||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|Humana Medicare Advantage|HUMANA MA|31.50||||31.50||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|31.50||||31.50||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|31.50||||||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|31.50||||||| 9520271|ERX|0250|SODIUM CHLORIDE 0.45% 250|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|127.50||||||| 9520271|ERX|0250|SODIUM CHLORIDE 0.45% 250|Humana Medicare Advantage|HUMANA MA|||||127.50||| 9520271|ERX|0250|SODIUM CHLORIDE 0.45% 250|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127.50||||||| 9520271|ERX|0250|SODIUM CHLORIDE 0.45% 250|Managed Medicare|HEALTHSPRING MA|127.50||||||| 9520271|ERX|0250|SODIUM CHLORIDE 0.45% 250|Medicare|MEDICARE ACUTE|127.50||||||| 9520289|ERX|0250|LIPASE-PROT-AMYL 6-19-30K|Tricare|TRICARE EAST REGION|12.25||||||| 9520289|ERX|0250|LIPASE-PROT-AMYL 6-19-30K|Medicare|MEDICARE ACUTE|12.25||||||| 9520289|ERX|0250|LIPASE-PROT-AMYL 6-19-30K|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||12.25||| 9520289|ERX|0250|LIPASE-PROT-AMYL 6-19-30K|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||||| 9520289|ERX|0250|LIPASE-PROT-AMYL 6-19-30K|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.25||||||| 9520321|ERX|0250|LIP-PROT-AMYL 16.8-56.8-9|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||26.75||| 9520354|ERX|0250|MILNACIPRAN 50MG TABLET|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9520370|ERX|0250|NIACIN SR 250MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|13.25||||||| 9520370|ERX|0250|NIACIN SR 250MG CAPSULE|Humana Medicare Advantage|HUMANA MA|||||13.25||| 9520370|ERX|0250|NIACIN SR 250MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|13.25||||||| 9520370|ERX|0250|NIACIN SR 250MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||13.25||| 9520370|ERX|0250|NIACIN SR 250MG CAPSULE|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9520404|ERX|0250|TETRACAINE 1% 2ML|Medicare|MEDICARE ACUTE|||||49.75||| 9520404|ERX|0250|TETRACAINE 1% 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||49.75||| 9520404|ERX|0250|TETRACAINE 1% 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||49.75||| 9520404|ERX|0250|TETRACAINE 1% 2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||49.75||| 9520420|ERX|0250|DARUNAVIR 600MG TABLET|Humana Medicare Advantage|HUMANA MA|1.29||||||| 9520420|ERX|0250|DARUNAVIR 600MG TABLET|Medicare|MEDICARE ACUTE|1.29||||||| 9520453|ERX|0250|IFOSFAMIDE 3000MG/60ML|Medicare|MEDICARE ACUTE|554.92||||||| 9520453|ERX|0250|IFOSFAMIDE 3000MG/60ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|554.92||||||| 9520453|ERX|0250|IFOSFAMIDE 3000MG/60ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|554.92||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Blue Cross HMO Specialty|BCBSTX HMO|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Blue Cross PPO Specialty|BCBSTX PPO|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Managed Medicaid|MEDICAID SUPERIOR|0.13||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|United Medicare Advantage|UHC AARP MCR HMO MA|0.13||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.13||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Managed Medicare|HEALTHSPRING MA|0.13||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9520487|ERX|0258|EMPTY CONTAINER 500ML|Medicare|MEDICARE ACUTE|82.25||||||| 9520487|ERX|0258|EMPTY CONTAINER 500ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|82.25||||||| 9520487|ERX|0258|EMPTY CONTAINER 500ML|Blue Cross PPO Specialty|BCBSTX PPO|82.25||||82.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|52.25||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Managed Medicaid|MEDICAID SUPERIOR|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Cigna|CIGNA|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Cigna|CIGNA OTHER|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Aetna|AETNA PPO|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Aetna|AETNA OTHER|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|52.25||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Tricare|TRICARE EAST REGION|52.25||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|United Healthcare|UNITED HEALTHCARE OTHER|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Medicaid|MEDICAID|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Medicaid|MEDICAID HMO|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||52.25||| 9520495|ERX|0250|MIDAZOLAM 10MG/5ML, 5ML|Medicare|MEDICARE ACUTE|||||52.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Medicare|MEDICARE PART B ONLY IP|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Managed Medicare|HEALTHSPRING MA|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|PHCS|HUMANA|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Humana Medicare Advantage|HUMANA MA|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|13.25||||13.25||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|13.25||||||| 9520529|ERX|0250|FENOFIBRATE 54MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Cigna|CIGNA OTHER|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Cigna|CIGNA|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Humana Medicare Advantage|HUMANA MA|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Aetna|AETNA OTHER|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Tricare|TRICARE EAST REGION|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Medicaid|MEDICAID|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.25||||||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Managed Medicare|HEALTHSPRING MA|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|13.25||||13.25||| 9520537|ERX|0250|FENOFIBRATE 134MG TABLET|Medicare|MEDICARE ACUTE|13.25||||13.25||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Managed Medicare|HEALTHSPRING MA|115.75||||115.75||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Managed Medicare|BCBS MEDICARE PPO MA|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|United Healthcare|UNITED HEALTHCARE OTHER|115.75||||115.75||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Blue Cross PPO Specialty|BCBSTX PPO|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||115.75||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Blue Cross PPO Specialty|BCBSTX OTHER|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Aetna|AETNA OTHER|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Humana Medicare Advantage|HUMANA MA|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Medicare|MEDICARE ACUTE|115.75||||115.75||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Cigna|CIGNA|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|115.75||||115.75||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Veterans Affairs|VETERANS ADMINISTRATION|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|United Medicare Advantage|UHC AARP MCR HMO MA|115.75||||115.75||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Aenta Medicare Advantage|AETNA MEDICARE MA|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|115.75||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Access Direct Platinum|HEALTHFIRST TPA UMR|115.75||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Workers Compensation|WORKERS COMPENSATION OTHER|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|19.50||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|United Medicare Advantage|UHC AARP MCR HMO MA|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Veterans Affairs|VETERANS ADMINISTRATION|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicaid|MEDICAID SUPERIOR|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicaid|MEDICAID AMERIGROUP|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Cigna|CIGNA|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Cigna|CIGNA|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Humana Medicare Advantage|HUMANA MA|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Aetna|AETNA PPO|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|19.50||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Access Direct Platinum|HEALTHFIRST TPA|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Blue Cross HMO Specialty|BCBSTX HMO|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Blue Cross PPO Specialty|BCBSTX PPO|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|19.50||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|United Healthcare|UNITED HEALTHCARE OTHER|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|United Healthcare|UNITED HEALTHCARE|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Tricare|TRICARE EAST REGION|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Multiplan|PACIFICARE|19.50||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|19.50||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicare|HEALTHSPRING MA|19.50||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicare|BCBS MEDICARE PPO MA|||||19.50||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Medicare|MEDICARE ACUTE|19.50||||19.50||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|Medicare|MEDICARE ACUTE|46.75||||46.75||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.75||||||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|46.75||||||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|Managed Medicare|HEALTHSPRING MA|46.75||||||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|Medicaid|MEDICAID|46.75||||||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|46.75||||||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|Humana Medicare Advantage|HUMANA MA|||||46.75||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|46.75||||46.75||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||46.75||| 9520636|ERX|0250|FEBUXOSTAT 40MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|46.75||||||| 9520644|ERX|0250|FEBUXOSTAT 80MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|46.75||||||| 9520644|ERX|0250|FEBUXOSTAT 80MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.75||||||| 9520644|ERX|0250|FEBUXOSTAT 80MG TABLET|Medicare|MEDICARE ACUTE|46.75||||46.75||| 9520651|ERX|0250|LACOSAMIDE 50MG TABLET|Medicare|MEDICARE ACUTE|39.50||||||| 9520651|ERX|0250|LACOSAMIDE 50MG TABLET|Aetna|AETNA PPO|39.50||||||| 9520651|ERX|0250|LACOSAMIDE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||39.50||| 9520651|ERX|0250|LACOSAMIDE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|39.50||||||| 9520651|ERX|0250|LACOSAMIDE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|39.50||||39.50||| 9520651|ERX|0250|LACOSAMIDE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39.50||||39.50||| 9520651|ERX|0250|LACOSAMIDE 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|39.50||||||| 9520651|ERX|0250|LACOSAMIDE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|39.50||||39.50||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|51.25||||||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|51.25||||||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|51.25||||||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|51.25||||||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|51.25||||51.25||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||51.25||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|51.25||||51.25||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|51.25||||51.25||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|51.25||||51.25||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|51.25||||||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Medicare|MEDICARE ACUTE|51.25||||51.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Tricare|TRICARE EAST REGION|||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|United Healthcare|UNITED HEALTHCARE OTHER|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Medicaid|SMITH COUNTY INDIGENT HEALTH|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Medicaid|CRIME VICTIMS COMPENSATION|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Medicaid|MEDICAID|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Managed Medicare|HEALTHSPRING MA|70.25||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Managed Medicare|BCBS MEDICARE PPO MA|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Blue Cross HMO Specialty|BCBSTX HMO|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Medicare|MEDICARE ACUTE|70.25||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Blue Cross PPO Specialty|BCBSTX PPO|70.25||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Humana Medicare Advantage|HUMANA MA|70.25||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|NON CONTRACTED|COMMERCIAL OTHER 1|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Managed Medicaid|MEDICAID AMERIGROUP|||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Veterans Affairs|VETERANS ADMINISTRATION|70.25||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|70.25||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|United Medicare Advantage|UHC AARP MCR HMO MA|||||70.25||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|United Medicare Advantage|UHC MEDICARE GOLD MA|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|United Medicare Advantage|UHC AARP WELLMED HMO MA|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Aenta Medicare Advantage|AETNA MEDICARE MA|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|70.25||||||| 9520800|ERX|0250|SALINE-MINERAL OIL-GLYC,3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|70.25||||||| 9520818|ERX|0250|DEXAME-NYST-DIPHE-SUCRAL,|Cigna|CIGNA OTHER|||||128.75||| 9520818|ERX|0250|DEXAME-NYST-DIPHE-SUCRAL,|Blue Cross PPO Specialty|BCBSTX PPO|128.75||||||| 9520818|ERX|0250|DEXAME-NYST-DIPHE-SUCRAL,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|128.75||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Managed Medicare|HEALTHSPRING MA|38.50||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|38.50||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Medicare|MEDICARE ACUTE|38.50||||38.50||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|38.50||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|38.50||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|38.50||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|||||38.50||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||38.50||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|38.50||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.50||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.50||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.50||||||| 9520826|ERX|0250|DABIGATRAN 150MG CAPSULE|Humana Medicare Advantage|HUMANA MA|38.50||||38.50||| 9520834|ERX|0250|DABIGATRAN 75MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|38.50||||||| 9520834|ERX|0250|DABIGATRAN 75MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||38.50||| 9520834|ERX|0250|DABIGATRAN 75MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|38.50||||||| 9520834|ERX|0250|DABIGATRAN 75MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|38.50||||||| 9520834|ERX|0250|DABIGATRAN 75MG CAPSULE|Medicare|MEDICARE ACUTE|38.50||||38.50||| 9520834|ERX|0250|DABIGATRAN 75MG CAPSULE|Managed Medicare|HEALTHSPRING MA|||||38.50||| 9520842|ERX|0250|NORETHINDRONE-ETHINYL EST|Medicare|MEDICARE ACUTE|12.25||||||| 9520842|ERX|0250|NORETHINDRONE-ETHINYL EST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.25||||||| 9520842|ERX|0250|NORETHINDRONE-ETHINYL EST|Blue Cross PPO Specialty|BCBSTX PPO|||||12.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Workers Compensation|ZURICH COMPANY|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Workers Compensation|TEXAS MUTUAL INSURANCE|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Workers Compensation|WORKERS COMPENSATION OTHER|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Workers Compensation|TRAVELERS INSURANCE COMPANY|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Workers Compensation|BROOKSHIRES WORKERS COMP|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Aenta Medicare Advantage|AETNA MEDICARE MA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Access Direct Platinum|HEALTHFIRST TPA UMR|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Access Direct Platinum|HEALTHFIRST TPA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Veterans Affairs|VETERANS ADMINISTRATION|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Medicare Advantage|UHC MEDICARE GOLD MA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Medicare Advantage|UHC AARP MCR HMO MA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Cigna|CIGNA OTHER|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Cigna|CIGNA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID UNITED HEALTHCARE|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID SUPERIOR|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID AMERIGROUP|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Aetna|AETNA QHP HMO|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Aetna|BOON CHAPMAN|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Aetna|AETNA PPO|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Aetna Value Network|AETNA VALUE NETWORK|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross HMO Specialty|BCBSTX HMO|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross PPO Specialty|BCBSTX OTHER|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross PPO Specialty|BCBSTX PPO|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Brinson Benefits|THE HEALTH PLAN SMITH CO|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Aetna|AETNA OTHER|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|ChampVA|CHAMPVA CENTER|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|UNITED HEALTHCARE|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|UTMB|UTMB CORRECTIONAL MANAGED CARE|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|UNITED HEALTHCARE ERS|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|UNITED HEALTHCARE OTHER|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|TML GROUP BENEFITS|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|GOLDEN RULE|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|GEHA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Humana Medicare Advantage|HUMANA MA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Medicare Advantage|UHC AARP WELLMED HMO MA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Rusk State Hospital|RUSK STATE HOSP|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|PHCS|GROUP AND PENSION|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|PHCS|HUMANA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|PHCS|HUMANA INSURANCE|102.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Texas Workforce Commission|DIS DETER SERV (DDS)|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Tricare|TRICARE EAST REGION|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Tricare|TRICARE FOR LIFE|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Multiplan|WEB TPA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|NON CONTRACTED|COMMERCIAL OTHER 2|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|NON CONTRACTED|COMMERCIAL OTHER 1|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Workers Compensation|GALLAGHER BASSETT|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|CRIME VICTIMS COMPENSATION|102.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|SMITH COUNTY JAIL|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|SUPERIOR HEALTHPLAN CHIP|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|SMITH COUNTY INDIGENT HEALTH|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|MEDICAID HMO|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|MEDICAID|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Workers Compensation|UT EMPLOYEE INJURY|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|LAW ENFORCEMENT OTHER|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|COUNTY INDIGENT HEALTH OTHER|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|MEDICAID BCBSTX|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|MOLINA HEALTHCARE OF TEXAS|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicare|BCBS MEDICARE PPO MA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicare|HEALTHSPRING MA|102.25||||102.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicare|MEDICARE PART B ONLY IP|102.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicare|MEDICARE ACUTE|102.25||||102.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Medicare|MEDICARE PART B ONLY IP|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Managed Medicare|HEALTHSPRING MA|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Medicaid|SMITH COUNTY JAIL|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Medicaid|MEDICAID|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|PHCS|HUMANA|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|United Healthcare|UNITED HEALTHCARE|158.25||||158.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Medicare|MEDICARE ACUTE|158.25||||158.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|158.25||||158.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Aetna|AETNA PPO|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|158.25||||158.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|158.25||||158.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Humana Medicare Advantage|HUMANA MA|158.25||||158.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|158.25||||158.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|158.25||||158.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|158.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|158.25||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Workers Compensation|WORKERS COMPENSATION OTHER|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||0.19||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|United Medicare Advantage|UHC AARP MCR HMO MA|0.19||||0.19||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||0.19||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Cigna|CIGNA OTHER|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Humana Medicare Advantage|HUMANA MA|0.19||||0.19||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||0.19||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||0.19||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Aenta Medicare Advantage|AETNA MEDICARE MA|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Blue Cross HMO Specialty|BCBSTX HMO|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|United Healthcare|UNITED HEALTHCARE OTHER|0.19||||0.19||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Tricare|TRICARE EAST REGION|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Medicaid|MEDICAID|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Managed Medicare|HEALTHSPRING MA|0.19||||0.19||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.19||||0.19||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Medicare|MEDICARE PART B ONLY IP|0.19||||||| 9520966|ERX|0250|OXYCODONE-ACETAM 10-325 T|Medicare|MEDICARE ACUTE|0.19||||||| 9521063|ERX|0250|EVEROLIMUS 0.25|Medicare|MEDICARE ACUTE|0.53||||||| 9521063|ERX|0250|EVEROLIMUS 0.25|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.53||||0.53||| 9521063|ERX|0250|EVEROLIMUS 0.25|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.53||||||| 9521071|ERX|0250|FLUCONAZOLE 400MG IN NS 2|Medicare|MEDICARE ACUTE|271.75||||||| 9521089|ERX|0250|METRONIDAZOLE IN NACL (IS|Cigna|CIGNA|60.75||||||| 9521089|ERX|0250|METRONIDAZOLE IN NACL (IS|PHCS|GROUP AND PENSION|60.75||||||| 9521089|ERX|0250|METRONIDAZOLE IN NACL (IS|Medicare|MEDICARE ACUTE|60.75||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||142.25||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Medicaid|MEDICAID HMO|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Medicaid|MEDICAID|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Medicare|MEDICARE ACUTE|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|United Healthcare|UNITED HEALTHCARE OTHER|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|United Healthcare|UNITED HEALTHCARE|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|UTMB|UTMB CORRECTIONAL MANAGED CARE|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|NON CONTRACTED|COMMERCIAL OTHER 1|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Managed Medicare|HEALTHSPRING MA|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Veterans Affairs|VETERANS ADMINISTRATION|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|United Medicare Advantage|UHC MEDICARE GOLD MA|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Blue Cross HMO Specialty|BCBSTX HMO|142.25||||142.25||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Blue Cross PPO Specialty|BCBSTX OTHER|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Blue Cross PPO Specialty|BCBSTX PPO|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Aetna|AETNA PPO|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Managed Medicaid|MEDICAID SUPERIOR|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Managed Medicaid|MEDICAID AMERIGROUP|142.25||||||| 9521097|ERX|0258|SODIUM CHLORIDE IRRIG SOL|Humana Medicare Advantage|HUMANA MA|142.25||||142.25||| 9521105|ERX|0250|NIMODIPINE 30MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|101.75||||||| 9521105|ERX|0250|NIMODIPINE 30MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|101.75||||||| 9521121|ERX|0250|ACARBOSE 50MG TABLET|Medicare|MEDICARE ACUTE|15.50||||||| 9521121|ERX|0250|ACARBOSE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9521147|ERX|0250|DICLOFENAC SODIUM EC 75MG|Medicare|MEDICARE ACUTE|34.25||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Humana Medicare Advantage|HUMANA MA|695.75||||695.75||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicaid|MEDICAID SUPERIOR|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicaid|MEDICAID AMERIGROUP|||||695.75||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|695.75||||695.75||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Blue Cross HMO Specialty|BCBSTX HMO|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Blue Cross PPO Specialty|BCBSTX PPO|695.75||||695.75||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Brinson Benefits|THE HEALTH PLAN SMITH CO|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Veterans Affairs|VETERANS ADMINISTRATION|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Aenta Medicare Advantage|AETNA MEDICARE MA|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|695.75||||695.75||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||695.75||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Cigna|CIGNA|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|NON CONTRACTED|COMMERCIAL OTHER 1|695.75||||695.75||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|UTMB|UTMB CORRECTIONAL MANAGED CARE|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|United Healthcare|UNITED HEALTHCARE OTHER|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Medicaid|CRIME VICTIMS COMPENSATION|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Medicaid|MEDICAID|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicare|BCBS MEDICARE PPO MA|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicare|HEALTHSPRING MA|695.75||||695.75||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Medicare|MEDICARE PART B ONLY IP|695.75||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Medicare|MEDICARE ACUTE|695.75||||695.75||| 9521162|ERX|0250|MUPIROCIN 2% NASAL OINT,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.94||||||| 9521162|ERX|0250|MUPIROCIN 2% NASAL OINT,|Humana Medicare Advantage|HUMANA MA|0.94||||||| 9521188|ERX|0250|MUPIROCIN 2% CREAM, 15 G|Medicare|MEDICARE ACUTE|480.25||||||| 9521188|ERX|0250|MUPIROCIN 2% CREAM, 15 G|Texas Workforce Commission|DIS DETER SERV (DDS)|480.25||||||| 9521188|ERX|0250|MUPIROCIN 2% CREAM, 15 G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|480.25||||||| 9521188|ERX|0250|MUPIROCIN 2% CREAM, 15 G|Cigna|CIGNA|480.25||||||| 9521188|ERX|0250|MUPIROCIN 2% CREAM, 15 G|Blue Cross PPO Specialty|BCBSTX PPO|480.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Aetna|BOON CHAPMAN|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||38.25||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||38.25||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|38.25||||38.25||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||38.25||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|38.25||||38.25||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Medicaid|MEDICAID|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|38.25||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Medicare|MEDICARE ACUTE|38.25||||38.25||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Medicaid|MEDICAID|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|United Healthcare|UNITED HEALTHCARE|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|United Healthcare|TML GROUP BENEFITS|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Optum Behavioral Health|BH OPTUM UHC|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Medicare|MEDICARE ACUTE|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|ChampVA|CHAMPVA CENTER|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|40.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|40.75||||40.75||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40.75||||||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.41||||||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.41||||0.41||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.41||||||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.41||||||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Humana Medicare Advantage|HUMANA MA|0.41||||0.41||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.41||||||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.41||||||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.41||||||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Managed Medicare|HEALTHSPRING MA|0.41||||0.41||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.41||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.41||||||| 9521261|ERX|0250|PAROXETINE 30MG TABLET|Medicare|MEDICARE ACUTE|0.41||||||| 9521279|ERX|0250|PAROXETINE 40MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.43||||||| 9521279|ERX|0250|PAROXETINE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.43||||||| 9521295|ERX|0250|AMOXICILLIN 200MG/5ML,100|Medicaid|MEDICAID HMO|||||1.04||| 9521295|ERX|0250|AMOXICILLIN 200MG/5ML,100|United Healthcare|UNITED HEALTHCARE|||||1.04||| 9521295|ERX|0250|AMOXICILLIN 200MG/5ML,100|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.04||| 9521295|ERX|0250|AMOXICILLIN 200MG/5ML,100|Blue Cross PPO Specialty|BCBSTX PPO|1.04||||||| 9521295|ERX|0250|AMOXICILLIN 200MG/5ML,100|Managed Medicaid|MEDICAID SUPERIOR|1.04||||1.04||| 9521295|ERX|0250|AMOXICILLIN 200MG/5ML,100|Managed Medicaid|MEDICAID AMERIGROUP|||||1.04||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Humana Medicare Advantage|HUMANA MA|63.75||||||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||63.75||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|63.75||||||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|63.75||||||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|63.75||||||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|63.75||||||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|63.75||||||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|United Healthcare|UNITED HEALTHCARE|63.75||||||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Medicare|MEDICARE ACUTE|63.75||||63.75||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||63.75||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Managed Medicare|HEALTHSPRING MA|63.75||||63.75||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Medicaid|MEDICAID|63.75||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicaid|MEDICAID|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicaid|SMITH COUNTY JAIL|||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicare|HEALTHSPRING MA|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicare|MEDICARE ACUTE|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|PHCS|HUMANA|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|United Healthcare|TML GROUP BENEFITS|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|United Healthcare|UNITED HEALTHCARE|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Workers Compensation|UT EMPLOYEE INJURY|||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Access Direct Platinum|HEALTHFIRST TPA|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicare|MEDICARE PART B ONLY IP|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicaid|LAW ENFORCEMENT OTHER|||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Aetna|AETNA PPO|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.87||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.87||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Cigna|CIGNA|||||0.87||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Humana Medicare Advantage|HUMANA MA|0.87||||0.87||| 9521345|ERX|0250|AMOX-CLAV 250-62.5MG/5ML,|Humana Medicare Advantage|HUMANA MA|6.70||||||| 9521345|ERX|0250|AMOX-CLAV 250-62.5MG/5ML,|Managed Medicaid|MEDICAID AMERIGROUP|||||6.70||| 9521345|ERX|0250|AMOX-CLAV 250-62.5MG/5ML,|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|6.70||||||| 9521345|ERX|0250|AMOX-CLAV 250-62.5MG/5ML,|Blue Cross PPO Specialty|BCBSTX PPO|6.70||||6.70||| 9521345|ERX|0250|AMOX-CLAV 250-62.5MG/5ML,|Medicare|MEDICARE ACUTE|6.70||||||| 9521360|ERX|0250|AMOX-CLAV 1000-62.5MG TAB|Medicaid|SUPERIOR HEALTHPLAN CHIP|38.50||||||| 9521360|ERX|0250|AMOX-CLAV 1000-62.5MG TAB|Medicare|MEDICARE ACUTE|38.50||||38.50||| 9521360|ERX|0250|AMOX-CLAV 1000-62.5MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|38.50||||||| 9521360|ERX|0250|AMOX-CLAV 1000-62.5MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|||||38.50||| 9521360|ERX|0250|AMOX-CLAV 1000-62.5MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||38.50||| 9521378|ERX|0250|GUAIFENESIN 100MG/5ML, 11|Humana Medicare Advantage|HUMANA MA|56.25||||||| 9521378|ERX|0250|GUAIFENESIN 100MG/5ML, 11|Veterans Affairs|VETERANS ADMINISTRATION|56.25||||||| 9521378|ERX|0250|GUAIFENESIN 100MG/5ML, 11|Medicare|MEDICARE ACUTE|56.25||||56.25||| 9521378|ERX|0250|GUAIFENESIN 100MG/5ML, 11|Managed Medicare|HEALTHSPRING MA|56.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Tricare|TRICARE EAST REGION|18.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Medicaid|SMITH COUNTY INDIGENT HEALTH|18.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Medicaid|MEDICAID|18.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Managed Medicare|HEALTHSPRING MA|||||18.25||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|United Medicare Advantage|UHC MEDICARE GOLD MA|18.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|United Medicare Advantage|UHC AARP MCR HMO MA|18.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Blue Cross PPO Specialty|BCBSTX PPO|18.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.25||||||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Managed Medicaid|MEDICAID AMERIGROUP|18.25||||18.25||| 9521436|ERX|0250|LIPASE-PROT-AMYL 12-38-60|Humana Medicare Advantage|HUMANA MA|18.25||||18.25||| 9521444|ERX|0250|ATOMOXETINE 10 MG CAPSULE|Medicare|MEDICARE ACUTE|45.50||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Cigna|CIGNA OTHER|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Humana Medicare Advantage|HUMANA MA|972.75||||972.75||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Blue Cross PPO Specialty|BCBSTX PPO|972.75||||972.75||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Aenta Medicare Advantage|AETNA MEDICARE MA|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|United Medicare Advantage|UHC MEDICARE GOLD MA|972.75||||972.75||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|United Medicare Advantage|UHC AARP MCR HMO MA|972.75||||972.75||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|UTMB|UTMB CORRECTIONAL MANAGED CARE|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|United Healthcare|UNITED HEALTHCARE OTHER|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Managed Medicare|BCBS MEDICARE PPO MA|972.75||||972.75||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Managed Medicare|HEALTHSPRING MA|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Medicare|MEDICARE PART B ONLY IP|972.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Medicare|MEDICARE ACUTE|972.75||||||| 9521485|ERX|0250|AZELASTINE 0.05% EYE DROP|Medicare|MEDICARE ACUTE|762.25||||||| 9521485|ERX|0250|AZELASTINE 0.05% EYE DROP|Blue Cross PPO Specialty|BCBSTX PPO|||||762.25||| 9521485|ERX|0250|AZELASTINE 0.05% EYE DROP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|762.25||||||| 9521485|ERX|0250|AZELASTINE 0.05% EYE DROP|Humana Medicare Advantage|HUMANA MA|762.25||||||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Veterans Affairs|VETERANS ADMINISTRATION|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Access Direct Platinum|HEALTHFIRST TPA|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Humana Medicare Advantage|HUMANA MA|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicaid|MEDICAID SUPERIOR|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|103.25||||||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Blue Cross PPO Specialty|BCBSTX PPO|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Blue Cross HMO Specialty|BCBSTX HMO|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|United Healthcare|UNITED HEALTHCARE|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicare|HEALTHSPRING MA|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicare|BCBS MEDICARE PPO MA|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||103.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9521519|ERX|0250|CEFOTAXIME 1 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||0.70||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Medicare|MEDICARE ACUTE|587.75||||587.75||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Medicaid|MEDICAID|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicare|HEALTHSPRING MA|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|NON CONTRACTED|COMMERCIAL OTHER 1|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|PHCS|HUMANA|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Tricare|TRICARE EAST REGION|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|United Healthcare|UNITED HEALTHCARE OTHER|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|587.75||||587.75||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Veterans Affairs|VETERANS ADMINISTRATION|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|United Medicare Advantage|UHC MEDICARE GOLD MA|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Medicaid|SMITH COUNTY JAIL|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|587.75||||587.75||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|United Medicare Advantage|UHC AARP MCR HMO MA|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Blue Cross HMO Specialty|BCBSTX HMO|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Blue Cross PPO Specialty|BCBSTX PPO|587.75||||587.75||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Aenta Medicare Advantage|AETNA MEDICARE MA|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Cigna|CIGNA OTHER|587.75||||587.75||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Cigna|CIGNA|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Humana Medicare Advantage|HUMANA MA|587.75||||587.75||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|587.75||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicaid|MEDICAID SUPERIOR|587.75||||587.75||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|587.75||||587.75||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicaid|MEDICAID AMERIGROUP|587.75||||587.75||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Humana Medicare Advantage|HUMANA MA|262.25||||262.25||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|United Medicare Advantage|UHC MEDICARE GOLD MA|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|United Medicare Advantage|UHC AARP MCR HMO MA|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Veterans Affairs|VETERANS ADMINISTRATION|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Managed Medicare|HEALTHSPRING MA|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Medicare|MEDICARE PART B ONLY IP|262.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Medicare|MEDICARE ACUTE|262.25||||262.25||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|496.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Healthcare|UNITED HEALTHCARE OTHER|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Healthcare|UNITED HEALTHCARE|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Healthcare|UNITED HEALTHCARE|||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|PHCS|GROUP AND PENSION|496.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Tricare|TRICARE EAST REGION|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Tricare|TRICARE SOUTH PHYSICIAN|||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Medicare|MEDICARE PART B ONLY IP|496.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Medicare|MEDICARE ACUTE|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Medicaid|MEDICAID|496.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Medicaid|SMITH COUNTY JAIL|496.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicare|WELLCARE CHOICE MA|||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicare|HEALTHSPRING MA|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicare|BCBS MEDICARE PPO MA|||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Access Direct Platinum|HEALTHFIRST TPA UMR|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|496.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Access Direct Platinum|HEALTHFIRST TPA|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Veterans Affairs|VETERANS ADMINISTRATION|496.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Multiplan|PACIFICARE|496.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Healthcare|AARP|||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Medicare Advantage|UHC AARP MCR HMO MA|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Blue Cross HMO Specialty|BCBSTX HMO|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Blue Cross PPO Specialty|BCBSTX OTHER|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Blue Cross PPO Specialty|BCBSTX PPO|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Aetna|AETNA PPO|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Aetna|AETNA OTHER|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Cigna|CIGNA|||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Cigna|CIGNA|496.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Humana Medicare Advantage|HUMANA MA|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicaid|MEDICAID SUPERIOR|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|496.50||||496.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicaid|MEDICAID AMERIGROUP|496.50||||496.50||| 9521576|ERX|0250|TRIAMCINOLONE 40MG/ML, 5M|Medicare|MEDICARE ACUTE|||||4.56||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|6.25||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|6.25||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|6.25||||||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Aetna|AETNA PPO|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Access Direct Platinum|HEALTHFIRST TPA|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Cigna|CIGNA|6.25||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|6.25||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Tricare|TRICARE FOR LIFE|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Tricare|TRICARE EAST REGION|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|United Healthcare|UNITED HEALTHCARE|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|MEDICAID HMO|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|MEDICAID|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.25||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicare|MEDICARE PART B ONLY IP|6.25||||||| 9521626|ERX|0250|HALOPERIDOL DECANOATE 50M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|513.50||||||| 9521634|ERX|0250|HALOPERIDOL DEC 100MG/1ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|822.50||||||| 9521634|ERX|0250|HALOPERIDOL DEC 100MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|822.50||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Medicare|MEDICARE PART B ONLY IP|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Medicare|MEDICARE ACUTE|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Medicaid|MEDICAID|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicare|HOSPICE OF EAST TEXAS|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicare|WELLCARE CHOICE MA|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Optum Behavioral Health|BH OPTUM UHC|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Healthcare|UNITED HEALTHCARE|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Humana Medicare Advantage|HUMANA MA|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicare|HEALTHSPRING MA|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Aetna|AETNA OTHER|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Cigna Behavioral Health|BH CIGNA|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Rusk State Hospital|RUSK STATE HOSP|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Cigna|CIGNA|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Aetna|AETNA PPO|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|140.75||||140.75||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Tricare|TRICARE EAST REGION|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|140.75||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Medicaid|SMITH COUNTY JAIL|140.75||||||| 9521659|ERX|0250|CHLORZOXAZONE 500MG TABLE|Medicare|MEDICARE ACUTE|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Cigna|CIGNA|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Cigna Behavioral Health|BH CIGNA|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Cigna|CIGNA OTHER|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Tricare|TRICARE EAST REGION|25.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Cigna|CIGNA|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Medicaid|MEDICAID|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Medicare|MEDICARE ACUTE|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Aetna|AETNA PPO|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Cigna|CIGNA OTHER|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Cigna|CIGNA|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Magellan Behavioral Health|BH MAGELLAN|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Aetna|AETNA OTHER|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|67.75||||67.75||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|67.75||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Aetna|BH AETNA|67.75||||||| 9521683|ERX|0250|TOPIRAMATE 200MG TABLET|Aetna|BH AETNA|79.50||||||| 9521683|ERX|0250|TOPIRAMATE 200MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|79.50||||||| 9521683|ERX|0250|TOPIRAMATE 200MG TABLET|Medicare|MEDICARE ACUTE|79.50||||||| 9521683|ERX|0250|TOPIRAMATE 200MG TABLET|Magellan Behavioral Health|BH MAGELLAN|79.50||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|19.25||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Medicare|MEDICARE ACUTE|19.25||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Managed Medicare|HEALTHSPRING MA|19.25||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Aenta Medicare Advantage|AETNA MEDICARE MA|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Managed Medicare|BCBS MEDICARE PPO MA|||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Brinson Benefits|THE HEALTH PLAN SMITH CO|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Blue Cross PPO Specialty|BCBSTX PPO|19.25||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|United Medicare Advantage|UHC AARP MCR HMO MA|||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.25||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|United Medicare Advantage|UHC MEDICARE GOLD MA|19.25||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Medicare|MEDICARE PART B ONLY IP|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.25||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|NON CONTRACTED|COMMERCIAL OTHER 1|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Tricare|TRICARE EAST REGION|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|United Healthcare|UNITED HEALTHCARE|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Humana Medicare Advantage|HUMANA MA|19.25||||19.25||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Aetna|AETNA OTHER|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Blue Cross HMO Specialty|BCBSTX HMO|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Cigna|CIGNA OTHER|19.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Tricare|TRICARE FOR LIFE|||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Cigna|CIGNA OTHER|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Aetna|AETNA QHP HMO|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Aetna|AETNA OTHER|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Cigna|CIGNA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Aetna|AETNA PPO|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Cigna|CIGNA|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicare|MEDICARE ACUTE|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|LAW ENFORCEMENT OTHER|||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|SMITH COUNTY JAIL|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicare|HEALTHSPRING MA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Tricare|TRICARE EAST REGION|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|MEDICAID|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Humana Medicare Advantage|HUMANA MA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Aetna|BOON CHAPMAN|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Healthcare|TML GROUP BENEFITS|||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Healthcare|GOLDEN RULE|||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|MEDICAID HMO|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|PHCS|GROUP AND PENSION|0.19||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Healthcare|UNITED HEALTHCARE|0.19||||0.19||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|PHCS|HUMANA|0.19||||||| 9521717|ERX|0250|LACTASE 9000 UNIT TABLET|Humana Medicare Advantage|HUMANA MA|4.75||||4.75||| 9521725|ERX|0250|LEVOFLOXACIN 250MG/10ML,3|Medicare|MEDICARE ACUTE|245.75||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Medicaid|MEDICAID|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Humana Medicare Advantage|HUMANA MA|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Medicare|MEDICARE ACUTE|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Managed Medicare|HEALTHSPRING MA|1.21||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|1.21||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Medicaid|MEDICAID|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Managed Medicare|HEALTHSPRING MA|138.25||||138.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|138.25||||138.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|United Healthcare|UNITED HEALTHCARE|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Multiplan|PACIFICARE|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Humana Medicare Advantage|HUMANA MA|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Aetna|BH AETNA|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|138.25||||138.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|138.25||||138.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Medicare|MEDICARE ACUTE|138.25||||138.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||138.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|138.25||||138.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|138.25||||138.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|138.25||||138.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|138.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|138.25||||138.25||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|257.50||||257.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||257.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||257.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|257.50||||257.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicare|HEALTHSPRING MA|257.50||||257.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Medicare|MEDICARE ACUTE|257.50||||257.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Humana Medicare Advantage|HUMANA MA|257.50||||257.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|257.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|257.50||||257.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Aetna|AETNA OTHER|257.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Blue Cross PPO Specialty|BCBSTX PPO|39.50||||39.50||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Aetna|BH AETNA|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Aenta Medicare Advantage|AETNA MEDICARE MA|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Blue Cross HMO Specialty|BCBSTX HMO|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Veterans Affairs|VETERANS ADMINISTRATION|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Medicare|MEDICARE ACUTE|39.50||||39.50||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|United Healthcare|UNITED HEALTHCARE OTHER|||||39.50||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|NON CONTRACTED|COMMUNITY HEALTH CENTER|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Humana Medicare Advantage|HUMANA MA|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Magellan Behavioral Health|BH MAGELLAN|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Managed Medicare|HEALTHSPRING MA|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|NON CONTRACTED|COMMERCIAL OTHER 1|39.50||||||| 9521766|ERX|0250|PROPRANOLOL XL 60MG CAPSU|Managed Medicaid|MEDICAID AMERIGROUP|39.50||||||| 9521782|ERX|0250|ESTROGENS,CONJ 0.625MG TA|Blue Cross PPO Specialty|BCBSTX PPO|||||0.19||| 9521782|ERX|0250|ESTROGENS,CONJ 0.625MG TA|Medicare|MEDICARE ACUTE|0.19||||||| 9521782|ERX|0250|ESTROGENS,CONJ 0.625MG TA|United Healthcare|UNITED HEALTHCARE OTHER|0.19||||||| 9521782|ERX|0250|ESTROGENS,CONJ 0.625MG TA|Tricare|TRICARE EAST REGION|0.19||||||| 9521782|ERX|0250|ESTROGENS,CONJ 0.625MG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||||| 9521790|ERX|0250|ESTROGENS,CONJ 0.3MG TABL|United Healthcare|UNITED HEALTHCARE OTHER|0.19||||||| 9521790|ERX|0250|ESTROGENS,CONJ 0.3MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||||| 9521790|ERX|0250|ESTROGENS,CONJ 0.3MG TABL|Humana Medicare Advantage|HUMANA MA|0.19||||||| 9521790|ERX|0250|ESTROGENS,CONJ 0.3MG TABL|Medicare|MEDICARE PART B ONLY IP|0.19||||||| 9521790|ERX|0250|ESTROGENS,CONJ 0.3MG TABL|Medicare|MEDICARE ACUTE|0.19||||||| 9521790|ERX|0250|ESTROGENS,CONJ 0.3MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||||| 9521790|ERX|0250|ESTROGENS,CONJ 0.3MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||||| 9521790|ERX|0250|ESTROGENS,CONJ 0.3MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,077.25||||||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Cigna|CIGNA|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Managed Medicare|HEALTHSPRING MA|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Blue Cross PPO Specialty|BCBSTX PPO|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Blue Cross HMO Specialty|BCBSTX HMO|1,077.25||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|United Healthcare|TML GROUP BENEFITS|1,077.25||||||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|United Healthcare|UNITED HEALTHCARE OTHER|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|United Healthcare|GOLDEN RULE|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Aetna|AETNA OTHER|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|United Healthcare|UNITED HEALTHCARE|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|ChampVA|CHAMPVA CENTER|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Humana Medicare Advantage|HUMANA MA|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Medicare|MEDICARE PART B ONLY IP|1,077.25||||||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Medicare|MEDICARE ACUTE|1,077.25||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Aetna|AETNA PPO|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Managed Medicare|BCBS MEDICARE PPO MA|||||1,077.25||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,077.25||||||| 9521816|ERX|0250|TRIAMCINOLONE 10MG/ML, 5M|Medicare|MEDICARE ACUTE|||||127.50||| 9521824|ERX|0250|ESTROG-M'PROGEST 0.625-2.|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9521824|ERX|0250|ESTROG-M'PROGEST 0.625-2.|United Healthcare|UNITED HEALTHCARE|||||25.50||| 9521824|ERX|0250|ESTROG-M'PROGEST 0.625-2.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||||| 9521857|ERX|0250|ESTROGENS,CONJ 0.45MG TAB|Medicare|MEDICARE ACUTE|0.21||||||| 9521857|ERX|0250|ESTROGENS,CONJ 0.45MG TAB|United Healthcare|UNITED HEALTHCARE OTHER|0.21||||||| 9521857|ERX|0250|ESTROGENS,CONJ 0.45MG TAB|Humana Medicare Advantage|HUMANA MA|0.21||||||| 9521873|ERX|0250|ESTROGENS,CONJ 1.25MG TAB|Access Direct Platinum|HEALTHFIRST TPA UMR|0.21||||||| 9521873|ERX|0250|ESTROGENS,CONJ 1.25MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|||||0.21||| 9521873|ERX|0250|ESTROGENS,CONJ 1.25MG TAB|Humana Medicare Advantage|HUMANA MA|||||0.21||| 9521881|ERX|0250|AMPICILLIN-SULBACTAM 1.5|Aetna|AETNA PPO|1.12||||||| 9521881|ERX|0250|AMPICILLIN-SULBACTAM 1.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.12||| 9521881|ERX|0250|AMPICILLIN-SULBACTAM 1.5|Managed Medicaid|MEDICAID SUPERIOR|1.12||||||| 9521899|ERX|0250|AMPICILLIN-SULBACTAM 3 G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||193.25||| 9521907|ERX|0250|TRIAMCINOLONE 10MG/ML, 1M|Blue Cross PPO Specialty|BCBSTX OTHER|0.28||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|PHCS|GROUP AND PENSION|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|United Healthcare|UNITED HEALTHCARE|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Medicaid|MEDICAID|0.68||||0.68||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Access Direct Platinum|HEALTHFIRST TPA|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Access Direct Platinum|HEALTHFIRST TPA UMR|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|United Healthcare|TML GROUP BENEFITS|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Medicare|MEDICARE ACUTE|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.68||||0.68||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Cigna|CIGNA OTHER|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Managed Medicaid|MEDICAID AMERIGROUP|0.68||||0.68||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|United Healthcare|UNITED HEALTHCARE OTHER|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|NON CONTRACTED|COMMERCIAL OTHER 1|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Aetna|AETNA PPO|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Cigna|CIGNA|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Blue Cross HMO Specialty|BCBSTX HMO|0.68||||||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Blue Cross PPO Specialty|BCBSTX PPO|0.68||||0.68||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Managed Medicaid|MEDICAID SUPERIOR|0.68||||0.68||| 9521923|ERX|0250|PENICILLIN G POTASSIUM 20|Medicare|MEDICARE ACUTE|182.75||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|9.25||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|United Healthcare|UNITED HEALTHCARE|9.25||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|9.25||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|||||9.25||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Managed Medicare|HEALTHSPRING MA|15.75||||15.75||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Medicare|MEDICARE ACUTE|15.75||||15.75||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.75||||||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|15.75||||||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|15.75||||||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Cigna|CIGNA|15.75||||||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.75||||||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||15.75||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.75||||||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.75||||||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|15.75||||15.75||| 9521956|ERX|0250|GLIPIZIDE XL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.75||||15.75||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Medicaid|MEDICAID|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.25||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Aetna|AETNA PPO|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|United Healthcare|UNITED HEALTHCARE|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||||| 9521964|ERX|0250|GLIPIZIDE XL 2.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|20.75||||||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|Managed Medicare|HEALTHSPRING MA|20.75||||||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|Medicare|MEDICARE ACUTE|20.75||||20.75||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|United Healthcare|TML GROUP BENEFITS|20.75||||||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|20.75||||||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.75||||||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|20.75||||20.75||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|20.75||||20.75||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|20.75||||||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|Cigna|CIGNA|20.75||||||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|Humana Medicare Advantage|HUMANA MA|20.75||||||| 9521972|ERX|0250|DOXAZOSIN 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|20.75||||20.75||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|20.75||||20.75||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Managed Medicare|HEALTHSPRING MA|20.75||||20.75||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||20.75||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Humana Medicare Advantage|HUMANA MA|20.75||||20.75||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Medicare|MEDICARE ACUTE|20.75||||20.75||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|20.75||||20.75||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|20.75||||20.75||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|20.75||||||| 9522004|ERX|0250|VORICONAZOLE 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|110.50||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Medicaid|MEDICAID|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Managed Medicare|HEALTHSPRING MA|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Medicare|MEDICARE ACUTE|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|4.42||||||| 9522012|ERX|0250|VORICONAZOLE 200MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|4.42||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicare|BCBS MEDICARE PPO MA|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|United Healthcare|UNITED HEALTHCARE|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Medicaid|MEDICAID|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|United Healthcare|UNITED HEALTHCARE OTHER|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|PHCS|HUMANA INSURANCE|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Rusk State Hospital|RUSK STATE HOSP|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|NON CONTRACTED|COMMERCIAL OTHER 2|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|NON CONTRACTED|COMMERCIAL OTHER 1|170.25||||170.25||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Aetna|AETNA PPO|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Medicaid|CRIME VICTIMS COMPENSATION|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Medicare|MEDICARE ACUTE|170.25||||170.25||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Tricare|TRICARE EAST REGION|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Aenta Medicare Advantage|AETNA MEDICARE MA|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|ChampVA|CHAMPVA CENTER|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Access Direct Platinum|HEALTHFIRST TPA|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Veterans Affairs|VETERANS ADMINISTRATION|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|United Medicare Advantage|UHC AARP MCR HMO MA|170.25||||170.25||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|United Medicare Advantage|UHC AARP WELLMED HMO MA|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|170.25||||170.25||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicaid|MEDICAID AMERIGROUP|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Blue Cross PPO Specialty|BCBSTX PPO|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Blue Cross HMO Specialty|BCBSTX HMO|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|170.25||||170.25||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Humana Medicare Advantage|HUMANA MA|170.25||||170.25||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Cigna|CIGNA|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicare|HEALTHSPRING MA|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Cigna|CIGNA OTHER|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|170.25||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|United Medicare Advantage|UHC MEDICARE GOLD MA|170.25||||||| 9522046|ERX|0250|FLUCONAZOLE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|0.78||||||| 9522046|ERX|0250|FLUCONAZOLE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.78||||||| 9522046|ERX|0250|FLUCONAZOLE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.78||||||| 9522046|ERX|0250|FLUCONAZOLE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.78||||||| 9522046|ERX|0250|FLUCONAZOLE 50MG TABLET|Medicare|MEDICARE ACUTE|0.78||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Tricare|TRICARE EAST REGION|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Aetna|AETNA PPO|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Medicare|MEDICARE ACUTE|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Medicaid|MEDICAID|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Cigna|CIGNA|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|122.25||||122.25||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Magellan Behavioral Health|BH MAGELLAN|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|122.25||||122.25||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|122.25||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|122.25||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Cigna|CIGNA OTHER|2.00||||2.00||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Aetna|AETNA OTHER|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Cigna|CIGNA|||||2.00||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.00||||2.00||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Medicaid|MEDICAID|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Medicare|MEDICARE ACUTE|2.00||||2.00||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Managed Medicare|HEALTHSPRING MA|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|United Healthcare|UNITED HEALTHCARE|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Rusk State Hospital|RUSK STATE HOSP|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Managed Medicare|OTHER INSTITUTIONS|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.00||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|United Healthcare|TML GROUP BENEFITS|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.00||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.00||||2.00||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.00||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.00||||||| 9522061|ERX|0250|FLUCONAZOLE 200MG TABLET|Humana Medicare Advantage|HUMANA MA|2.00||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|United Healthcare|UNITED HEALTHCARE OTHER|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|UTMB|UTMB CORRECTIONAL MANAGED CARE|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Medicaid|CRIME VICTIMS COMPENSATION|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|United Healthcare|TML GROUP BENEFITS|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Rusk State Hospital|RUSK STATE HOSP|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|NON CONTRACTED|COMMERCIAL OTHER 1|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Managed Medicare|BCBS MEDICARE PPO MA|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Medicaid|MOLINA HEALTHCARE OF TEXAS|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Managed Medicare|WELLCARE CHOICE MA|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Medicaid|MEDICAID|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Managed Medicare|HEALTHSPRING MA|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Medicare|MEDICARE ACUTE|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Humana Medicare Advantage|HUMANA MA|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Brinson Benefits|THE HEALTH PLAN SMITH CO|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Aetna|BOON CHAPMAN|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Blue Cross PPO Specialty|BCBSTX PPO|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Cigna|CIGNA OTHER|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Blue Cross HMO Specialty|BCBSTX HMO|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|ChampVA|CHAMPVA CENTER|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Medicaid|COUNTY INDIGENT HEALTH OTHER|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|United Medicare Advantage|UHC MEDICARE GOLD MA|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|United Medicare Advantage|UHC AARP WELLMED HMO MA|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Aetna|AETNA PPO|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|United Medicare Advantage|UHC AARP MCR HMO MA|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Veterans Affairs|VETERANS ADMINISTRATION|271.75||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|271.75||||||| 9522087|ERX|0250|TRIAMCINOLONE ACET 0.1%,|Managed Medicaid|MEDICAID AMERIGROUP|||||5.10||| 9522087|ERX|0250|TRIAMCINOLONE ACET 0.1%,|Medicare|MEDICARE ACUTE|5.10||||||| 9522087|ERX|0250|TRIAMCINOLONE ACET 0.1%,|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.10||||||| 9522087|ERX|0250|TRIAMCINOLONE ACET 0.1%,|NON CONTRACTED|COMMERCIAL OTHER 1|5.10||||||| 9522087|ERX|0250|TRIAMCINOLONE ACET 0.1%,|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.10||| 9522087|ERX|0250|TRIAMCINOLONE ACET 0.1%,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.10||||||| 9522095|ERX|0250|FLUCONAZOLE 40MG/ML, 35ML|Blue Cross PPO Specialty|BCBSTX PPO|284.25||||||| 9522095|ERX|0250|FLUCONAZOLE 40MG/ML, 35ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|284.25||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Medicaid|MEDICAID|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Medicare|MEDICARE ACUTE|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Medicaid|SMITH COUNTY JAIL|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Cigna|CIGNA|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Humana Medicare Advantage|HUMANA MA|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Rusk State Hospital|RUSK STATE HOSP|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Aetna|AETNA PPO|||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Optum Behavioral Health|BH OPTUM UHC|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicare|HEALTHSPRING MA|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|150.75||||150.75||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|ChampVA|CHAMPVA CENTER|150.75||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|150.75||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|67.50||||67.50||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Humana Medicare Advantage|HUMANA MA|67.50||||67.50||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|67.50||||67.50||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|||||67.50||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Medicare|MEDICARE ACUTE|67.50||||67.50||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Managed Medicare|HEALTHSPRING MA|67.50||||67.50||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Tricare|TRICARE EAST REGION|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|67.50||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|67.50||||||| 9522129|ERX|0250|ZIPRASIDONE 40MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|67.50||||||| 9522129|ERX|0250|ZIPRASIDONE 40MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|67.50||||||| 9522129|ERX|0250|ZIPRASIDONE 40MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|67.50||||||| 9522129|ERX|0250|ZIPRASIDONE 40MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|67.50||||||| 9522129|ERX|0250|ZIPRASIDONE 40MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|67.50||||||| 9522129|ERX|0250|ZIPRASIDONE 40MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|67.50||||||| 9522129|ERX|0250|ZIPRASIDONE 40MG CAPSULE|Medicare|MEDICARE ACUTE|67.50||||||| 9522129|ERX|0250|ZIPRASIDONE 40MG CAPSULE|Managed Medicare|HEALTHSPRING MA|67.50||||||| 9522137|ERX|0250|ZIPRASIDONE 60MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.82||||||| 9522137|ERX|0250|ZIPRASIDONE 60MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.82||||||| 9522137|ERX|0250|ZIPRASIDONE 60MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.82||||||| 9522137|ERX|0250|ZIPRASIDONE 60MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|0.82||||||| 9522137|ERX|0250|ZIPRASIDONE 60MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|0.82||||||| 9522137|ERX|0250|ZIPRASIDONE 60MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|0.82||||||| 9522137|ERX|0250|ZIPRASIDONE 60MG CAPSULE|Medicare|MEDICARE ACUTE|0.82||||||| 9522137|ERX|0250|ZIPRASIDONE 60MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.82||||||| 9522137|ERX|0250|ZIPRASIDONE 60MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|0.82||||||| 9522145|ERX|0250|ZIPRASIDONE 80MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|0.82||||||| 9522145|ERX|0250|ZIPRASIDONE 80MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.82||||||| 9522145|ERX|0250|ZIPRASIDONE 80MG CAPSULE|Medicare|MEDICARE ACUTE|0.82||||||| 9522145|ERX|0250|ZIPRASIDONE 80MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.82||||||| 9522145|ERX|0250|ZIPRASIDONE 80MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|0.82||||||| 9522145|ERX|0250|ZIPRASIDONE 80MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.82||||||| 9522145|ERX|0250|ZIPRASIDONE 80MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|0.82||||||| 9522145|ERX|0250|ZIPRASIDONE 80MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.82||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Cigna|CIGNA|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Aetna|BH AETNA|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Aetna|AETNA PPO|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|ChampVA|CHAMPVA CENTER|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Access Direct Platinum|ANDREWS CENTER|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Magellan Behavioral Health|BH MAGELLAN|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Workers Compensation|TEXAS MUTUAL INSURANCE|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicare|MEDICARE ACUTE|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicaid|SMITH COUNTY JAIL|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicaid|MEDICAID HMO|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Cigna Behavioral Health|BH CIGNA|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Aetna|AETNA QHP HMO|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicaid|MEDICAID|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Healthcare|UNITED HEALTHCARE|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Healthcare|UNITED HEALTHCARE|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicare|HEALTHSPRING MA|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|PHCS|GROUP AND PENSION|||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|PHCS|HUMANA INSURANCE|38.25||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Tricare|TRICARE EAST REGION|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|PHCS|HUMANA|38.25||||38.25||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Optum Behavioral Health|BH OPTUM UHC|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Optum Behavioral Health|BH OPTUM UHC|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Tricare|TRICARE EAST REGION|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Medicaid|MEDICAID HMO|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Medicaid|MEDICAID|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Medicare|MEDICARE ACUTE|38.25||||38.25||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.25||||38.25||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Access Direct Platinum|ANDREWS CENTER|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Aetna|BH AETNA|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Magellan Behavioral Health|BH MAGELLAN|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.25||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|38.25||||38.25||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|38.25||||38.25||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Cigna Behavioral Health|BH CIGNA|38.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Humana Medicare Advantage|HUMANA MA|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|73.25||||73.25||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Managed Medicare|HEALTHSPRING MA|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|73.25||||||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Medicare|MEDICARE ACUTE|73.25||||73.25||| 9522178|ERX|0250|DRONABINOL 2.5MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|73.25||||||| 9522194|ERX|0250|TESTOSTERONE 5 G PACKET|Managed Medicare|HEALTHSPRING MA|94.50||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|United Medicare Advantage|UHC MEDICARE GOLD MA|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Multiplan|WEB TPA|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Aetna|BH AETNA|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Managed Medicaid|MEDICAID AMERIGROUP|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Medicaid|MEDICAID|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Humana Medicare Advantage|HUMANA MA|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|NON CONTRACTED|COMMUNITY HEALTH CENTER|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Medicare|MEDICARE ACUTE|29.75||||29.75||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Aenta Medicare Advantage|AETNA MEDICARE MA|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Blue Cross PPO Specialty|BCBSTX PPO|29.75||||||| 9522202|ERX|0250|MIRTAZAPINE SOLUTAB 15MG|Magellan Behavioral Health|BH MAGELLAN|29.75||||||| 9522210|ERX|0250|MIRTAZAPINE SOLUTAB 30MG|Medicaid|MEDICAID|30.75||||||| 9522210|ERX|0250|MIRTAZAPINE SOLUTAB 30MG|Multiplan|WEB TPA|30.75||||||| 9522210|ERX|0250|MIRTAZAPINE SOLUTAB 30MG|NON CONTRACTED|COMMUNITY HEALTH CENTER|30.75||||||| 9522210|ERX|0250|MIRTAZAPINE SOLUTAB 30MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|30.75||||||| 9522210|ERX|0250|MIRTAZAPINE SOLUTAB 30MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30.75||||||| 9522210|ERX|0250|MIRTAZAPINE SOLUTAB 30MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|30.75||||||| 9522210|ERX|0250|MIRTAZAPINE SOLUTAB 30MG|Medicare|MEDICARE ACUTE|30.75||||||| 9522228|ERX|0250|MIRTAZAPINE 45MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|42.75||||||| 9522228|ERX|0250|MIRTAZAPINE 45MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|42.75||||||| 9522228|ERX|0250|MIRTAZAPINE 45MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|42.75||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|GEHA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|UNITED HEALTHCARE ERS|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Rusk State Hospital|RUSK STATE HOSP|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|CRIME VICTIMS COMPENSATION|2.04||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Tricare|TRICARE FOR LIFE|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|OTHER INSTITUTIONS|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Multiplan|PACIFICARE|2.04||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicare|MEDICARE PART B ONLY IP|2.04||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 2|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|HEALTHSPRING MA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|LAW ENFORCEMENT OTHER|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|PHCS|HUMANA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|GOLDEN RULE|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Multiplan|WEB TPA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|PHCS|GROUP AND PENSION|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|MEDICAID|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.04||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Workers Compensation|UT EMPLOYEE INJURY|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|MEDICAID BCBSTX|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Workers Compensation|WORKERS COMPENSATION OTHER|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Cigna|CIGNA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|UNITED HEALTHCARE|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Workers Compensation|GALLAGHER BASSETT|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|2.04||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|MEDICAID HMO|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Texas Workforce Commission|DIS DETER SERV (DDS)|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Tricare|TRICARE EAST REGION|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|2.04||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicare|MEDICARE ACUTE|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Workers Compensation|TEXAS MUTUAL INSURANCE|2.04||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Workers Compensation|BROOKSHIRES WORKERS COMP|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Cigna|CIGNA OTHER|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Humana Medicare Advantage|HUMANA MA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|TML GROUP BENEFITS|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Aetna|AETNA QHP HMO|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Aetna Value Network|AETNA VALUE NETWORK|||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Aetna|BOON CHAPMAN|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Aetna|AETNA PPO|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Aetna|AETNA OTHER|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross PPO Specialty|BCBSTX OTHER|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|ChampVA|CHAMPVA CENTER|2.04||||2.04||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.04||||2.04||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Aetna|AETNA PPO|3.92||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|3.92||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.92||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Managed Medicaid|MEDICAID SUPERIOR|||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.92||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Humana Medicare Advantage|HUMANA MA|3.92||||||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.92||||||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|3.92||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|3.92||||||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Managed Medicare|HEALTHSPRING MA|3.92||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|United Healthcare|UNITED HEALTHCARE|||||3.92||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|3.92||||||| 9522244|ERX|0250|ROCURONIUM 100MG/10ML|Medicare|MEDICARE ACUTE|3.92||||3.92||| 9522251|ERX|0250|ATOMOXETINE 25MG CAPSULE|Medicare|MEDICARE ACUTE|45.50||||||| 9522251|ERX|0250|ATOMOXETINE 25MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|45.50||||||| 9522251|ERX|0250|ATOMOXETINE 25MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|45.50||||||| 9522251|ERX|0250|ATOMOXETINE 25MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|45.50||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.25||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Aetna|AETNA PPO|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Cigna|CIGNA|||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|4.25||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Cigna|CIGNA|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|PHCS|HUMANA|||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Tricare|TRICARE EAST REGION|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Healthcare|UNITED HEALTHCARE|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Healthcare|GOLDEN RULE|4.25||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|SMITH COUNTY JAIL|4.25||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|MEDICAID|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|4.25||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.25||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|4.25||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.25||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|4.25||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicare|MEDICARE ACUTE|4.25||||4.25||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.25||||4.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Medicaid|MEDICAID|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Medicare|MEDICARE ACUTE|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Managed Medicare|HEALTHSPRING MA|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Tricare|TRICARE EAST REGION|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|United Healthcare|UNITED HEALTHCARE|||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Cigna|CIGNA|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|6.25||||||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.25||||6.25||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|6.25||||6.25||| 9522327|ERX|0250|ZIDOVUDINE 300MG TABLET|Medicaid|MEDICAID|62.75||||||| 9522335|ERX|0250|DIGOXIN 50MCG/ML, 60ML|Tricare|TRICARE EAST REGION|346.50||||||| 9522335|ERX|0250|DIGOXIN 50MCG/ML, 60ML|Medicare|MEDICARE ACUTE|346.50||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Aenta Medicare Advantage|AETNA MEDICARE MA|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Aetna|AETNA PPO|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Blue Cross HMO Specialty|BCBSTX HMO|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Humana Medicare Advantage|HUMANA MA|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Blue Cross PPO Specialty|BCBSTX OTHER|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicaid|MEDICAID AMERIGROUP|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Blue Cross PPO Specialty|BCBSTX PPO|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Veterans Affairs|VETERANS ADMINISTRATION|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Medicare Advantage|UHC AARP MCR HMO MA|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Access Direct Platinum|HEALTHFIRST TPA|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicare|BCBS MEDICARE PPO MA|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Medicare|MEDICARE PART B ONLY IP|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Medicare|MEDICARE ACUTE|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Healthcare|UNITED HEALTHCARE OTHER|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicare|HEALTHSPRING MA|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Healthcare|UNITED HEALTHCARE|||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|NON CONTRACTED|COMMERCIAL OTHER 1|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicaid|MEDICAID SUPERIOR|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Medicare Advantage|UHC MEDICARE GOLD MA|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Medicaid|COUNTY INDIGENT HEALTH OTHER|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Healthcare|UNITED HEALTHCARE|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Medicaid|MEDICAID|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|UTMB|UTMB CORRECTIONAL MANAGED CARE|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|89.25||||89.25||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Cigna|CIGNA|89.25||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Access Direct Platinum|HEALTHFIRST TPA UMR|89.25||||89.25||| 9522368|ERX|0250|BUTORPHANOL 10MG/ML, 2.5M|ChampVA|CHAMPVA CENTER|8.14||||||| 9522368|ERX|0250|BUTORPHANOL 10MG/ML, 2.5M|Aenta Medicare Advantage|AETNA MEDICARE MA|8.14||||||| 9522368|ERX|0250|BUTORPHANOL 10MG/ML, 2.5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.14||||||| 9522376|ERX|0250|CALCIUM CARB 500MG/5ML,30|Blue Cross PPO Specialty|BCBSTX PPO|0.12||||||| 9522376|ERX|0250|CALCIUM CARB 500MG/5ML,30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.12||||||| 9522376|ERX|0250|CALCIUM CARB 500MG/5ML,30|Medicare|MEDICARE ACUTE|0.12||||||| 9522376|ERX|0250|CALCIUM CARB 500MG/5ML,30|Humana Medicare Advantage|HUMANA MA|||||0.12||| 9522376|ERX|0250|CALCIUM CARB 500MG/5ML,30|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.12||| 9522384|ERX|0250|DEXAMETH 0.5MG/0.5ML,30ML|Managed Medicaid|MEDICAID AMERIGROUP|||||1.96||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|0.35||||0.35||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Workers Compensation|TEXAS MUTUAL INSURANCE|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicare|BCBS MEDICARE PPO MA|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Healthcare|UNITED HEALTHCARE|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Medicaid|MEDICAID|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.35||||0.35||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Medicare|MEDICARE ACUTE|0.35||||0.35||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Access Direct Platinum|HEALTHFIRST TPA|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Veterans Affairs|VETERANS ADMINISTRATION|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Medicare Advantage|UHC AARP MCR HMO MA|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Aetna|AETNA OTHER|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Aenta Medicare Advantage|AETNA MEDICARE MA|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicare|HEALTHSPRING MA|0.35||||0.35||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.35||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross PPO Specialty|BCBSTX PPO|0.35||||0.35||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Humana Medicare Advantage|HUMANA MA|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.35||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.35||||0.35||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID SUPERIOR|0.35||||0.35||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID AMERIGROUP|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross HMO Specialty|BCBSTX HMO|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Cigna|CIGNA|0.35||||||| 9522418|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.35||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.75||||18.75||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Humana Medicare Advantage|HUMANA MA|18.75||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Brinson Benefits|THE HEALTH PLAN SMITH CO|18.75||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|18.75||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Medicare|MEDICARE ACUTE|18.75||||18.75||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|18.75||||18.75||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|18.75||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.75||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|18.75||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.75||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.75||||||| 9522491|ERX|0250|PREDNISONE 5MG/5ML, 30ML|Medicare|MEDICARE ACUTE|0.51||||||| 9522491|ERX|0250|PREDNISONE 5MG/5ML, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.51||| 9522491|ERX|0250|PREDNISONE 5MG/5ML, 30ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.51||| 9522491|ERX|0250|PREDNISONE 5MG/5ML, 30ML|Managed Medicaid|MEDICAID SUPERIOR|0.51||||||| 9522517|ERX|0250|MERCAPTOPURINE 50MG TABLE|Humana Medicare Advantage|HUMANA MA|0.42||||||| 9522517|ERX|0250|MERCAPTOPURINE 50MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.42||||||| 9522517|ERX|0250|MERCAPTOPURINE 50MG TABLE|Medicare|MEDICARE ACUTE|0.42||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Blue Cross HMO Specialty|BCBSTX HMO|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Blue Cross PPO Specialty|BCBSTX PPO|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Humana Medicare Advantage|HUMANA MA|0.03||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Aetna|AETNA PPO|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|PHCS|HUMANA|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Tricare|TRICARE EAST REGION|||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|United Healthcare|UNITED HEALTHCARE|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|United Healthcare|UNITED HEALTHCARE OTHER|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.03||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Managed Medicare|HEALTHSPRING MA|0.03||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Managed Medicare|BCBS MEDICARE PPO MA|0.03||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Medicare|MEDICARE PART B ONLY IP|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Medicare|MEDICARE ACUTE|0.03||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Veterans Affairs|VETERANS ADMINISTRATION|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Access Direct Platinum|HEALTHFIRST TPA|||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.03||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.03||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|United Medicare Advantage|UHC AARP MCR HMO MA|0.03||||0.03||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Medicaid|MEDICAID|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.03||||||| 9522558|ERX|0250|CALCIUM CARB 1250MG (500M|Aetna|BH AETNA|0.03||||||| 9522574|ERX|0250|CODEINE 30MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.09||||||| 9522574|ERX|0250|CODEINE 30MG TABLET|Medicare|MEDICARE ACUTE|0.09||||||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|United Healthcare|UNITED HEALTHCARE|6.25||||||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|6.25||||||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|6.25||||||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|6.25||||6.25||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.25||||6.25||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.25||||||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|6.25||||||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|6.25||||||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|Medicare|MEDICARE ACUTE|6.25||||||| 9522590|ERX|0250|DEXAMETHASONE 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|6.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Aetna|AETNA OTHER|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Aetna|AETNA QHP HMO|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Cigna|CIGNA|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Humana Medicare Advantage|HUMANA MA|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicare|WELLCARE CHOICE MA|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Medicaid|MEDICAID|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|PHCS|HUMANA|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|PHCS|HUMANA INSURANCE|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|9.25||||9.25||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|United Healthcare|TML GROUP BENEFITS|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|United Healthcare|UNITED HEALTHCARE|9.25||||||| 9522624|ERX|0250|DEXAMETHASONE 0.75MG TABL|Medicare|MEDICARE ACUTE|6.25||||||| 9522624|ERX|0250|DEXAMETHASONE 0.75MG TABL|Humana Medicare Advantage|HUMANA MA|6.25||||||| 9522624|ERX|0250|DEXAMETHASONE 0.75MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|||||6.25||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Veterans Affairs|VETERANS ADMINISTRATION|0.16||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|0.16||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.16||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Aenta Medicare Advantage|AETNA MEDICARE MA|0.16||||||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross HMO Specialty|BCBSTX HMO|0.16||||||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross PPO Specialty|BCBSTX PPO|||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.16||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID AMERIGROUP|0.16||||||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID SUPERIOR|0.16||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Humana Medicare Advantage|HUMANA MA|0.16||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Healthcare|UNITED HEALTHCARE|0.16||||||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Healthcare|UNITED HEALTHCARE OTHER|||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicare|HEALTHSPRING MA|0.16||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Tricare|TRICARE EAST REGION|||||0.16||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Medicaid|MEDICAID|0.16||||||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Medicare|MEDICARE ACUTE|0.16||||0.16||| 9522657|ERX|0250|LITHIUM 150MG CAPSULE|Medicare|MEDICARE ACUTE|4.50||||||| 9522657|ERX|0250|LITHIUM 150MG CAPSULE|Workers Compensation|UT EMPLOYEE INJURY|4.50||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.13||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Medicaid|MEDICAID|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Medicaid|SMITH COUNTY JAIL|||||0.13||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Medicare|MEDICARE ACUTE|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.13||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.13||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|36.50||||||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|Medicare|MEDICARE ACUTE|36.50||||||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|Medicaid|MEDICAID|36.50||||||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||36.50||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|36.50||||||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36.50||||||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|36.50||||||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.50||||||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|36.50||||36.50||| 9522699|ERX|0250|METHADONE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.07||||0.07||| 9522699|ERX|0250|METHADONE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Medicaid|SMITH COUNTY JAIL|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Medicaid|MEDICAID|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Medicare|MEDICARE ACUTE|0.07||||0.07||| 9522699|ERX|0250|METHADONE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.07||||0.07||| 9522699|ERX|0250|METHADONE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.07||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.07||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|7.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Tricare|TRICARE EAST REGION|||||7.75||| 9522707|ERX|0250|METHADONE 10MG TABLET|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9522707|ERX|0250|METHADONE 10MG TABLET|Medicaid|MEDICAID|7.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Medicaid|SMITH COUNTY JAIL|7.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|7.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||7.75||| 9522707|ERX|0250|METHADONE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9522707|ERX|0250|METHADONE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||7.75||| 9522707|ERX|0250|METHADONE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||7.75||| 9522707|ERX|0250|METHADONE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.75||||5.75||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Cigna|CIGNA|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Humana Medicare Advantage|HUMANA MA|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.75||||5.75||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|United Healthcare|UNITED HEALTHCARE|5.75||||5.75||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Medicare|MEDICARE ACUTE|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Medicaid|MEDICAID|5.75||||||| 9522715|ERX|0250|MORPHINE IR 15MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||||| 9522723|ERX|0250|PREDNISONE 1MG TABLET|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9522723|ERX|0250|PREDNISONE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||||| 9522723|ERX|0250|PREDNISONE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.05||||||| 9522723|ERX|0250|PREDNISONE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.05||||||| 9522723|ERX|0250|PREDNISONE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.05||| 9522723|ERX|0250|PREDNISONE 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||0.05||| 9522731|ERX|0250|WARFARIN 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.15||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Managed Medicare|HEALTHSPRING MA|0.15||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|||||0.15||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Medicaid|MEDICAID|0.15||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9522749|ERX|0250|WARFARIN 2MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Medicaid|MEDICAID|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9522756|ERX|0250|WARFARIN 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9522756|ERX|0250|WARFARIN 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||15.50||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Medicaid|MEDICAID|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||15.50||| 9522756|ERX|0250|WARFARIN 5MG TABLET|United Healthcare|UNITED HEALTHCARE|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Tricare|TRICARE EAST REGION|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|United Healthcare|GEHA|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Medicare|MEDICARE ACUTE|0.19||||0.19||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.19||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Aetna|AETNA PPO|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||0.19||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||0.19||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||0.19||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.19||||0.19||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.19||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.19||||||| 9522772|ERX|0250|WARFARIN 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.75||||||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|19.75||||||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Medicaid|MEDICAID|19.75||||||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Medicare|MEDICARE ACUTE|19.75||||19.75||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Tricare|TRICARE EAST REGION|19.75||||||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|19.75||||||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|19.75||||||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|19.75||||19.75||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.75||||||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|19.75||||19.75||| 9522772|ERX|0250|WARFARIN 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19.75||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Tricare|TRICARE EAST REGION|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Medicaid|MEDICAID|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||15.50||| 9522806|ERX|0250|EFAVIRENZ 200MG CAPSULE|Medicare|MEDICARE ACUTE|68.75||||68.75||| 9522814|ERX|0250|CARBIDOPA 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||||| 9522814|ERX|0250|CARBIDOPA 25MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|12.25||||||| 9522814|ERX|0250|CARBIDOPA 25MG TABLET|Humana Medicare Advantage|HUMANA MA|||||12.25||| 9522814|ERX|0250|CARBIDOPA 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||||| 9522814|ERX|0250|CARBIDOPA 25MG TABLET|Medicare|MEDICARE ACUTE|12.25||||||| 9522848|ERX|0250|TRAMADOL XL 100MG TABLET|Medicare|MEDICARE ACUTE|28.25||||28.25||| 9522848|ERX|0250|TRAMADOL XL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|28.25||||||| 9522848|ERX|0250|TRAMADOL XL 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||28.25||| 9522848|ERX|0250|TRAMADOL XL 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|28.25||||||| 9522848|ERX|0250|TRAMADOL XL 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||28.25||| 9522848|ERX|0250|TRAMADOL XL 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.25||||||| 9522848|ERX|0250|TRAMADOL XL 100MG TABLET|Humana Medicare Advantage|HUMANA MA|28.25||||28.25||| 9522863|ERX|0250|MICONAZOLE VAG CREAM, 45|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.50||||||| 9522863|ERX|0250|MICONAZOLE VAG CREAM, 45|Magellan Behavioral Health|BH MAGELLAN|99.50||||||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Medicaid|MEDICAID|762.25||||||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Medicare|MEDICARE ACUTE|762.25||||762.25||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|762.25||||||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|762.25||||||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Managed Medicaid|MEDICAID SUPERIOR|762.25||||||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Humana Medicare Advantage|HUMANA MA|762.25||||||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Blue Cross PPO Specialty|BCBSTX PPO|762.25||||||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Veterans Affairs|VETERANS ADMINISTRATION|762.25||||||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|762.25||||||| 9522921|ERX|0250|CARBACHOL 0.01% 100MCG 1M|Medicare|MEDICARE ACUTE|||||314.75||| 9522954|ERX|0250|OLOPATADINE 0.1% EYE DROP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.81||| 9522954|ERX|0250|OLOPATADINE 0.1% EYE DROP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.81||||||| 9522954|ERX|0250|OLOPATADINE 0.1% EYE DROP|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.81||| 9522954|ERX|0250|OLOPATADINE 0.1% EYE DROP|Humana Medicare Advantage|HUMANA MA|9.81||||9.81||| 9522954|ERX|0250|OLOPATADINE 0.1% EYE DROP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.81||||||| 9522954|ERX|0250|OLOPATADINE 0.1% EYE DROP|Managed Medicare|HEALTHSPRING MA|9.81||||||| 9522954|ERX|0250|OLOPATADINE 0.1% EYE DROP|Medicare|MEDICARE ACUTE|9.81||||||| 9522962|ERX|0250|BRINZOLAMIDE 1% EYE DROP,|United Healthcare|UNITED HEALTHCARE OTHER|675.25||||675.25||| 9522962|ERX|0250|BRINZOLAMIDE 1% EYE DROP,|Medicare|MEDICARE ACUTE|675.25||||675.25||| 9522962|ERX|0250|BRINZOLAMIDE 1% EYE DROP,|Humana Medicare Advantage|HUMANA MA|675.25||||||| 9522962|ERX|0250|BRINZOLAMIDE 1% EYE DROP,|Access Direct Platinum|HEALTHFIRST TPA UMR|675.25||||||| 9522962|ERX|0250|BRINZOLAMIDE 1% EYE DROP,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|675.25||||||| 9522962|ERX|0250|BRINZOLAMIDE 1% EYE DROP,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||675.25||| 9522962|ERX|0250|BRINZOLAMIDE 1% EYE DROP,|Rusk State Hospital|RUSK STATE HOSP|675.25||||||| 9523002|ERX|0250|CYCLOPENTOLATE 1% EYE DRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||174.25||| 9523002|ERX|0250|CYCLOPENTOLATE 1% EYE DRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||174.25||| 9523002|ERX|0250|CYCLOPENTOLATE 1% EYE DRO|Humana Medicare Advantage|HUMANA MA|174.25||||||| 9523002|ERX|0250|CYCLOPENTOLATE 1% EYE DRO|Medicaid|MEDICAID HMO|||||174.25||| 9523002|ERX|0250|CYCLOPENTOLATE 1% EYE DRO|NON CONTRACTED|COMMERCIAL OTHER 1|||||174.25||| 9523002|ERX|0250|CYCLOPENTOLATE 1% EYE DRO|Tricare|TRICARE FOR LIFE|||||174.25||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|630.50||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Medicare|MEDICARE ACUTE|630.50||||630.50||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Humana Medicare Advantage|HUMANA MA|630.50||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|||||630.50||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Aenta Medicare Advantage|AETNA MEDICARE MA|630.50||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||630.50||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|630.50||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Veterans Affairs|VETERANS ADMINISTRATION|630.50||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Workers Compensation|WORKERS COMPENSATION OTHER|630.50||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Medicare|MEDICARE PART B ONLY IP|630.50||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|United Healthcare|GOLDEN RULE|630.50||||||| 9523051|ERX|0250|TOBRAMYCIN 0.3% EYE OINT,|Medicare|MEDICARE ACUTE|723.50||||||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Access Direct Platinum|HEALTHFIRST TPA|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Veterans Affairs|VETERANS ADMINISTRATION|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Workers Compensation|WORKERS COMPENSATION OTHER|421.50||||||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|421.50||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|United Medicare Advantage|UHC AARP MCR HMO MA|421.50||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Blue Cross PPO Specialty|BCBSTX PPO|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Blue Cross HMO Specialty|BCBSTX HMO|421.50||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Managed Medicaid|MEDICAID SUPERIOR|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Cigna|CIGNA|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Humana Medicare Advantage|HUMANA MA|421.50||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|NON CONTRACTED|COMMERCIAL OTHER 1|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|United Healthcare|GEHA|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|United Healthcare|UNITED HEALTHCARE|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|United Healthcare|TML GROUP BENEFITS|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Managed Medicare|HEALTHSPRING MA|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Managed Medicaid|MEDICAID AMERIGROUP|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Managed Medicare|BCBS MEDICARE PPO MA|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Medicaid|MEDICAID|||||421.50||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Medicare|MEDICARE ACUTE|421.50||||421.50||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Medicare|MEDICARE ACUTE|950.25||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Medicaid|MEDICAID HMO|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Managed Medicare|HEALTHSPRING MA|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|UTMB|UTMB CORRECTIONAL MANAGED CARE|950.25||||||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|United Healthcare|UNITED HEALTHCARE OTHER|950.25||||||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|United Healthcare|UNITED HEALTHCARE|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|United Healthcare|TML GROUP BENEFITS|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|United Healthcare|GEHA|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Tricare|TRICARE FOR LIFE|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|NON CONTRACTED|COMMERCIAL OTHER 1|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Managed Medicare|BCBS MEDICARE PPO MA|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Humana Medicare Advantage|HUMANA MA|950.25||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Cigna|CIGNA|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Managed Medicaid|MEDICAID SUPERIOR|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Medicaid|MEDICAID|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Managed Medicaid|MEDICAID AMERIGROUP|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Blue Cross PPO Specialty|BCBSTX PPO|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Blue Cross HMO Specialty|BCBSTX HMO|950.25||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|950.25||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|United Medicare Advantage|UHC AARP MCR HMO MA|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Veterans Affairs|VETERANS ADMINISTRATION|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Access Direct Platinum|HEALTHFIRST TPA|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||950.25||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|950.25||||||| 9523077|ERX|0250|TOBRAMYCIN/DEXAMETH EYE ,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|950.25||||950.25||| 9523085|ERX|0250|CIPROFLOXACIN 0.3% EYE ,3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|793.50||||||| 9523085|ERX|0250|CIPROFLOXACIN 0.3% EYE ,3|Blue Cross PPO Specialty|BCBSTX PPO|793.50||||||| 9523085|ERX|0250|CIPROFLOXACIN 0.3% EYE ,3|Humana Medicare Advantage|HUMANA MA|793.50||||||| 9523093|ERX|0250|ATOMOXETINE 40MG CAPSULE|Medicare|MEDICARE ACUTE|49.25||||||| 9523093|ERX|0250|ATOMOXETINE 40MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|49.25||||||| 9523093|ERX|0250|ATOMOXETINE 40MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|49.25||||||| 9523093|ERX|0250|ATOMOXETINE 40MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|49.25||||||| 9523093|ERX|0250|ATOMOXETINE 40MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|49.25||||||| 9523093|ERX|0250|ATOMOXETINE 40MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|49.25||||||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.78||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.78||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.78||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.78||||||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|||||0.78||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Humana Medicare Advantage|HUMANA MA|0.78||||||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Managed Medicaid|MEDICAID AMERIGROUP|||||0.78||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Medicare|MEDICARE ACUTE|0.78||||||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|NON CONTRACTED|COMMERCIAL OTHER 1|80.50||||||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|United Healthcare|UNITED HEALTHCARE|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Medicaid|MEDICAID|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Medicare|MEDICARE ACUTE|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Managed Medicaid|MEDICAID AMERIGROUP|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Managed Medicaid|MEDICAID SUPERIOR|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Humana Medicare Advantage|HUMANA MA|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Blue Cross PPO Specialty|BCBSTX PPO|80.50||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|80.50||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Access Direct Platinum|HEALTHFIRST TPA|||||80.50||| 9523143|ERX|0250|BALANCED SALT SOLN 15ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|80.50||||80.50||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|United Medicare Advantage|UHC MEDICARE GOLD MA|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|707.75||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Veterans Affairs|VETERANS ADMINISTRATION|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Access Direct Platinum|HEALTHFIRST TPA|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|United Medicare Advantage|UHC AARP MCR HMO MA|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Blue Cross PPO Specialty|BCBSTX PPO|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Blue Cross HMO Specialty|BCBSTX HMO|707.75||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Cigna|CIGNA|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Humana Medicare Advantage|HUMANA MA|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Medicare|MEDICARE ACUTE|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Managed Medicare|HEALTHSPRING MA|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Managed Medicare|BCBS MEDICARE PPO MA|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|United Healthcare|GEHA|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|United Healthcare|UNITED HEALTHCARE|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|United Healthcare|TML GROUP BENEFITS|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|NON CONTRACTED|COMMERCIAL OTHER 1|||||707.75||| 9523168|ERX|0250|BALANCED SALT SOLN COMB 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||707.75||| 9523184|ERX|0250|CIPROFLOX-DEXAMETH DROP,|Humana Medicare Advantage|HUMANA MA|7.05||||||| 9523184|ERX|0250|CIPROFLOX-DEXAMETH DROP,|NON CONTRACTED|COMMERCIAL OTHER 1|7.05||||7.05||| 9523184|ERX|0250|CIPROFLOX-DEXAMETH DROP,|Medicare|MEDICARE ACUTE|7.05||||||| 9523184|ERX|0250|CIPROFLOX-DEXAMETH DROP,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.05||| 9523184|ERX|0250|CIPROFLOX-DEXAMETH DROP,|Blue Cross PPO Specialty|BCBSTX PPO|||||7.05||| 9523184|ERX|0250|CIPROFLOX-DEXAMETH DROP,|Aetna|AETNA PPO|||||7.05||| 9523184|ERX|0250|CIPROFLOX-DEXAMETH DROP,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.05||||7.05||| 9523200|ERX|0250|MAG-AL HYDROX-SIMETH,148M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.50||||||| 9523200|ERX|0250|MAG-AL HYDROX-SIMETH,148M|Medicare|MEDICARE ACUTE|26.50||||||| 9523226|ERX|0250|TERBINAFINE 1% CREAM, 12|Medicaid|SMITH COUNTY JAIL|0.92||||||| 9523226|ERX|0250|TERBINAFINE 1% CREAM, 12|Blue Cross PPO Specialty|BCBSTX PPO|0.92||||||| 9523226|ERX|0250|TERBINAFINE 1% CREAM, 12|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.92||||||| 9523226|ERX|0250|TERBINAFINE 1% CREAM, 12|Medicare|MEDICARE ACUTE|0.92||||||| 9523226|ERX|0250|TERBINAFINE 1% CREAM, 12|Workers Compensation|TEXAS MUTUAL INSURANCE|0.92||||||| 9523226|ERX|0250|TERBINAFINE 1% CREAM, 12|United Medicare Advantage|UHC AARP MCR HMO MA|0.92||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Access Direct Platinum|HEALTHFIRST TPA|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Access Direct Platinum|HEALTHFIRST TPA UMR|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Workers Compensation|WORKERS COMPENSATION OTHER|||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Workers Compensation|BROOKSHIRES WORKERS COMP|||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Cigna|CIGNA OTHER|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Cigna|CIGNA|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Humana Medicare Advantage|HUMANA MA|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Aetna|AETNA PPO|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Aetna|AETNA OTHER|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicaid|MEDICAID SUPERIOR|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Aetna|BOON CHAPMAN|97.75||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|ChampVA|CHAMPVA CENTER|97.75||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|United Healthcare|UNITED HEALTHCARE|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|United Healthcare|UNITED HEALTHCARE OTHER|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Rusk State Hospital|RUSK STATE HOSP|97.75||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Tricare|TRICARE EAST REGION|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicare|HEALTHSPRING MA|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Medicaid|MEDICAID|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Medicaid|SMITH COUNTY INDIGENT HEALTH|97.75||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Medicaid|COUNTY INDIGENT HEALTH OTHER|97.75||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicare|ETMC AFFILIATE HOSPITALS|97.75||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Medicare|MEDICARE PART B ONLY IP|97.75||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicare|HOSPICE OF EAST TEXAS|97.75||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Medicare|MEDICARE ACUTE|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Multiplan|WEB TPA|97.75||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Texas Workforce Commission|DIS DETER SERV (DDS)|||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|PHCS|GROUP AND PENSION|97.75||||97.75||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|PHCS|HUMANA|||||97.75||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Medicaid|CRIME VICTIMS COMPENSATION|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Medicaid|MEDICAID|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Medicare|MEDICARE ACUTE|27.25||||27.25||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Managed Medicare|HEALTHSPRING MA|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|27.25||||27.25||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Aetna|AETNA OTHER|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.25||||27.25||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Managed Medicaid|MEDICAID SUPERIOR|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Magellan Behavioral Health|BH MAGELLAN|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Humana Medicare Advantage|HUMANA MA|27.25||||27.25||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|27.25||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|27.25||||27.25||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Access Direct Platinum|ANDREWS CENTER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Access Direct Platinum|HEALTHFIRST TPA UMR|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Access Direct Platinum|ANDREWS CENTER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Medicare Advantage|UHC AARP WELLMED HMO MA|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Workers Compensation|WORKERS COMPENSATION OTHER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Cigna|CIGNA OTHER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Cigna Behavioral Health|BH CIGNA|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Magellan Behavioral Health|BH MAGELLAN|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicaid|MEDICAID SUPERIOR|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Aetna|AETNA PPO|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|ChampVA|CHAMPVA CENTER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Healthcare|AARP|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Healthcare|UNITED HEALTHCARE OTHER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Humana Medicare Advantage|HUMANA MA|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Blue Cross PPO Specialty|BCBSTX OTHER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Healthcare|UNITED HEALTHCARE|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Healthcare|TML GROUP BENEFITS|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|PHCS|HUMANA|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Cigna|CIGNA|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Access Direct Platinum|HEALTHFIRST TPA|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Optum Behavioral Health|BH OPTUM UHC|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Aetna|AETNA OTHER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Tricare|TRICARE EAST REGION|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|NON CONTRACTED|COMMUNITY HEALTH CENTER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicare|HEALTHSPRING MA|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicare|BCBS MEDICARE PPO MA|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicare|MEDICARE PART B ONLY IP|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicare|MEDICARE ACUTE|27.25||||27.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicaid|MEDICAID|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicaid|SMITH COUNTY INDIGENT HEALTH|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicaid|COUNTY INDIGENT HEALTH OTHER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicaid|CRIME VICTIMS COMPENSATION|27.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicaid|BH TEXAS CHILDRENS MEDICAID|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|CRIME VICTIMS COMPENSATION|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|BH TEXAS CHILDRENS MEDICAID|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|MEDICAID|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|SMITH COUNTY JAIL|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicare|MEDICARE PART B ONLY IP|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicare|MEDICARE ACUTE|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicare|JACKSONVILLE ACCESS|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicare|BCBS MEDICARE PPO MA|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|NON CONTRACTED|COMMUNITY HEALTH CENTER|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|NON CONTRACTED|COMMERCIAL OTHER 2|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|PHCS|HUMANA|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Optum Behavioral Health|BH OPTUM UHC|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Tricare|TRICARE EAST REGION|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|UTMB|UTMB CORRECTIONAL MANAGED CARE|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Healthcare|UNITED HEALTHCARE OTHER|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Healthcare|UNITED HEALTHCARE|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Healthcare|TML GROUP BENEFITS|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Brinson Benefits|THE HEALTH PLAN SMITH CO|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Healthcare|UNITED HEALTHCARE|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Aetna|BOON CHAPMAN|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Aetna|BH AETNA|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Aetna|AETNA PPO|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Aetna|AETNA OTHER|||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Healthcare|GOLDEN RULE|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID SUPERIOR|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicare|HEALTHSPRING MA|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Magellan Behavioral Health|BH MAGELLAN|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Humana Medicare Advantage|HUMANA MA|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Cigna|CIGNA OTHER|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicare|WELLCARE CHOICE MA|||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|COUNTY INDIGENT HEALTH OTHER|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Cigna|CIGNA|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|MEDICAID HMO|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Cigna Behavioral Health|BH CIGNA|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Workers Compensation|WORKERS COMPENSATION OTHER|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Workers Compensation|TEXAS MUTUAL INSURANCE|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Access Direct Platinum|HEALTHFIRST TPA UMR|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Access Direct Platinum|HEALTHFIRST TPA|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Access Direct Platinum|ANDREWS CENTER|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|27.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Medicare Advantage|UHC AARP WELLMED HMO MA|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Medicare Advantage|UHC AARP MCR HMO MA|27.25||||27.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Workers Compensation|UT EMPLOYEE INJURY|27.25||||||| 9523309|ERX|0250|METHENAMINE HIPPURATE 1 G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9523309|ERX|0250|METHENAMINE HIPPURATE 1 G|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9523309|ERX|0250|METHENAMINE HIPPURATE 1 G|Aetna|AETNA OTHER|25.50||||||| 9523309|ERX|0250|METHENAMINE HIPPURATE 1 G|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9523309|ERX|0250|METHENAMINE HIPPURATE 1 G|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9523309|ERX|0250|METHENAMINE HIPPURATE 1 G|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9523309|ERX|0250|METHENAMINE HIPPURATE 1 G|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|United Healthcare|UNITED HEALTHCARE|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Managed Medicare|HEALTHSPRING MA|33.25||||33.25||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Medicare|MEDICARE ACUTE|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|ChampVA|CHAMPVA CENTER|||||33.25||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Aetna|AETNA QHP HMO|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Humana Medicare Advantage|HUMANA MA|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33.25||||||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|33.25||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Humana Medicare Advantage|HUMANA MA|1,024.50||||1,024.50||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Aetna|AETNA PPO|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Medicare|MEDICARE ACUTE|1,024.50||||1,024.50||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|United Healthcare|UNITED HEALTHCARE|||||1,024.50||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Medicaid|MEDICAID|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,024.50||||||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|1,024.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Medicare|MEDICARE ACUTE|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Cigna|CIGNA OTHER|||||25.50||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||25.50||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|Access Direct Platinum|ANDREWS CENTER|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9523341|ERX|0250|VARENICLINE 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Magellan Behavioral Health|BH MAGELLAN|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Cigna|CIGNA OTHER|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Cigna|CIGNA|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Cigna Behavioral Health|BH CIGNA|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Aetna|BH AETNA|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Aetna|AETNA PPO|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Aetna|AETNA OTHER|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|ChampVA|CHAMPVA CENTER|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Medicaid|MEDICAID|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Medicaid|MEDICAID HMO|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Cigna|CIGNA|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|United Healthcare|TML GROUP BENEFITS|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|PHCS|GROUP AND PENSION|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Optum Behavioral Health|BH OPTUM UHC|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Tricare|TRICARE EAST REGION|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|28.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|28.50||||28.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Multiplan|WEB TPA|28.50||||||| 9523366|ERX|0250|CETIRIZINE 5MG TABLET|Medicaid|MEDICAID|28.50||||||| 9523366|ERX|0250|CETIRIZINE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.50||||||| 9523366|ERX|0250|CETIRIZINE 5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|28.50||||||| 9523366|ERX|0250|CETIRIZINE 5MG TABLET|Access Direct Platinum|ANDREWS CENTER|28.50||||||| 9523366|ERX|0250|CETIRIZINE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.50||||||| 9523374|ERX|0250|DOXYCYCLINE 50MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9523374|ERX|0250|DOXYCYCLINE 50MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||||| 9523374|ERX|0250|DOXYCYCLINE 50MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9523374|ERX|0250|DOXYCYCLINE 50MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9523374|ERX|0250|DOXYCYCLINE 50MG CAPSULE|Aetna|AETNA PPO|||||25.50||| 9523374|ERX|0250|DOXYCYCLINE 50MG CAPSULE|Humana Medicare Advantage|HUMANA MA|||||25.50||| 9523374|ERX|0250|DOXYCYCLINE 50MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523374|ERX|0250|DOXYCYCLINE 50MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9523374|ERX|0250|DOXYCYCLINE 50MG CAPSULE|Medicaid|MEDICAID|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Tricare|TRICARE EAST REGION|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Cigna Behavioral Health|BH CIGNA|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Cigna|CIGNA|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Medicaid|MEDICAID|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Access Direct Platinum|ANDREWS CENTER|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Aetna|AETNA OTHER|||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Access Direct Platinum|ANDREWS CENTER|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Aetna|BH AETNA|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Aetna|AETNA PPO|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Aetna|AETNA OTHER|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Cigna|CIGNA|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Cigna|CIGNA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Cigna Behavioral Health|BH CIGNA|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Cigna|CIGNA OTHER|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid|SMITH COUNTY JAIL|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Aetna|AETNA QHP HMO|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid|MEDICAID|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicare|OTHER INSTITUTIONS|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Healthcare|TML GROUP BENEFITS|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Healthcare|GEHA|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Rusk State Hospital|RUSK STATE HOSP|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|PHCS|HUMANA INSURANCE|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|PHCS|GROUP AND PENSION|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|PHCS|HUMANA|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Healthcare|GOLDEN RULE|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Tricare|TRICARE EAST REGION|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|25.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|NON CONTRACTED|COMMERCIAL OTHER 1|17.50||||17.50||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||17.50||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Medicare|MEDICARE PART B ONLY IP|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Managed Medicaid|MEDICAID SUPERIOR|||||17.50||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Managed Medicaid|MEDICAID AMERIGROUP|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Cigna|CIGNA|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Humana Medicare Advantage|HUMANA MA|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Aenta Medicare Advantage|AETNA MEDICARE MA|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Blue Cross PPO Specialty|BCBSTX OTHER|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Veterans Affairs|VETERANS ADMINISTRATION|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Access Direct Platinum|HEALTHFIRST TPA|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.50||||||| 9523424|ERX|0250|CETIRIZINE-PSEUDOEPHED TA|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Aetna|AETNA OTHER|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Magellan Behavioral Health|BH MAGELLAN|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Humana Medicare Advantage|HUMANA MA|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Cigna|CIGNA OTHER|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Cigna|CIGNA|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Aetna|AETNA PPO|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|SMITH COUNTY JAIL|||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|MEDICAID HMO|||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|MEDICAID|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicare|MEDICARE PART B ONLY IP|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicare|MEDICARE ACUTE|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicare|HEALTHSPRING MA|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Healthcare|GEHA|||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Tricare|TRICARE FOR LIFE|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|PHCS|HUMANA|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Multiplan|WEB TPA|||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Tricare|TRICARE EAST REGION|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Healthcare|UNITED HEALTHCARE|109.25||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Healthcare|UNITED HEALTHCARE|109.25||||109.25||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|109.25||||109.25||| 9523440|ERX|0250|AZITHROMYCIN 600MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|261.50||||||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Tricare|TRICARE EAST REGION|461.25||||||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|United Healthcare|UNITED HEALTHCARE OTHER|461.25||||461.25||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Medicare|MEDICARE ACUTE|461.25||||||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Medicaid|MEDICAID|461.25||||461.25||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Medicaid|MEDICAID HMO|461.25||||||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Blue Cross PPO Specialty|BCBSTX PPO|||||461.25||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Humana Medicare Advantage|HUMANA MA|461.25||||||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|461.25||||||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Managed Medicaid|MEDICAID SUPERIOR|461.25||||461.25||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Managed Medicaid|MEDICAID AMERIGROUP|461.25||||461.25||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Workers Compensation|UT EMPLOYEE INJURY|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Cigna|CIGNA OTHER|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Aetna|AETNA QHP HMO|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Aetna|AETNA PPO|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Aetna|AETNA OTHER|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Cigna|CIGNA|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Humana Medicare Advantage|HUMANA MA|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Managed Medicare|HEALTHSPRING MA|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Medicare|MEDICARE ACUTE|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|United Healthcare|GEHA|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|367.75||||367.75||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|United Healthcare|UNITED HEALTHCARE|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|United Healthcare|TML GROUP BENEFITS|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Medicare|MEDICARE PART B ONLY IP|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Rusk State Hospital|RUSK STATE HOSP|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|PHCS|HUMANA|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Tricare|TRICARE EAST REGION|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Medicaid|MEDICAID|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Medicaid|SMITH COUNTY JAIL|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Medicaid|LAW ENFORCEMENT OTHER|367.75||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|367.75||||367.75||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|147.50||||||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||147.50||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|Medicare|MEDICARE ACUTE|147.50||||147.50||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|147.50||||||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|147.50||||||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|Humana Medicare Advantage|HUMANA MA|147.50||||147.50||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|147.50||||||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|147.50||||||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|147.50||||||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|147.50||||||| 9523499|ERX|0250|SILDENAFIL 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|147.50||||||| 9523515|ERX|0250|PHENYTOIN CHEWABLE 50MG T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.25||| 9523515|ERX|0250|PHENYTOIN CHEWABLE 50MG T|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9523515|ERX|0250|PHENYTOIN CHEWABLE 50MG T|Medicare|MEDICARE PART B ONLY IP|9.25||||||| 9523515|ERX|0250|PHENYTOIN CHEWABLE 50MG T|Medicare|MEDICARE ACUTE|9.25||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Cigna|CIGNA OTHER|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Cigna|CIGNA|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Cigna Behavioral Health|BH CIGNA|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Aetna|AETNA OTHER|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Access Direct Platinum|ANDREWS CENTER|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Healthcare|UNITED HEALTHCARE|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Healthcare|TML GROUP BENEFITS|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Healthcare|UNITED HEALTHCARE|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Tricare|TRICARE EAST REGION|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Rusk State Hospital|RUSK STATE HOSP|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|PHCS|GROUP AND PENSION|||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|PHCS|HUMANA|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicare|HEALTHSPRING MA|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Medicaid|MEDICAID|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Medicaid|SMITH COUNTY JAIL|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Medicare|MEDICARE ACUTE|32.75||||32.75||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Aetna|BOON CHAPMAN|32.75||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Aetna|AETNA PPO|32.75||||32.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Humana Medicare Advantage|HUMANA MA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Cigna|CIGNA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Cigna|CIGNA|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|ChampVA|CHAMPVA CENTER|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Aetna|AETNA PPO|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Aetna|AETNA OTHER|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Cigna|CIGNA OTHER|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicare|MEDICARE ACUTE|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicaid|MEDICAID|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Workers Compensation|BROOKSHIRES WORKERS COMP|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicare|HEALTHSPRING MA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Rusk State Hospital|RUSK STATE HOSP|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|PHCS|HUMANA INSURANCE|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|PHCS|HUMANA|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|PHCS|GROUP AND PENSION|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Tricare|TRICARE EAST REGION|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.75||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|46.75||||46.75||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Healthcare|UNITED HEALTHCARE|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Healthcare|TML GROUP BENEFITS|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Healthcare|UNITED HEALTHCARE|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Healthcare|GEHA|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Rusk State Hospital|RUSK STATE HOSP|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|PHCS|HUMANA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Optum Behavioral Health|BH OPTUM UHC|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Tricare|TRICARE FOR LIFE|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Tricare|TRICARE EAST REGION|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicare|HEALTHSPRING MA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicaid|LAW ENFORCEMENT OTHER|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicaid|SMITH COUNTY JAIL|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicare|MEDICARE ACUTE|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Aetna|BH AETNA|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Aetna|AETNA QHP HMO|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Aetna|AETNA PPO|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Aetna|AETNA OTHER|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicare|MEDICARE PART B ONLY IP|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicaid|MEDICAID|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|ChampVA|CHAMPVA CENTER|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicare|ETMC AFFILIATE HOSPITALS|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|PHCS|GROUP AND PENSION|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Cigna|CIGNA OTHER|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Cigna|CIGNA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Cigna|CIGNA|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Humana Medicare Advantage|HUMANA MA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Magellan Behavioral Health|BH MAGELLAN|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Healthcare|UNITED HEALTHCARE|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|46.75||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|46.75||||46.75||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|46.75||||46.75||| 9523580|ERX|0250|PHENYTOIN 30MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.07||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Medicaid|LAW ENFORCEMENT OTHER|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Managed Medicare|MA PART B ONLY IP|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|7.75||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.75||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE ERS|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Medicaid|MEDICAID|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||7.75||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Cigna|CIGNA|7.75||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9523606|ERX|0250|VALGANCICLOVIR 450MG TABL|Humana Medicare Advantage|HUMANA MA|4.40||||4.40||| 9523606|ERX|0250|VALGANCICLOVIR 450MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.40||||||| 9523606|ERX|0250|VALGANCICLOVIR 450MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.40||||||| 9523606|ERX|0250|VALGANCICLOVIR 450MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|4.40||||||| 9523606|ERX|0250|VALGANCICLOVIR 450MG TABL|Medicaid|MEDICAID|4.40||||||| 9523606|ERX|0250|VALGANCICLOVIR 450MG TABL|Medicare|MEDICARE PART B ONLY IP|4.40||||||| 9523606|ERX|0250|VALGANCICLOVIR 450MG TABL|Medicare|MEDICARE ACUTE|4.40||||4.40||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|NON CONTRACTED|COMMUNITY HEALTH CENTER|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 2|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Tricare|TRICARE EAST REGION|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|PHCS|HUMANA|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Texas Workforce Commission|DIS DETER SERV (DDS)|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicaid|MEDICAID|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicaid|MEDICAID HMO|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicaid|SMITH COUNTY JAIL|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicaid|CRIME VICTIMS COMPENSATION|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicaid|SMITH COUNTY INDIGENT HEALTH|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Workers Compensation|TEXAS MUTUAL INSURANCE|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Aetna|AETNA PPO|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|PHCS|GROUP AND PENSION|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Cigna|CIGNA|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Cigna|CIGNA OTHER|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Cigna Behavioral Health|BH CIGNA|13.50||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|13.50||||13.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|13.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Cigna|CIGNA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Cigna|CIGNA OTHER|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Cigna Behavioral Health|BH CIGNA|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Brinson Benefits|THE HEALTH PLAN SMITH CO|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|ChampVA|CHAMPVA CENTER|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Aetna|BH AETNA|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Aetna|AETNA QHP HMO|||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Aetna|AETNA OTHER|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Aetna|AETNA PPO|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Workers Compensation|BROOKSHIRES WORKERS COMP|||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicaid|BH TEXAS CHILDRENS MEDICAID|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicaid|SMITH COUNTY INDIGENT HEALTH|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicaid|SMITH COUNTY JAIL|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicaid|MEDICAID HMO|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicaid|CRIME VICTIMS COMPENSATION|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicaid|MEDICAID|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicare|OTHER INSTITUTIONS|||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Healthcare|TML GROUP BENEFITS|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Healthcare|GEHA|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|PHCS|GROUP AND PENSION|||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|PHCS|HUMANA INSURANCE|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|PHCS|HUMANA|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Texas Workforce Commission|DIS DETER SERV (DDS)|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Tricare|TRICARE FOR LIFE|||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Tricare|TRICARE EAST REGION|25.50||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Multiplan|WEB TPA|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|NON CONTRACTED|COMMUNITY HEALTH CENTER|25.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 2|||||25.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|NON CONTRACTED|COMMUNITY HEALTH CENTER|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|United Healthcare|AARP|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|United Healthcare|GEHA|||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Medicaid|MEDICAID|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Aetna|AETNA OTHER|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Aetna|BH AETNA|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 2|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||25.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Cigna|CIGNA OTHER|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Cigna|CIGNA|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Brinson Benefits|THE HEALTH PLAN SMITH CO|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Aetna|AETNA OTHER|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Medicaid|SMITH COUNTY JAIL|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Medicaid|MEDICAID|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Medicaid|CRIME VICTIMS COMPENSATION|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||25.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Tricare|TRICARE EAST REGION|25.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Aetna|AETNA QHP HMO|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9523671|ERX|0250|PREGABALIN 100MG CAPSULE|Cigna|CIGNA|25.50||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Cigna Behavioral Health|BH CIGNA|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Medicaid|MEDICAID|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Medicare|MEDICARE ACUTE|0.21||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicare|HEALTHSPRING MA|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.21||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Tricare|TRICARE EAST REGION|||||0.21||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.21||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Multiplan|WEB TPA|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|PHCS|GROUP AND PENSION|||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Tricare|TRICARE EAST REGION|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|93.25||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|United Healthcare|UNITED HEALTHCARE|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|United Healthcare|UNITED HEALTHCARE|||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Medicare|MEDICARE ACUTE|93.25||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Medicaid|MEDICAID HMO|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Medicaid|MEDICAID|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|93.25||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Medicaid|BH TEXAS CHILDRENS MEDICAID|93.25||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Access Direct Platinum|HEALTHFIRST TPA|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|93.25||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|93.25||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Aetna|AETNA PPO|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Managed Medicare|HEALTHSPRING MA|93.25||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Aetna|AETNA OTHER|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|ChampVA|CHAMPVA CENTER|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|93.25||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|93.25||||93.25||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Humana Medicare Advantage|HUMANA MA|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Cigna|CIGNA OTHER|93.25||||||| 9523697|ERX|0250|GABAPENTIN 250MG/5ML|Cigna|CIGNA|93.25||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Cigna|CIGNA|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Cigna|CIGNA|||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Cigna Behavioral Health|BH CIGNA|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Magellan Behavioral Health|BH MAGELLAN|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Aetna|BH AETNA|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Access Direct Platinum|ANDREWS CENTER|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Medicaid|MEDICAID|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Medicare|MEDICARE ACUTE|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicare|HEALTHSPRING MA|18.75||||18.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|United Healthcare|UNITED HEALTHCARE|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Rusk State Hospital|RUSK STATE HOSP|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Optum Behavioral Health|BH OPTUM UHC|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Tricare|TRICARE EAST REGION|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Multiplan|WEB TPA|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|18.75||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||18.75||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Rusk State Hospital|RUSK STATE HOSP|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|United Healthcare|UNITED HEALTHCARE|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Managed Medicare|HEALTHSPRING MA|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Medicare|MEDICARE ACUTE|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Medicaid|MEDICAID|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Medicaid|SMITH COUNTY JAIL|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.92||| 9523762|ERX|0250|VALPROATE 500MG 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.92||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|United Medicare Advantage|UHC AARP MCR HMO MA|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.92||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Blue Cross PPO Specialty|BCBSTX PPO|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Managed Medicaid|MEDICAID AMERIGROUP|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Managed Medicaid|MEDICAID SUPERIOR|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.92||||1.92||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Humana Medicare Advantage|HUMANA MA|1.92||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Cigna|CIGNA|1.92||||||| 9523788|ERX|0250|HYDROCOD-IBUPR 7.5-200MG|Humana Medicare Advantage|HUMANA MA|28.75||||||| 9523788|ERX|0250|HYDROCOD-IBUPR 7.5-200MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.75||||||| 9523788|ERX|0250|HYDROCOD-IBUPR 7.5-200MG|Blue Cross PPO Specialty|BCBSTX PPO|28.75||||28.75||| 9523788|ERX|0250|HYDROCOD-IBUPR 7.5-200MG|Medicare|MEDICARE ACUTE|28.75||||28.75||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Managed Medicare|HOSPICE OF EAST TEXAS|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|ChampVA|CHAMPVA CENTER|||||0.13||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9523812|ERX|0250|CLONAZEPAM 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9523812|ERX|0250|CLONAZEPAM 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9523812|ERX|0250|CLONAZEPAM 2MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Medicare|MEDICARE ACUTE|0.16||||0.16||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Managed Medicare|HEALTHSPRING MA|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||0.16||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Medicaid|MEDICAID|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.16||||0.16||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.16||||0.16||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.16||||0.16||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Cigna|CIGNA|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Humana Medicare Advantage|HUMANA MA|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.16||||0.16||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.16||||||| 9523820|ERX|0250|HYDROMORPHONE 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.39||||0.39||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Cigna|CIGNA OTHER|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Aetna|AETNA PPO|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.39||||0.39||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.39||||0.39||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|0.39||||0.39||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|United Healthcare|UNITED HEALTHCARE|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.39||||0.39||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|0.39||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Medicare|MEDICARE ACUTE|0.39||||0.39||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Managed Medicare|HEALTHSPRING MA|11.75||||11.75||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Medicaid|MEDICAID|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||11.75||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.75||||||| 9523903|ERX|0250|BUMETANIDE 0.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.75||||||| 9523929|ERX|0250|CLARITHROMYCIN 250MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|60.25||||||| 9523929|ERX|0250|CLARITHROMYCIN 250MG TABL|Humana Medicare Advantage|HUMANA MA|60.25||||60.25||| 9523929|ERX|0250|CLARITHROMYCIN 250MG TABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|60.25||||||| 9523929|ERX|0250|CLARITHROMYCIN 250MG TABL|United Medicare Advantage|UHC AARP MCR HMO MA|60.25||||||| 9523929|ERX|0250|CLARITHROMYCIN 250MG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|60.25||||||| 9523929|ERX|0250|CLARITHROMYCIN 250MG TABL|Medicare|MEDICARE ACUTE|60.25||||||| 9523937|ERX|0250|ESTAZOLAM 1MG TABLET|Optum Behavioral Health|BH OPTUM UHC|20.75||||||| 9523937|ERX|0250|ESTAZOLAM 1MG TABLET|Medicaid|MEDICAID|20.75||||||| 9523937|ERX|0250|ESTAZOLAM 1MG TABLET|Medicare|MEDICARE ACUTE|20.75||||||| 9523945|ERX|0250|ESTAZOLAM 2MG TABLET|Access Direct Platinum|ANDREWS CENTER|22.50||||||| 9523945|ERX|0250|ESTAZOLAM 2MG TABLET|Medicare|MEDICARE ACUTE|22.50||||||| 9523945|ERX|0250|ESTAZOLAM 2MG TABLET|Medicaid|MEDICAID|22.50||||||| 9523945|ERX|0250|ESTAZOLAM 2MG TABLET|Optum Behavioral Health|BH OPTUM UHC|22.50||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Tricare|TRICARE EAST REGION|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Managed Medicare|HEALTHSPRING MA|61.25||||61.25||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Medicaid|MEDICAID|||||61.25||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Medicaid|LAW ENFORCEMENT OTHER|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Medicaid|MOLINA HEALTHCARE OF TEXAS|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Aetna|BH AETNA|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Aetna|AETNA PPO|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Aetna|AETNA OTHER|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|61.25||||61.25||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Medicare|MEDICARE ACUTE|61.25||||61.25||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|United Healthcare|UNITED HEALTHCARE|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Cigna|CIGNA|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Humana Medicare Advantage|HUMANA MA|61.25||||61.25||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|61.25||||61.25||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|61.25||||61.25||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||61.25||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||61.25||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|61.25||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Workers Compensation|UT EMPLOYEE INJURY|61.25||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|NON CONTRACTED|COMMUNITY HEALTH CENTER|25.50||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||25.50||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||25.50||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||25.50||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9523994|ERX|0250|TERAZOSIN 2MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||25.50||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Medicare|MEDICARE ACUTE|0.22||||0.22||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.22||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|0.22||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.22||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.22||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|0.22||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Humana Medicare Advantage|HUMANA MA|0.22||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.22||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|0.22||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.22||| 9524034|ERX|0250|PARICALCITOL 1MCG CAPSULE|Medicare|MEDICARE ACUTE|86.25||||||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|United Medicare Advantage|UHC MEDICARE GOLD MA|2.46||||||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.46||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|Humana Medicare Advantage|HUMANA MA|2.46||||||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.46||||2.46||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|Managed Medicaid|MEDICAID SUPERIOR|||||2.46||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.46||||||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.46||||||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|Blue Cross PPO Specialty|BCBSTX PPO|2.46||||2.46||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|United Healthcare|UNITED HEALTHCARE OTHER|2.46||||2.46||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|Managed Medicare|HEALTHSPRING MA|2.46||||||| 9524042|ERX|0250|CISATRACURIUM 2MG/ML, 10M|Medicare|MEDICARE ACUTE|2.46||||2.46||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Medicare|MEDICARE ACUTE|3.14||||3.14||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Managed Medicare|HEALTHSPRING MA|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Tricare|TRICARE EAST REGION|||||3.14||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|United Healthcare|UNITED HEALTHCARE|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|United Healthcare|UNITED HEALTHCARE|||||3.14||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|United Healthcare|TML GROUP BENEFITS|||||3.14||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.14||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.14||||3.14||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Cigna|CIGNA|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Humana Medicare Advantage|HUMANA MA|3.14||||3.14||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|3.14||||||| 9524059|ERX|0250|REMIFENTANIL 2MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.14||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|28.50||||||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.50||||||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|28.50||||||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.50||||||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|Aetna|AETNA OTHER|28.50||||||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|28.50||||||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||28.50||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|28.50||||||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|Managed Medicare|HEALTHSPRING MA|28.50||||||| 9524075|ERX|0250|VALPROIC 250MG CAPSULE|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.25||||||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|Medicare|MEDICARE ACUTE|15.25||||||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.25||||||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|Humana Medicare Advantage|HUMANA MA|15.25||||15.25||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.25||||15.25||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|United Medicare Advantage|UHC MEDICARE GOLD MA|15.25||||15.25||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.25||||||| 9524109|ERX|0250|DIVALPROEX 125MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9524109|ERX|0250|DIVALPROEX 125MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||||| 9524109|ERX|0250|DIVALPROEX 125MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9524109|ERX|0250|DIVALPROEX 125MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9524109|ERX|0250|DIVALPROEX 125MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||||| 9524109|ERX|0250|DIVALPROEX 125MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9524109|ERX|0250|DIVALPROEX 125MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|15.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||25.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Aetna|BH AETNA|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||25.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Access Direct Platinum|ANDREWS CENTER|25.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Access Direct Platinum|ANDREWS CENTER|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.25||||38.25||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Cigna Behavioral Health|BH CIGNA|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Humana Medicare Advantage|HUMANA MA|38.25||||38.25||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Magellan Behavioral Health|BH MAGELLAN|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||38.25||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.25||||38.25||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.25||||38.25||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.25||||38.25||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Aetna|BH AETNA|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|38.25||||38.25||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Rusk State Hospital|RUSK STATE HOSP|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Tricare|TRICARE EAST REGION|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Medicare|MEDICARE PART B ONLY IP|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Medicare|MEDICARE ACUTE|38.25||||38.25||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Medicaid|MEDICAID|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Medicaid|CRIME VICTIMS COMPENSATION|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|38.25||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicare|HEALTHSPRING MA|38.25||||38.25||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|38.25||||||| 9524133|ERX|0250|ERYTHROMYCIN BASE 500MG T|Managed Medicare|HEALTHSPRING MA|41.50||||||| 9524133|ERX|0250|ERYTHROMYCIN BASE 500MG T|Managed Medicare|BCBS MEDICARE PPO MA|41.50||||||| 9524133|ERX|0250|ERYTHROMYCIN BASE 500MG T|Medicare|MEDICARE ACUTE|41.50||||||| 9524133|ERX|0250|ERYTHROMYCIN BASE 500MG T|Blue Cross PPO Specialty|BCBSTX PPO|41.50||||||| 9524133|ERX|0250|ERYTHROMYCIN BASE 500MG T|Blue Cross HMO Specialty|BCBSTX HMO|41.50||||||| 9524133|ERX|0250|ERYTHROMYCIN BASE 500MG T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41.50||||||| 9524133|ERX|0250|ERYTHROMYCIN BASE 500MG T|Humana Medicare Advantage|HUMANA MA|41.50||||||| 9524133|ERX|0250|ERYTHROMYCIN BASE 500MG T|United Medicare Advantage|UHC MEDICARE GOLD MA|41.50||||||| 9524133|ERX|0250|ERYTHROMYCIN BASE 500MG T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|41.50||||||| 9524158|ERX|0250|ERYTHRO.ES 400MG/5ML,100M|United Healthcare|UNITED HEALTHCARE OTHER|1,928.50||||||| 9524158|ERX|0250|ERYTHRO.ES 400MG/5ML,100M|United Healthcare|UNITED HEALTHCARE|1,928.50||||||| 9524158|ERX|0250|ERYTHRO.ES 400MG/5ML,100M|Medicare|MEDICARE ACUTE|1,928.50||||1,928.50||| 9524166|ERX|0250|ERYTHROMYCIN BASE 250MG T|Workers Compensation|TEXAS MUTUAL INSURANCE|0.26||||||| 9524166|ERX|0250|ERYTHROMYCIN BASE 250MG T|United Medicare Advantage|UHC MEDICARE GOLD MA|0.26||||||| 9524166|ERX|0250|ERYTHROMYCIN BASE 250MG T|Managed Medicaid|MEDICAID SUPERIOR|||||0.26||| 9524166|ERX|0250|ERYTHROMYCIN BASE 250MG T|Humana Medicare Advantage|HUMANA MA|0.26||||||| 9524166|ERX|0250|ERYTHROMYCIN BASE 250MG T|Blue Cross PPO Specialty|BCBSTX PPO|0.26||||0.26||| 9524166|ERX|0250|ERYTHROMYCIN BASE 250MG T|Managed Medicare|HEALTHSPRING MA|0.26||||||| 9524166|ERX|0250|ERYTHROMYCIN BASE 250MG T|Medicaid|MEDICAID|0.26||||||| 9524166|ERX|0250|ERYTHROMYCIN BASE 250MG T|Medicare|MEDICARE ACUTE|0.26||||0.26||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Rusk State Hospital|RUSK STATE HOSP|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Medicare|MEDICARE ACUTE|31.25||||31.25||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Medicaid|SMITH COUNTY INDIGENT HEALTH|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Medicaid|MEDICAID|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Managed Medicare|HEALTHSPRING MA|31.25||||31.25||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Aetna|BH AETNA|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||31.25||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|31.25||||31.25||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Humana Medicare Advantage|HUMANA MA|31.25||||31.25||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Magellan Behavioral Health|BH MAGELLAN|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|31.25||||31.25||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Tricare|TRICARE EAST REGION|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31.25||||31.25||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|31.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.25||||31.25||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|31.25||||||| 9524232|ERX|0250|DESMOPRESSIN 0.1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|40.75||||||| 9524232|ERX|0250|DESMOPRESSIN 0.1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|40.75||||||| 9524232|ERX|0250|DESMOPRESSIN 0.1MG TABLET|Medicare|MEDICARE ACUTE|40.75||||||| 9524232|ERX|0250|DESMOPRESSIN 0.1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|40.75||||||| 9524232|ERX|0250|DESMOPRESSIN 0.1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|40.75||||||| 9524240|ERX|0250|DESMOPRESSIN 0.2MG TABLET|Rusk State Hospital|RUSK STATE HOSP|58.75||||||| 9524240|ERX|0250|DESMOPRESSIN 0.2MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|58.75||||||| 9524240|ERX|0250|DESMOPRESSIN 0.2MG TABLET|Medicare|MEDICARE ACUTE|58.75||||58.75||| 9524240|ERX|0250|DESMOPRESSIN 0.2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|58.75||||||| 9524240|ERX|0250|DESMOPRESSIN 0.2MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|58.75||||||| 9524240|ERX|0250|DESMOPRESSIN 0.2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|58.75||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Workers Compensation|UT EMPLOYEE INJURY|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Workers Compensation|WORKERS COMPENSATION OTHER|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Workers Compensation|BROOKSHIRES WORKERS COMP|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Veterans Affairs|VETERANS ADMINISTRATION|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Access Direct Platinum|HEALTHFIRST TPA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Access Direct Platinum|HEALTHFIRST TPA UMR|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Medicare Advantage|UHC AARP MCR HMO MA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Cigna|CIGNA OTHER|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Cigna|CIGNA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Humana Medicare Advantage|HUMANA MA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID AMERIGROUP|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID SUPERIOR|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Aetna|BOON CHAPMAN|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Aetna|AETNA PPO|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Aetna|AETNA OTHER|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Aetna|AETNA QHP HMO|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|ChampVA|CHAMPVA CENTER|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross PPO Specialty|BCBSTX PPO|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross PPO Specialty|BCBSTX OTHER|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross HMO Specialty|BCBSTX HMO|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|OTHER INSTITUTIONS|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|HEALTHSPRING MA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|BCBS MEDICARE PPO MA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicare|MEDICARE PART B ONLY IP|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicare|MEDICARE ACUTE|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|MEDICAID|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|LAW ENFORCEMENT OTHER|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Cigna|CIGNA|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|CRIME VICTIMS COMPENSATION|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|SMITH COUNTY JAIL|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|MEDICAID HMO|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Healthcare|GEHA|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Healthcare|UNITED HEALTHCARE|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Healthcare|UNITED HEALTHCARE OTHER|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Healthcare|TML GROUP BENEFITS|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Healthcare|GOLDEN RULE|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Healthcare|AARP|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Multiplan|WEB TPA|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Multiplan|TRUSTMARK|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|NON CONTRACTED|COMMERCIAL OTHER 1|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Tricare|TRICARE FOR LIFE|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Rusk State Hospital|RUSK STATE HOSP|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|PHCS|HUMANA INSURANCE|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|PHCS|GROUP AND PENSION|350.50||||350.50||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|PHCS|HUMANA|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Texas Workforce Commission|DIS DETER SERV (DDS)|350.50||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Tricare|TRICARE EAST REGION|350.50||||350.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Rusk State Hospital|RUSK STATE HOSP|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|NON CONTRACTED|COMMERCIAL OTHER 1|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Medicaid|MEDICAID|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Medicare|MEDICARE PART B ONLY IP|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Medicare|MEDICARE ACUTE|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Managed Medicare|HEALTHSPRING MA|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Managed Medicare|BCBS MEDICARE PPO MA|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Blue Cross PPO Specialty|BCBSTX PPO|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Blue Cross HMO Specialty|BCBSTX HMO|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Medicaid|SMITH COUNTY JAIL|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Aetna|AETNA PPO|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Aenta Medicare Advantage|AETNA MEDICARE MA|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|PHCS|GROUP AND PENSION|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Managed Medicaid|MEDICAID SUPERIOR|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Humana Medicare Advantage|HUMANA MA|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|United Medicare Advantage|UHC MEDICARE GOLD MA|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|United Medicare Advantage|UHC AARP MCR HMO MA|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|513.50||||513.50||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Access Direct Platinum|HEALTHFIRST TPA|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Access Direct Platinum|HEALTHFIRST TPA UMR|513.50||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Veterans Affairs|VETERANS ADMINISTRATION|513.50||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Veterans Affairs|VETERANS ADMINISTRATION|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Access Direct Platinum|HEALTHFIRST TPA|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Access Direct Platinum|HEALTHFIRST TPA UMR|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Medicare Advantage|UHC AARP MCR HMO MA|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Cigna|CIGNA|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Humana Medicare Advantage|HUMANA MA|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicaid|MEDICAID SUPERIOR|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Aenta Medicare Advantage|AETNA MEDICARE MA|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Blue Cross PPO Specialty|BCBSTX PPO|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Blue Cross PPO Specialty|BCBSTX OTHER|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Blue Cross HMO Specialty|BCBSTX HMO|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Cigna|CIGNA OTHER|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Medicare Advantage|UHC MEDICARE GOLD MA|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicare|WELLCARE CHOICE MA|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicare|HEALTHSPRING MA|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicare|BCBS MEDICARE PPO MA|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Medicare|MEDICARE PART B ONLY IP|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Medicare|MEDICARE ACUTE|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Medicaid|MEDICAID|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Workers Compensation|TEXAS MUTUAL INSURANCE|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Healthcare|UNITED HEALTHCARE OTHER|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Healthcare|UNITED HEALTHCARE|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Healthcare|TML GROUP BENEFITS|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|NON CONTRACTED|COMMERCIAL OTHER 2|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|NON CONTRACTED|COMMERCIAL OTHER 1|6.31||||6.31||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Rusk State Hospital|RUSK STATE HOSP|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|PHCS|HUMANA INSURANCE|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|PHCS|HUMANA|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|PHCS|GROUP AND PENSION|6.31||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Tricare|TRICARE EAST REGION|6.31||||6.31||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Rusk State Hospital|RUSK STATE HOSP|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|PHCS|GROUP AND PENSION|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Tricare|TRICARE EAST REGION|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Healthcare|UNITED HEALTHCARE|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Medicaid|MEDICAID|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Medicare|MEDICARE PART B ONLY IP|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Medicare|MEDICARE ACUTE|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicare|HEALTHSPRING MA|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Aetna|AETNA OTHER|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Aetna|AETNA PPO|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Humana Medicare Advantage|HUMANA MA|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|PHCS|HUMANA|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Cigna|CIGNA OTHER|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Cigna|CIGNA|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.89||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.89||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|7.89||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|7.89||||7.89||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Workers Compensation|TEXAS MUTUAL INSURANCE|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Veterans Affairs|VETERANS ADMINISTRATION|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Access Direct Platinum|HEALTHFIRST TPA UMR|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Medicare Advantage|UHC MEDICARE GOLD MA|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Medicare Advantage|UHC AARP MCR HMO MA|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Cigna|CIGNA OTHER|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Cigna|CIGNA|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicaid|MEDICAID SUPERIOR|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicaid|MEDICAID AMERIGROUP|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Aenta Medicare Advantage|AETNA MEDICARE MA|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Aetna|AETNA PPO|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Aetna|AETNA OTHER|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Blue Cross HMO Specialty|BCBSTX HMO|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Blue Cross PPO Specialty|BCBSTX OTHER|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Blue Cross PPO Specialty|BCBSTX PPO|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicare|HEALTHSPRING MA|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicare|BCBS MEDICARE PPO MA|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicare|MEDICARE PART B ONLY IP|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicare|MEDICARE ACUTE|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Humana Medicare Advantage|HUMANA MA|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|SMITH COUNTY JAIL|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|MEDICAID|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|LAW ENFORCEMENT OTHER|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|MEDICAID HMO|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Workers Compensation|BROOKSHIRES WORKERS COMP|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|CRIME VICTIMS COMPENSATION|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|MEDICAID BCBSTX|||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Healthcare|TML GROUP BENEFITS|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Workers Compensation|WORKERS COMPENSATION OTHER|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Healthcare|UNITED HEALTHCARE OTHER|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Healthcare|UNITED HEALTHCARE|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Healthcare|UNITED HEALTHCARE|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Multiplan|WEB TPA|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|NON CONTRACTED|COMMERCIAL OTHER 2|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|NON CONTRACTED|COMMERCIAL OTHER 1|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Rusk State Hospital|RUSK STATE HOSP|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|PHCS|HUMANA|262.75||||262.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|PHCS|GROUP AND PENSION|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|PHCS|HUMANA INSURANCE|262.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Tricare|TRICARE EAST REGION|262.75||||||| 9524315|ERX|0250|DESMOPRESSIN 0.01% NASAL,|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,306.25||||||| 9524315|ERX|0250|DESMOPRESSIN 0.01% NASAL,|United Healthcare|UNITED HEALTHCARE|2,306.25||||||| 9524315|ERX|0250|DESMOPRESSIN 0.01% NASAL,|Blue Cross PPO Specialty|BCBSTX PPO|2,306.25||||||| 9524315|ERX|0250|DESMOPRESSIN 0.01% NASAL,|Managed Medicaid|MEDICAID SUPERIOR|2,306.25||||||| 9524315|ERX|0250|DESMOPRESSIN 0.01% NASAL,|United Medicare Advantage|UHC MEDICARE GOLD MA|2,306.25||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Access Direct Platinum|HEALTHFIRST TPA|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Veterans Affairs|VETERANS ADMINISTRATION|8.42||||8.42||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Medicare Advantage|UHC MEDICARE GOLD MA|8.42||||8.42||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.42||||8.42||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Medicare Advantage|UHC AARP MCR HMO MA|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Humana Medicare Advantage|HUMANA MA|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Cigna|CIGNA|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.42||||8.42||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicaid|MEDICAID AMERIGROUP|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.42||||8.42||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicaid|MEDICAID SUPERIOR|||||8.42||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Aenta Medicare Advantage|AETNA MEDICARE MA|8.42||||8.42||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Aetna|AETNA PPO|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.42||||8.42||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Workers Compensation|WORKERS COMPENSATION OTHER|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Blue Cross PPO Specialty|BCBSTX PPO|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Blue Cross PPO Specialty|BCBSTX OTHER|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Blue Cross HMO Specialty|BCBSTX HMO|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Medicaid|MEDICAID|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Medicare|MEDICARE ACUTE|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicare|HEALTHSPRING MA|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||8.42||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|NON CONTRACTED|COMMERCIAL OTHER 1|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Healthcare|TML GROUP BENEFITS|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Healthcare|UNITED HEALTHCARE OTHER|8.42||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Healthcare|UNITED HEALTHCARE|8.42||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|United Healthcare|UNITED HEALTHCARE|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Managed Medicare|HEALTHSPRING MA|1,052.25||||1,052.25||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|1,052.25||||1,052.25||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Medicaid|MEDICAID|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|1,052.25||||1,052.25||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|1,052.25||||1,052.25||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Medicare|MEDICARE ACUTE|1,052.25||||1,052.25||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Tricare|TRICARE EAST REGION|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Cigna|CIGNA|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Humana Medicare Advantage|HUMANA MA|1,052.25||||1,052.25||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,052.25||||1,052.25||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|1,052.25||||1,052.25||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Access Direct Platinum|HEALTHFIRST TPA|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,052.25||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,052.25||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,052.25||||||| 9524380|ERX|0250|BROMOCRIPTINE 2.5MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||49.25||| 9524380|ERX|0250|BROMOCRIPTINE 2.5MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|49.25||||||| 9524380|ERX|0250|BROMOCRIPTINE 2.5MG TABLE|Medicare|MEDICARE ACUTE|49.25||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|United Healthcare|UNITED HEALTHCARE OTHER|79.75||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|United Healthcare|UNITED HEALTHCARE|||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Medicaid|MEDICAID|79.75||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Medicaid|SMITH COUNTY JAIL|||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Medicare|MEDICARE ACUTE|||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Cigna|CIGNA|||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|79.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Managed Medicaid|MEDICAID SUPERIOR|79.75||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Managed Medicaid|MEDICAID AMERIGROUP|79.75||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Aetna|AETNA PPO|||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Aetna|BOON CHAPMAN|||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|79.75||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Blue Cross HMO Specialty|BCBSTX HMO|79.75||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Blue Cross PPO Specialty|BCBSTX PPO|79.75||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|79.75||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|79.75||||79.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Access Direct Platinum|HEALTHFIRST TPA UMR|79.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Access Direct Platinum|HEALTHFIRST TPA|79.75||||79.75||| 9524406|ERX|0250|METHYLERGONOVINE 0.2MG TA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|324.45||||||| 9524406|ERX|0250|METHYLERGONOVINE 0.2MG TA|Blue Cross HMO Specialty|BCBSTX HMO|324.45||||||| 9524406|ERX|0250|METHYLERGONOVINE 0.2MG TA|Blue Cross PPO Specialty|BCBSTX PPO|324.45||||||| 9524430|ERX|0250|CLOZAPINE 25MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9524430|ERX|0250|CLOZAPINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9524430|ERX|0250|CLOZAPINE 25MG TABLET|Rusk State Hospital|RUSK STATE HOSP|25.50||||||| 9524430|ERX|0250|CLOZAPINE 25MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9524448|ERX|0250|CLOZAPINE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|65.75||||||| 9524448|ERX|0250|CLOZAPINE 100MG TABLET|Access Direct Platinum|ANDREWS CENTER|65.75||||||| 9524448|ERX|0250|CLOZAPINE 100MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|65.75||||||| 9524448|ERX|0250|CLOZAPINE 100MG TABLET|Rusk State Hospital|RUSK STATE HOSP|65.75||||||| 9524448|ERX|0250|CLOZAPINE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|65.75||||||| 9524448|ERX|0250|CLOZAPINE 100MG TABLET|Medicare|MEDICARE ACUTE|65.75||||65.75||| 9524471|ERX|0250|TERBINAFINE 250MG TABLET|Medicare|MEDICARE ACUTE|163.75||||163.75||| 9524471|ERX|0250|TERBINAFINE 250MG TABLET|Managed Medicare|HEALTHSPRING MA|163.75||||||| 9524471|ERX|0250|TERBINAFINE 250MG TABLET|United Healthcare|UNITED HEALTHCARE|163.75||||||| 9524471|ERX|0250|TERBINAFINE 250MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|163.75||||163.75||| 9524471|ERX|0250|TERBINAFINE 250MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|163.75||||||| 9524471|ERX|0250|TERBINAFINE 250MG TABLET|Cigna|CIGNA|||||163.75||| 9524471|ERX|0250|TERBINAFINE 250MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|163.75||||||| 9524471|ERX|0250|TERBINAFINE 250MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||163.75||| 9524497|ERX|0250|CYCLOSPORINE 25MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.75||||||| 9524497|ERX|0250|CYCLOSPORINE 25MG CAPSULE|Medicare|MEDICARE ACUTE|20.75||||||| 9524505|ERX|0250|CYCLOSPORINE 100MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|||||66.25||| 9524513|ERX|0250|CYCLOSPORINE,MODIFIED 25M|Medicare|MEDICARE ACUTE|0.20||||||| 9524513|ERX|0250|CYCLOSPORINE,MODIFIED 25M|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.20||| 9524513|ERX|0250|CYCLOSPORINE,MODIFIED 25M|Veterans Affairs|VETERANS ADMINISTRATION|0.20||||||| 9524513|ERX|0250|CYCLOSPORINE,MODIFIED 25M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.20||||||| 9524513|ERX|0250|CYCLOSPORINE,MODIFIED 25M|Blue Cross PPO Specialty|BCBSTX PPO|0.20||||||| 9524521|ERX|0250|CYCLOSPORINE,MODIFIED 100|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.63||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|121.50||||||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|121.50||||||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|Medicare|MEDICARE ACUTE|121.50||||||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|121.50||||||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|121.50||||||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|121.50||||||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||121.50||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|121.50||||||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|121.50||||||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|121.50||||||| 9524539|ERX|0250|LETROZOLE 2.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|121.50||||||| 9524554|ERX|0250|CALCITONIN 200 UNITS, 3.7|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,352.75||||||| 9524554|ERX|0250|CALCITONIN 200 UNITS, 3.7|Medicare|MEDICARE ACUTE|1,352.75||||||| 9524562|ERX|0250|RIVASTIGMINE 1.5MG CAPSUL|Medicare|MEDICARE ACUTE|39.75||||39.75||| 9524562|ERX|0250|RIVASTIGMINE 1.5MG CAPSUL|Aenta Medicare Advantage|AETNA MEDICARE MA|39.75||||||| 9524570|ERX|0250|ENTACAPONE 200MG TABLET|Medicare|MEDICARE ACUTE|31.25||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33.50||||33.50||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||33.50||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Humana Medicare Advantage|HUMANA MA|33.50||||33.50||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.50||||33.50||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|33.50||||33.50||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Aetna|BH AETNA|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|NON CONTRACTED|COMMUNITY HEALTH CENTER|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Optum Behavioral Health|BH OPTUM UHC|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Managed Medicare|HEALTHSPRING MA|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Medicaid|BH TEXAS CHILDRENS MEDICAID|33.50||||33.50||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Medicaid|MEDICAID|33.50||||33.50||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Medicaid|MEDICAID HMO|33.50||||33.50||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Medicare|MEDICARE PART B ONLY IP|33.50||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Medicare|MEDICARE ACUTE|33.50||||33.50||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Medicare|MEDICARE ACUTE|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||43.50||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Aetna|BH AETNA|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Humana Medicare Advantage|HUMANA MA|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|43.50||||||| 9524620|ERX|0250|DULOXETINE 60MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|43.50||||||| 9524653|ERX|0250|NATEGLINIDE 60MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.21||||||| 9524653|ERX|0250|NATEGLINIDE 60MG TABLET|Medicare|MEDICARE ACUTE|0.21||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Cigna|CIGNA|25.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||25.50||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|25.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Aetna|AETNA QHP HMO|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Aetna|AETNA PPO|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Aetna|AETNA OTHER|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|ChampVA|CHAMPVA CENTER|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Humana Medicare Advantage|HUMANA MA|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Magellan Behavioral Health|BH MAGELLAN|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Cigna|CIGNA|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Cigna|CIGNA OTHER|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Cigna|CIGNA|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Medicare|MEDICARE PART B ONLY IP|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Medicare|MEDICARE ACUTE|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Managed Medicare|HEALTHSPRING MA|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|26.50||||26.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|26.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|United Healthcare|UNITED HEALTHCARE|26.50||||||| 9524695|ERX|0250|FAMCICLOVIR 500MG TABLET|Medicare|MEDICARE ACUTE|1.38||||||| 9524695|ERX|0250|FAMCICLOVIR 500MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.38||| 9524703|ERX|0250|PIMECROLIMUS 1% CREAM, 30|UTMB|UTMB CORRECTIONAL MANAGED CARE|852.25||||||| 9524703|ERX|0250|PIMECROLIMUS 1% CREAM, 30|Medicare|MEDICARE ACUTE|852.25||||||| 9524711|ERX|0250|DEXMETHYLPHENIDATE 5MG TA|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||||| 9524711|ERX|0250|DEXMETHYLPHENIDATE 5MG TA|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|15.50||||||| 9524711|ERX|0250|DEXMETHYLPHENIDATE 5MG TA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9524711|ERX|0250|DEXMETHYLPHENIDATE 5MG TA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9524729|ERX|0250|MYCOPHENOLATE SODIUM 180M|Medicare|MEDICARE PART B ONLY IP|33.50||||||| 9524729|ERX|0250|MYCOPHENOLATE SODIUM 180M|Medicare|MEDICARE ACUTE|33.50||||33.50||| 9524729|ERX|0250|MYCOPHENOLATE SODIUM 180M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.50||||||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.67||||0.67||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|United Medicare Advantage|UHC AARP MCR HMO MA|0.67||||0.67||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.67||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Blue Cross PPO Specialty|BCBSTX PPO|0.67||||0.67||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Aetna|AETNA PPO|||||0.67||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.67||||||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Cigna|CIGNA|0.67||||||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Humana Medicare Advantage|HUMANA MA|0.67||||0.67||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|NON CONTRACTED|COMMERCIAL OTHER 1|0.67||||||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|United Healthcare|UNITED HEALTHCARE OTHER|0.67||||||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Managed Medicare|HEALTHSPRING MA|0.67||||||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.67||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Medicare|MEDICARE PART B ONLY IP|0.67||||||| 9524737|ERX|0250|MYCOPHENOLATE SODIUM 360M|Medicare|MEDICARE ACUTE|0.67||||0.67||| 9524752|ERX|0250|IMATINIB 100MG TABLET|Medicare|MEDICARE ACUTE|3.52||||3.52||| 9524752|ERX|0250|IMATINIB 100MG TABLET|Managed Medicare|HEALTHSPRING MA|||||3.52||| 9524752|ERX|0250|IMATINIB 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.52||||||| 9524752|ERX|0250|IMATINIB 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|3.52||||||| 9524752|ERX|0250|IMATINIB 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.52||| 9524786|ERX|0250|CARB-LEVO-ENTA 25-100-200|Managed Medicare|BCBS MEDICARE PPO MA|30.75||||||| 9524810|ERX|0250|MYCOPHENOLATE MOFETIL 250|Veterans Affairs|VETERANS ADMINISTRATION|0.42||||||| 9524810|ERX|0250|MYCOPHENOLATE MOFETIL 250|United Medicare Advantage|UHC MEDICARE GOLD MA|0.42||||||| 9524810|ERX|0250|MYCOPHENOLATE MOFETIL 250|United Medicare Advantage|UHC AARP MCR HMO MA|0.42||||||| 9524810|ERX|0250|MYCOPHENOLATE MOFETIL 250|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.42||||0.42||| 9524810|ERX|0250|MYCOPHENOLATE MOFETIL 250|Blue Cross PPO Specialty|BCBSTX PPO|0.42||||||| 9524810|ERX|0250|MYCOPHENOLATE MOFETIL 250|Humana Medicare Advantage|HUMANA MA|0.42||||||| 9524810|ERX|0250|MYCOPHENOLATE MOFETIL 250|Medicare|MEDICARE ACUTE|0.42||||0.42||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Tricare|TRICARE EAST REGION|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||25.50||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||||| 9524836|ERX|0250|DEXMETHYLPHENIDATE XR 5MG|Managed Medicaid|MEDICAID AMERIGROUP|43.75||||||| 9524836|ERX|0250|DEXMETHYLPHENIDATE XR 5MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|43.75||||||| 9524844|ERX|0250|DEXMETHYLPHENIDATE XR 10M|Optum Behavioral Health|BH OPTUM UHC|44.25||||||| 9524844|ERX|0250|DEXMETHYLPHENIDATE XR 10M|Blue Cross PPO Specialty|BCBSTX PPO|44.25||||||| 9524844|ERX|0250|DEXMETHYLPHENIDATE XR 10M|Managed Medicaid|MEDICAID AMERIGROUP|44.25||||||| 9524844|ERX|0250|DEXMETHYLPHENIDATE XR 10M|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|44.25||||||| 9524869|ERX|0250|METHYLPHENIDATE 5MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|12.25||||||| 9524869|ERX|0250|METHYLPHENIDATE 5MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|12.25||||||| 9524869|ERX|0250|METHYLPHENIDATE 5MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.25||||||| 9524869|ERX|0250|METHYLPHENIDATE 5MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||||| 9524869|ERX|0250|METHYLPHENIDATE 5MG TABLE|Medicaid|BH TEXAS CHILDRENS MEDICAID|12.25||||||| 9524877|ERX|0250|METHYLPHENIDATE 10MG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9524877|ERX|0250|METHYLPHENIDATE 10MG TABL|Medicare|MEDICARE ACUTE|15.50||||||| 9524877|ERX|0250|METHYLPHENIDATE 10MG TABL|Medicaid|MEDICAID|15.50||||||| 9524877|ERX|0250|METHYLPHENIDATE 10MG TABL|Medicaid|BH TEXAS CHILDRENS MEDICAID|15.50||||||| 9524877|ERX|0250|METHYLPHENIDATE 10MG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9524877|ERX|0250|METHYLPHENIDATE 10MG TABL|Humana Medicare Advantage|HUMANA MA|15.50||||||| 9524877|ERX|0250|METHYLPHENIDATE 10MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||||| 9524877|ERX|0250|METHYLPHENIDATE 10MG TABL|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|15.50||||||| 9524885|ERX|0250|METHYLPHENIDATE 20MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.50||||||| 9524893|ERX|0250|METHYLPHENIDATE SR 20MG T|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Medicaid|MEDICAID|83.75||||||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Medicare|MEDICARE ACUTE|83.75||||83.75||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Managed Medicare|HEALTHSPRING MA|83.75||||||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|83.75||||||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Access Direct Platinum|HEALTHFIRST TPA|83.75||||||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|United Medicare Advantage|UHC MEDICARE GOLD MA|83.75||||83.75||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Blue Cross PPO Specialty|BCBSTX PPO|83.75||||83.75||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Blue Cross PPO Specialty|BCBSTX OTHER|||||83.75||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Blue Cross HMO Specialty|BCBSTX HMO|83.75||||||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|83.75||||83.75||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Cigna|CIGNA OTHER|83.75||||||| 9524901|ERX|0250|MYCOPHENOLATE MOFETIL 500|Humana Medicare Advantage|HUMANA MA|83.75||||83.75||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|22.50||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22.50||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|22.50||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Humana Medicare Advantage|HUMANA MA|22.50||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|22.50||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|22.50||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|NON CONTRACTED|COMMUNITY HEALTH CENTER|22.50||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Optum Behavioral Health|BH OPTUM UHC|22.50||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Medicare|MEDICARE ACUTE|22.50||||22.50||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Medicaid|BH TEXAS CHILDRENS MEDICAID|22.50||||||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|Medicaid|BH TEXAS CHILDRENS MEDICAID|64.50||||||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|Medicare|MEDICARE ACUTE|64.50||||||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|NON CONTRACTED|COMMUNITY HEALTH CENTER|64.50||||||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|64.50||||||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|64.50||||||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|64.50||||||| 9524935|ERX|0250|ALISKIREN 150MG TABLET|Humana Medicare Advantage|HUMANA MA|26.75||||||| 9524935|ERX|0250|ALISKIREN 150MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||26.75||| 9524935|ERX|0250|ALISKIREN 150MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||26.75||| 9524935|ERX|0250|ALISKIREN 150MG TABLET|Managed Medicare|HEALTHSPRING MA|26.75||||||| 9524935|ERX|0250|ALISKIREN 150MG TABLET|Medicare|MEDICARE ACUTE|26.75||||||| 9524943|ERX|0250|MYCOPHENOLATE 200MG/ML,17|Medicare|MEDICARE ACUTE|67.88||||||| 9524943|ERX|0250|MYCOPHENOLATE 200MG/ML,17|Blue Cross PPO Specialty|BCBSTX PPO|67.88||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|8.50||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Access Direct Platinum|ANDREWS CENTER|8.50||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.50||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Humana Medicare Advantage|HUMANA MA|||||8.50||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|8.50||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|8.50||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Optum Behavioral Health|BH OPTUM UHC|8.50||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Multiplan|WEB TPA|8.50||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Medicare|MEDICARE ACUTE|8.50||||||| 9524976|ERX|0250|RIVASTIGMINE 4.6MG PATCH|Medicare|MEDICARE PART B ONLY IP|79.50||||||| 9524976|ERX|0250|RIVASTIGMINE 4.6MG PATCH|Medicare|MEDICARE ACUTE|79.50||||||| 9524976|ERX|0250|RIVASTIGMINE 4.6MG PATCH|Humana Medicare Advantage|HUMANA MA|79.50||||||| 9524984|ERX|0250|CARBAMAZEPINE 100MG/5ML,3|United Medicare Advantage|UHC MEDICARE GOLD MA|0.41||||||| 9524984|ERX|0250|CARBAMAZEPINE 100MG/5ML,3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.41||||||| 9524984|ERX|0250|CARBAMAZEPINE 100MG/5ML,3|Humana Medicare Advantage|HUMANA MA|0.41||||||| 9524984|ERX|0250|CARBAMAZEPINE 100MG/5ML,3|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.41||||||| 9524984|ERX|0250|CARBAMAZEPINE 100MG/5ML,3|Rusk State Hospital|RUSK STATE HOSP|0.41||||||| 9524992|ERX|0250|CARBAMAZEPINE XR 100MG TA|Medicare|MEDICARE ACUTE|8.25||||||| 9524992|ERX|0250|CARBAMAZEPINE XR 100MG TA|Tricare|TRICARE EAST REGION|8.25||||||| 9524992|ERX|0250|CARBAMAZEPINE XR 100MG TA|Humana Medicare Advantage|HUMANA MA|||||8.25||| 9525007|ERX|0250|CARBAMAZEPINE XR 200MG TA|Humana Medicare Advantage|HUMANA MA|14.50||||14.50||| 9525007|ERX|0250|CARBAMAZEPINE XR 200MG TA|Medicare|MEDICARE ACUTE|14.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|NON CONTRACTED|COMMERCIAL OTHER 1|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Texas Workforce Commission|DIS DETER SERV (DDS)|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Optum Behavioral Health|BH OPTUM UHC|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Managed Medicare|HEALTHSPRING MA|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Workers Compensation|WORKERS COMPENSATION OTHER|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.50||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Managed Medicaid|MEDICAID AMERIGROUP|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.50||||||| 9525031|ERX|0250|BACITRACIN-POLYMYX B SULF|Cigna Behavioral Health|BH CIGNA|0.50||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Magellan Behavioral Health|BH MAGELLAN|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|||||0.05||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Blue Cross PPO Specialty|BCBSTX OTHER|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|||||0.05||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Aetna|AETNA PPO|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Aetna|AETNA OTHER|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Cigna Behavioral Health|BH CIGNA|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||0.05||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|United Medicare Advantage|UHC AARP MCR HMO MA|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Medicaid|MEDICAID|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Medicare|MEDICARE PART B ONLY IP|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Managed Medicare|HEALTHSPRING MA|||||0.05||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|Tricare|TRICARE EAST REGION|0.05||||||| 9525056|ERX|0250|FERROUS SULFATE 140MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|0.05||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|United Healthcare|UNITED HEALTHCARE OTHER|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|United Healthcare|UNITED HEALTHCARE|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|NON CONTRACTED|COMMERCIAL OTHER 1|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Tricare|TRICARE EAST REGION|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicare|BCBS MEDICARE PPO MA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Medicare|MEDICARE ACUTE|384.75||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Workers Compensation|WORKERS COMPENSATION OTHER|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Workers Compensation|TEXAS MUTUAL INSURANCE|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Workers Compensation|BROOKSHIRES WORKERS COMP|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Access Direct Platinum|HEALTHFIRST TPA UMR|384.75||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|384.75||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|384.75||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Access Direct Platinum|HEALTHFIRST TPA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|United Medicare Advantage|UHC MEDICARE GOLD MA|384.75||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicare|HEALTHSPRING MA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|United Medicare Advantage|UHC AARP MCR HMO MA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|384.75||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|PHCS|HUMANA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Aenta Medicare Advantage|AETNA MEDICARE MA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Aetna|AETNA PPO|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Aetna|AETNA OTHER|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross PPO Specialty|BCBSTX OTHER|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross PPO Specialty|BCBSTX PPO|384.75||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross HMO Specialty|BCBSTX HMO|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID AMERIGROUP|384.75||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID SUPERIOR|384.75||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Cigna|CIGNA|||||384.75||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Humana Medicare Advantage|HUMANA MA|||||384.75||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Humana Medicare Advantage|HUMANA MA|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Blue Cross HMO Specialty|BCBSTX HMO|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|United Medicare Advantage|UHC MEDICARE GOLD MA|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Veterans Affairs|VETERANS ADMINISTRATION|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Medicaid|MEDICAID|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Medicare|MEDICARE ACUTE|401.75||||401.75||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|NON CONTRACTED|COMMUNITY HEALTH CENTER|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|NON CONTRACTED|COMMERCIAL OTHER 1|401.75||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|United Healthcare|UNITED HEALTHCARE|401.75||||||| 9525130|ERX|0250|MYCOPHENOLATE 500MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|513.50||||||| 9525148|ERX|0250|POSACONAZOLE 200MG/5ML,10|NON CONTRACTED|COMMERCIAL OTHER 1|6,680.50||||||| 9525148|ERX|0250|POSACONAZOLE 200MG/5ML,10|Medicare|MEDICARE ACUTE|6,680.50||||||| 9525148|ERX|0250|POSACONAZOLE 200MG/5ML,10|Blue Cross PPO Specialty|BCBSTX PPO|6,680.50||||||| 9525148|ERX|0250|POSACONAZOLE 200MG/5ML,10|Blue Cross HMO Specialty|BCBSTX HMO|6,680.50||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.75||||20.75||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Cigna|CIGNA|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Humana Medicare Advantage|HUMANA MA|20.75||||20.75||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|20.75||||20.75||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||20.75||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Managed Medicare|HEALTHSPRING MA|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Medicaid|MEDICAID|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Medicare|MEDICARE PART B ONLY IP|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|Medicare|MEDICARE ACUTE|20.75||||20.75||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|United Healthcare|UNITED HEALTHCARE|20.75||||||| 9525189|ERX|0250|NIFEDIPINE SA 30MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||20.75||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.30||||||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.30||||||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Medicare|MEDICARE ACUTE|0.30||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Medicaid|MEDICAID|0.30||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Managed Medicare|HEALTHSPRING MA|0.30||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|United Healthcare|UNITED HEALTHCARE|0.30||||||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.30||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.30||||||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.30||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Humana Medicare Advantage|HUMANA MA|0.30||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.30||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.30||||||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.30||||||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.30||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.30||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.30||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.30||||||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.30||||||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.30||||||| 9525197|ERX|0250|NIFEDIPINE SA 60MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.30||||||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.35||||||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.35||||0.35||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.35||||||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.35||||||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.35||||0.35||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.35||||||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Cigna|CIGNA|||||0.35||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Humana Medicare Advantage|HUMANA MA|0.35||||0.35||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.35||||||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.35||||0.35||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Managed Medicare|HEALTHSPRING MA|||||0.35||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.35||||||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Medicare|MEDICARE ACUTE|0.35||||0.35||| 9525205|ERX|0250|NIFEDIPINE SA 90MG TABLET|Tricare|TRICARE EAST REGION|0.35||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Tricare|TRICARE EAST REGION|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicare|MEDICARE ACUTE|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicaid|BH TEXAS CHILDRENS MEDICAID|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicaid|MEDICAID|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicare|HEALTHSPRING MA|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Aetna|AETNA PPO|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Brinson Benefits|THE HEALTH PLAN SMITH CO|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicaid|SMITH COUNTY JAIL|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Humana Medicare Advantage|HUMANA MA|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Cigna|CIGNA OTHER|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|95.25||||95.25||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|95.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|95.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Access Direct Platinum|HEALTHFIRST TPA|||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Workers Compensation|ZURICH COMPANY|336.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Veterans Affairs|VETERANS ADMINISTRATION|336.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|United Medicare Advantage|UHC AARP MCR HMO MA|336.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicaid|MEDICAID SUPERIOR|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicaid|MEDICAID AMERIGROUP|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Cigna|CIGNA|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Humana Medicare Advantage|HUMANA MA|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Blue Cross HMO Specialty|BCBSTX HMO|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|United Medicare Advantage|UHC MEDICARE GOLD MA|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Blue Cross PPO Specialty|BCBSTX PPO|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Aenta Medicare Advantage|AETNA MEDICARE MA|336.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Aetna|AETNA PPO|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicare|WELLCARE CHOICE MA|336.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicare|HEALTHSPRING MA|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicare|BCBS MEDICARE PPO MA|||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Medicaid|SMITH COUNTY JAIL|336.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Medicaid|MEDICAID|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Medicare|MEDICARE ACUTE|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|NON CONTRACTED|COMMERCIAL OTHER 1|336.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|336.25||||336.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|United Healthcare|UNITED HEALTHCARE OTHER|336.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|United Healthcare|UNITED HEALTHCARE|||||336.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|United Healthcare|UNITED HEALTHCARE|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Optum Behavioral Health|BH OPTUM UHC|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Tricare|TRICARE EAST REGION|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Medicaid|SMITH COUNTY JAIL|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Medicaid|MEDICAID|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicare|HEALTHSPRING MA|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Aetna|AETNA PPO|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Medicare|MEDICARE ACUTE|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Humana Medicare Advantage|HUMANA MA|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Cigna|CIGNA|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|66.25||||66.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|66.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||66.25||| 9525270|ERX|0250|CIPROFLOXACIN 200MG/100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.97||||||| 9525270|ERX|0250|CIPROFLOXACIN 200MG/100ML|Humana Medicare Advantage|HUMANA MA|1.97||||||| 9525270|ERX|0250|CIPROFLOXACIN 200MG/100ML|Blue Cross HMO Specialty|BCBSTX HMO|||||1.97||| 9525270|ERX|0250|CIPROFLOXACIN 200MG/100ML|Blue Cross PPO Specialty|BCBSTX PPO|1.97||||||| 9525270|ERX|0250|CIPROFLOXACIN 200MG/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.97||||||| 9525270|ERX|0250|CIPROFLOXACIN 200MG/100ML|Medicare|MEDICARE ACUTE|1.97||||1.97||| 9525270|ERX|0250|CIPROFLOXACIN 200MG/100ML|United Healthcare|UNITED HEALTHCARE OTHER|1.97||||||| 9525288|ERX|0250|CIPROFLOXACIN 750MG TABLE|Medicaid|MEDICAID|66.50||||||| 9525288|ERX|0250|CIPROFLOXACIN 750MG TABLE|Medicare|MEDICARE ACUTE|66.50||||||| 9525288|ERX|0250|CIPROFLOXACIN 750MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|66.50||||||| 9525288|ERX|0250|CIPROFLOXACIN 750MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|66.50||||||| 9525288|ERX|0250|CIPROFLOXACIN 750MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|66.50||||||| 9525288|ERX|0250|CIPROFLOXACIN 750MG TABLE|Humana Medicare Advantage|HUMANA MA|66.50||||||| 9525288|ERX|0250|CIPROFLOXACIN 750MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|66.50||||||| 9525296|ERX|0250|CIPROFLOXACIN 250MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|56.50||||||| 9525296|ERX|0250|CIPROFLOXACIN 250MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|56.50||||||| 9525296|ERX|0250|CIPROFLOXACIN 250MG TABLE|United Medicare Advantage|UHC AARP MCR HMO MA|56.50||||||| 9525296|ERX|0250|CIPROFLOXACIN 250MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|||||56.50||| 9525296|ERX|0250|CIPROFLOXACIN 250MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|56.50||||||| 9525296|ERX|0250|CIPROFLOXACIN 250MG TABLE|Humana Medicare Advantage|HUMANA MA|56.50||||||| 9525296|ERX|0250|CIPROFLOXACIN 250MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|56.50||||||| 9525296|ERX|0250|CIPROFLOXACIN 250MG TABLE|Managed Medicare|HEALTHSPRING MA|56.50||||||| 9525296|ERX|0250|CIPROFLOXACIN 250MG TABLE|Medicare|MEDICARE ACUTE|56.50||||||| 9525320|ERX|0250|TEMOZOLOMIDE 5MG CAPSULE|Medicare|MEDICARE ACUTE|69.82||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Aetna|BH AETNA|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Aetna|AETNA OTHER|||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Humana Medicare Advantage|HUMANA MA|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|PHCS|HUMANA|||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Texas Workforce Commission|DIS DETER SERV (DDS)|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Tricare|TRICARE EAST REGION|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Optum Behavioral Health|BH OPTUM UHC|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|United Healthcare|UNITED HEALTHCARE|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Managed Medicare|HEALTHSPRING MA|0.36||||0.36||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Medicaid|MEDICAID HMO|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Medicaid|MEDICAID|0.36||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Medicare|MEDICARE ACUTE|0.36||||0.36||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Medicaid|MEDICAID|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Medicaid|MEDICAID HMO|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|United Healthcare|UNITED HEALTHCARE|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|United Healthcare|GEHA|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Tricare|TRICARE EAST REGION|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Cigna|CIGNA OTHER|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Cigna|CIGNA|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Aetna|AETNA OTHER|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Aetna|AETNA PPO|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9525411|ERX|0250|BUSPIRONE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Aetna|BH AETNA|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Aetna|AETNA OTHER|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Magellan Behavioral Health|BH MAGELLAN|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Cigna|CIGNA|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Aetna|BOON CHAPMAN|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|PHCS|HUMANA INSURANCE|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Optum Behavioral Health|BH OPTUM UHC|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Tricare|TRICARE EAST REGION|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|United Healthcare|TML GROUP BENEFITS|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|25.50||||25.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Medicaid|MEDICAID|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|25.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Medicaid|MEDICAID|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Tricare|TRICARE EAST REGION|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Medicare|MEDICARE ACUTE|30.75||||30.75||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Access Direct Platinum|ANDREWS CENTER|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Aetna|BH AETNA|30.75||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|30.75||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|ChampVA|CHAMPVA CENTER|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Aetna|BH AETNA|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Aetna|AETNA PPO|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Cigna|CIGNA OTHER|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Cigna|CIGNA|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Access Direct Platinum|ANDREWS CENTER|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Cigna|CIGNA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Healthcare|UNITED HEALTHCARE|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Aetna|AETNA OTHER|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|PHCS|GROUP AND PENSION|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|PHCS|HUMANA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|PHCS|HUMANA INSURANCE|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Tricare|TRICARE EAST REGION|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Optum Behavioral Health|BH OPTUM UHC|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicaid|SMITH COUNTY JAIL|||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicaid|MEDICAID|15.50||||15.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicare|MEDICARE PART B ONLY IP|15.50||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Managed Medicare|HEALTHSPRING MA|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|PHCS|GROUP AND PENSION|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|United Healthcare|UNITED HEALTHCARE|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|United Healthcare|UNITED HEALTHCARE|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Medicaid|MEDICAID|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Cigna|CIGNA|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Aetna|BH AETNA|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Aetna|AETNA PPO|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|15.50||||15.50||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15.50||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|15.50||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.24||||0.24||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Humana Medicare Advantage|HUMANA MA|0.24||||0.24||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.24||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.24||||0.24||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.24||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.24||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.24||||0.24||| 9525494|ERX|0250|METFORMIN 850MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.24||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.24||| 9525494|ERX|0250|METFORMIN 850MG TABLET|United Healthcare|UNITED HEALTHCARE|0.24||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||0.24||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Managed Medicare|HEALTHSPRING MA|||||0.24||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Medicaid|MEDICAID|0.24||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Medicare|MEDICARE ACUTE|0.24||||0.24||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|PHCS|HUMANA|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Tricare|TRICARE EAST REGION|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|United Healthcare|UNITED HEALTHCARE OTHER|||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||220.75||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|220.75||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|220.75||||220.75||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|220.75||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|220.75||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|220.75||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|220.75||||220.75||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|220.75||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|220.75||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|220.75||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|220.75||||220.75||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|220.75||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Medicare|MEDICARE ACUTE|220.75||||220.75||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Cigna|CIGNA OTHER|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Cigna|CIGNA|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Magellan Behavioral Health|BH MAGELLAN|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicaid|MEDICAID AMERIGROUP|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Humana Medicare Advantage|HUMANA MA|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Aetna|BOON CHAPMAN|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Aetna|AETNA PPO|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Aetna|AETNA OTHER|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross HMO Specialty|BCBSTX HMO|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross PPO Specialty|BCBSTX OTHER|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross PPO Specialty|BCBSTX PPO|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Rusk State Hospital|RUSK STATE HOSP|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Healthcare|UNITED HEALTHCARE|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Workers Compensation|WORKERS COMPENSATION OTHER|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Medicare Advantage|UHC AARP MCR HMO MA|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicaid|MEDICAID SUPERIOR|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicare|BCBS MEDICARE PPO MA|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Tricare|TRICARE EAST REGION|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Access Direct Platinum|HEALTHFIRST TPA|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|PHCS|HUMANA INSURANCE|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicaid|SMITH COUNTY JAIL|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Veterans Affairs|VETERANS ADMINISTRATION|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Healthcare|TML GROUP BENEFITS|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicare|MEDICARE ACUTE|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Healthcare|UNITED HEALTHCARE OTHER|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicare|MEDICARE PART B ONLY IP|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicaid|MEDICAID|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|NON CONTRACTED|COMMUNITY HEALTH CENTER|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|PHCS|GROUP AND PENSION|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicare|WELLCARE CHOICE MA|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|NON CONTRACTED|COMMERCIAL OTHER 1|58.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicare|HEALTHSPRING MA|58.25||||58.25||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|58.25||||58.25||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Access Direct Platinum|HEALTHFIRST TPA|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.89||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|2.89||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Cigna|CIGNA|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Medicaid|MEDICAID|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.89||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Humana Medicare Advantage|HUMANA MA|2.89||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|2.89||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicare|HEALTHSPRING MA|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Healthcare|UNITED HEALTHCARE|2.89||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Medicare|MEDICARE ACUTE|2.89||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|2.89||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Aetna|AETNA OTHER|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Tricare|TRICARE FOR LIFE|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Tricare|TRICARE EAST REGION|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||2.89||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Aetna|AETNA PPO|||||2.89||| 9525635|ERX|0250|HC ACETAT-PRAMOXINE FOAM,|Blue Cross PPO Specialty|BCBSTX PPO|674.75||||674.75||| 9525635|ERX|0250|HC ACETAT-PRAMOXINE FOAM,|Cigna|CIGNA|674.75||||||| 9525635|ERX|0250|HC ACETAT-PRAMOXINE FOAM,|Medicare|MEDICARE ACUTE|674.75||||||| 9525635|ERX|0250|HC ACETAT-PRAMOXINE FOAM,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|674.75||||||| 9525635|ERX|0250|HC ACETAT-PRAMOXINE FOAM,|Access Direct Platinum|HEALTHFIRST TPA UMR|674.75||||||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Cigna|CIGNA|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Humana Medicare Advantage|HUMANA MA|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|170.25||||||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Healthcare|UNITED HEALTHCARE OTHER|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Healthcare|UNITED HEALTHCARE|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicare|HEALTHSPRING MA|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicaid|MEDICAID HMO|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Aetna|AETNA PPO|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Veterans Affairs|VETERANS ADMINISTRATION|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Tricare|TRICARE EAST REGION|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|PHCS|MULTIPLAN PHCS|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicare|MEDICARE PART B ONLY IP|||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicare|MEDICARE ACUTE|170.25||||170.25||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicaid|MEDICAID|170.25||||170.25||| 9525684|ERX|0250|HYOSCYAMINE ER 0.375MG TA|United Healthcare|UNITED HEALTHCARE|19.75||||||| 9525684|ERX|0250|HYOSCYAMINE ER 0.375MG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|19.75||||||| 9525684|ERX|0250|HYOSCYAMINE ER 0.375MG TA|Medicare|MEDICARE ACUTE|19.75||||19.75||| 9525700|ERX|0250|VERAPAMIL PM 100MG CAPSUL|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9525718|ERX|0250|HYOSCYAMINE 0.125MG/ML, 1|Managed Medicaid|MEDICAID AMERIGROUP|4.85||||||| 9525742|ERX|0250|VENLAFAXINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.25||||||| 9525759|ERX|0250|ALBUTEROL 2MG/5ML, 30ML|Humana Medicare Advantage|HUMANA MA|25.25||||||| 9525759|ERX|0250|ALBUTEROL 2MG/5ML, 30ML|Managed Medicare|HEALTHSPRING MA|||||25.25||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Medicare|MEDICARE ACUTE|12.25||||12.25||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|United Healthcare|UNITED HEALTHCARE|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Managed Medicare|HEALTHSPRING MA|12.25||||12.25||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Medicaid|SMITH COUNTY JAIL|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||12.25||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Humana Medicare Advantage|HUMANA MA|12.25||||12.25||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Workers Compensation|WORKERS COMPENSATION OTHER|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Medicaid|MEDICAID|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||12.25||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|12.25||||||| 9525783|ERX|0250|KETOCONAZOLE 2% CREAM, 15|United Medicare Advantage|UHC AARP MCR HMO MA|169.25||||||| 9525783|ERX|0250|KETOCONAZOLE 2% CREAM, 15|Humana Medicare Advantage|HUMANA MA|169.25||||||| 9525783|ERX|0250|KETOCONAZOLE 2% CREAM, 15|UTMB|UTMB CORRECTIONAL MANAGED CARE|169.25||||||| 9525783|ERX|0250|KETOCONAZOLE 2% CREAM, 15|United Medicare Advantage|UHC MEDICARE GOLD MA|||||169.25||| 9525783|ERX|0250|KETOCONAZOLE 2% CREAM, 15|Managed Medicare|HEALTHSPRING MA|169.25||||||| 9525783|ERX|0250|KETOCONAZOLE 2% CREAM, 15|Veterans Affairs|VETERANS ADMINISTRATION|169.25||||||| 9525783|ERX|0250|KETOCONAZOLE 2% CREAM, 15|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|169.25||||||| 9525783|ERX|0250|KETOCONAZOLE 2% CREAM, 15|Medicare|MEDICARE ACUTE|169.25||||169.25||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Cigna|CIGNA|32.50||||||| 9525817|ERX|0250|SOTALOL 120MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|32.50||||||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|32.50||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|32.50||||||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|32.50||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|32.50||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Managed Medicare|HEALTHSPRING MA|32.50||||||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Medicare|MEDICARE ACUTE|32.50||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Aetna|AETNA QHP HMO|||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|32.50||||||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|32.50||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Humana Medicare Advantage|HUMANA MA|32.50||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|32.50||||32.50||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32.50||||32.50||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||252.75||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Medicare|MEDICARE ACUTE|252.75||||252.75||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|252.75||||252.75||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Medicaid|MEDICAID HMO|||||252.75||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|United Healthcare|UNITED HEALTHCARE|||||252.75||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|252.75||||||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|252.75||||||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Humana Medicare Advantage|HUMANA MA|252.75||||||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||252.75||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|252.75||||||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|252.75||||||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||252.75||| 9525825|ERX|0250|CEFTRIAXONE 2 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||252.75||| 9525841|ERX|0250|PENICILLIN VK 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.07||| 9525841|ERX|0250|PENICILLIN VK 500MG TABLE|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.07||||||| 9525841|ERX|0250|PENICILLIN VK 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||||| 9525841|ERX|0250|PENICILLIN VK 500MG TABLE|Medicare|MEDICARE ACUTE|0.07||||||| 9525841|ERX|0250|PENICILLIN VK 500MG TABLE|Humana Medicare Advantage|HUMANA MA|0.07||||||| 9525841|ERX|0250|PENICILLIN VK 500MG TABLE|Medicaid|MEDICAID|0.07||||||| 9525858|ERX|0250|AMOXICILLIN 875MG TABLET|Humana Medicare Advantage|HUMANA MA|13.50||||||| 9525858|ERX|0250|AMOXICILLIN 875MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.50||||||| 9525858|ERX|0250|AMOXICILLIN 875MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.50||||||| 9525858|ERX|0250|AMOXICILLIN 875MG TABLET|Medicare|MEDICARE ACUTE|13.50||||||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Managed Medicaid|MEDICAID SUPERIOR|63.25||||63.25||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Access Direct Platinum|HEALTHFIRST TPA|63.25||||||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Medicare|MEDICARE ACUTE|63.25||||||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|United Healthcare|UNITED HEALTHCARE|||||63.25||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|United Healthcare|UNITED HEALTHCARE|63.25||||||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Managed Medicaid|MEDICAID AMERIGROUP|63.25||||63.25||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Medicaid|MEDICAID|||||63.25||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Blue Cross PPO Specialty|BCBSTX PPO|63.25||||63.25||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||63.25||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Aetna|AETNA PPO|||||63.25||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Blue Cross PPO Specialty|BCBSTX PPO|194.50||||||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Medicare|MEDICARE ACUTE|194.50||||||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Humana Medicare Advantage|HUMANA MA|194.50||||||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Medicaid|MEDICAID|194.50||||||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|194.50||||||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|31.25||||||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|31.25||||||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|31.25||||||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||31.25||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|31.25||||||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Aetna|AETNA OTHER|31.25||||||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Medicare|MEDICARE ACUTE|31.25||||31.25||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Cigna|CIGNA|31.25||||||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|31.25||||31.25||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|31.25||||||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||25.50||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|25.50||||||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|25.50||||||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|Medicare|MEDICARE ACUTE|25.50||||||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|Medicaid|MEDICAID HMO|25.50||||||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||25.50||| 9525973|ERX|0250|VENLAFAXINE 37.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9525981|ERX|0250|VENLAFAXINE 50MG TABLET|Medicare|MEDICARE ACUTE|25.50||||||| 9525981|ERX|0250|VENLAFAXINE 50MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|25.50||||||| 9525981|ERX|0250|VENLAFAXINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9525981|ERX|0250|VENLAFAXINE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9525981|ERX|0250|VENLAFAXINE 50MG TABLET|Aetna|AETNA OTHER|25.50||||||| 9525981|ERX|0250|VENLAFAXINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|Medicare|MEDICARE ACUTE|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|Cigna|CIGNA OTHER|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|United Healthcare|UNITED HEALTHCARE|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9526005|ERX|0250|MEXILETINE 150MG CAPSULE|Medicare|MEDICARE ACUTE|0.14||||0.14||| 9526005|ERX|0250|MEXILETINE 150MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.14||||||| 9526005|ERX|0250|MEXILETINE 150MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|0.14||||||| 9526005|ERX|0250|MEXILETINE 150MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.14||||||| 9526005|ERX|0250|MEXILETINE 150MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.14||||||| 9526005|ERX|0250|MEXILETINE 150MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.14||||||| 9526005|ERX|0250|MEXILETINE 150MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.14||||||| 9526054|ERX|0250|HALOPERIDOL CONC 2MG/ML,|Medicaid|COUNTY INDIGENT HEALTH OTHER|133.75||||||| 9526070|ERX|0250|ORPHENADRINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||25.50||| 9526070|ERX|0250|ORPHENADRINE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||25.50||| 9526070|ERX|0250|ORPHENADRINE 100MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9526070|ERX|0250|ORPHENADRINE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||25.50||| 9526070|ERX|0250|ORPHENADRINE 100MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||25.50||| 9526070|ERX|0250|ORPHENADRINE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||||| 9526070|ERX|0250|ORPHENADRINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||25.50||| 9526088|ERX|0250|TERBUTALINE 2.5MG TABLET|Medicare|MEDICARE ACUTE|7.75||||||| 9526096|ERX|0250|DANTROLENE 25MG CAPSULE|Medicare|MEDICARE ACUTE|15.50||||||| 9526096|ERX|0250|DANTROLENE 25MG CAPSULE|Medicaid|MEDICAID|15.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|CRIME VICTIMS COMPENSATION|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|MEDICAID|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|SMITH COUNTY JAIL|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Texas Workforce Commission|DIS DETER SERV (DDS)|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Medicare Advantage|UHC AARP MCR HMO MA|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Workers Compensation|WORKERS COMPENSATION OTHER|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Access Direct Platinum|HEALTHFIRST TPA|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Veterans Affairs|VETERANS ADMINISTRATION|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Workers Compensation|TEXAS MUTUAL INSURANCE|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Aetna|AETNA QHP HMO|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Aetna|AETNA OTHER|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Aetna|AETNA PPO|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Cigna|CIGNA|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Blue Cross HMO Specialty|BCBSTX HMO|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|PHCS|HUMANA|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicaid|MEDICAID SUPERIOR|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Cigna|CIGNA OTHER|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Rusk State Hospital|RUSK STATE HOSP|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Cigna|CIGNA|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Healthcare|UNITED HEALTHCARE|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Healthcare|UNITED HEALTHCARE|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Healthcare|TML GROUP BENEFITS|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Healthcare|UNITED HEALTHCARE OTHER|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Humana Medicare Advantage|HUMANA MA|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Tricare|TRICARE EAST REGION|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Multiplan|PACIFICARE|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Tricare|TRICARE FOR LIFE|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|NON CONTRACTED|COMMERCIAL OTHER 1|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicaid|MEDICAID AMERIGROUP|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicare|BCBS MEDICARE PPO MA|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicare|HEALTHSPRING MA|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|7.75||||7.75||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Healthcare|GOLDEN RULE|7.75||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|MEDICAID HMO|7.75||||||| 9526112|ERX|0250|MINERAL OIL 30ML|Medicaid|MEDICAID|9.25||||||| 9526112|ERX|0250|MINERAL OIL 30ML|Managed Medicare|HEALTHSPRING MA|9.25||||9.25||| 9526112|ERX|0250|MINERAL OIL 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.25||| 9526112|ERX|0250|MINERAL OIL 30ML|Medicare|MEDICARE ACUTE|9.25||||9.25||| 9526112|ERX|0250|MINERAL OIL 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.25||||||| 9526112|ERX|0250|MINERAL OIL 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.25||||||| 9526112|ERX|0250|MINERAL OIL 30ML|Blue Cross PPO Specialty|BCBSTX PPO|||||9.25||| 9526112|ERX|0250|MINERAL OIL 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.25||| 9526112|ERX|0250|MINERAL OIL 30ML|Humana Medicare Advantage|HUMANA MA|9.25||||||| 9526112|ERX|0250|MINERAL OIL 30ML|United Medicare Advantage|UHC AARP MCR HMO MA|9.25||||9.25||| 9526112|ERX|0250|MINERAL OIL 30ML|Managed Medicaid|MEDICAID SUPERIOR|||||9.25||| 9526112|ERX|0250|MINERAL OIL 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|9.25||||9.25||| 9526112|ERX|0250|MINERAL OIL 30ML|United Healthcare|UNITED HEALTHCARE|9.25||||||| 9526120|ERX|0250|ATOMOXETINE 60MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|49.25||||||| 9526120|ERX|0250|ATOMOXETINE 60MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|49.25||||||| 9526120|ERX|0250|ATOMOXETINE 60MG CAPSULE|Medicare|MEDICARE ACUTE|49.25||||||| 9526138|ERX|0250|SALSALATE 500MG TABLET|Medicare|MEDICARE ACUTE|5.50||||||| 9526138|ERX|0250|SALSALATE 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|5.50||||||| 9526138|ERX|0250|SALSALATE 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|ChampVA|CHAMPVA CENTER|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Aetna|AETNA QHP HMO|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Aetna|BOON CHAPMAN|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Aetna|BH AETNA|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Aetna|AETNA OTHER|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Aetna|AETNA PPO|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Cigna Behavioral Health|BH CIGNA|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Workers Compensation|BROOKSHIRES WORKERS COMP|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Access Direct Platinum|HEALTHFIRST TPA|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Access Direct Platinum|ANDREWS CENTER|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Healthcare|GOLDEN RULE|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Healthcare|TML GROUP BENEFITS|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Medicare Advantage|UHC AARP MCR HMO MA|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Optum Behavioral Health|BH OPTUM UHC|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Multiplan|TRUSTMARK|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|PHCS|GROUP AND PENSION|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Cigna|CIGNA OTHER|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Workers Compensation|UT EMPLOYEE INJURY|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|PHCS|HUMANA INSURANCE|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Magellan Behavioral Health|BH MAGELLAN|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicare|JACKSONVILLE ACCESS|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicaid|BH TEXAS CHILDRENS MEDICAID|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicaid|MEDICAID HMO|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicaid|MEDICAID|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicare|WELLCARE CHOICE MA|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Tricare|TRICARE EAST REGION|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicaid|SMITH COUNTY JAIL|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicaid|CRIME VICTIMS COMPENSATION|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|NON CONTRACTED|COMMUNITY HEALTH CENTER|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Cigna|CIGNA|2.50||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Humana Medicare Advantage|HUMANA MA|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Medicare|MEDICARE ACUTE|7.25||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicare|ETMC AFFILIATE HOSPITALS|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Medicaid|MEDICAID|7.25||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|United Medicare Advantage|UHC MEDICARE GOLD MA|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicare|HEALTHSPRING MA|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Tricare|TRICARE EAST REGION|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicaid|MEDICAID SUPERIOR|||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicaid|MEDICAID AMERIGROUP|7.25||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Cigna|CIGNA|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Cigna|CIGNA OTHER|||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Cigna|CIGNA|7.25||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Blue Cross PPO Specialty|BCBSTX PPO|7.25||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Aetna|AETNA PPO|||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Blue Cross HMO Specialty|BCBSTX HMO|7.25||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|United Healthcare|UNITED HEALTHCARE|||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|7.25||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.25||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|United Medicare Advantage|UHC AARP MCR HMO MA|||||7.25||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Magellan Behavioral Health|BH MAGELLAN|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Cigna Behavioral Health|BH CIGNA|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Humana Medicare Advantage|HUMANA MA|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Multiplan|WEB TPA|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Access Direct Platinum|ANDREWS CENTER|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Optum Behavioral Health|BH OPTUM UHC|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Tricare|TRICARE EAST REGION|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Medicare|MEDICARE ACUTE|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Medicaid|MEDICAID|123.50||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|123.50||||||| 9526229|ERX|0250|NITROGLYCERIN 50MG/500ML|Medicare|MEDICARE ACUTE|5.89||||||| 9526229|ERX|0250|NITROGLYCERIN 50MG/500ML|United Medicare Advantage|UHC MEDICARE GOLD MA|5.89||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.25||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.25||||26.25||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.25||||26.25||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|26.25||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Medicare|MEDICARE PART B ONLY IP|26.25||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.25||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|26.25||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|26.25||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Humana Medicare Advantage|HUMANA MA|26.25||||26.25||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Medicare|MEDICARE ACUTE|26.25||||26.25||| 9526260|ERX|0250|PALIPERIDONE 6MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|90.25||||||| 9526260|ERX|0250|PALIPERIDONE 6MG TABLET|Medicare|MEDICARE ACUTE|90.25||||90.25||| 9526260|ERX|0250|PALIPERIDONE 6MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|90.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Healthcare|UNITED HEALTHCARE|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Aenta Medicare Advantage|AETNA MEDICARE MA|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Access Direct Platinum|HEALTHFIRST TPA|||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Veterans Affairs|VETERANS ADMINISTRATION|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Medicare Advantage|UHC AARP MCR HMO MA|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicaid|MEDICAID SUPERIOR|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Access Direct Platinum|HEALTHFIRST TPA UMR|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicaid|MEDICAID AMERIGROUP|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Healthcare|UNITED HEALTHCARE|||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Healthcare|UNITED HEALTHCARE OTHER|12.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Humana Medicare Advantage|HUMANA MA|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Aetna|AETNA PPO|||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Workers Compensation|WORKERS COMPENSATION OTHER|12.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Cigna|CIGNA|12.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Rusk State Hospital|RUSK STATE HOSP|||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Blue Cross HMO Specialty|BCBSTX HMO|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|NON CONTRACTED|COMMERCIAL OTHER 1|12.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicaid|CRIME VICTIMS COMPENSATION|12.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicare|MEDICARE PART B ONLY IP|12.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|PHCS|HUMANA|||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicare|MEDICARE ACUTE|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicare|HEALTHSPRING MA|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Aetna|BOON CHAPMAN|12.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||12.25||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicare|BCBS MEDICARE PPO MA|12.25||||||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|United Healthcare|UNITED HEALTHCARE|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicare|MEDICARE ACUTE|7.25||||||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Tricare|TRICARE EAST REGION|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|MEDICAID HMO|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|SUPERIOR HEALTHPLAN CHIP|7.25||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Blue Cross HMO Specialty|BCBSTX HMO|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.25||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Cigna|CIGNA|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Blue Cross PPO Specialty|BCBSTX OTHER|7.25||||||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.25||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Blue Cross PPO Specialty|BCBSTX PPO|7.25||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Managed Medicaid|MEDICAID SUPERIOR|7.25||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Cigna|CIGNA OTHER|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Aetna|AETNA PPO|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Managed Medicaid|MEDICAID AMERIGROUP|7.25||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|United Healthcare|UNITED HEALTHCARE|7.25||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|United Healthcare|UNITED HEALTHCARE OTHER|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|MEDICAID|||||7.25||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7.25||| 9526351|ERX|0250|FLUORESCEIN 10%, 5ML VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||299.25||| 9526351|ERX|0250|FLUORESCEIN 10%, 5ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|299.25||||||| 9526351|ERX|0250|FLUORESCEIN 10%, 5ML VIAL|Humana Medicare Advantage|HUMANA MA|299.25||||||| 9526351|ERX|0250|FLUORESCEIN 10%, 5ML VIAL|Medicare|MEDICARE ACUTE|299.25||||||| 9526351|ERX|0250|FLUORESCEIN 10%, 5ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|299.25||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Medicaid|SMITH COUNTY JAIL|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|United Healthcare|UNITED HEALTHCARE|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Medicaid|LAW ENFORCEMENT OTHER|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Medicaid|MEDICAID HMO|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Medicaid|CRIME VICTIMS COMPENSATION|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Medicaid|MEDICAID|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Aetna|AETNA PPO|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|United Healthcare|UNITED HEALTHCARE OTHER|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Cigna|CIGNA|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Managed Medicaid|MEDICAID AMERIGROUP|||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|ChampVA|CHAMPVA CENTER|0.13||||||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Cigna|CIGNA OTHER|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9526369|ERX|0250|LIDO 2%-EPI 1:100,000, 1.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Access Direct Platinum|HEALTHFIRST TPA UMR|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Veterans Affairs|VETERANS ADMINISTRATION|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|United Medicare Advantage|UHC MEDICARE GOLD MA|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Access Direct Platinum|HEALTHFIRST TPA|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Managed Medicaid|MEDICAID AMERIGROUP|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Aetna|AETNA PPO|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Blue Cross PPO Specialty|BCBSTX OTHER|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Aetna Value Network|AETNA VALUE NETWORK|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Cigna|CIGNA|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Blue Cross PPO Specialty|BCBSTX PPO|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Aetna|BOON CHAPMAN|||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Humana Medicare Advantage|HUMANA MA|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Managed Medicare|BCBS MEDICARE PPO MA|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|NON CONTRACTED|COMMERCIAL OTHER 1|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|PHCS|GROUP AND PENSION|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Tricare|TRICARE EAST REGION|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Blue Cross HMO Specialty|BCBSTX HMO|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|United Healthcare|UNITED HEALTHCARE|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|United Healthcare|UNITED HEALTHCARE OTHER|0.29||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Medicaid|MEDICAID|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|United Healthcare|UNITED HEALTHCARE|||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.29||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Managed Medicare|HEALTHSPRING MA|0.29||||||| 9526401|ERX|0250|SILVER NITRATE APPLICATOR|Medicare|MEDICARE ACUTE|0.29||||0.29||| 9526427|ERX|0250|AMMONIUM ALUM 30 GM PWDR|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|United Healthcare|UNITED HEALTHCARE|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|United Healthcare|TML GROUP BENEFITS|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|PHCS|GROUP AND PENSION|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|PHCS|HUMANA|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Texas Workforce Commission|DIS DETER SERV (DDS)|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Tricare|TRICARE FOR LIFE|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Multiplan|PACIFICARE|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|NON CONTRACTED|COMMERCIAL OTHER 2|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Medicaid|MEDICAID|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Medicaid|MOLINA HEALTHCARE OF TEXAS|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Medicare|MEDICARE ACUTE|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Medicaid|CRIME VICTIMS COMPENSATION|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicare|HEALTHSPRING MA|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Rusk State Hospital|RUSK STATE HOSP|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Aetna|AETNA PPO|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Aetna|AETNA QHP HMO|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Aetna|BOON CHAPMAN|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicare|BCBS MEDICARE PPO MA|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Aenta Medicare Advantage|AETNA MEDICARE MA|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Brinson Benefits|THE HEALTH PLAN SMITH CO|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Aetna|AETNA OTHER|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Access Direct Platinum|HEALTHFIRST TPA UMR|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicaid|MEDICAID SUPERIOR|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Cigna|CIGNA OTHER|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Veterans Affairs|VETERANS ADMINISTRATION|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Workers Compensation|TEXAS MUTUAL INSURANCE|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicare|OTHER INSTITUTIONS|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Medicare|MEDICARE PART B ONLY IP|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Cigna|CIGNA|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|NON CONTRACTED|COMMERCIAL OTHER 1|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Workers Compensation|BROOKSHIRES WORKERS COMP|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Workers Compensation|GALLAGHER BASSETT|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Humana Medicare Advantage|HUMANA MA|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Workers Compensation|ZURICH COMPANY|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Workers Compensation|UT EMPLOYEE INJURY|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Blue Cross PPO Specialty|BCBSTX PPO|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Blue Cross PPO Specialty|BCBSTX OTHER|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Tricare|TRICARE EAST REGION|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Blue Cross HMO Specialty|BCBSTX HMO|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Aetna Value Network|AETNA VALUE NETWORK|||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Workers Compensation|WORKERS COMPENSATION OTHER|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicaid|MEDICAID AMERIGROUP|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|United Healthcare|GEHA|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|United Healthcare|UNITED HEALTHCARE OTHER|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|United Medicare Advantage|UHC AARP WELLMED HMO MA|46.50||||||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|United Medicare Advantage|UHC AARP MCR HMO MA|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Access Direct Platinum|HEALTHFIRST TPA|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|United Medicare Advantage|UHC MEDICARE GOLD MA|46.50||||46.50||| 9526468|ERX|0250|EPHEDRINE 50 MG/10 ML SYR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.50||||46.50||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Blue Cross HMO Specialty|BCBSTX HMO|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Aetna|AETNA PPO|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Humana Medicare Advantage|HUMANA MA|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Aetna|AETNA OTHER|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Blue Cross PPO Specialty|BCBSTX PPO|0.55||||0.55||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Managed Medicare|HEALTHSPRING MA|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Veterans Affairs|VETERANS ADMINISTRATION|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Managed Medicare|BCBS MEDICARE PPO MA|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Medicare|MEDICARE ACUTE|0.55||||0.55||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|Cigna|CIGNA|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|United Healthcare|UNITED HEALTHCARE|0.55||||||| 9526476|ERX|0250|EPINEPHRINE 100 MCG/10 ML|United Healthcare|UNITED HEALTHCARE OTHER|0.55||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Rusk State Hospital|RUSK STATE HOSP|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|United Healthcare|TML GROUP BENEFITS|||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|PHCS|GROUP AND PENSION|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|United Healthcare|GEHA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Texas Workforce Commission|DIS DETER SERV (DDS)|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicaid|CRIME VICTIMS COMPENSATION|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicaid|LAW ENFORCEMENT OTHER|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicaid|MEDICAID HMO|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicare|MEDICARE PART B ONLY IP|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|PHCS|HUMANA|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicare|MEDICARE ACUTE|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicaid|MEDICAID|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Managed Medicare|HEALTHSPRING MA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|United Healthcare|UNITED HEALTHCARE|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Aetna|AETNA OTHER|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Aetna|AETNA QHP HMO|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Aetna|AETNA PPO|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Managed Medicare|BCBS MEDICARE PPO MA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Aetna|BOON CHAPMAN|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Multiplan|WEB TPA|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Tricare|TRICARE EAST REGION|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Aetna Value Network|AETNA VALUE NETWORK|||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Multiplan|PACIFICARE|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|ChampVA|CHAMPVA CENTER|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Managed Medicaid|MEDICAID SUPERIOR|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Humana Medicare Advantage|HUMANA MA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Cigna|CIGNA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Cigna|CIGNA OTHER|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Managed Medicaid|MEDICAID AMERIGROUP|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.39||||||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Veterans Affairs|VETERANS ADMINISTRATION|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Workers Compensation|GALLAGHER BASSETT|||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Access Direct Platinum|HEALTHFIRST TPA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.39||||0.39||| 9526484|ERX|0250|PHENYLEPH 1,000 MCG/10ML|Workers Compensation|UT EMPLOYEE INJURY|||||0.39||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|United Medicare Advantage|UHC AARP MCR HMO MA|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Access Direct Platinum|HEALTHFIRST TPA UMR|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Veterans Affairs|VETERANS ADMINISTRATION|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Cigna|CIGNA OTHER|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Managed Medicaid|MEDICAID AMERIGROUP|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Aetna|AETNA OTHER|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Blue Cross PPO Specialty|BCBSTX PPO|682.25||||682.25||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Blue Cross PPO Specialty|BCBSTX OTHER|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Aetna|AETNA PPO|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Humana Medicare Advantage|HUMANA MA|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Aetna|AETNA QHP HMO|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Aenta Medicare Advantage|AETNA MEDICARE MA|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|United Medicare Advantage|UHC MEDICARE GOLD MA|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Managed Medicare|HEALTHSPRING MA|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|United Medicare Advantage|UHC AARP WELLMED HMO MA|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Managed Medicare|BCBS MEDICARE PPO MA|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Medicaid|MEDICAID|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|NON CONTRACTED|COMMERCIAL OTHER 1|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Medicare|MEDICARE ACUTE|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|United Healthcare|UNITED HEALTHCARE|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|PHCS|GROUP AND PENSION|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|United Healthcare|UNITED HEALTHCARE OTHER|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Blue Cross HMO Specialty|BCBSTX HMO|682.25||||||| 9526500|ERX|0258|CARDIOPLEGIC-WARM INDUC 5|Cigna|CIGNA|682.25||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|United Healthcare|UNITED HEALTHCARE|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|NON CONTRACTED|COMMERCIAL OTHER 1|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|PHCS|GROUP AND PENSION|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Medicaid|MEDICAID|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Aenta Medicare Advantage|AETNA MEDICARE MA|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Managed Medicare|BCBS MEDICARE PPO MA|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Medicare|MEDICARE ACUTE|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Aetna|AETNA PPO|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Aetna|AETNA QHP HMO|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Aetna|AETNA OTHER|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Blue Cross HMO Specialty|BCBSTX HMO|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Blue Cross PPO Specialty|BCBSTX OTHER|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Blue Cross PPO Specialty|BCBSTX PPO|413.50||||413.50||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Managed Medicare|HEALTHSPRING MA|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|United Healthcare|UNITED HEALTHCARE OTHER|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Managed Medicaid|MEDICAID AMERIGROUP|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Cigna|CIGNA|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Access Direct Platinum|HEALTHFIRST TPA UMR|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Managed Medicaid|MEDICAID UNITED HEALTHCARE|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Veterans Affairs|VETERANS ADMINISTRATION|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Humana Medicare Advantage|HUMANA MA|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|United Medicare Advantage|UHC AARP WELLMED HMO MA|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|United Medicare Advantage|UHC AARP MCR HMO MA|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|Cigna|CIGNA OTHER|413.50||||||| 9526518|ERX|0258|CARDIOPLEGIC-MULTI DOSE 8|United Medicare Advantage|UHC MEDICARE GOLD MA|413.50||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|United Medicare Advantage|UHC AARP MCR HMO MA|32.25||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|MEDICAID AMERIGROUP|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Workers Compensation|TEXAS MUTUAL INSURANCE|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Veterans Affairs|VETERANS ADMINISTRATION|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Magellan Behavioral Health|BH MAGELLAN|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Cigna|CIGNA OTHER|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Cigna|CIGNA|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|MEDICAID SUPERIOR|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Cigna Behavioral Health|BH CIGNA|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32.25||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Access Direct Platinum|HEALTHFIRST TPA UMR|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Access Direct Platinum|HEALTHFIRST TPA|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Blue Cross HMO Specialty|BCBSTX HMO|32.25||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Medicaid|COUNTY INDIGENT HEALTH OTHER|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Medicaid|SMITH COUNTY INDIGENT HEALTH|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|NON CONTRACTED|COMMERCIAL OTHER 1|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Medicaid|MEDICAID|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Multiplan|WEB TPA|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|United Medicare Advantage|UHC MEDICARE GOLD MA|32.25||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Humana Medicare Advantage|HUMANA MA|32.25||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Medicaid|BH TEXAS CHILDRENS MEDICAID|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Aetna|BH AETNA|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|NON CONTRACTED|COMMUNITY HEALTH CENTER|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Rusk State Hospital|RUSK STATE HOSP|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicare|HEALTHSPRING MA|32.25||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Blue Cross PPO Specialty|BCBSTX PPO|32.25||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Texas Workforce Commission|DIS DETER SERV (DDS)|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Workers Compensation|WORKERS COMPENSATION OTHER|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Tricare|TRICARE EAST REGION|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|UTMB|UTMB CORRECTIONAL MANAGED CARE|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|United Healthcare|UNITED HEALTHCARE|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicare|BCBS MEDICARE PPO MA|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32.25||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|United Healthcare|TML GROUP BENEFITS|32.25||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|United Healthcare|UNITED HEALTHCARE OTHER|32.25||||32.25||| 9526534|ERX|0250|NON-FORMULARY DRUG|Medicare|MEDICARE ACUTE|32.25||||32.25||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|Managed Medicare|HEALTHSPRING MA|591.75||||591.75||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|United Medicare Advantage|UHC MEDICARE GOLD MA|591.75||||||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||591.75||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|591.75||||591.75||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|591.75||||||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|591.75||||||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|Medicare|MEDICARE ACUTE|591.75||||591.75||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|Humana Medicare Advantage|HUMANA MA|591.75||||591.75||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|United Medicare Advantage|UHC AARP MCR HMO MA|591.75||||||| 9526575|ERX|0250|COMBIGAN 5 ML OPTH DROP|Blue Cross PPO Specialty|BCBSTX PPO|591.75||||||| 9526591|ERX|0250|FENTANYL 1500 MCG/30 ML P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|137.25||||||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Cigna|CIGNA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|UTMB|UTMB CORRECTIONAL MANAGED CARE|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Healthcare|UNITED HEALTHCARE OTHER|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Rusk State Hospital|RUSK STATE HOSP|337.75||||||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Healthcare|GOLDEN RULE|||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Healthcare|UNITED HEALTHCARE|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|PHCS|HUMANA|337.75||||||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Healthcare|TML GROUP BENEFITS|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Texas Workforce Commission|DIS DETER SERV (DDS)|||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Medicaid|MEDICAID HMO|337.75||||||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Managed Medicare|BCBS MEDICARE PPO MA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Managed Medicare|HEALTHSPRING MA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Medicaid|MEDICAID|337.75||||||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Medicaid|COUNTY INDIGENT HEALTH OTHER|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Medicare|MEDICARE PART B ONLY IP|337.75||||||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Medicare|MEDICARE ACUTE|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Cigna|CIGNA OTHER|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Humana Medicare Advantage|HUMANA MA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Managed Medicaid|MEDICAID SUPERIOR|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Managed Medicaid|MEDICAID AMERIGROUP|||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Aetna|AETNA QHP HMO|||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Aetna|AETNA PPO|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Aenta Medicare Advantage|AETNA MEDICARE MA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Tricare|TRICARE EAST REGION|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|NON CONTRACTED|COMMERCIAL OTHER 1|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Healthcare|UNITED HEALTHCARE ERS|||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|PHCS|GROUP AND PENSION|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Medicare Advantage|UHC AARP WELLMED HMO MA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Healthcare|UNITED HEALTHCARE|||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Blue Cross HMO Specialty|BCBSTX HMO|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Veterans Affairs|VETERANS ADMINISTRATION|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Medicare Advantage|UHC MEDICARE GOLD MA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Blue Cross PPO Specialty|BCBSTX PPO|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Workers Compensation|BROOKSHIRES WORKERS COMP|337.75||||||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|United Medicare Advantage|UHC AARP MCR HMO MA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|ChampVA|CHAMPVA CENTER|337.75||||||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Blue Cross PPO Specialty|BCBSTX OTHER|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Workers Compensation|WORKERS COMPENSATION OTHER|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Access Direct Platinum|HEALTHFIRST TPA|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Access Direct Platinum|HEALTHFIRST TPA UMR|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|337.75||||337.75||| 9526641|ERX|0250|DESFLURANE ANESTHETIC GAS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|337.75||||||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Access Direct Platinum|HEALTHFIRST TPA|||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|127.50||||||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Blue Cross PPO Specialty|BCBSTX PPO|127.50||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|United Medicare Advantage|UHC AARP MCR HMO MA|||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|United Medicare Advantage|UHC MEDICARE GOLD MA|127.50||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|ChampVA|CHAMPVA CENTER|127.50||||||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|127.50||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Aenta Medicare Advantage|AETNA MEDICARE MA|127.50||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Humana Medicare Advantage|HUMANA MA|127.50||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Medicare|MEDICARE ACUTE|127.50||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|United Healthcare|UNITED HEALTHCARE|127.50||||||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|United Healthcare|TML GROUP BENEFITS|127.50||||||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Medicaid|CRIME VICTIMS COMPENSATION|127.50||||||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Medicaid|MEDICAID|127.50||||||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|NON CONTRACTED|COMMERCIAL OTHER 1|||||127.50||| 9526658|ERX|0250|ISOFLURANE ANESTHETIC GAS|Cigna|CIGNA OTHER|127.50||||||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|United Healthcare|UNITED HEALTHCARE OTHER|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Rusk State Hospital|RUSK STATE HOSP|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|UTMB|UTMB CORRECTIONAL MANAGED CARE|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|United Healthcare|UNITED HEALTHCARE|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|United Healthcare|UNITED HEALTHCARE ERS|423.25||||||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|United Healthcare|TML GROUP BENEFITS|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|PHCS|GROUP AND PENSION|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|PHCS|HUMANA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|PHCS|HUMANA INSURANCE|423.25||||||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Tricare|TRICARE FOR LIFE|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Tricare|TRICARE EAST REGION|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicare|HEALTHSPRING MA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|SMITH COUNTY JAIL|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|United Healthcare|GEHA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicare|OTHER INSTITUTIONS|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicare|BCBS MEDICARE PPO MA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|423.25||||||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|MOLINA HEALTHCARE OF TEXAS|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|MEDICAID HMO|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Multiplan|WEB TPA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|LAW ENFORCEMENT OTHER|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|CRIME VICTIMS COMPENSATION|423.25||||||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Multiplan|PACIFICARE|423.25||||||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|NON CONTRACTED|COMMERCIAL OTHER 2|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicare|MEDICARE ACUTE|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicaid|MEDICAID AMERIGROUP|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Cigna|CIGNA OTHER|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Cigna|CIGNA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicare|MEDICARE PART B ONLY IP|423.25||||||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Humana Medicare Advantage|HUMANA MA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicaid|MEDICAID SUPERIOR|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Aetna|BOON CHAPMAN|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Aetna|AETNA QHP HMO|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Aetna|AETNA OTHER|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Aetna|AETNA PPO|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Aetna Value Network|AETNA VALUE NETWORK|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|SUPERIOR HEALTHPLAN CHIP|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Aenta Medicare Advantage|AETNA MEDICARE MA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|COUNTY INDIGENT HEALTH OTHER|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|MEDICAID|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|NON CONTRACTED|COMMERCIAL OTHER 1|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Texas Workforce Commission|DIS DETER SERV (DDS)|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Medicaid|MEDICAID BCBSTX|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|ChampVA|CHAMPVA CENTER|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Brinson Benefits|THE HEALTH PLAN SMITH CO|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Veterans Affairs|VETERANS ADMINISTRATION|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|United Medicare Advantage|UHC AARP WELLMED HMO MA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Blue Cross HMO Specialty|BCBSTX HMO|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Blue Cross PPO Specialty|BCBSTX OTHER|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|United Medicare Advantage|UHC MEDICARE GOLD MA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|United Medicare Advantage|UHC AARP MCR HMO MA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|TEXAS MUTUAL INSURANCE|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|ZURICH COMPANY|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|TRAVELERS INSURANCE COMPANY|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Access Direct Platinum|HEALTHFIRST TPA UMR|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|BROOKSHIRES WORKERS COMP|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Blue Cross PPO Specialty|BCBSTX PPO|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|GALLAGHER BASSETT|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|WORKERS COMP PHYSICIAN|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Access Direct Platinum|HEALTHFIRST TPA|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|UT EMPLOYEE INJURY|||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|423.25||||423.25||| 9526666|ERX|0250|SEVOFLURANE ANESTHETIC GA|Workers Compensation|WORKERS COMPENSATION OTHER|423.25||||423.25||| 9526674|ERX|0250|FONDAPARINUX 5 MG/0.4 ML|United Medicare Advantage|UHC MEDICARE GOLD MA|8.41||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Medicare|MEDICARE ACUTE|218.50||||218.50||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Medicaid|MEDICAID|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Managed Medicare|HEALTHSPRING MA|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|NON CONTRACTED|COMMERCIAL OTHER 1|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Tricare|TRICARE EAST REGION|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|United Healthcare|UNITED HEALTHCARE|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Managed Medicaid|MEDICAID AMERIGROUP|||||218.50||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Blue Cross PPO Specialty|BCBSTX PPO|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Cigna|CIGNA|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Veterans Affairs|VETERANS ADMINISTRATION|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|United Medicare Advantage|UHC MEDICARE GOLD MA|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|United Medicare Advantage|UHC AARP MCR HMO MA|218.50||||218.50||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||218.50||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Humana Medicare Advantage|HUMANA MA|218.50||||218.50||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Blue Cross HMO Specialty|BCBSTX HMO|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|United Healthcare|UNITED HEALTHCARE OTHER|218.50||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|218.50||||||| 9526724|ERX|0250|KETROLAC 0.5% 3ML|Veterans Affairs|VETERANS ADMINISTRATION|332.25||||||| 9526724|ERX|0250|KETROLAC 0.5% 3ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||332.25||| 9526724|ERX|0250|KETROLAC 0.5% 3ML|Humana Medicare Advantage|HUMANA MA|332.25||||332.25||| 9526724|ERX|0250|KETROLAC 0.5% 3ML|NON CONTRACTED|COMMERCIAL OTHER 1|332.25||||||| 9526724|ERX|0250|KETROLAC 0.5% 3ML|Medicare|MEDICARE PART B ONLY IP|332.25||||||| 9526724|ERX|0250|KETROLAC 0.5% 3ML|Medicare|MEDICARE ACUTE|332.25||||||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Blue Cross PPO Specialty|BCBSTX OTHER|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Managed Medicare|WELLCARE CHOICE MA|12.25||||||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.25||||||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Medicaid|MEDICAID|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.25||||||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|United Healthcare|UNITED HEALTHCARE OTHER|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|United Healthcare|UNITED HEALTHCARE|||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Medicaid|MEDICAID HMO|||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|NON CONTRACTED|COMMERCIAL OTHER 1|||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Tricare|TRICARE EAST REGION|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Medicaid|SUPERIOR HEALTHPLAN CHIP|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|United Healthcare|UNITED HEALTHCARE|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Aetna|AETNA PPO|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Medicare|MEDICARE ACUTE|12.25||||||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Blue Cross HMO Specialty|BCBSTX HMO|12.25||||||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Cigna|CIGNA|||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Cigna|CIGNA OTHER|||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Humana Medicare Advantage|HUMANA MA|12.25||||||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Managed Medicaid|MEDICAID AMERIGROUP|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Managed Medicaid|MEDICAID SUPERIOR|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Access Direct Platinum|HEALTHFIRST TPA UMR|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|12.25||||12.25||| 9526757|ERX|0250|IBUPROFEN 200 MG/10ML UD|Access Direct Platinum|HEALTHFIRST TPA|||||12.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Veterans Affairs|VETERANS ADMINISTRATION|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Workers Compensation|WORKERS COMPENSATION OTHER|||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Access Direct Platinum|HEALTHFIRST TPA|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Access Direct Platinum|HEALTHFIRST TPA UMR|||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|United Medicare Advantage|UHC AARP WELLMED HMO MA|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|United Medicare Advantage|UHC AARP MCR HMO MA|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicaid|MEDICAID AMERIGROUP|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicaid|MEDICAID SUPERIOR|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Cigna|CIGNA OTHER|||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Blue Cross HMO Specialty|BCBSTX HMO|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Cigna|CIGNA|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Blue Cross PPO Specialty|BCBSTX PPO|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Aetna|AETNA QHP HMO|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Aetna|AETNA OTHER|||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Aenta Medicare Advantage|AETNA MEDICARE MA|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|NON CONTRACTED|COMMERCIAL OTHER 1|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Rusk State Hospital|RUSK STATE HOSP|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Tricare|TRICARE FOR LIFE|||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Tricare|TRICARE EAST REGION|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|United Medicare Advantage|UHC MEDICARE GOLD MA|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|UTMB|UTMB CORRECTIONAL MANAGED CARE|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|United Healthcare|UNITED HEALTHCARE OTHER|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|United Healthcare|UNITED HEALTHCARE|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|United Healthcare|TML GROUP BENEFITS|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicare|MEDICARE PART B ONLY IP|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Workers Compensation|TEXAS MUTUAL INSURANCE|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicare|MEDICARE ACUTE|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicaid|MOLINA HEALTHCARE OF TEXAS|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicaid|SUPERIOR HEALTHPLAN CHIP|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicaid|MEDICAID HMO|||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicare|BCBS MEDICARE PPO MA|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicare|HEALTHSPRING MA|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicaid|MEDICAID|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicaid|COUNTY INDIGENT HEALTH OTHER|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicaid|CRIME VICTIMS COMPENSATION|14.25||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Humana Medicare Advantage|HUMANA MA|14.25||||14.25||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|14.25||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|United Healthcare|UNITED HEALTHCARE|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Humana Medicare Advantage|HUMANA MA|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Cigna|CIGNA|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.64||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.64||||0.64||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.64||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Medicare|MEDICARE ACUTE|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.64||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.64||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Workers Compensation|WORKERS COMPENSATION OTHER|12.25||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Veterans Affairs|VETERANS ADMINISTRATION|||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Access Direct Platinum|HEALTHFIRST TPA|12.25||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|12.25||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|United Medicare Advantage|UHC AARP MCR HMO MA|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicaid|MEDICAID SUPERIOR|||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Humana Medicare Advantage|HUMANA MA|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Cigna|CIGNA OTHER|12.25||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Cigna|CIGNA|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Cigna|CIGNA|||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicaid|MEDICAID AMERIGROUP|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Blue Cross HMO Specialty|BCBSTX HMO|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Blue Cross PPO Specialty|BCBSTX OTHER|12.25||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Aetna|AETNA PPO|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|PHCS|HUMANA|||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|PHCS|GROUP AND PENSION|||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Access Direct Platinum|HEALTHFIRST TPA UMR|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Tricare|TRICARE EAST REGION|12.25||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.25||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|United Healthcare|UNITED HEALTHCARE OTHER|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|United Healthcare|UNITED HEALTHCARE|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicare|HEALTHSPRING MA|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicare|BCBS MEDICARE PPO MA|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Medicaid|MEDICAID HMO|12.25||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Medicaid|MEDICAID|12.25||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|United Healthcare|UNITED HEALTHCARE|||||12.25||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Medicare|MEDICARE PART B ONLY IP|12.25||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Medicare|MEDICARE ACUTE|12.25||||12.25||| 9526799|ERX|0250|ALCOHOL DEHYD 98% 5 ML AM|Medicare|MEDICARE ACUTE|3.03||||3.03||| 9526799|ERX|0250|ALCOHOL DEHYD 98% 5 ML AM|United Healthcare|UNITED HEALTHCARE|||||3.03||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Managed Medicare|HEALTHSPRING MA|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Aetna|AETNA PPO|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Managed Medicaid|MEDICAID SUPERIOR|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Veterans Affairs|VETERANS ADMINISTRATION|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|NON CONTRACTED|COMMERCIAL OTHER 1|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.87||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Medicare|MEDICARE ACUTE|0.87||||0.87||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Medicaid|MEDICAID|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Medicare|MEDICARE ACUTE|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Managed Medicare|HEALTHSPRING MA|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|41.75||||||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|United Healthcare|UNITED HEALTHCARE|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|United Healthcare|UNITED HEALTHCARE|41.75||||||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|PHCS|HUMANA|||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Tricare|TRICARE EAST REGION|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Tricare|TRICARE FOR LIFE|41.75||||||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Cigna|CIGNA|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Aetna|AETNA PPO|41.75||||||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|41.75||||||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Aetna|AETNA OTHER|41.75||||||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Cigna|CIGNA OTHER|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Humana Medicare Advantage|HUMANA MA|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|41.75||||||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|41.75||||||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|41.75||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||41.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41.75||||41.75||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Aetna|AETNA PPO|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Blue Cross HMO Specialty|BCBSTX HMO|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Humana Medicare Advantage|HUMANA MA|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Blue Cross PPO Specialty|BCBSTX PPO|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|United Medicare Advantage|UHC MEDICARE GOLD MA|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|60.25||||60.25||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Rusk State Hospital|RUSK STATE HOSP|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|UTMB|UTMB CORRECTIONAL MANAGED CARE|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|United Healthcare|UNITED HEALTHCARE|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Managed Medicare|HEALTHSPRING MA|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Managed Medicare|BCBS MEDICARE PPO MA|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Medicare|MEDICARE ACUTE|60.25||||||| 9526872|ERX|0250|SEVELAMER 0.8 G POWDER PK|Medicaid|MEDICAID|60.25||||||| 9526880|ERX|0250|ADENOSINE 3 MG/ML 30 ML V|Medicare|MEDICARE ACUTE|2,025.75||||2,025.75||| 9526880|ERX|0250|ADENOSINE 3 MG/ML 30 ML V|United Healthcare|UNITED HEALTHCARE OTHER|||||2,025.75||| 9526880|ERX|0250|ADENOSINE 3 MG/ML 30 ML V|Tricare|TRICARE EAST REGION|||||2,025.75||| 9526880|ERX|0250|ADENOSINE 3 MG/ML 30 ML V|Humana Medicare Advantage|HUMANA MA|||||2,025.75||| 9526880|ERX|0250|ADENOSINE 3 MG/ML 30 ML V|Blue Cross PPO Specialty|BCBSTX OTHER|||||2,025.75||| 9526880|ERX|0250|ADENOSINE 3 MG/ML 30 ML V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,025.75||| 9526930|ERX|0250|FONDAPARINUX 10 MG/0.8 ML|Medicare|MEDICARE ACUTE|8.41||||||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|59.25||||||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Aetna|AETNA PPO|59.25||||||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|59.25||||||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Humana Medicare Advantage|HUMANA MA|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|PHCS|HUMANA INSURANCE|59.25||||||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|59.25||||||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|United Healthcare|UNITED HEALTHCARE|||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Managed Medicare|HEALTHSPRING MA|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|59.25||||||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Medicare|MEDICARE ACUTE|59.25||||59.25||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Cigna|CIGNA OTHER|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Medicare|MEDICARE ACUTE|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Medicaid|MEDICAID|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Managed Medicare|HEALTHSPRING MA|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|United Healthcare|UNITED HEALTHCARE|||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Tricare|TRICARE EAST REGION|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Humana Medicare Advantage|HUMANA MA|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Cigna|CIGNA|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Aetna|AETNA PPO|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|59.25||||||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|59.25||||59.25||| 9526955|ERX|0250|RIVAROXABAN 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|59.25||||59.25||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|United Medicare Advantage|UHC MEDICARE GOLD MA|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|United Medicare Advantage|UHC AARP MCR HMO MA|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Veterans Affairs|VETERANS ADMINISTRATION|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Aetna|AETNA QHP HMO|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Aetna|AETNA OTHER|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Aenta Medicare Advantage|AETNA MEDICARE MA|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Blue Cross HMO Specialty|BCBSTX HMO|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Blue Cross PPO Specialty|BCBSTX PPO|1.59||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Managed Medicaid|MEDICAID SUPERIOR|||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.59||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Cigna|CIGNA|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Humana Medicare Advantage|HUMANA MA|1.59||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Rusk State Hospital|RUSK STATE HOSP|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Tricare|TRICARE EAST REGION|1.59||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Managed Medicaid|MEDICAID AMERIGROUP|1.59||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|NON CONTRACTED|COMMERCIAL OTHER 1|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|United Healthcare|UNITED HEALTHCARE|||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|United Healthcare|UNITED HEALTHCARE OTHER|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|United Healthcare|UNITED HEALTHCARE|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.59||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Managed Medicare|WELLCARE CHOICE MA|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Managed Medicare|HEALTHSPRING MA|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Managed Medicare|BCBS MEDICARE PPO MA|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Medicaid|MEDICAID|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Medicaid|SMITH COUNTY JAIL|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.59||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Medicaid|CRIME VICTIMS COMPENSATION|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Medicare|MEDICARE PART B ONLY IP|1.59||||||| 9526963|ERX|0250|PIPERACILLIN-TAZO 2.25 G/|Medicare|MEDICARE ACUTE|1.59||||1.59||| 9526971|ERX|0250|LOTEPREDNOL 0.5% 5ML OPTH|Medicare|MEDICARE ACUTE|640.75||||640.75||| 9526971|ERX|0250|LOTEPREDNOL 0.5% 5ML OPTH|Humana Medicare Advantage|HUMANA MA|||||640.75||| 9526971|ERX|0250|LOTEPREDNOL 0.5% 5ML OPTH|Veterans Affairs|VETERANS ADMINISTRATION|640.75||||||| 9527003|ERX|0250|IBUPROFEN INFT 50 MG/1.25|Access Direct Platinum|HEALTHFIRST TPA UMR|||||49.50||| 9527003|ERX|0250|IBUPROFEN INFT 50 MG/1.25|Blue Cross PPO Specialty|BCBSTX PPO|49.50||||49.50||| 9527003|ERX|0250|IBUPROFEN INFT 50 MG/1.25|Managed Medicaid|MEDICAID SUPERIOR|49.50||||49.50||| 9527003|ERX|0250|IBUPROFEN INFT 50 MG/1.25|Managed Medicaid|MEDICAID AMERIGROUP|49.50||||49.50||| 9527003|ERX|0250|IBUPROFEN INFT 50 MG/1.25|NON CONTRACTED|COMMERCIAL OTHER 1|49.50||||||| 9527003|ERX|0250|IBUPROFEN INFT 50 MG/1.25|Medicaid|SUPERIOR HEALTHPLAN CHIP|49.50||||||| 9527011|ERX|0250|BENZOIN TINCT SPRAY 4 OZ|Medicare|MEDICARE ACUTE|65.75||||||| 9527011|ERX|0250|BENZOIN TINCT SPRAY 4 OZ|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||65.75||| 9527011|ERX|0250|BENZOIN TINCT SPRAY 4 OZ|Humana Medicare Advantage|HUMANA MA|65.75||||||| 9527011|ERX|0250|BENZOIN TINCT SPRAY 4 OZ|Blue Cross PPO Specialty|BCBSTX PPO|||||65.75||| 9527011|ERX|0250|BENZOIN TINCT SPRAY 4 OZ|Access Direct Platinum|HEALTHFIRST TPA UMR|65.75||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Access Direct Platinum|HEALTHFIRST TPA UMR|||||11.50||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Aenta Medicare Advantage|AETNA MEDICARE MA|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Humana Medicare Advantage|HUMANA MA|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|United Healthcare|UNITED HEALTHCARE|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Medicare|MEDICARE ACUTE|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|Managed Medicare|HEALTHSPRING MA|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|NON CONTRACTED|COMMERCIAL OTHER 1|11.50||||||| 9527029|ERX|0250|SORBITOL 70% SOLUTION, 30|United Healthcare|UNITED HEALTHCARE|||||11.50||| 9527045|ERX|0250|LACOSAMIDE 200 MG/20 ML|Medicare|MEDICARE ACUTE|291.50||||291.50||| 9527045|ERX|0250|LACOSAMIDE 200 MG/20 ML|Humana Medicare Advantage|HUMANA MA|291.50||||||| 9527045|ERX|0250|LACOSAMIDE 200 MG/20 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|291.50||||||| 9527045|ERX|0250|LACOSAMIDE 200 MG/20 ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||291.50||| 9527045|ERX|0250|LACOSAMIDE 200 MG/20 ML|United Medicare Advantage|UHC AARP MCR HMO MA|291.50||||||| 9527045|ERX|0250|LACOSAMIDE 200 MG/20 ML|Blue Cross PPO Specialty|BCBSTX PPO|291.50||||||| 9527045|ERX|0250|LACOSAMIDE 200 MG/20 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|291.50||||||| 9527045|ERX|0250|LACOSAMIDE 200 MG/20 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|291.50||||||| 9527045|ERX|0250|LACOSAMIDE 200 MG/20 ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|291.50||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|United Medicare Advantage|UHC MEDICARE GOLD MA|213.25||||213.25||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Workers Compensation|WORKERS COMPENSATION OTHER|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Veterans Affairs|VETERANS ADMINISTRATION|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Aetna|AETNA QHP HMO|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Aenta Medicare Advantage|AETNA MEDICARE MA|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Blue Cross HMO Specialty|BCBSTX HMO|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Blue Cross PPO Specialty|BCBSTX PPO|213.25||||213.25||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Managed Medicaid|MEDICAID SUPERIOR|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Aetna|AETNA PPO|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Cigna|CIGNA|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Humana Medicare Advantage|HUMANA MA|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|United Medicare Advantage|UHC AARP MCR HMO MA|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Rusk State Hospital|RUSK STATE HOSP|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|PHCS|GROUP AND PENSION|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|NON CONTRACTED|COMMERCIAL OTHER 2|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|UTMB|UTMB CORRECTIONAL MANAGED CARE|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|United Healthcare|UNITED HEALTHCARE OTHER|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Managed Medicare|HEALTHSPRING MA|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Managed Medicare|BCBS MEDICARE PPO MA|213.25||||213.25||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Tricare|TRICARE EAST REGION|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Medicaid|MEDICAID|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Medicaid|COUNTY INDIGENT HEALTH OTHER|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Medicaid|MOLINA HEALTHCARE OF TEXAS|213.25||||||| 9527060|ERX|0250|PHENYLEPHRINE 60 MG/250 M|Medicare|MEDICARE ACUTE|213.25||||213.25||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicare|MEDICARE ACUTE|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|CRIME VICTIMS COMPENSATION|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|MOLINA HEALTHCARE OF TEXAS|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|MEDICAID|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|LAW ENFORCEMENT OTHER|||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|SMITH COUNTY INDIGENT HEALTH|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|MEDICAID HMO|||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|COUNTY INDIGENT HEALTH OTHER|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|SMITH COUNTY JAIL|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|OTHER INSTITUTIONS|||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|HOSPICE OF EAST TEXAS|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|BCBS MEDICARE PPO MA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|UNITED HEALTHCARE OTHER|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|UNITED HEALTHCARE|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|TML GROUP BENEFITS|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|GEHA|||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|AARP|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|NON CONTRACTED|COMMERCIAL OTHER 2|||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|NON CONTRACTED|COMMERCIAL OTHER 1|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|PHCS|HUMANA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Texas Workforce Commission|DIS DETER SERV (DDS)|||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Rusk State Hospital|RUSK STATE HOSP|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Tricare|TRICARE EAST REGION|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Tricare|TRICARE FOR LIFE|||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Humana Medicare Advantage|HUMANA MA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Cigna|CIGNA OTHER|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Cigna|CIGNA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|UNITED HEALTHCARE|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Cigna|CIGNA|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicaid|MEDICAID SUPERIOR|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicaid|MEDICAID AMERIGROUP|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross PPO Specialty|BCBSTX OTHER|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross HMO Specialty|BCBSTX HMO|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross PPO Specialty|BCBSTX PPO|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|HEALTHSPRING MA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|WELLCARE CHOICE MA|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Brinson Benefits|THE HEALTH PLAN SMITH CO|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Aetna|BOON CHAPMAN|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicare|MEDICARE PART B ONLY IP|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Aetna|AETNA PPO|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Aenta Medicare Advantage|AETNA MEDICARE MA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Access Direct Platinum|HEALTHFIRST TPA UMR|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Access Direct Platinum|HEALTHFIRST TPA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Workers Compensation|WORKERS COMPENSATION OTHER|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Workers Compensation|TEXAS MUTUAL INSURANCE|19.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Veterans Affairs|VETERANS ADMINISTRATION|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Medicare Advantage|UHC MEDICARE GOLD MA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Medicare Advantage|UHC AARP WELLMED HMO MA|19.75||||19.75||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Medicare Advantage|UHC AARP MCR HMO MA|19.75||||19.75||| 9527094|ERX|0250|DEXTROMETHORPHAN-QUINIDIN|Medicaid|MEDICAID|62.50||||||| 9527094|ERX|0250|DEXTROMETHORPHAN-QUINIDIN|Medicare|MEDICARE ACUTE|62.50||||||| 9527110|ERX|0250|FLUCONAZOLE 800MG/200 ML|United Medicare Advantage|UHC MEDICARE GOLD MA|3.16||||||| 9527110|ERX|0250|FLUCONAZOLE 800MG/200 ML|Veterans Affairs|VETERANS ADMINISTRATION|3.16||||||| 9527110|ERX|0250|FLUCONAZOLE 800MG/200 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.16||||||| 9527110|ERX|0250|FLUCONAZOLE 800MG/200 ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.16||||||| 9527110|ERX|0250|FLUCONAZOLE 800MG/200 ML|Medicare|MEDICARE ACUTE|3.16||||||| 9527144|ERX|0250|METRONIDAZOLE 1G/200ML NS|Veterans Affairs|VETERANS ADMINISTRATION|107.50||||||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Medicaid|MEDICAID|||||322.50||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Medicare|MEDICARE ACUTE|322.50||||||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||322.50||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Humana Medicare Advantage|HUMANA MA|322.50||||||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Managed Medicaid|MEDICAID SUPERIOR|322.50||||322.50||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Managed Medicaid|MEDICAID AMERIGROUP|||||322.50||| 9527243|ERX|0250|PYRIDOXINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||||| 9527243|ERX|0250|PYRIDOXINE 100MG TABLET|Medicare|MEDICARE ACUTE|11.50||||||| 9527391|ERX|0250|QUETIAPINE XR 50MG TABLET|Medicare|MEDICARE ACUTE|46.25||||||| 9527391|ERX|0250|QUETIAPINE XR 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.25||||||| 9527391|ERX|0250|QUETIAPINE XR 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.25||||||| 9527391|ERX|0250|QUETIAPINE XR 50MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|46.25||||||| 9527391|ERX|0250|QUETIAPINE XR 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|46.25||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|50.50||||50.50||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|50.50||||50.50||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|50.50||||50.50||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Humana Medicare Advantage|HUMANA MA|50.50||||50.50||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Managed Medicare|HEALTHSPRING MA|50.50||||50.50||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Medicaid|SMITH COUNTY JAIL|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Medicare|MEDICARE PART B ONLY IP|50.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Medicare|MEDICARE ACUTE|50.50||||50.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicare|HEALTHSPRING MA|107.50||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Tricare|TRICARE EAST REGION|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|United Healthcare|UNITED HEALTHCARE OTHER|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Access Direct Platinum|HEALTHFIRST TPA|107.50||||||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Veterans Affairs|VETERANS ADMINISTRATION|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107.50||||||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Medicare|MEDICARE ACUTE|107.50||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|United Medicare Advantage|UHC AARP MCR HMO MA|107.50||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|107.50||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID SUPERIOR|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID AMERIGROUP|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Humana Medicare Advantage|HUMANA MA|107.50||||||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross HMO Specialty|BCBSTX HMO|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross PPO Specialty|BCBSTX PPO|107.50||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Aenta Medicare Advantage|AETNA MEDICARE MA|||||107.50||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Aetna|AETNA PPO|||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|107.50||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Aetna|AETNA PPO|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|107.50||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Blue Cross PPO Specialty|BCBSTX PPO|107.50||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Cigna|CIGNA|107.50||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Humana Medicare Advantage|HUMANA MA|107.50||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Managed Medicaid|MEDICAID AMERIGROUP|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|107.50||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Cigna|CIGNA OTHER|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|United Medicare Advantage|UHC MEDICARE GOLD MA|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107.50||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|United Medicare Advantage|UHC AARP MCR HMO MA|107.50||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Veterans Affairs|VETERANS ADMINISTRATION|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Aenta Medicare Advantage|AETNA MEDICARE MA|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Managed Medicare|HEALTHSPRING MA|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Medicare|MEDICARE ACUTE|107.50||||107.50||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Medicaid|MEDICAID|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Medicaid|SMITH COUNTY JAIL|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Medicaid|MOLINA HEALTHCARE OF TEXAS|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|United Healthcare|UNITED HEALTHCARE OTHER|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|107.50||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|NON CONTRACTED|COMMERCIAL OTHER 1|107.50||||||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.43||||||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Medicare|MEDICARE ACUTE|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Medicaid|MEDICAID|0.43||||||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.43||||||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.43||||||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Humana Medicare Advantage|HUMANA MA|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.43||||||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.43||||||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.43||||||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Managed Medicare|HEALTHSPRING MA|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Tricare|TRICARE EAST REGION|0.43||||0.43||| 9527573|ERX|0250|PRAVASTATIN 10 MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.43||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Cigna|CIGNA OTHER|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Cigna|CIGNA|||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Aetna|AETNA QHP HMO|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Humana Medicare Advantage|HUMANA MA|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Cigna|CIGNA|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Healthcare|UNITED HEALTHCARE|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Healthcare|GOLDEN RULE|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Managed Medicare|OTHER INSTITUTIONS|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Managed Medicare|HEALTHSPRING MA|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Medicaid|MEDICAID|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Medicare|MEDICARE PART B ONLY IP|43.50||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Medicare|MEDICARE ACUTE|43.50||||43.50||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43.50||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Medicare|MEDICARE ACUTE|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Medicaid|MEDICAID|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Managed Medicare|ETMC REHABILITATION HOSPITAL|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Tricare|TRICARE EAST REGION|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|United Healthcare|UNITED HEALTHCARE|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|United Healthcare|TML GROUP BENEFITS|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|United Healthcare|GOLDEN RULE|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Managed Medicare|HEALTHSPRING MA|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|United Healthcare|UNITED HEALTHCARE|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Magellan Behavioral Health|BH MAGELLAN|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Humana Medicare Advantage|HUMANA MA|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Cigna|CIGNA|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Medicare|MEDICARE PART B ONLY IP|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Aetna|AETNA OTHER|||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Aetna|BH AETNA|50.25||||||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Aetna|AETNA PPO|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|50.25||||50.25||| 9527599|ERX|0250|PRAVASTATIN 40 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|50.25||||50.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|Blue Cross PPO Specialty|BCBSTX PPO|107.50||||||| 9527698|ERX|0250|CEFAZOLIN 1G/100ML NS|Medicare|MEDICARE ACUTE|124.50||||||| 9527698|ERX|0250|CEFAZOLIN 1G/100ML NS|Workers Compensation|WORKERS COMPENSATION OTHER|||||124.50||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Cigna|CIGNA|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Humana Medicare Advantage|HUMANA MA|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|115.75||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.75||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|115.75||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|115.75||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|United Healthcare|UNITED HEALTHCARE|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|United Healthcare|GEHA|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|115.75||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicaid|MEDICAID HMO|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicaid|SMITH COUNTY JAIL|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Cigna|CIGNA OTHER|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicare|MEDICARE ACUTE|115.75||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicaid|MEDICAID|115.75||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicare|HEALTHSPRING MA|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Tricare|TRICARE FOR LIFE|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Tricare|TRICARE EAST REGION|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Multiplan|WEB TPA|||||115.75||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||115.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicare|MEDICARE ACUTE|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicaid|MEDICAID HMO|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicaid|MEDICAID|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicare|HEALTHSPRING MA|289.75||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Tricare|TRICARE EAST REGION|289.75||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|289.75||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|United Healthcare|UNITED HEALTHCARE|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|289.75||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Aetna|AETNA PPO|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Multiplan|WEB TPA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|PHCS|HUMANA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Aetna|AETNA OTHER|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|289.75||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|289.75||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|289.75||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Humana Medicare Advantage|HUMANA MA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Cigna|CIGNA|||||289.75||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||289.75||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|107.50||||107.50||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|107.50||||107.50||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|United Medicare Advantage|UHC AARP MCR HMO MA|107.50||||107.50||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Workers Compensation|WORKERS COMPENSATION OTHER|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Veterans Affairs|VETERANS ADMINISTRATION|107.50||||107.50||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|United Healthcare|UNITED HEALTHCARE OTHER|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|United Healthcare|UNITED HEALTHCARE|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|United Healthcare|GEHA|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|107.50||||107.50||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|107.50||||107.50||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|PHCS|HUMANA|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|PHCS|GROUP AND PENSION|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Managed Medicare|HEALTHSPRING MA|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|107.50||||107.50||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Managed Medicare|BCBS MEDICARE PPO MA|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Medicaid|MEDICAID|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Medicare|MEDICARE PART B ONLY IP|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Cigna|CIGNA|107.50||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Medicare|MEDICARE ACUTE|107.50||||107.50||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Humana Medicare Advantage|HUMANA MA|107.50||||107.50||| 9528001|ERX|0250|NITROPRUSSIDE 50MG/250ML|Medicare|MEDICARE ACUTE|15.48||||||| 9528001|ERX|0250|NITROPRUSSIDE 50MG/250ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.48||||||| 9528001|ERX|0250|NITROPRUSSIDE 50MG/250ML|Blue Cross HMO Specialty|BCBSTX HMO|15.48||||||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Managed Medicaid|MEDICAID SUPERIOR|107.50||||||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Humana Medicare Advantage|HUMANA MA|107.50||||107.50||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.50||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|107.50||||||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107.50||||||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Tricare|TRICARE EAST REGION|107.50||||||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|NON CONTRACTED|COMMERCIAL OTHER 1|107.50||||||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|107.50||||||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Medicare|MEDICARE ACUTE|107.50||||107.50||| 9528126|ERX|0250|UNASYN 3G/100ML NS|Humana Medicare Advantage|HUMANA MA|||||1.26||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Managed Medicare|HEALTHSPRING MA|134.25||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Medicare|MEDICARE ACUTE|134.25||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|||||134.25||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|146.75||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Humana Medicare Advantage|HUMANA MA|146.75||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|146.75||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Medicare|MEDICARE ACUTE|146.75||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicare|WELLCARE CHOICE MA|146.75||||||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Medicare|MEDICARE ACUTE|1.83||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|ChampVA|CHAMPVA CENTER|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross PPO Specialty|BCBSTX OTHER|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Aetna|BOON CHAPMAN|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross HMO Specialty|BCBSTX HMO|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Aetna|AETNA PPO|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Aetna|AETNA OTHER|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross PPO Specialty|BCBSTX PPO|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID AMERIGROUP|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID SUPERIOR|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Cigna|CIGNA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Cigna|CIGNA OTHER|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Magellan Behavioral Health|BH MAGELLAN|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Humana Medicare Advantage|HUMANA MA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Workers Compensation|WORKERS COMPENSATION OTHER|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Veterans Affairs|VETERANS ADMINISTRATION|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Access Direct Platinum|HEALTHFIRST TPA UMR|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Access Direct Platinum|HEALTHFIRST TPA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Access Direct Platinum|ANDREWS CENTER|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Medicare Advantage|UHC MEDICARE GOLD MA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Medicare Advantage|UHC AARP WELLMED HMO MA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Medicare Advantage|UHC AARP MCR HMO MA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|UTMB|UTMB CORRECTIONAL MANAGED CARE|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Healthcare|UNITED HEALTHCARE OTHER|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Healthcare|UNITED HEALTHCARE|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Cigna|CIGNA|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Healthcare|TML GROUP BENEFITS|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Healthcare|GEHA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Rusk State Hospital|RUSK STATE HOSP|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|PHCS|HUMANA|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|PHCS|HUMANA INSURANCE|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicare|WELLCARE CHOICE MA|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicare|ETMC AFFILIATE HOSPITALS|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Aenta Medicare Advantage|AETNA MEDICARE MA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicare|BCBS MEDICARE PPO MA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Tricare|TRICARE EAST REGION|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|SUPERIOR HEALTHPLAN CHIP|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|SMITH COUNTY JAIL|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|PHCS|GROUP AND PENSION|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|COUNTY INDIGENT HEALTH OTHER|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|SMITH COUNTY INDIGENT HEALTH|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|NON CONTRACTED|COMMERCIAL OTHER 1|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|MEDICAID HMO|||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicare|HEALTHSPRING MA|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|NON CONTRACTED|COMMUNITY HEALTH CENTER|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|MOLINA HEALTHCARE OF TEXAS|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|LAW ENFORCEMENT OTHER|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|MEDICAID|107.75||||107.75||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicare|MEDICARE PART B ONLY IP|107.75||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicare|MEDICARE ACUTE|107.75||||107.75||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicare|MEDICARE PART B ONLY IP|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicaid|MEDICAID|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicaid|LAW ENFORCEMENT OTHER|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicaid|CRIME VICTIMS COMPENSATION|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicaid|SMITH COUNTY JAIL|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicare|BCBS MEDICARE PPO MA|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Rusk State Hospital|RUSK STATE HOSP|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|PHCS|HUMANA|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|PHCS|GROUP AND PENSION|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Tricare|TRICARE EAST REGION|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|NON CONTRACTED|COMMERCIAL OTHER 1|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Healthcare|UNITED HEALTHCARE OTHER|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Healthcare|UNITED HEALTHCARE|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Healthcare|UNITED HEALTHCARE|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Medicare Advantage|UHC AARP MCR HMO MA|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Access Direct Platinum|HEALTHFIRST TPA UMR|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Access Direct Platinum|HEALTHFIRST TPA|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Workers Compensation|UT EMPLOYEE INJURY|||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|NON CONTRACTED|COMMERCIAL OTHER 2|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicare|HEALTHSPRING MA|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|PHCS|HUMANA INSURANCE|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Workers Compensation|WORKERS COMPENSATION OTHER|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Workers Compensation|TEXAS MUTUAL INSURANCE|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Veterans Affairs|VETERANS ADMINISTRATION|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Humana Medicare Advantage|HUMANA MA|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Cigna|CIGNA OTHER|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Cigna|CIGNA|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Cigna|CIGNA|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID AMERIGROUP|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Aetna|AETNA OTHER|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicare|MEDICARE ACUTE|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Aetna|AETNA QHP HMO|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID SUPERIOR|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Aetna|AETNA PPO|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Aetna|BOON CHAPMAN|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross HMO Specialty|BCBSTX HMO|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross PPO Specialty|BCBSTX PPO|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross PPO Specialty|BCBSTX OTHER|0.62||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.62||||0.62||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|ChampVA|CHAMPVA CENTER|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Blue Cross PPO Specialty|BCBSTX PPO|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.62||||0.62||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Managed Medicaid|MEDICAID AMERIGROUP|0.62||||0.62||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Humana Medicare Advantage|HUMANA MA|0.62||||0.62||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Access Direct Platinum|HEALTHFIRST TPA UMR|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|United Medicare Advantage|UHC AARP MCR HMO MA|0.62||||0.62||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|0.62||||0.62||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|NON CONTRACTED|COMMERCIAL OTHER 1|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|United Healthcare|GEHA|||||0.62||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Managed Medicare|HEALTHSPRING MA|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|United Healthcare|UNITED HEALTHCARE OTHER|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Medicaid|MEDICAID|0.62||||0.62||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.62||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Medicare|MEDICARE ACUTE|0.62||||0.62||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|0.62||||0.62||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Veterans Affairs|VETERANS ADMINISTRATION|0.62||||0.62||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Medicaid|SMITH COUNTY INDIGENT HEALTH|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Medicare|MEDICARE PART B ONLY IP|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Medicaid|MEDICAID|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Medicaid|SMITH COUNTY JAIL|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicare|HEALTHSPRING MA|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicare|BCBS MEDICARE PPO MA|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|PHCS|HUMANA|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|NON CONTRACTED|COMMERCIAL OTHER 1|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|United Healthcare|UNITED HEALTHCARE OTHER|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|United Medicare Advantage|UHC AARP MCR HMO MA|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|United Medicare Advantage|UHC MEDICARE GOLD MA|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|United Healthcare|UNITED HEALTHCARE|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Access Direct Platinum|HEALTHFIRST TPA UMR|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|PHCS|HUMANA INSURANCE|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Veterans Affairs|VETERANS ADMINISTRATION|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|UTMB|UTMB CORRECTIONAL MANAGED CARE|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Cigna|CIGNA|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Humana Medicare Advantage|HUMANA MA|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicaid|MEDICAID SUPERIOR|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Aenta Medicare Advantage|AETNA MEDICARE MA|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Medicare|MEDICARE ACUTE|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Blue Cross HMO Specialty|BCBSTX HMO|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Blue Cross PPO Specialty|BCBSTX PPO|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Aetna|AETNA PPO|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Aetna|AETNA OTHER|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Blue Cross PPO Specialty|BCBSTX OTHER|57.25||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|57.25||||57.25||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicaid|MEDICAID AMERIGROUP|57.25||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Aetna|AETNA PPO|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Aenta Medicare Advantage|AETNA MEDICARE MA|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicaid|MEDICAID AMERIGROUP|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Humana Medicare Advantage|HUMANA MA|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Aetna|BH AETNA|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Workers Compensation|WORKERS COMPENSATION OTHER|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Veterans Affairs|VETERANS ADMINISTRATION|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Aetna|BOON CHAPMAN|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicaid|MEDICAID SUPERIOR|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Blue Cross HMO Specialty|BCBSTX HMO|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Workers Compensation|UT EMPLOYEE INJURY|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Cigna Behavioral Health|BH CIGNA|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Access Direct Platinum|HEALTHFIRST TPA UMR|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Access Direct Platinum|HEALTHFIRST TPA|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Magellan Behavioral Health|BH MAGELLAN|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Tricare|TRICARE EAST REGION|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicare|JACKSONVILLE ACCESS|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicare|BCBS MEDICARE PPO MA|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicaid|CRIME VICTIMS COMPENSATION|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicaid|SMITH COUNTY INDIGENT HEALTH|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicaid|BH TEXAS CHILDRENS MEDICAID|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicaid|MEDICAID|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicare|MEDICARE PART B ONLY IP|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicare|HEALTHSPRING MA|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicare|MEDICARE ACUTE|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|United Healthcare|UNITED HEALTHCARE|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|NON CONTRACTED|COMMERCIAL OTHER 1|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|United Healthcare|UNITED HEALTHCARE OTHER|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|United Medicare Advantage|UHC AARP MCR HMO MA|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Optum Behavioral Health|BH OPTUM UHC|11.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.50||||11.50||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.50||||||| 9528407|ERX|0250|PAIN EASE SPRAY (1 APPLIC|Managed Medicaid|MEDICAID AMERIGROUP|||||25.25||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.72||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicare|MEDICARE PART B ONLY IP|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicare|MEDICARE ACUTE|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|SUPERIOR HEALTHPLAN CHIP|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|SMITH COUNTY INDIGENT HEALTH|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|MEDICAID HMO|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|MOLINA HEALTHCARE OF TEXAS|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|COUNTY INDIGENT HEALTH OTHER|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicare|HEALTHSPRING MA|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicare|BCBS MEDICARE PPO MA|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Tricare|TRICARE EAST REGION|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Rusk State Hospital|RUSK STATE HOSP|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|PHCS|GROUP AND PENSION|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|NON CONTRACTED|COMMERCIAL OTHER 1|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|NON CONTRACTED|COMMERCIAL OTHER 2|||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|UTMB|UTMB CORRECTIONAL MANAGED CARE|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Healthcare|UNITED HEALTHCARE OTHER|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Healthcare|UNITED HEALTHCARE|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Healthcare|GEHA|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Medicare Advantage|UHC AARP WELLMED HMO MA|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Medicare Advantage|UHC AARP MCR HMO MA|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Medicare Advantage|UHC MEDICARE GOLD MA|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Access Direct Platinum|HEALTHFIRST TPA UMR|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Access Direct Platinum|HEALTHFIRST TPA|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Workers Compensation|WORKERS COMPENSATION OTHER|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Veterans Affairs|VETERANS ADMINISTRATION|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Cigna|CIGNA OTHER|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|SMITH COUNTY JAIL|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|CRIME VICTIMS COMPENSATION|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|PHCS|HUMANA|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicare|ETMC AFFILIATE HOSPITALS|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicare|WELLCARE CHOICE MA|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Humana Medicare Advantage|HUMANA MA|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicaid|MEDICAID SUPERIOR|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicaid|MEDICAID AMERIGROUP|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Brinson Benefits|THE HEALTH PLAN SMITH CO|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Cigna|CIGNA|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|MEDICAID|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|ChampVA|CHAMPVA CENTER|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Blue Cross HMO Specialty|BCBSTX HMO|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Workers Compensation|TEXAS MUTUAL INSURANCE|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Blue Cross PPO Specialty|BCBSTX PPO|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Blue Cross PPO Specialty|BCBSTX OTHER|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Aenta Medicare Advantage|AETNA MEDICARE MA|107.50||||107.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Aetna|BOON CHAPMAN|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Workers Compensation|TRAVELERS INSURANCE COMPANY|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Aetna|AETNA OTHER|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Aetna|AETNA QHP HMO|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Aetna|AETNA PPO|107.50||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|107.50||||107.50||| 9528563|ERX|0250|BUDESONIDE 1MG/2ML RESPUL|Managed Medicare|HEALTHSPRING MA|146.75||||||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Blue Cross HMO Specialty|BCBSTX HMO|11.50||||||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.50||||11.50||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Humana Medicare Advantage|HUMANA MA|11.50||||||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Access Direct Platinum|HEALTHFIRST TPA|11.50||||||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Medicaid|MEDICAID|11.50||||||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Medicare|MEDICARE ACUTE|11.50||||||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Managed Medicare|HOSPICE OF EAST TEXAS|11.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Veterans Affairs|VETERANS ADMINISTRATION|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Access Direct Platinum|HEALTHFIRST TPA|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Humana Medicare Advantage|HUMANA MA|107.50||||107.50||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Blue Cross HMO Specialty|BCBSTX HMO|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Blue Cross PPO Specialty|BCBSTX PPO|107.50||||107.50||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Aetna|AETNA OTHER|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Aenta Medicare Advantage|AETNA MEDICARE MA|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|UTMB|UTMB CORRECTIONAL MANAGED CARE|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|United Healthcare|UNITED HEALTHCARE OTHER|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|United Healthcare|UNITED HEALTHCARE|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|107.50||||107.50||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Managed Medicare|HEALTHSPRING MA|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||107.50||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||107.50||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Managed Medicare|BCBS MEDICARE PPO MA|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Medicare|MEDICARE ACUTE|107.50||||107.50||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Medicaid|MEDICAID|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|United Medicare Advantage|UHC MEDICARE GOLD MA|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107.50||||107.50||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|United Medicare Advantage|UHC AARP MCR HMO MA|107.50||||||| 9528704|ERX|0250|SODIUM CHLORIDE 0.9% IRRI|Workers Compensation|ZURICH COMPANY|||||107.50||| 9528829|ERX|0250|FESOTERODINE 4MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|44.25||||||| 9528829|ERX|0250|FESOTERODINE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.25||||||| 9528829|ERX|0250|FESOTERODINE 4MG TABLET|Humana Medicare Advantage|HUMANA MA|||||44.25||| 9528829|ERX|0250|FESOTERODINE 4MG TABLET|Medicare|MEDICARE ACUTE|44.25||||||| 9528829|ERX|0250|FESOTERODINE 4MG TABLET|United Healthcare|UNITED HEALTHCARE|44.25||||||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|NON CONTRACTED|COMMERCIAL OTHER 1|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Rusk State Hospital|RUSK STATE HOSP|18.58||||||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|PHCS|GROUP AND PENSION|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Tricare|TRICARE FOR LIFE|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Tricare|TRICARE EAST REGION|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|UNITED HEALTHCARE OTHER|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|TML GROUP BENEFITS|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|HEALTHSPRING MA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|BCBS MEDICARE PPO MA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|SMITH COUNTY JAIL|18.58||||||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|SMITH COUNTY INDIGENT HEALTH|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|CRIME VICTIMS COMPENSATION|18.58||||||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|COUNTY INDIGENT HEALTH OTHER|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|MEDICAID HMO|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicare|MEDICARE ACUTE|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA UMR|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicare|MEDICARE PART B ONLY IP|18.58||||||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Workers Compensation|WORKERS COMPENSATION OTHER|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Workers Compensation|UT EMPLOYEE INJURY|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|LAW ENFORCEMENT OTHER|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Workers Compensation|TEXAS MUTUAL INSURANCE|18.58||||||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Workers Compensation|GALLAGHER BASSETT|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|MEDICAID|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|18.58||||||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Veterans Affairs|VETERANS ADMINISTRATION|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC MEDICARE GOLD MA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC AARP MCR HMO MA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Cigna|CIGNA OTHER|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Cigna|CIGNA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Humana Medicare Advantage|HUMANA MA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID SUPERIOR|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID AMERIGROUP|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|UNITED HEALTHCARE|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Texas Workforce Commission|DIS DETER SERV (DDS)|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aetna Value Network|AETNA VALUE NETWORK|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Multiplan|WEB TPA|18.58||||||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aetna|AETNA QHP HMO|||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aetna|AETNA PPO|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aetna|BOON CHAPMAN|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aetna|AETNA OTHER|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aenta Medicare Advantage|AETNA MEDICARE MA|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Brinson Benefits|THE HEALTH PLAN SMITH CO|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|ChampVA|CHAMPVA CENTER|18.58||||||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross HMO Specialty|BCBSTX HMO|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross PPO Specialty|BCBSTX PPO|18.58||||18.58||| 9528852|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross PPO Specialty|BCBSTX OTHER|18.58||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross HMO Specialty|BCBSTX HMO|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|ChampVA|CHAMPVA CENTER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aetna|AETNA QHP HMO|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aetna|AETNA PPO|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aetna|BOON CHAPMAN|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aetna|AETNA OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Humana Medicare Advantage|HUMANA MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Cigna|CIGNA OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Cigna|CIGNA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|ZURICH COMPANY|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|UT EMPLOYEE INJURY|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|TEXAS MUTUAL INSURANCE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|BROOKSHIRES WORKERS COMP|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|TRAVELERS INSURANCE COMPANY|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Veterans Affairs|VETERANS ADMINISTRATION|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Access Direct Platinum|HEALTHFIRST TPA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicare|MEDICARE PART B ONLY IP|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicare|MEDICARE ACUTE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|LAW ENFORCEMENT OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|CRIME VICTIMS COMPENSATION|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|MEDICAID HMO|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|MEDICAID|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|SMITH COUNTY JAIL|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|WELLCARE CHOICE MA|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicaid|MEDICAID AMERIGROUP|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|OTHER INSTITUTIONS|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|HOSPICE OF EAST TEXAS|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|HEALTHSPRING MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|BCBS MEDICARE PPO MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|UNITED HEALTHCARE OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|UNITED HEALTHCARE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|TML GROUP BENEFITS|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|GEHA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Tricare|TRICARE FOR LIFE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Rusk State Hospital|RUSK STATE HOSP|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|PHCS|HUMANA INSURANCE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|PHCS|HUMANA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|PHCS|GROUP AND PENSION|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|PHCS|MULTIPLAN PHCS|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Texas Workforce Commission|DIS DETER SERV (DDS)|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Optum Behavioral Health|BH OPTUM UHC|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Tricare|TRICARE EAST REGION|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Multiplan|WEB TPA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|NON CONTRACTED|COMMERCIAL OTHER 4|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.16||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Rusk State Hospital|RUSK STATE HOSP|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Tricare|TRICARE EAST REGION|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|United Healthcare|UNITED HEALTHCARE OTHER|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|United Healthcare|UNITED HEALTHCARE|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|United Healthcare|TML GROUP BENEFITS|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Managed Medicare|WELLCARE CHOICE MA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Managed Medicare|HEALTHSPRING MA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Managed Medicare|BCBS MEDICARE PPO MA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Medicaid|MEDICAID|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Medicaid|COUNTY INDIGENT HEALTH OTHER|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Medicaid|SMITH COUNTY INDIGENT HEALTH|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Medicaid|MOLINA HEALTHCARE OF TEXAS|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Medicare|MEDICARE ACUTE|135.75||||135.75||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|135.75||||135.75||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA UMR|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Workers Compensation|WORKERS COMPENSATION OTHER|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Medicaid|CRIME VICTIMS COMPENSATION|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Workers Compensation|TEXAS MUTUAL INSURANCE|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Veterans Affairs|VETERANS ADMINISTRATION|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|135.75||||135.75||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|United Medicare Advantage|UHC AARP WELLMED HMO MA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|United Medicare Advantage|UHC AARP MCR HMO MA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Cigna|CIGNA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Humana Medicare Advantage|HUMANA MA|135.75||||135.75||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|135.75||||135.75||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|135.75||||135.75||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|135.75||||135.75||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Aetna|BOON CHAPMAN|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Aetna|AETNA QHP HMO|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Aetna|AETNA PPO|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|135.75||||135.75||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Blue Cross PPO Specialty|BCBSTX OTHER|135.75||||||| 9528878|ERX|0250|FENTANYL 2000MCG/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|135.75||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Blue Cross HMO Specialty|BCBSTX HMO|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Blue Cross PPO Specialty|BCBSTX PPO|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Blue Cross PPO Specialty|BCBSTX OTHER|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Aetna|BOON CHAPMAN|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Humana Medicare Advantage|HUMANA MA|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Cigna|CIGNA|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|United Medicare Advantage|UHC AARP MCR HMO MA|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Medicare|MEDICARE ACUTE|15.25||||15.25||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Managed Medicare|HOSPICE OF EAST TEXAS|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|Managed Medicare|HEALTHSPRING MA|15.25||||15.25||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|United Healthcare|UNITED HEALTHCARE OTHER|15.25||||||| 9528951|ERX|0250|GLYCOPYROLATE 0.4MG 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|15.25||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|NON CONTRACTED|COMMERCIAL OTHER 1|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|UTMB|UTMB CORRECTIONAL MANAGED CARE|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|United Healthcare|UNITED HEALTHCARE|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Managed Medicare|JACKSONVILLE ACCESS|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Managed Medicare|HEALTHSPRING MA|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Medicaid|BH TEXAS CHILDRENS MEDICAID|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Medicaid|MEDICAID|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Medicare|MEDICARE PART B ONLY IP|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||10.50||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Medicare|MEDICARE ACUTE|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Veterans Affairs|VETERANS ADMINISTRATION|10.50||||10.50||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Access Direct Platinum|ANDREWS CENTER|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|United Medicare Advantage|UHC MEDICARE GOLD MA|10.50||||10.50||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|United Medicare Advantage|UHC AARP WELLMED HMO MA|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|United Medicare Advantage|UHC AARP MCR HMO MA|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Cigna|CIGNA OTHER|10.50||||10.50||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Humana Medicare Advantage|HUMANA MA|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.50||||10.50||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Managed Medicaid|MEDICAID SUPERIOR|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Managed Medicaid|MEDICAID AMERIGROUP|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Aenta Medicare Advantage|AETNA MEDICARE MA|10.50||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||||| 9529017|ERX|0250|MEROPENEM 500MG IN 100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|228.75||||||| 9529066|ERX|0250|SODIUM CHLORIDE 7% INH 4M|Medicare|MEDICARE ACUTE|5.75||||||| 9529066|ERX|0250|SODIUM CHLORIDE 7% INH 4M|Medicaid|MEDICAID|5.75||||||| 9529066|ERX|0250|SODIUM CHLORIDE 7% INH 4M|Blue Cross PPO Specialty|BCBSTX PPO|5.75||||||| 9529066|ERX|0250|SODIUM CHLORIDE 7% INH 4M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.75||||||| 9529066|ERX|0250|SODIUM CHLORIDE 7% INH 4M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.75||| 9529066|ERX|0250|SODIUM CHLORIDE 7% INH 4M|Humana Medicare Advantage|HUMANA MA|5.75||||||| 9529066|ERX|0250|SODIUM CHLORIDE 7% INH 4M|Veterans Affairs|VETERANS ADMINISTRATION|5.75||||||| 9529066|ERX|0250|SODIUM CHLORIDE 7% INH 4M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.75||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Workers Compensation|WORKERS COMPENSATION OTHER|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Workers Compensation|UT EMPLOYEE INJURY|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Cigna|CIGNA|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Humana Medicare Advantage|HUMANA MA|32.50||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Managed Medicaid|MEDICAID SUPERIOR|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Cigna|CIGNA OTHER|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Managed Medicaid|MEDICAID AMERIGROUP|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Blue Cross PPO Specialty|BCBSTX PPO|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|United Healthcare|UNITED HEALTHCARE OTHER|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|United Healthcare|UNITED HEALTHCARE|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|United Healthcare|TML GROUP BENEFITS|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Tricare|TRICARE EAST REGION|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|NON CONTRACTED|COMMERCIAL OTHER 1|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Managed Medicare|BCBS MEDICARE PPO MA|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Medicaid|SMITH COUNTY JAIL|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Medicaid|MEDICAID|||||32.50||| 9529082|ERX|0250|LET GEL 2ML SYRINGE|Medicare|MEDICARE ACUTE|32.50||||32.50||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicare|MEDICARE PART B ONLY IP|509.75||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicare|MEDICARE ACUTE|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicaid|CRIME VICTIMS COMPENSATION|509.75||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicaid|MEDICAID|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicaid|MEDICAID HMO|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicaid|MEDICAID BCBSTX|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicare|OTHER INSTITUTIONS|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicare|HEALTHSPRING MA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicare|BCBS MEDICARE PPO MA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Multiplan|WEB TPA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Multiplan|PACIFICARE|509.75||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Rusk State Hospital|RUSK STATE HOSP|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Tricare|TRICARE SOUTH PHYSICIAN|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|PHCS|HUMANA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|PHCS|GROUP AND PENSION|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Texas Workforce Commission|DIS DETER SERV (DDS)|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Tricare|TRICARE FOR LIFE|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Tricare|TRICARE EAST REGION|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Healthcare|GEHA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Healthcare|UNITED HEALTHCARE|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Healthcare|TML GROUP BENEFITS|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Healthcare|GOLDEN RULE|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Healthcare|UNITED HEALTHCARE OTHER|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|ChampVA|CHAMPVA CENTER|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Healthcare|UNITED HEALTHCARE ERS|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross HMO Specialty|BCBSTX HMO|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Aetna|AETNA QHP HMO|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Aetna|AETNA PPO|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Aetna|AETNA OTHER|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Aetna|BOON CHAPMAN|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|PHCS|HUMANA INSURANCE|509.75||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|NON CONTRACTED|COMMERCIAL OTHER 2|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Aetna Value Network|AETNA VALUE NETWORK|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicaid|MEDICAID AMERIGROUP|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Humana Medicare Advantage|HUMANA MA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Cigna|CIGNA OTHER|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Cigna|CIGNA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicaid|SMITH COUNTY JAIL|509.75||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Workers Compensation|TEXAS MUTUAL INSURANCE|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Workers Compensation|UT EMPLOYEE INJURY|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicaid|LAW ENFORCEMENT OTHER|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Workers Compensation|TRAVELERS INSURANCE COMPANY|509.75||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|509.75||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|509.75||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Workers Compensation|BROOKSHIRES WORKERS COMP|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Veterans Affairs|VETERANS ADMINISTRATION|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|509.75||||509.75||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA|509.75||||509.75||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.78||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.78||||0.78||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.78||||0.78||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|United Medicare Advantage|UHC AARP MCR HMO MA|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Humana Medicare Advantage|HUMANA MA|0.78||||0.78||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.78||||0.78||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Aetna|AETNA OTHER|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|0.78||||0.78||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|United Healthcare|UNITED HEALTHCARE|||||0.78||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Tricare|TRICARE EAST REGION|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Managed Medicare|HEALTHSPRING MA|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Managed Medicare|BCBS MEDICARE PPO MA|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Medicaid|MEDICAID HMO|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Medicare|MEDICARE PART B ONLY IP|0.78||||||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Medicare|MEDICARE ACUTE|0.78||||0.78||| 9529199|ERX|0250|TICAGRELOR 60MG TABLET|Medicare|MEDICARE ACUTE|0.36||||||| 9529199|ERX|0250|TICAGRELOR 60MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.36||||||| 9529199|ERX|0250|TICAGRELOR 60MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.36||||0.36||| 9529199|ERX|0250|TICAGRELOR 60MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.36||| 9529199|ERX|0250|TICAGRELOR 60MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.36||||||| 9529223|ERX|0250|BRINZOLAMIDE 1%/BRIMON 0.|Humana Medicare Advantage|HUMANA MA|5.89||||||| 9529223|ERX|0250|BRINZOLAMIDE 1%/BRIMON 0.|United Medicare Advantage|UHC MEDICARE GOLD MA|5.89||||5.89||| 9529223|ERX|0250|BRINZOLAMIDE 1%/BRIMON 0.|Medicare|MEDICARE PART B ONLY IP|5.89||||||| 9529223|ERX|0250|BRINZOLAMIDE 1%/BRIMON 0.|Medicare|MEDICARE ACUTE|5.89||||||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||26.28||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|Medicare|MEDICARE ACUTE|26.28||||26.28||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||26.28||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||26.28||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|Blue Cross HMO Specialty|BCBSTX HMO|||||26.28||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|Blue Cross PPO Specialty|BCBSTX PPO|26.28||||26.28||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||26.28||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||26.28||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|Managed Medicaid|MEDICAID AMERIGROUP|||||26.28||| 9529231|ERX|0250|ISOPROTERENOL 0.2 MG IN 5|Humana Medicare Advantage|HUMANA MA|26.28||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|Humana Medicare Advantage|HUMANA MA|66.82||||66.82||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||66.82||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|66.82||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|66.82||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|66.82||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|66.82||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|66.82||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|66.82||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|United Healthcare|UNITED HEALTHCARE|66.82||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|Medicare|MEDICARE ACUTE|66.82||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|Managed Medicare|HEALTHSPRING MA|66.82||||||| 9529256|ERX|0250|NALOXEGOL 25 MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|66.82||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Managed Medicare|HEALTHSPRING MA|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Medicaid|MEDICAID|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Medicare|MEDICARE ACUTE|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|UTMB|UTMB CORRECTIONAL MANAGED CARE|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|United Healthcare|UNITED HEALTHCARE|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|United Medicare Advantage|UHC MEDICARE GOLD MA|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Blue Cross PPO Specialty|BCBSTX PPO|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|83.98||||83.98||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Aenta Medicare Advantage|AETNA MEDICARE MA|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Aetna|AETNA PPO|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Managed Medicaid|MEDICAID UNITED HEALTHCARE|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Managed Medicaid|MEDICAID AMERIGROUP|83.98||||||| 9529280|ERX|0250|LACTULOSE-NS ENEMA (300:7|Humana Medicare Advantage|HUMANA MA|83.98||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Cigna|CIGNA|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Cigna|CIGNA|||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Humana Medicare Advantage|HUMANA MA|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Managed Medicaid|MEDICAID SUPERIOR|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Managed Medicaid|MEDICAID AMERIGROUP|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Aetna|AETNA PPO|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|ChampVA|CHAMPVA CENTER|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Blue Cross PPO Specialty|BCBSTX PPO|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Blue Cross HMO Specialty|BCBSTX HMO|||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Veterans Affairs|VETERANS ADMINISTRATION|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Access Direct Platinum|HEALTHFIRST TPA UMR|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Access Direct Platinum|HEALTHFIRST TPA|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Aenta Medicare Advantage|AETNA MEDICARE MA|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|United Medicare Advantage|UHC MEDICARE GOLD MA|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|United Medicare Advantage|UHC AARP MCR HMO MA|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|NON CONTRACTED|COMMERCIAL OTHER 1|||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|PHCS|GROUP AND PENSION|||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Tricare|TRICARE EAST REGION|||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|United Healthcare|TML GROUP BENEFITS|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|United Healthcare|UNITED HEALTHCARE OTHER|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|United Healthcare|UNITED HEALTHCARE|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Medicare|MEDICARE PART B ONLY IP|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Medicare|MEDICARE ACUTE|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Medicaid|CRIME VICTIMS COMPENSATION|962.04||||||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Medicaid|MEDICAID|962.04||||962.04||| 9529322|ERX|0250|METHYLENE BLUE 0.5%(5MG/M|Managed Medicare|HEALTHSPRING MA|962.04||||962.04||| 9529330|ERX|0636|SIROLIMUS 0.5 MG TABLET|Medicare|MEDICARE ACUTE|60.05||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|82.24||||82.24||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Aetna|AETNA PPO|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Humana Medicare Advantage|HUMANA MA|82.24||||82.24||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Cigna|CIGNA|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Managed Medicare|HEALTHSPRING MA|82.24||||82.24||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|82.24||||82.24||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Medicaid|MEDICAID HMO|||||82.24||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Medicare|MEDICARE ACUTE|82.24||||82.24||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|82.24||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Rusk State Hospital|RUSK STATE HOSP|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|NON CONTRACTED|COMMERCIAL OTHER 1|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|United Healthcare|UNITED HEALTHCARE OTHER|46.18||||46.18||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Medicaid|MEDICAID|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Medicare|MEDICARE ACUTE|46.18||||46.18||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Managed Medicare|HEALTHSPRING MA|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Cigna|CIGNA|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Humana Medicare Advantage|HUMANA MA|46.18||||46.18||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.18||||46.18||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Managed Medicaid|MEDICAID AMERIGROUP|46.18||||46.18||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.18||||46.18||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Blue Cross HMO Specialty|BCBSTX HMO|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Blue Cross PPO Specialty|BCBSTX PPO|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|46.18||||46.18||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|Access Direct Platinum|HEALTHFIRST TPA|46.18||||||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|United Medicare Advantage|UHC MEDICARE GOLD MA|46.18||||46.18||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.18||||46.18||| 9529363|ERX|0250|LIPASE-PROT-AMYL 36-114-1|United Medicare Advantage|UHC AARP MCR HMO MA|46.18||||||| 9529389|ERX|0250|MULTIVITAMIN LIQUID, 15 M|United Medicare Advantage|UHC MEDICARE GOLD MA|8.80||||||| 9529389|ERX|0250|MULTIVITAMIN LIQUID, 15 M|United Medicare Advantage|UHC AARP MCR HMO MA|8.80||||||| 9529389|ERX|0250|MULTIVITAMIN LIQUID, 15 M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|8.80||||||| 9529389|ERX|0250|MULTIVITAMIN LIQUID, 15 M|Blue Cross PPO Specialty|BCBSTX PPO|8.80||||||| 9529389|ERX|0250|MULTIVITAMIN LIQUID, 15 M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.80||||||| 9529389|ERX|0250|MULTIVITAMIN LIQUID, 15 M|Humana Medicare Advantage|HUMANA MA|8.80||||8.80||| 9529389|ERX|0250|MULTIVITAMIN LIQUID, 15 M|Managed Medicare|HEALTHSPRING MA|8.80||||||| 9529389|ERX|0250|MULTIVITAMIN LIQUID, 15 M|Medicaid|MEDICAID|8.80||||||| 9529389|ERX|0250|MULTIVITAMIN LIQUID, 15 M|Medicare|MEDICARE ACUTE|8.80||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|United Healthcare|UNITED HEALTHCARE OTHER|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|United Healthcare|UNITED HEALTHCARE|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Medicare|MEDICARE ACUTE|46.92||||46.92||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Medicaid|LAW ENFORCEMENT OTHER|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Managed Medicare|HEALTHSPRING MA|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Cigna|CIGNA OTHER|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Humana Medicare Advantage|HUMANA MA|46.92||||46.92||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.92||||46.92||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Aetna|AETNA QHP HMO|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Blue Cross PPO Specialty|BCBSTX PPO|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|Veterans Affairs|VETERANS ADMINISTRATION|46.92||||||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|United Medicare Advantage|UHC MEDICARE GOLD MA|46.92||||46.92||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.92||||46.92||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||46.92||| 9529397|ERX|0250|SACUBITRIL-VALSARTAN 24-2|United Medicare Advantage|UHC AARP MCR HMO MA|46.92||||46.92||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.92||||46.92||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Access Direct Platinum|HEALTHFIRST TPA UMR|46.92||||||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Veterans Affairs|VETERANS ADMINISTRATION|46.92||||46.92||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.92||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Aenta Medicare Advantage|AETNA MEDICARE MA|||||46.92||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.92||||46.92||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.92||||46.92||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Humana Medicare Advantage|HUMANA MA|46.92||||46.92||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Managed Medicare|HEALTHSPRING MA|46.92||||46.92||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Managed Medicare|BCBS MEDICARE PPO MA|46.92||||||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Medicare|MEDICARE PART B ONLY IP|46.92||||||| 9529405|ERX|0250|SACUBITRIL-VALSARTAN 49-5|Medicare|MEDICARE ACUTE|46.92||||46.92||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|United Healthcare|UNITED HEALTHCARE|||||46.92||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|Medicare|MEDICARE ACUTE|46.92||||46.92||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|46.92||||||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|Managed Medicare|HEALTHSPRING MA|46.92||||||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|Cigna|CIGNA|46.92||||||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|Humana Medicare Advantage|HUMANA MA|46.92||||46.92||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.92||||||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.92||||46.92||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|Blue Cross PPO Specialty|BCBSTX PPO|||||46.92||| 9529413|ERX|0250|SACUBITRIL-VALSARTAN 97-1|United Medicare Advantage|UHC MEDICARE GOLD MA|46.92||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|75.05||||75.05||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||75.05||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|75.05||||75.05||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Humana Medicare Advantage|HUMANA MA|75.05||||75.05||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Managed Medicare|HEALTHSPRING MA|75.05||||75.05||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Medicare|MEDICARE ACUTE|75.05||||75.05||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Medicare|MEDICARE PART B ONLY IP|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|PHCS|HUMANA|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|Tricare|TRICARE EAST REGION|75.05||||||| 9529421|ERX|0250|MIRABEGRON 25 MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|75.05||||||| 9529439|ERX|0250|MIRABEGRON 50MG TABLET|PHCS|HUMANA|75.05||||||| 9529439|ERX|0250|MIRABEGRON 50MG TABLET|Medicare|MEDICARE ACUTE|75.05||||75.05||| 9529439|ERX|0250|MIRABEGRON 50MG TABLET|Managed Medicare|HEALTHSPRING MA|75.05||||||| 9529439|ERX|0250|MIRABEGRON 50MG TABLET|Humana Medicare Advantage|HUMANA MA|75.05||||||| 9529439|ERX|0250|MIRABEGRON 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||75.05||| 9529439|ERX|0250|MIRABEGRON 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|75.05||||||| 9529439|ERX|0250|MIRABEGRON 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|75.05||||||| 9529439|ERX|0250|MIRABEGRON 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|75.05||||||| 9529439|ERX|0250|MIRABEGRON 50MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|75.05||||||| 9529512|ERX|0250|ZONISAMIDE 25 MG CAPSULE|Medicare|MEDICARE ACUTE|8.80||||||| 9529546|ERX|0250|TRANEXAMIC ACID 650 MG TA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.80||||||| 9529546|ERX|0250|TRANEXAMIC ACID 650 MG TA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.80||||||| 9529546|ERX|0250|TRANEXAMIC ACID 650 MG TA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.80||||||| 9529546|ERX|0250|TRANEXAMIC ACID 650 MG TA|United Healthcare|UNITED HEALTHCARE OTHER|||||8.80||| 9529546|ERX|0250|TRANEXAMIC ACID 650 MG TA|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.80||| 9529546|ERX|0250|TRANEXAMIC ACID 650 MG TA|Medicare|MEDICARE ACUTE|8.80||||||| 9529553|ERX|0250|CARIPRAZINE 1.5 MG CAPSUL|Medicare|MEDICARE ACUTE|219.33||||||| 9529553|ERX|0250|CARIPRAZINE 1.5 MG CAPSUL|Optum Behavioral Health|BH OPTUM UHC|219.33||||||| 9529553|ERX|0250|CARIPRAZINE 1.5 MG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|219.33||||||| 9529553|ERX|0250|CARIPRAZINE 1.5 MG CAPSUL|Managed Medicaid|MEDICAID AMERIGROUP|219.33||||||| 9529553|ERX|0250|CARIPRAZINE 1.5 MG CAPSUL|Access Direct Platinum|HEALTHFIRST TPA UMR|219.33||||||| 9529561|ERX|0250|CARIPRAZINE 3 MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|219.33||||||| 9529561|ERX|0250|CARIPRAZINE 3 MG CAPSULE|Aetna|BH AETNA|219.33||||||| 9529561|ERX|0250|CARIPRAZINE 3 MG CAPSULE|Cigna Behavioral Health|BH CIGNA|219.33||||||| 9529561|ERX|0250|CARIPRAZINE 3 MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|219.33||||||| 9529561|ERX|0250|CARIPRAZINE 3 MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|219.33||||||| 9529561|ERX|0250|CARIPRAZINE 3 MG CAPSULE|Medicare|MEDICARE ACUTE|219.33||||||| 9529579|ERX|0250|PHENOL LIQUID TOPICAL SWA|Managed Medicare|BCBS MEDICARE PPO MA|||||0.35||| 9529579|ERX|0250|PHENOL LIQUID TOPICAL SWA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.35||| 9529579|ERX|0250|PHENOL LIQUID TOPICAL SWA|Medicare|MEDICARE ACUTE|||||0.35||| 9529579|ERX|0250|PHENOL LIQUID TOPICAL SWA|Managed Medicaid|MEDICAID SUPERIOR|||||0.35||| 9529579|ERX|0250|PHENOL LIQUID TOPICAL SWA|Managed Medicaid|MEDICAID AMERIGROUP|||||0.35||| 9529579|ERX|0250|PHENOL LIQUID TOPICAL SWA|Humana Medicare Advantage|HUMANA MA|||||0.35||| 9529579|ERX|0250|PHENOL LIQUID TOPICAL SWA|Blue Cross PPO Specialty|BCBSTX PPO|||||0.35||| 9529587|ERX|0250|MULTIVITAMIN LIQUID 30 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.80||||||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|UTMB|UTMB CORRECTIONAL MANAGED CARE|91.93||||||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|United Healthcare|UNITED HEALTHCARE OTHER|91.93||||||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|United Healthcare|UNITED HEALTHCARE|||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|NON CONTRACTED|COMMERCIAL OTHER 1|91.93||||||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|PHCS|GROUP AND PENSION|||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Texas Workforce Commission|DIS DETER SERV (DDS)|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Medicare|MEDICARE PART B ONLY IP|91.93||||||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Medicare|MEDICARE ACUTE|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Medicaid|MEDICAID|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Managed Medicare|HEALTHSPRING MA|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Managed Medicare|BCBS MEDICARE PPO MA|91.93||||||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|United Medicare Advantage|UHC MEDICARE GOLD MA|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|United Medicare Advantage|UHC AARP MCR HMO MA|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Workers Compensation|WORKERS COMPENSATION OTHER|91.93||||||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Veterans Affairs|VETERANS ADMINISTRATION|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Access Direct Platinum|HEALTHFIRST TPA UMR|91.93||||||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Aenta Medicare Advantage|AETNA MEDICARE MA|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Aetna|AETNA OTHER|||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|United Healthcare|UNITED HEALTHCARE|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Aetna|AETNA PPO|||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|91.93||||||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Blue Cross HMO Specialty|BCBSTX HMO|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Blue Cross PPO Specialty|BCBSTX PPO|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Cigna|CIGNA|||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Humana Medicare Advantage|HUMANA MA|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Managed Medicaid|MEDICAID UNITED HEALTHCARE|91.93||||91.93||| 9529629|ERX|0250|BUPIVACAINE-EPI 0.5%, 50|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|91.93||||91.93||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID SUPERIOR|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID AMERIGROUP|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Humana Medicare Advantage|HUMANA MA|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross PPO Specialty|BCBSTX PPO|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aenta Medicare Advantage|AETNA MEDICARE MA|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aetna|AETNA PPO|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA UMR|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Workers Compensation|TEXAS MUTUAL INSURANCE|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Veterans Affairs|VETERANS ADMINISTRATION|877.20||||||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC MEDICARE GOLD MA|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross HMO Specialty|BCBSTX HMO|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC AARP MCR HMO MA|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|HEALTHSPRING MA|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|BCBS MEDICARE PPO MA|877.20||||||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|MEDICAID|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|CRIME VICTIMS COMPENSATION|877.20||||||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|SMITH COUNTY JAIL|877.20||||||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID UNITED HEALTHCARE|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicare|MEDICARE ACUTE|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Rusk State Hospital|RUSK STATE HOSP|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Tricare|TRICARE EAST REGION|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|NON CONTRACTED|COMMERCIAL OTHER 1|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|UNITED HEALTHCARE OTHER|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|UNITED HEALTHCARE|||||877.20||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|NON CONTRACTED|COMMUNITY HEALTH CENTER|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Texas Workforce Commission|DIS DETER SERV (DDS)|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Optum Behavioral Health|BH OPTUM UHC|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Medicare|MEDICARE ACUTE|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Medicaid|BH TEXAS CHILDRENS MEDICAID|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Medicaid|MEDICAID|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Tricare|TRICARE EAST REGION|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Managed Medicare|JACKSONVILLE ACCESS|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Access Direct Platinum|ANDREWS CENTER|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Aetna|BH AETNA|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Cigna Behavioral Health|BH CIGNA|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Magellan Behavioral Health|BH MAGELLAN|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Humana Medicare Advantage|HUMANA MA|17.64||||17.64||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|17.64||||||| 9529694|ERX|0250|PRAZOSIN 2 MG CAPSULE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|17.64||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Magellan Behavioral Health|BH MAGELLAN|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Humana Medicare Advantage|HUMANA MA|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Cigna Behavioral Health|BH CIGNA|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Blue Cross PPO Specialty|BCBSTX PPO|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Aetna|BH AETNA|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Access Direct Platinum|HEALTHFIRST TPA UMR|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|United Medicare Advantage|UHC MEDICARE GOLD MA|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Managed Medicare|HEALTHSPRING MA|3.10||||||| 9529702|ERX|0250|DOXEPIN 10 MG/ML ORAL SOL|Medicare|MEDICARE ACUTE|3.10||||||| 9529710|ERX|0250|BREXPIPRAZOLE 1 MG TABLET|Medicare|MEDICARE ACUTE|201.90||||||| 9529710|ERX|0250|BREXPIPRAZOLE 1 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|201.90||||201.90||| 9529710|ERX|0250|BREXPIPRAZOLE 1 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|201.90||||||| 9529710|ERX|0250|BREXPIPRAZOLE 1 MG TABLET|Aetna|BH AETNA|201.90||||||| 9529710|ERX|0250|BREXPIPRAZOLE 1 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|201.90||||||| 9529710|ERX|0250|BREXPIPRAZOLE 1 MG TABLET|Humana Medicare Advantage|HUMANA MA|201.90||||||| 9529710|ERX|0250|BREXPIPRAZOLE 1 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|201.90||||||| 9529728|ERX|0250|BREXPIPRAZOLE 2 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|201.90||||||| 9529728|ERX|0250|BREXPIPRAZOLE 2 MG TABLET|Humana Medicare Advantage|HUMANA MA|201.90||||||| 9529728|ERX|0250|BREXPIPRAZOLE 2 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|201.90||||||| 9529728|ERX|0250|BREXPIPRAZOLE 2 MG TABLET|Managed Medicare|HEALTHSPRING MA|||||201.90||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|Medicaid|MEDICAID|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|Medicare|MEDICARE ACUTE|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|Magellan Behavioral Health|BH MAGELLAN|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|Humana Medicare Advantage|HUMANA MA|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.80||||||| 9529736|ERX|0250|OLANZAPINE 15 MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|8.80||||||| 9529744|ERX|0250|OLANZAPINE 20 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.80||||||| 9529744|ERX|0250|OLANZAPINE 20 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.80||||||| 9529744|ERX|0250|OLANZAPINE 20 MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|8.80||||||| 9529744|ERX|0250|OLANZAPINE 20 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.80||||||| 9529744|ERX|0250|OLANZAPINE 20 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|8.80||||||| 9529744|ERX|0250|OLANZAPINE 20 MG TABLET|Medicare|MEDICARE ACUTE|8.80||||||| 9529744|ERX|0250|OLANZAPINE 20 MG TABLET|Medicaid|MEDICAID|8.80||||||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|165.75||||||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|Tricare|TRICARE FOR LIFE|165.75||||||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|165.75||||||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|Medicare|MEDICARE ACUTE|165.75||||165.75||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|Medicare|MEDICARE PART B ONLY IP|165.75||||||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|165.75||||||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|165.75||||165.75||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|165.75||||||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|165.75||||||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|165.75||||||| 9529751|ERX|0250|DOLUTEGRAVIR 25 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|165.75||||165.75||| 9529918|ERX|0250|PHYTONADIONE 1 MG/ML O/S,|Humana Medicare Advantage|HUMANA MA|81.76||||||| 9529918|ERX|0250|PHYTONADIONE 1 MG/ML O/S,|Veterans Affairs|VETERANS ADMINISTRATION|81.76||||||| 9529918|ERX|0250|PHYTONADIONE 1 MG/ML O/S,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|81.76||||||| 9529918|ERX|0250|PHYTONADIONE 1 MG/ML O/S,|United Medicare Advantage|UHC AARP MCR HMO MA|81.76||||||| 9529918|ERX|0250|PHYTONADIONE 1 MG/ML O/S,|Medicare|MEDICARE ACUTE|81.76||||||| 9529918|ERX|0250|PHYTONADIONE 1 MG/ML O/S,|UTMB|UTMB CORRECTIONAL MANAGED CARE|81.76||||||| 9529918|ERX|0250|PHYTONADIONE 1 MG/ML O/S,|United Healthcare|UNITED HEALTHCARE|81.76||||||| 9529926|ERX|0250|LOKELMA 10 G ORAL POWDER|Medicare|MEDICARE ACUTE|112.44||||||| 9529926|ERX|0250|LOKELMA 10 G ORAL POWDER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|112.44||||||| 9529942|ERX|0250|DAPAGLIFLOZIN 5 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|99.99||||||| 9529959|ERX|0250|DAPAGLIFLOZIN 10 MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|99.99||||||| 9529959|ERX|0250|DAPAGLIFLOZIN 10 MG TABLE|Medicare|MEDICARE ACUTE|99.99||||||| 9529959|ERX|0250|DAPAGLIFLOZIN 10 MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|99.99||||||| 9529959|ERX|0250|DAPAGLIFLOZIN 10 MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.99||||||| 9529967|ERX|0250|FLUOXETINE 20 MG/5 ML UD|Managed Medicaid|MEDICAID AMERIGROUP|||||41.09||| 9530023|ERX|0250|EPINEPHRINE 4 MG/250 ML N|Managed Medicare|HEALTHSPRING MA|1.44||||||| 9530023|ERX|0250|EPINEPHRINE 4 MG/250 ML N|Medicare|MEDICARE ACUTE|1.44||||1.44||| 9530023|ERX|0250|EPINEPHRINE 4 MG/250 ML N|NON CONTRACTED|COMMERCIAL OTHER 1|1.44||||||| 9530023|ERX|0250|EPINEPHRINE 4 MG/250 ML N|United Medicare Advantage|UHC MEDICARE GOLD MA|1.44||||||| 9530023|ERX|0250|EPINEPHRINE 4 MG/250 ML N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.44||||||| 9530023|ERX|0250|EPINEPHRINE 4 MG/250 ML N|Workers Compensation|WORKERS COMPENSATION OTHER|1.44||||||| 9530023|ERX|0250|EPINEPHRINE 4 MG/250 ML N|Aenta Medicare Advantage|AETNA MEDICARE MA|1.44||||||| 9530023|ERX|0250|EPINEPHRINE 4 MG/250 ML N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.44||||||| 9530023|ERX|0250|EPINEPHRINE 4 MG/250 ML N|Humana Medicare Advantage|HUMANA MA|1.44||||||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Humana Medicare Advantage|HUMANA MA|109,715.90|23263.99|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|165,794.56|43159.18|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|180,454.15|21840.09|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Blue Cross PPO Specialty|BCBSTX PPO|359,083.55|897.68|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Blue Cross HMO Specialty|BCBSTX HMO|436,977.90|21840.09|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Aetna|AETNA PPO|238,293.65|39993.27|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Workers Compensation|TRAVELERS INSURANCE COMPANY|142,726.55|142726.55|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Veterans Affairs|VETERANS ADMINISTRATION|246,367.47|23045.43|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|United Medicare Advantage|UHC MEDICARE GOLD MA|95,055.60|22815.86|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|United Healthcare|UNITED HEALTHCARE OTHER|119,356.05|50062.18|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Rusk State Hospital|RUSK STATE HOSP|283,899.65|139110.83|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|NON CONTRACTED|COMMERCIAL OTHER 1|131,702.42|114424.36|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Medicare|MEDICARE ACUTE|176,360.36|22811.98|220779.07|897.68|||| 956|DRG||LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA|Medicaid|MEDICAID|584,219.68|220779.07|220779.07|897.68|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Medicaid|MEDICAID|560,226.44|54155.99|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Medicaid|CRIME VICTIMS COMPENSATION|452,430.38|39801.535|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Medicare|MEDICARE ACUTE|693,112.39|47628.73|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|348,844.10|42627.34|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|707,791.15|48780.32|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|387,422.36|73504.34|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Blue Cross HMO Specialty|BCBSTX HMO|429,883.10|43858.54|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Blue Cross PPO Specialty|BCBSTX PPO|334,778.87|106599.5|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Brinson Benefits|THE HEALTH PLAN SMITH CO|164,248.29|784.52|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Managed Medicaid|MEDICAID SUPERIOR|261,917.64|78007.07|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|250,207.84|43159.18|106599.5|784.52|||| 957|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC|Humana Medicare Advantage|HUMANA MA|241,124.91|42655.99|106599.5|784.52|||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Managed Medicaid|MEDICAID SUPERIOR|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Managed Medicaid|MEDICAID AMERIGROUP|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Humana Medicare Advantage|HUMANA MA|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Blue Cross PPO Specialty|BCBSTX PPO|6.84||||6.84||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Blue Cross PPO Specialty|BCBSTX OTHER|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Blue Cross HMO Specialty|BCBSTX HMO|6.84||||6.84||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Aenta Medicare Advantage|AETNA MEDICARE MA|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.84||||6.84||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|United Medicare Advantage|UHC MEDICARE GOLD MA|6.84||||6.84||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|United Medicare Advantage|UHC AARP MCR HMO MA|6.84||||6.84||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Veterans Affairs|VETERANS ADMINISTRATION|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.84||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Medicare|MEDICARE ACUTE|6.84||||6.84||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|NON CONTRACTED|COMMERCIAL OTHER 1|6.84||||6.84||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|United Healthcare|UNITED HEALTHCARE|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|United Healthcare|UNITED HEALTHCARE OTHER|||||6.84||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Medicaid|SMITH COUNTY JAIL|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Medicaid|MEDICAID|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Managed Medicare|HEALTHSPRING MA|6.84||||||| 95700|EAP|0740|EEG CONT REC W/VID EEG TE|Managed Medicare|BCBS MEDICARE PPO MA|6.84||||||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|Managed Medicare|BCBS MEDICARE PPO MA|6.84||||||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|United Healthcare|UNITED HEALTHCARE|6.84||||||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|NON CONTRACTED|COMMERCIAL OTHER 1|6.84||||||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|Medicare|MEDICARE ACUTE|6.84||||||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.84||||||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.84||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|Blue Cross PPO Specialty|BCBSTX PPO|6.84||||||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|Humana Medicare Advantage|HUMANA MA|6.84||||||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|Managed Medicaid|MEDICAID SUPERIOR|6.84||||||| 95711|EAP|0740|VEEG 2-12 HR UNMONITORED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.84||||||| 95712|EAP|0740|VEEG 2-12 HR INTMT MNTR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.84||||||| 95713|EAP|0740|VEEG 2-12 HR CONT MNTR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Medicare|MEDICARE ACUTE|13.12||||13.12||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|NON CONTRACTED|COMMERCIAL OTHER 1|13.12||||13.12||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|United Healthcare|UNITED HEALTHCARE OTHER|||||13.12||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Medicaid|MEDICAID|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Medicaid|SMITH COUNTY JAIL|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Managed Medicare|HEALTHSPRING MA|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Managed Medicare|BCBS MEDICARE PPO MA|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|United Medicare Advantage|UHC MEDICARE GOLD MA|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|United Medicare Advantage|UHC AARP MCR HMO MA|13.12||||13.12||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Veterans Affairs|VETERANS ADMINISTRATION|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||13.12||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Managed Medicaid|MEDICAID SUPERIOR|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Managed Medicaid|MEDICAID AMERIGROUP|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Humana Medicare Advantage|HUMANA MA|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Blue Cross HMO Specialty|BCBSTX HMO|13.12||||13.12||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Blue Cross PPO Specialty|BCBSTX PPO|13.12||||13.12||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Blue Cross PPO Specialty|BCBSTX OTHER|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Aenta Medicare Advantage|AETNA MEDICARE MA|13.12||||||| 95714|EAP|0740|VEEG EA 12-26 HR UNMNTR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.12||||||| 95715|EAP|0740|VEEG EA 12-26HR INTMT MNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.12||||||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Medicaid|MEDICAID HMO|||||14.35||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||14.35||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,650.25||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Medicaid|MEDICAID|||||1,650.25||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|United Healthcare|UNITED HEALTHCARE|||||14.35||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|PHCS|GROUP AND PENSION|||||1,650.25||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,650.25||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||14.35||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||14.35||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Cigna|CIGNA|||||14.35||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Managed Medicaid|MEDICAID SUPERIOR|||||14.35||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Managed Medicaid|MEDICAID AMERIGROUP|||||1,650.25||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Blue Cross PPO Specialty|BCBSTX PPO|||||14.35||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Blue Cross PPO Specialty|BCBSTX OTHER|||||14.35||| 95782|EAP|0920|POLYSOM <6 YRS 4/> PARAMT|Aetna|AETNA PPO|||||14.35||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|384,309.37|391.23|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Blue Cross HMO Specialty|BCBSTX HMO|134,899.85|24125.81|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Blue Cross PPO Specialty|BCBSTX PPO|159,933.91|28380.84|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|331,698.97|24125.81|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Managed Medicaid|MEDICAID SUPERIOR|227,833.39|44368.7|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|159,801.96|32979.24|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Cigna|CIGNA|101,025.25|46799.36|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Humana Medicare Advantage|HUMANA MA|87,705.51|24763.37|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|101,692.27|31881.47|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|286,684.25|30906.97|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|NON CONTRACTED|COMMERCIAL OTHER 1|212,814.46|212814.46|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|United Healthcare|TML GROUP BENEFITS|142,182.88|53229.49|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|United Healthcare|UNITED HEALTHCARE|432,103.98|66775.49|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|426,363.80|242.11|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Medicaid|CRIME VICTIMS COMPENSATION|415,885.55|18951.88|212814.46|242.11|||| 958|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC|Medicare|MEDICARE ACUTE|120,098.90|24280.83|212814.46|242.11|||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Managed Medicare|HEALTHSPRING MA|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|United Healthcare|UNITED HEALTHCARE|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|United Healthcare|UNITED HEALTHCARE OTHER|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|United Healthcare|UNITED HEALTHCARE|||||617.05||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Tricare|TRICARE EAST REGION|||||617.05||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|PHCS|HUMANA INSURANCE|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|PHCS|HUMANA|||||617.05||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|NON CONTRACTED|COMMERCIAL OTHER 2|||||617.05||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|NON CONTRACTED|COMMERCIAL OTHER 1|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Medicare|MEDICARE ACUTE|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|United Medicare Advantage|UHC AARP MCR HMO MA|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Veterans Affairs|VETERANS ADMINISTRATION|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||617.05||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|PHCS|GROUP AND PENSION|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Access Direct Platinum|HEALTHFIRST TPA|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|United Healthcare|AARP|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Managed Medicaid|MEDICAID AMERIGROUP|||||617.05||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Cigna|CIGNA OTHER|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Cigna|CIGNA|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Cigna|CIGNA|||||617.05||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Cigna Behavioral Health|BH CIGNA|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Humana Medicare Advantage|HUMANA MA|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Blue Cross PPO Specialty|BCBSTX PPO|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Blue Cross HMO Specialty|BCBSTX HMO|||||617.05||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Aenta Medicare Advantage|AETNA MEDICARE MA|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Aetna|BOON CHAPMAN|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Aetna|BH AETNA|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Aetna|AETNA PPO|||||5.74||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Aetna|AETNA OTHER|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Aetna Value Network|AETNA VALUE NETWORK|||||660.10||| 95801|EAP|0740|UNATTENDED SLEEP STUDY, 4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||660.10||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Aetna|AETNA PPO|||||3,197.05||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,420.10||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,420.10||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Blue Cross PPO Specialty|BCBSTX PPO|||||29.74||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Humana Medicare Advantage|HUMANA MA|||||3,420.10||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Managed Medicaid|MEDICAID SUPERIOR|||||29.74||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||29.74||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||29.74||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Access Direct Platinum|HEALTHFIRST TPA|||||3,420.10||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,197.05||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|United Medicare Advantage|UHC AARP MCR HMO MA|||||29.74||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|Medicare|MEDICARE ACUTE|||||29.74||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|United Healthcare|UNITED HEALTHCARE OTHER|||||3,420.10||| 95805|EAP|0740|MULTIPLE SLEEP LATENCY TE|United Healthcare|UNITED HEALTHCARE|||||29.74||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicare|HEALTHSPRING MA|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Medicaid|MEDICAID HMO|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Medicaid|MEDICAID|||||9,592.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Healthcare|UNITED HEALTHCARE OTHER|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Healthcare|UNITED HEALTHCARE|||||9,592.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Healthcare|GOLDEN RULE|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Healthcare|TML GROUP BENEFITS|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|NON CONTRACTED|COMMERCIAL OTHER 3|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|NON CONTRACTED|COMMERCIAL OTHER 2|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|NON CONTRACTED|COMMERCIAL OTHER 1|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Texas Workforce Commission|DIS DETER SERV (DDS)|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Multiplan|WEB TPA|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Medicare|MEDICARE ACUTE|89.23||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Medicare Advantage|UHC AARP MCR HMO MA|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Veterans Affairs|VETERANS ADMINISTRATION|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|United Healthcare|UNITED HEALTHCARE|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Access Direct Platinum|HEALTHFIRST TPA|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicaid|MEDICAID SUPERIOR|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9,592.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicaid|MEDICAID AMERIGROUP|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|ChampVA|CHAMPVA CENTER|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Tricare|TRICARE EAST REGION|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicare|BCBS MEDICARE PPO MA|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Cigna|CIGNA OTHER|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Cigna|CIGNA|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Humana Medicare Advantage|HUMANA MA|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Blue Cross HMO Specialty|BCBSTX HMO|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Blue Cross PPO Specialty|BCBSTX PPO|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Blue Cross PPO Specialty|BCBSTX OTHER|||||9,592.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||89.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Aenta Medicare Advantage|AETNA MEDICARE MA|||||10,261.45||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Aetna|AETNA PPO|||||9,592.23||| 95810|EAP|0740|POLYSOMNOGRAM DIAGNOSTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10,261.45||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Aetna|AETNA PPO|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Aenta Medicare Advantage|AETNA MEDICARE MA|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Blue Cross PPO Specialty|BCBSTX OTHER|||||10,390.95||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Blue Cross HMO Specialty|BCBSTX HMO|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Blue Cross HMO Specialty|BCBSTX HMO|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Humana Medicare Advantage|HUMANA MA|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Humana Medicare Advantage|HUMANA MA|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|ChampVA|CHAMPVA CENTER|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Cigna|CIGNA|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Cigna|CIGNA|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Managed Medicaid|MEDICAID AMERIGROUP|||||10,390.95||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Access Direct Platinum|HEALTHFIRST TPA|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Access Direct Platinum|HEALTHFIRST TPA|||||10,390.95||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Veterans Affairs|VETERANS ADMINISTRATION|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Managed Medicaid|MEDICAID SUPERIOR|||||10,390.95||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Cigna|CIGNA OTHER|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|United Medicare Advantage|UHC AARP MCR HMO MA|||||10,390.95||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|United Medicare Advantage|UHC AARP MCR HMO MA|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Medicare|MEDICARE ACUTE|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Medicare|MEDICARE ACUTE|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|PHCS|GROUP AND PENSION|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|NON CONTRACTED|COMMERCIAL OTHER 3|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Blue Cross PPO Specialty|BCBSTX PPO|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|NON CONTRACTED|COMMERCIAL OTHER 1|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|NON CONTRACTED|COMMERCIAL OTHER 3|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|NON CONTRACTED|COMMERCIAL OTHER 1|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Texas Workforce Commission|DIS DETER SERV (DDS)|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Blue Cross PPO Specialty|BCBSTX PPO|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|United Healthcare|UNITED HEALTHCARE OTHER|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|United Healthcare|UNITED HEALTHCARE|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Aetna|AETNA PPO|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|United Healthcare|UNITED HEALTHCARE|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|United Healthcare|TML GROUP BENEFITS|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|United Healthcare|GOLDEN RULE|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Tricare|TRICARE EAST REGION|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Medicaid|MEDICAID HMO|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Medicaid|MEDICAID|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Managed Medicare|HEALTHSPRING MA|||||96.66||| 95811|EAP|0740|POLYSOMNOGRAM THERAPUTIC|Managed Medicare|BCBS MEDICARE PPO MA|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Managed Medicare|HEALTHSPRING MA|||||11,115.90||| 95811|EAP|0740|POLYSOMNOGRAM SPLIT NIGHT|Managed Medicare|BCBS MEDICARE PPO MA|||||11,115.90||| 95812|EAP|0740|EEG 41-60 MINUTES|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2,285.80||| 95812|EAP|0740|EEG 41-60 MINUTES|Medicaid|MEDICAID|||||20.78||| 95812|EAP|0740|EEG 41-60 MINUTES|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,493.60||| 95812|EAP|0740|EEG 41-60 MINUTES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||20.78||| 95812|EAP|0740|EEG 41-60 MINUTES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||20.78||| 95812|EAP|0740|EEG 41-60 MINUTES|Managed Medicaid|MEDICAID SUPERIOR|||||2,493.60||| 95812|EAP|0740|EEG 41-60 MINUTES|Managed Medicaid|MEDICAID AMERIGROUP|2,493.60||||20.78||| 95812|EAP|0740|EEG 41-60 MINUTES|Humana Medicare Advantage|HUMANA MA|||||2,493.60||| 95812|EAP|0740|EEG 41-60 MINUTES|Blue Cross PPO Specialty|BCBSTX PPO|||||20.78||| 95812|EAP|0740|EEG 41-60 MINUTES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,493.60||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Aetna|AETNA OTHER|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.43||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.24||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Blue Cross HMO Specialty|BCBSTX HMO|18.43||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Blue Cross PPO Specialty|BCBSTX PPO|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Humana Medicare Advantage|HUMANA MA|18.43||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Managed Medicaid|MEDICAID SUPERIOR|||||33.24||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.43||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Humana Medicare Advantage|HUMANA MA|30.47||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Managed Medicaid|MEDICAID AMERIGROUP|||||33.24||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|United Medicare Advantage|UHC MEDICARE GOLD MA|33.24||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|United Medicare Advantage|UHC MEDICARE GOLD MA|2,027.30||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.43||||33.24||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|United Medicare Advantage|UHC AARP MCR HMO MA|33.24||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|United Medicare Advantage|UHC AARP MCR HMO MA|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Access Direct Platinum|HEALTHFIRST TPA|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|United Healthcare|UNITED HEALTHCARE OTHER|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|United Healthcare|UNITED HEALTHCARE|18.43||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|United Healthcare|TML GROUP BENEFITS|18.43||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Medicare|MEDICARE ACUTE|27.70||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Medicare|MEDICARE ACUTE|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|NON CONTRACTED|COMMERCIAL OTHER 1|18.43||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Managed Medicare|HEALTHSPRING MA|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Managed Medicare|BCBS MEDICARE PPO MA|2,211.60||||||| 95813|EAP|0740|EEG EXTENDED MONITORING 6|Medicaid|MEDICAID|2,027.30||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2,065.20||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Medicaid|SMITH COUNTY INDIGENT HEALTH|2,065.20||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Medicaid|MEDICAID|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Medicaid|MEDICAID HMO|||||2,065.20||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.21||||17.21||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Managed Medicare|HEALTHSPRING MA|2,065.20||||2,065.20||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Managed Medicare|BCBS MEDICARE PPO MA|2,065.20||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|NON CONTRACTED|COMMERCIAL OTHER 1|||||17.21||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Medicare|MEDICARE ACUTE|17.21||||17.21||| 95816|EAP|0740|EEG AWAKE AND DROWSY|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|United Healthcare|UNITED HEALTHCARE|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Veterans Affairs|VETERANS ADMINISTRATION|1,893.10||||17.21||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,065.20||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Access Direct Platinum|HEALTHFIRST TPA UMR|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Medicare|MEDICARE PART B ONLY IP|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2,065.20||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|United Medicare Advantage|UHC MEDICARE GOLD MA|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,065.20||||2,065.20||| 95816|EAP|0740|EEG AWAKE AND DROWSY|United Medicare Advantage|UHC AARP MCR HMO MA|2,065.20||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,065.20||||17.21||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Managed Medicaid|MEDICAID SUPERIOR|||||2,065.20||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,065.20||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Managed Medicaid|MEDICAID AMERIGROUP|17.21||||1,893.10||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Medicaid|SMITH COUNTY JAIL|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|ChampVA|CHAMPVA CENTER|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Cigna|CIGNA|1,893.10||||17.21||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Cigna|CIGNA|||||17.21||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Humana Medicare Advantage|HUMANA MA|17.21||||17.21||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2,065.20||||1,893.10||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Blue Cross PPO Specialty|BCBSTX PPO|2,065.20||||2,065.20||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Blue Cross PPO Specialty|BCBSTX OTHER|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Blue Cross HMO Specialty|BCBSTX HMO|2,065.20||||2,065.20||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Aenta Medicare Advantage|AETNA MEDICARE MA|17.21||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.21||||2,065.20||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Aetna|AETNA QHP HMO|1,653.60||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Aetna|AETNA PPO|13.78||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,653.60||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Aenta Medicare Advantage|AETNA MEDICARE MA|13.78||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Blue Cross HMO Specialty|BCBSTX HMO|13.78||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Blue Cross PPO Specialty|BCBSTX OTHER|1,653.60||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Humana Medicare Advantage|HUMANA MA|13.78||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Cigna|CIGNA OTHER|13.78||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.78||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicaid|MEDICAID SUPERIOR|13.78||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.78||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|United Medicare Advantage|UHC MEDICARE GOLD MA|13.78||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.78||||1,515.80||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|United Medicare Advantage|UHC AARP WELLMED HMO MA|1,653.60||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|United Medicare Advantage|UHC AARP MCR HMO MA|1,653.60||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,515.80||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|13.78||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Access Direct Platinum|HEALTHFIRST TPA UMR|13.78||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicaid|MEDICAID AMERIGROUP|1,653.60||||1,515.80||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,653.60||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Access Direct Platinum|HEALTHFIRST TPA|1,653.60||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Veterans Affairs|VETERANS ADMINISTRATION|1,653.60||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|United Healthcare|UNITED HEALTHCARE OTHER|1,653.60||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Cigna|CIGNA|13.78||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|United Healthcare|UNITED HEALTHCARE|1,653.60||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|United Healthcare|UNITED HEALTHCARE|13.78||||1,515.80||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|United Healthcare|GOLDEN RULE|1,653.60||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,515.80||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Blue Cross PPO Specialty|BCBSTX PPO|1,653.60||||1,515.80||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Multiplan|WEB TPA|||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Medicare|MEDICARE PART B ONLY IP|13.78||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Medicare|MEDICARE ACUTE|13.78||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|NON CONTRACTED|COMMERCIAL OTHER 1|1,653.60||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicare|OTHER INSTITUTIONS|||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.78||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicare|MA PART B ONLY IP|13.78||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicare|HEALTHSPRING MA|13.78||||13.78||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicare|ETMC AFFILIATE HOSPITALS|13.78||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicare|BCBS MEDICARE PPO MA|13.78||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Medicaid|SMITH COUNTY JAIL|13.78||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Medicaid|MEDICAID|13.78||||1,653.60||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Medicaid|COUNTY INDIGENT HEALTH OTHER|13.78||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Medicaid|MEDICAID HMO|||||1,653.60||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Medicaid|MEDICAID|2,523.60||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Managed Medicare|HEALTHSPRING MA|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|PHCS|HUMANA|2,523.60||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Medicare|MEDICARE ACUTE|2,523.60||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|UTMB|UTMB CORRECTIONAL MANAGED CARE|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|United Healthcare|UNITED HEALTHCARE OTHER|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|United Healthcare|UNITED HEALTHCARE|2,523.60||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|United Healthcare|UNITED HEALTHCARE|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Veterans Affairs|VETERANS ADMINISTRATION|2,523.60||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Managed Medicare|BCBS MEDICARE PPO MA|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Medicaid|MOLINA HEALTHCARE OF TEXAS|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|United Medicare Advantage|UHC MEDICARE GOLD MA|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,313.30||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|United Medicare Advantage|UHC AARP MCR HMO MA|2,523.60||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,523.60||||2,523.60||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Humana Medicare Advantage|HUMANA MA|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Blue Cross PPO Specialty|BCBSTX PPO|2,523.60||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Blue Cross HMO Specialty|BCBSTX HMO|21.03||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Aenta Medicare Advantage|AETNA MEDICARE MA|2,313.30||||||| 95822|EAP|0740|EEG COMA OR SLEEP ONLY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,523.60||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Aetna|AETNA QHP HMO|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Aetna|AETNA PPO|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Blue Cross HMO Specialty|BCBSTX HMO|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Cigna|CIGNA OTHER|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Cigna|CIGNA|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Humana Medicare Advantage|HUMANA MA|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Managed Medicaid|MEDICAID AMERIGROUP|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA|||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Aetna|AETNA OTHER|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Veterans Affairs|VETERANS ADMINISTRATION|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|United Healthcare|UNITED HEALTHCARE OTHER|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|United Healthcare|UNITED HEALTHCARE|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|PHCS|GROUP AND PENSION|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Managed Medicare|HEALTHSPRING MA|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Managed Medicare|BCBS MEDICARE PPO MA|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Medicare|MEDICARE PART B ONLY IP|27.50||||||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Medicare|MEDICARE ACUTE|27.50||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Medicaid|LAW ENFORCEMENT OTHER|||||27.50||| 9582883|ERX|0250|PAPAVERINE 60MG/ 2ML VIAL|Medicaid|MEDICAID|27.50||||27.50||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Medicaid|MEDICAID|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Medicaid|COUNTY INDIGENT HEALTH OTHER|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Medicare|MEDICARE ACUTE|305.50||||305.50||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Managed Medicare|HEALTHSPRING MA|305.50||||305.50||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Managed Medicare|BCBS MEDICARE PPO MA|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|PHCS|HUMANA|||||305.50||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|UTMB|UTMB CORRECTIONAL MANAGED CARE|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Healthcare|UNITED HEALTHCARE OTHER|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Healthcare|UNITED HEALTHCARE|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Healthcare|TML GROUP BENEFITS|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Veterans Affairs|VETERANS ADMINISTRATION|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|NON CONTRACTED|COMMERCIAL OTHER 1|305.50||||305.50||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Access Direct Platinum|HEALTHFIRST TPA UMR|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Medicare Advantage|UHC MEDICARE GOLD MA|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|305.50||||305.50||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Medicare Advantage|UHC AARP WELLMED HMO MA|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Medicare Advantage|UHC AARP MCR HMO MA|305.50||||305.50||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Managed Medicare|WELLCARE CHOICE MA|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Humana Medicare Advantage|HUMANA MA|305.50||||305.50||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Cigna|CIGNA OTHER|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Cigna|CIGNA|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Blue Cross HMO Specialty|BCBSTX HMO|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Blue Cross PPO Specialty|BCBSTX PPO|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Blue Cross PPO Specialty|BCBSTX OTHER|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Aenta Medicare Advantage|AETNA MEDICARE MA|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Aetna|AETNA PPO|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Aetna|AETNA OTHER|305.50||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|305.50||||||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Aenta Medicare Advantage|AETNA MEDICARE MA|12.75||||||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Blue Cross HMO Specialty|BCBSTX HMO|12.75||||||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.75||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Medicaid|MEDICAID HMO|||||12.75||| 9583014|ERX|0250|WARFARIN 3MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||12.75||| 9583014|ERX|0250|WARFARIN 3MG TABLET|United Healthcare|UNITED HEALTHCARE|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Managed Medicare|HEALTHSPRING MA|12.75||||12.75||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Medicaid|MEDICAID|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9583014|ERX|0250|WARFARIN 3MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||12.75||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.75||||12.75||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|12.75||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Aenta Medicare Advantage|AETNA MEDICARE MA|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Aetna|AETNA QHP HMO|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Aetna|AETNA PPO|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Blue Cross PPO Specialty|BCBSTX OTHER|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Blue Cross HMO Specialty|BCBSTX HMO|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Brinson Benefits|THE HEALTH PLAN SMITH CO|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Cigna|CIGNA OTHER|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Cigna|CIGNA|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Humana Medicare Advantage|HUMANA MA|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Workers Compensation|WORKERS COMPENSATION OTHER|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Veterans Affairs|VETERANS ADMINISTRATION|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Medicare Advantage|UHC MEDICARE GOLD MA|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Access Direct Platinum|HEALTHFIRST TPA|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicaid|MEDICAID AMERIGROUP|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Medicare Advantage|UHC AARP WELLMED HMO MA|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Medicare Advantage|UHC AARP MCR HMO MA|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicare|MEDICARE ACUTE|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicare|MEDICARE PART B ONLY IP|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicaid|SMITH COUNTY JAIL|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicaid|SMITH COUNTY INDIGENT HEALTH|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicaid|MEDICAID HMO|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicaid|MEDICAID|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicaid|COUNTY INDIGENT HEALTH OTHER|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicare|HEALTHSPRING MA|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicare|BCBS MEDICARE PPO MA|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|NON CONTRACTED|COMMERCIAL OTHER 1|10.50||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|PHCS|HUMANA|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|PHCS|GROUP AND PENSION|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Tricare|TRICARE EAST REGION|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|UTMB|UTMB CORRECTIONAL MANAGED CARE|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Healthcare|UNITED HEALTHCARE OTHER|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Healthcare|UNITED HEALTHCARE|10.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Healthcare|UNITED HEALTHCARE|||||10.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Healthcare|TML GROUP BENEFITS|10.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|UNITED HEALTHCARE ERS|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|UNITED HEALTHCARE|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|UTMB|UTMB CORRECTIONAL MANAGED CARE|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|AARP|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|TML GROUP BENEFITS|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|GOLDEN RULE|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|GEHA|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|PHCS|GROUP AND PENSION|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|PHCS|HUMANA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Texas Workforce Commission|DIS DETER SERV (DDS)|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Tricare|TRICARE FOR LIFE|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Multiplan|WEB TPA|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|NON CONTRACTED|COMMERCIAL OTHER 2|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|NON CONTRACTED|COMMERCIAL OTHER 1|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicare|HEALTHSPRING MA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicare|BCBS MEDICARE PPO MA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|SUPERIOR HEALTHPLAN CHIP|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|SMITH COUNTY INDIGENT HEALTH|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|MOLINA HEALTHCARE OF TEXAS|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|MEDICAID HMO|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|MEDICAID|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|LAW ENFORCEMENT OTHER|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|CRIME VICTIMS COMPENSATION|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicare|MEDICARE PART B ONLY IP|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicare|MEDICARE ACUTE|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|UHC AARP WELLMED HMO MA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|UHC AARP MCR HMO MA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|WORKERS COMPENSATION OTHER|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|UT EMPLOYEE INJURY|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|TRAVELERS INSURANCE COMPANY|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|MEDICAID BCBSTX|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|GALLAGHER BASSETT|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|SMITH COUNTY JAIL|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|BROOKSHIRES WORKERS COMP|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|TEXAS MUTUAL INSURANCE|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|ZURICH COMPANY|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Veterans Affairs|VETERANS ADMINISTRATION|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST TPA UMR|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Tricare|TRICARE EAST REGION|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST TPA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Humana Medicare Advantage|HUMANA MA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Cigna|CIGNA OTHER|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Cigna|CIGNA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Rusk State Hospital|RUSK STATE HOSP|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID SUPERIOR|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|UNITED HEALTHCARE OTHER|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID AMERIGROUP|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|ChampVA|CHAMPVA CENTER|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Brinson Benefits|THE HEALTH PLAN SMITH CO|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross HMO Specialty|BCBSTX HMO|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross PPO Specialty|BCBSTX PPO|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross PPO Specialty|BCBSTX OTHER|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Aetna Value Network|AETNA VALUE NETWORK|99.50||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Aenta Medicare Advantage|AETNA MEDICARE MA|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Aetna|BOON CHAPMAN|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Aetna|AETNA QHP HMO|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Aetna|AETNA PPO|99.50||||99.50||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Aetna|AETNA OTHER|99.50||||99.50||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Aenta Medicare Advantage|AETNA MEDICARE MA|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Aetna|AETNA PPO|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Humana Medicare Advantage|HUMANA MA|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Access Direct Platinum|HEALTHFIRST TPA|||||10.50||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Veterans Affairs|VETERANS ADMINISTRATION|10.50||||10.50||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|United Medicare Advantage|UHC MEDICARE GOLD MA|10.50||||10.50||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|United Medicare Advantage|UHC AARP MCR HMO MA|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Medicare|MEDICARE ACUTE|10.50||||10.50||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Managed Medicare|HEALTHSPRING MA|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|Managed Medicare|BCBS MEDICARE PPO MA|10.50||||||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||10.50||| 9583105|ERX|0250|REFRESH PLUS 0.5% UD EYE|United Healthcare|UNITED HEALTHCARE|10.50||||||| 9583147|ERX|0250|LEVETIRACETAM 500MG IN 10|Medicare|MEDICARE ACUTE|271.50||||||| 9583147|ERX|0250|LEVETIRACETAM 500MG IN 10|Blue Cross PPO Specialty|BCBSTX PPO|271.50||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|99.50||||99.50||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.50||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Humana Medicare Advantage|HUMANA MA|99.50||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.50||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99.50||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.50||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Blue Cross HMO Specialty|BCBSTX HMO|99.50||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Managed Medicare|HEALTHSPRING MA|99.50||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Medicare|MEDICARE ACUTE|99.50||||||| 9583519|ERX|0250|OXYCODONE IR 15MG TABLET|Medicare|MEDICARE ACUTE|10.50||||||| 9583576|ERX|0250|PROMETHAZINE W.COD 6.25MG|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||10.50||| 9583576|ERX|0250|PROMETHAZINE W.COD 6.25MG|Humana Medicare Advantage|HUMANA MA|10.50||||||| 9583576|ERX|0250|PROMETHAZINE W.COD 6.25MG|Workers Compensation|WORKERS COMPENSATION OTHER|10.50||||||| 9583576|ERX|0250|PROMETHAZINE W.COD 6.25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||||| 9583576|ERX|0250|PROMETHAZINE W.COD 6.25MG|Medicare|MEDICARE ACUTE|10.50||||||| 9583584|ERX|0250|POLYETHYLENE GLYCOL OPHT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.54||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|NON CONTRACTED|COMMERCIAL OTHER 2|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Tricare|TRICARE EAST REGION|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|PHCS|GROUP AND PENSION|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|PHCS|HUMANA INSURANCE|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Tricare|TRICARE FOR LIFE|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|United Healthcare|UNITED HEALTHCARE OTHER|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|United Healthcare|UNITED HEALTHCARE|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|United Healthcare|TML GROUP BENEFITS|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|United Healthcare|GOLDEN RULE|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Managed Medicare|HEALTHSPRING MA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Managed Medicare|BCBS MEDICARE PPO MA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Medicaid|SMITH COUNTY JAIL|||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Medicaid|MEDICAID|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Medicare|MEDICARE PART B ONLY IP|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Medicare|UTSW MC KIDNEY PROGRAM|||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Medicare|MEDICARE ACUTE|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Managed Medicaid|MEDICAID SUPERIOR|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Managed Medicaid|MEDICAID AMERIGROUP|||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Cigna|CIGNA OTHER|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Cigna|CIGNA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Humana Medicare Advantage|HUMANA MA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Aetna|AETNA QHP HMO|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Aetna|AETNA PPO|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Aetna|AETNA OTHER|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|PHCS|HUMANA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Blue Cross PPO Specialty|BCBSTX OTHER|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Blue Cross HMO Specialty|BCBSTX HMO|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Blue Cross PPO Specialty|BCBSTX PPO|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Access Direct Platinum|HEALTHFIRST TPA UMR|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Access Direct Platinum|HEALTHFIRST TPA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|Veterans Affairs|VETERANS ADMINISTRATION|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|169.50||||169.50||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|169.50||||||| 9583691|ERX|0250|HEPARIN 2000 UNITS/1000ML|United Medicare Advantage|UHC AARP MCR HMO MA|169.50||||169.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|United Medicare Advantage|UHC MEDICARE GOLD MA|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|United Medicare Advantage|UHC AARP MCR HMO MA|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Veterans Affairs|VETERANS ADMINISTRATION|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Blue Cross HMO Specialty|BCBSTX HMO|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Blue Cross PPO Specialty|BCBSTX PPO|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Brinson Benefits|THE HEALTH PLAN SMITH CO|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Aenta Medicare Advantage|AETNA MEDICARE MA|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Aetna|AETNA OTHER|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Humana Medicare Advantage|HUMANA MA|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Cigna|CIGNA OTHER|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Cigna|CIGNA|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Managed Medicaid|MEDICAID AMERIGROUP|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Medicare|MEDICARE PART B ONLY IP|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Medicare|MEDICARE ACUTE|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Medicaid|COUNTY INDIGENT HEALTH OTHER|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Medicaid|MEDICAID|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|Managed Medicare|HEALTHSPRING MA|23.50||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|UTMB|UTMB CORRECTIONAL MANAGED CARE|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|United Healthcare|UNITED HEALTHCARE|||||23.50||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|United Healthcare|UNITED HEALTHCARE OTHER|23.50||||||| 9583725|ERX|0250|LOPERAMIDE 1MG/ 7.5ML 4OZ|NON CONTRACTED|COMMERCIAL OTHER 1|23.50||||23.50||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|NON CONTRACTED|COMMERCIAL OTHER 1|608.75||||||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|United Healthcare|UNITED HEALTHCARE OTHER|||||608.75||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|United Healthcare|UNITED HEALTHCARE|||||608.75||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Medicaid|MEDICAID|608.75||||||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Medicaid|SUPERIOR HEALTHPLAN CHIP|608.75||||608.75||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Medicaid|MEDICAID HMO|||||608.75||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Managed Medicaid|MEDICAID SUPERIOR|608.75||||608.75||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Managed Medicaid|MEDICAID AMERIGROUP|608.75||||||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Humana Medicare Advantage|HUMANA MA|608.75||||||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Blue Cross PPO Specialty|BCBSTX PPO|608.75||||||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||608.75||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|50.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|United Medicare Advantage|UHC AARP MCR HMO MA|50.50||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Veterans Affairs|VETERANS ADMINISTRATION|50.50||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Access Direct Platinum|HEALTHFIRST TPA|50.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Aetna|AETNA PPO|||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|50.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Blue Cross PPO Specialty|BCBSTX PPO|50.50||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|United Medicare Advantage|UHC MEDICARE GOLD MA|50.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Humana Medicare Advantage|HUMANA MA|50.50||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicaid|MEDICAID SUPERIOR|||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|50.50||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicaid|MEDICAID AMERIGROUP|||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|50.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicare|HEALTHSPRING MA|50.50||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicare|BCBS MEDICARE PPO MA|50.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Medicare|MEDICARE PART B ONLY IP|50.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Medicare|MEDICARE ACUTE|50.50||||50.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Medicaid|CRIME VICTIMS COMPENSATION|50.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|United Healthcare|UNITED HEALTHCARE|50.50||||||| 9583782|ERX|0250|NAPROXEN 250MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.50||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|48.50||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Medicare|MEDICARE ACUTE|48.50||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Access Direct Platinum|ANDREWS CENTER|48.50||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|48.50||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|48.50||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Aetna|BH AETNA|48.50||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|48.50||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|48.50||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|48.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Cigna|CIGNA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Humana Medicare Advantage|HUMANA MA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Blue Cross HMO Specialty|BCBSTX HMO|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Blue Cross PPO Specialty|BCBSTX OTHER|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Aetna|AETNA PPO|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Veterans Affairs|VETERANS ADMINISTRATION|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Access Direct Platinum|HEALTHFIRST TPA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|PHCS|HUMANA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|NON CONTRACTED|COMMERCIAL OTHER 1|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|United Healthcare|UNITED HEALTHCARE OTHER|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|United Healthcare|UNITED HEALTHCARE|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Managed Medicare|HEALTHSPRING MA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Managed Medicare|BCBS MEDICARE PPO MA|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Medicare|MEDICARE ACUTE|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Medicaid|MEDICAID HMO|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Medicaid|MEDICAID|7.50||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Medicaid|CRIME VICTIMS COMPENSATION|7.50||||||| 9583865|ERX|0250|GUAIFENSEIN 200MG/10ML 10|Medicare|MEDICARE ACUTE|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|United Medicare Advantage|UHC MEDICARE GOLD MA|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|NON CONTRACTED|COMMERCIAL OTHER 1|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|Rusk State Hospital|RUSK STATE HOSP|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|Medicaid|MEDICAID|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|Medicaid|COUNTY INDIGENT HEALTH OTHER|10.50||||||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|Medicare|MEDICARE ACUTE|10.50||||10.50||| 9584160|ERX|0250|SODIUM CHLORIDE 3% 15ML I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.50||||||| 9584160|ERX|0250|SODIUM CHLORIDE 3% 15ML I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Managed Medicare|HEALTHSPRING MA|||||915.50||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Medicare|MEDICARE ACUTE|915.50||||915.50||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|NON CONTRACTED|COMMERCIAL OTHER 1|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Humana Medicare Advantage|HUMANA MA|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Cigna|CIGNA|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||915.50||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Managed Medicaid|MEDICAID AMERIGROUP|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Aenta Medicare Advantage|AETNA MEDICARE MA|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Blue Cross HMO Specialty|BCBSTX HMO|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Blue Cross PPO Specialty|BCBSTX PPO|915.50||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||915.50||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|United Medicare Advantage|UHC AARP MCR HMO MA|915.50||||915.50||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Veterans Affairs|VETERANS ADMINISTRATION|||||915.50||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|915.50||||||| 9584277|ERX|0250|CITALOPRAM 10MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.20||||||| 9584277|ERX|0250|CITALOPRAM 10MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.20||||||| 9584277|ERX|0250|CITALOPRAM 10MG TABLET|Humana Medicare Advantage|HUMANA MA|0.20||||||| 9584277|ERX|0250|CITALOPRAM 10MG TABLET|United Healthcare|UNITED HEALTHCARE|0.20||||||| 9584277|ERX|0250|CITALOPRAM 10MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.20||||||| 9584277|ERX|0250|CITALOPRAM 10MG TABLET|Medicare|MEDICARE ACUTE|0.20||||||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Managed Medicare|HEALTHSPRING MA|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Managed Medicare|BCBS MEDICARE PPO MA|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Medicare|MEDICARE ACUTE|99.50||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|NON CONTRACTED|COMMERCIAL OTHER 1|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|UTMB|UTMB CORRECTIONAL MANAGED CARE|99.50||||||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|United Healthcare|UNITED HEALTHCARE|99.50||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|United Healthcare|UNITED HEALTHCARE OTHER|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|United Healthcare|UNITED HEALTHCARE|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST TPA|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST TPA UMR|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Veterans Affairs|VETERANS ADMINISTRATION|99.50||||||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Medicaid|CRIME VICTIMS COMPENSATION|99.50||||||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|United Medicare Advantage|UHC MEDICARE GOLD MA|99.50||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Blue Cross HMO Specialty|BCBSTX HMO|99.50||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Blue Cross PPO Specialty|BCBSTX PPO|99.50||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Blue Cross PPO Specialty|BCBSTX OTHER|99.50||||||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.50||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Aetna|BOON CHAPMAN|99.50||||||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Aetna|AETNA PPO|99.50||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Aetna|AETNA OTHER|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Cigna|CIGNA|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Humana Medicare Advantage|HUMANA MA|||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.50||||99.50||| 9584434|ERX|0250|CEFOXITIN 1G D5W 50ML DUP|Managed Medicaid|MEDICAID SUPERIOR|99.50||||99.50||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Managed Medicaid|MEDICAID AMERIGROUP|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Humana Medicare Advantage|HUMANA MA|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Cigna|CIGNA OTHER|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Aenta Medicare Advantage|AETNA MEDICARE MA|135.75||||||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Aetna|AETNA PPO|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Aetna|AETNA OTHER|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Aetna|AETNA QHP HMO|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Blue Cross HMO Specialty|BCBSTX HMO|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Blue Cross PPO Specialty|BCBSTX PPO|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|ChampVA|CHAMPVA CENTER|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|United Medicare Advantage|UHC MEDICARE GOLD MA|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|United Medicare Advantage|UHC AARP MCR HMO MA|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Veterans Affairs|VETERANS ADMINISTRATION|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST TPA|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST TPA UMR|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|United Healthcare|UNITED HEALTHCARE|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|United Healthcare|UNITED HEALTHCARE|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|United Healthcare|TML GROUP BENEFITS|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|United Healthcare|GOLDEN RULE|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|United Healthcare|GEHA|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Cigna|CIGNA|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|United Healthcare|UNITED HEALTHCARE OTHER|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Rusk State Hospital|RUSK STATE HOSP|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Texas Workforce Commission|DIS DETER SERV (DDS)|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Tricare|TRICARE EAST REGION|135.75||||||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|NON CONTRACTED|COMMERCIAL OTHER 2|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|NON CONTRACTED|COMMERCIAL OTHER 1|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Medicaid|MEDICAID|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Medicaid|COUNTY INDIGENT HEALTH OTHER|135.75||||||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Medicare|MEDICARE ACUTE|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Managed Medicare|HEALTHSPRING MA|135.75||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||135.75||| 9584442|ERX|0250|CEFOXITIN 2G D5W 50ML DUP|Managed Medicare|BCBS MEDICARE PPO MA|135.75||||135.75||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Managed Medicare|HEALTHSPRING MA|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Managed Medicare|BCBS MEDICARE PPO MA|99.50||||||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Medicare|MEDICARE ACUTE|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Medicaid|MEDICAID HMO|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Medicaid|MEDICAID|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|NON CONTRACTED|COMMERCIAL OTHER 1|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Tricare|TRICARE EAST REGION|||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|United Healthcare|TML GROUP BENEFITS|||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|United Healthcare|UNITED HEALTHCARE OTHER|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|99.50||||||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Medicaid|SUPERIOR HEALTHPLAN CHIP|99.50||||||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Workers Compensation|UT EMPLOYEE INJURY|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Veterans Affairs|VETERANS ADMINISTRATION|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|United Medicare Advantage|UHC MEDICARE GOLD MA|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|United Medicare Advantage|UHC AARP MCR HMO MA|99.50||||||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Blue Cross PPO Specialty|BCBSTX PPO|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Aenta Medicare Advantage|AETNA MEDICARE MA|||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Cigna|CIGNA|99.50||||||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Humana Medicare Advantage|HUMANA MA|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Managed Medicaid|MEDICAID SUPERIOR|||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99.50||||99.50||| 9584459|ERX|0250|CEFTRIAXONE 1G D5W 50ML D|Managed Medicaid|MEDICAID AMERIGROUP|99.50||||99.50||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Managed Medicaid|MEDICAID SUPERIOR|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Humana Medicare Advantage|HUMANA MA|135.75||||135.75||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Cigna|CIGNA OTHER|||||135.75||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Cigna|CIGNA|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Blue Cross HMO Specialty|BCBSTX HMO|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Blue Cross PPO Specialty|BCBSTX PPO|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Blue Cross PPO Specialty|BCBSTX OTHER|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|United Medicare Advantage|UHC MEDICARE GOLD MA|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|135.75||||135.75||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|United Medicare Advantage|UHC AARP MCR HMO MA|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Workers Compensation|BROOKSHIRES WORKERS COMP|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Veterans Affairs|VETERANS ADMINISTRATION|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Access Direct Platinum|HEALTHFIRST TPA UMR|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Aenta Medicare Advantage|AETNA MEDICARE MA|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Access Direct Platinum|HEALTHFIRST TPA|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|United Healthcare|UNITED HEALTHCARE OTHER|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|United Healthcare|UNITED HEALTHCARE|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|United Healthcare|TML GROUP BENEFITS|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|UTMB|UTMB CORRECTIONAL MANAGED CARE|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|NON CONTRACTED|COMMERCIAL OTHER 1|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Medicaid|SMITH COUNTY JAIL|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Medicaid|MOLINA HEALTHCARE OF TEXAS|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Medicaid|MEDICAID|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Medicare|MEDICARE ACUTE|135.75||||135.75||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Managed Medicare|HEALTHSPRING MA|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Managed Medicare|ETMC AFFILIATE HOSPITALS|135.75||||||| 9584467|ERX|0250|CEFTRIAXONE 2G D5W 50ML D|Managed Medicare|BCBS MEDICARE PPO MA|135.75||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicare|MA PART B ONLY IP|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicare|HEALTHSPRING MA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicare|ETMC AFFILIATE HOSPITALS|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicare|BCBS MEDICARE PPO MA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicare|MEDICARE PART B ONLY IP|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicaid|SUPERIOR HEALTHPLAN CHIP|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicaid|SMITH COUNTY JAIL|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicaid|SMITH COUNTY INDIGENT HEALTH|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicaid|MEDICAID|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicaid|CRIME VICTIMS COMPENSATION|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|PHCS|HUMANA|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|PHCS|HUMANA INSURANCE|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Tricare|TRICARE FOR LIFE|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Tricare|TRICARE EAST REGION|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|NON CONTRACTED|COMMERCIAL OTHER 1|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|UTMB|UTMB CORRECTIONAL MANAGED CARE|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Healthcare|TML GROUP BENEFITS|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Healthcare|UNITED HEALTHCARE OTHER|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Healthcare|UNITED HEALTHCARE|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST TPA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Healthcare|GOLDEN RULE|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST TPA UMR|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Workers Compensation|TEXAS MUTUAL INSURANCE|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Workers Compensation|WORKERS COMPENSATION OTHER|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Veterans Affairs|VETERANS ADMINISTRATION|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Medicare Advantage|UHC MEDICARE GOLD MA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Medicare Advantage|UHC AARP WELLMED HMO MA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Medicare Advantage|UHC AARP MCR HMO MA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Rusk State Hospital|RUSK STATE HOSP|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicaid|MEDICAID HMO|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicare|MEDICARE ACUTE|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Brinson Benefits|THE HEALTH PLAN SMITH CO|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|ChampVA|CHAMPVA CENTER|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Blue Cross HMO Specialty|BCBSTX HMO|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Blue Cross PPO Specialty|BCBSTX PPO|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Blue Cross PPO Specialty|BCBSTX OTHER|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Aenta Medicare Advantage|AETNA MEDICARE MA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Aetna|AETNA QHP HMO|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Aetna|AETNA PPO|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Aetna|AETNA OTHER|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Cigna|CIGNA OTHER|99.50||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Cigna|CIGNA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Humana Medicare Advantage|HUMANA MA|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicaid|MEDICAID SUPERIOR|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99.50||||99.50||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicaid|MEDICAID AMERIGROUP|99.50||||99.50||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Managed Medicaid|MEDICAID AMERIGROUP|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Humana Medicare Advantage|HUMANA MA|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Cigna|CIGNA|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Aenta Medicare Advantage|AETNA MEDICARE MA|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Aetna|BOON CHAPMAN|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Aetna|AETNA PPO|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Aetna|AETNA OTHER|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Blue Cross HMO Specialty|BCBSTX HMO|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Blue Cross PPO Specialty|BCBSTX OTHER|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|ChampVA|CHAMPVA CENTER|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|United Medicare Advantage|UHC AARP WELLMED HMO MA|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|United Medicare Advantage|UHC AARP MCR HMO MA|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Workers Compensation|TEXAS MUTUAL INSURANCE|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Workers Compensation|BROOKSHIRES WORKERS COMP|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Workers Compensation|UT EMPLOYEE INJURY|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Veterans Affairs|VETERANS ADMINISTRATION|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Workers Compensation|WORKERS COMPENSATION OTHER|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|United Medicare Advantage|UHC MEDICARE GOLD MA|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST TPA UMR|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Access Direct Platinum|HEALTHFIRST TPA|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|United Healthcare|UNITED HEALTHCARE OTHER|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Blue Cross PPO Specialty|BCBSTX PPO|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|United Healthcare|UNITED HEALTHCARE|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|United Healthcare|TML GROUP BENEFITS|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|United Healthcare|UNITED HEALTHCARE|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|UTMB|UTMB CORRECTIONAL MANAGED CARE|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|NON CONTRACTED|COMMERCIAL OTHER 1|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|PHCS|HUMANA|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Cigna|CIGNA OTHER|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|PHCS|HUMANA INSURANCE|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Tricare|TRICARE EAST REGION|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Medicaid|SUPERIOR HEALTHPLAN CHIP|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Medicaid|SMITH COUNTY JAIL|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Medicaid|SMITH COUNTY INDIGENT HEALTH|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Managed Medicaid|MEDICAID SUPERIOR|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Medicaid|MEDICAID HMO|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Medicaid|MEDICAID|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Medicaid|COUNTY INDIGENT HEALTH OTHER|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Medicare|MEDICARE PART B ONLY IP|135.75||||||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Medicare|MEDICARE ACUTE|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Managed Medicare|HEALTHSPRING MA|135.75||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||135.75||| 9584483|ERX|0250|CEFEPIME 2G D5W 50ML DUPL|Managed Medicare|BCBS MEDICARE PPO MA|135.75||||135.75||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicare|HEALTHSPRING MA|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicare|BCBS MEDICARE PPO MA|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicare|MEDICARE ACUTE|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicaid|MEDICAID HMO|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicaid|MEDICAID|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicaid|BH TEXAS CHILDRENS MEDICAID|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicaid|SMITH COUNTY JAIL|||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicaid|SMITH COUNTY INDIGENT HEALTH|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicaid|MOLINA HEALTHCARE OF TEXAS|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Optum Behavioral Health|BH OPTUM UHC|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Tricare|TRICARE EAST REGION|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|NON CONTRACTED|COMMERCIAL OTHER 1|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Healthcare|UNITED HEALTHCARE OTHER|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Healthcare|UNITED HEALTHCARE|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Healthcare|GOLDEN RULE|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Access Direct Platinum|HEALTHFIRST TPA UMR|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Access Direct Platinum|HEALTHFIRST TPA|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Access Direct Platinum|ANDREWS CENTER|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Workers Compensation|WORKERS COMPENSATION OTHER|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Workers Compensation|TEXAS MUTUAL INSURANCE|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Veterans Affairs|VETERANS ADMINISTRATION|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|UTMB|UTMB CORRECTIONAL MANAGED CARE|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Medicare Advantage|UHC MEDICARE GOLD MA|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Medicare Advantage|UHC AARP MCR HMO MA|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Brinson Benefits|THE HEALTH PLAN SMITH CO|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicaid|CRIME VICTIMS COMPENSATION|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|ChampVA|CHAMPVA CENTER|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicare|MEDICARE PART B ONLY IP|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Blue Cross HMO Specialty|BCBSTX HMO|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Aenta Medicare Advantage|AETNA MEDICARE MA|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Aetna|BOON CHAPMAN|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Aetna|AETNA PPO|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Aetna|BH AETNA|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Cigna|CIGNA OTHER|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Cigna|CIGNA|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Magellan Behavioral Health|BH MAGELLAN|10.50||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Humana Medicare Advantage|HUMANA MA|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicaid|MEDICAID SUPERIOR|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicaid|MEDICAID AMERIGROUP|10.50||||10.50||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|10.50||||||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.50||||||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Blue Cross PPO Specialty|BCBSTX PPO|99.50||||99.50||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||99.50||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|99.50||||||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Medicare|MEDICARE ACUTE|99.50||||||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|99.50||||||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Managed Medicare|HEALTHSPRING MA|99.50||||||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|United Healthcare|UNITED HEALTHCARE|10.50||||||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.50||||||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Managed Medicare|HEALTHSPRING MA|10.50||||||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|10.50||||||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Medicaid|MEDICAID|10.50||||||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Medicare|MEDICARE ACUTE|10.50||||10.50||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.50||||||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.50||||||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Humana Medicare Advantage|HUMANA MA|10.50||||10.50||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|10.50||||||| 9584772|ERX|0250|FERROUS SULFATE 300MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|10.50||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Aetna|AETNA PPO|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Cigna|CIGNA|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Cigna|CIGNA OTHER|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Cigna|CIGNA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Aetna|AETNA QHP HMO|||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicare|MEDICARE ACUTE|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicaid|SMITH COUNTY JAIL|||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicaid|MEDICAID|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicare|OTHER INSTITUTIONS|||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|PHCS|HUMANA|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Tricare|TRICARE EAST REGION|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.28||||0.28||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.28||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.28||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.28||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|0.28||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.28||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.28||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Cigna|CIGNA OTHER|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Aetna|AETNA QHP HMO|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Medicare|MEDICARE ACUTE|0.28||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.28||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.28||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Cigna|CIGNA|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.28||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||0.28||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Medicaid|MEDICAID|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.28||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.28||||0.28||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Medicaid|MEDICAID|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Medicare|MEDICARE ACUTE|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|United Medicare Advantage|UHC AARP WELLMED HMO MA|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|UTMB|UTMB CORRECTIONAL MANAGED CARE|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Managed Medicare|WELLCARE CHOICE MA|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Aenta Medicare Advantage|AETNA MEDICARE MA|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Cigna|CIGNA|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Medicaid|COUNTY INDIGENT HEALTH OTHER|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|NON CONTRACTED|COMMERCIAL OTHER 1|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Aetna|AETNA PPO|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|United Healthcare|UNITED HEALTHCARE OTHER|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Managed Medicare|HEALTHSPRING MA|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Veterans Affairs|VETERANS ADMINISTRATION|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|United Medicare Advantage|UHC MEDICARE GOLD MA|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Medicaid|MOLINA HEALTHCARE OF TEXAS|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|United Medicare Advantage|UHC AARP MCR HMO MA|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Workers Compensation|TEXAS MUTUAL INSURANCE|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Managed Medicare|BCBS MEDICARE PPO MA|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Blue Cross HMO Specialty|BCBSTX HMO|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Blue Cross PPO Specialty|BCBSTX OTHER|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|PHCS|HUMANA|||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Humana Medicare Advantage|HUMANA MA|229.75||||229.75||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|United Healthcare|UNITED HEALTHCARE|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|United Healthcare|TML GROUP BENEFITS|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Blue Cross PPO Specialty|BCBSTX PPO|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Cigna|CIGNA OTHER|229.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Access Direct Platinum|HEALTHFIRST TPA UMR|229.75||||229.75||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Medicare|MEDICARE ACUTE|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Cigna|CIGNA|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Blue Cross HMO Specialty|BCBSTX HMO|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Blue Cross PPO Specialty|BCBSTX PPO|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|39.50||||39.50||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Access Direct Platinum|HEALTHFIRST TPA UMR|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Cigna|CIGNA OTHER|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Access Direct Platinum|HEALTHFIRST TPA|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Blue Cross PPO Specialty|BCBSTX OTHER|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Aetna|AETNA PPO|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Tricare|TRICARE EAST REGION|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|United Healthcare|UNITED HEALTHCARE OTHER|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|PHCS|GROUP AND PENSION|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|United Healthcare|UNITED HEALTHCARE|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|NON CONTRACTED|COMMERCIAL OTHER 1|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Managed Medicaid|MEDICAID AMERIGROUP|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|United Healthcare|TML GROUP BENEFITS|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Medicaid|MEDICAID|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|39.50||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Managed Medicaid|MEDICAID SUPERIOR|39.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Access Direct Platinum|HEALTHFIRST TPA UMR|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Blue Cross HMO Specialty|BCBSTX HMO|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Managed Medicaid|MEDICAID SUPERIOR|10.50||||10.50||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Managed Medicaid|MEDICAID AMERIGROUP|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Access Direct Platinum|HEALTHFIRST TPA|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Medicaid|MEDICAID|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|United Healthcare|UNITED HEALTHCARE OTHER|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Managed Medicare|BCBS MEDICARE PPO MA|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||10.50||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|United Healthcare|UNITED HEALTHCARE|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|PHCS|HUMANA INSURANCE|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Cigna|CIGNA|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Blue Cross PPO Specialty|BCBSTX OTHER|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|United Healthcare|TML GROUP BENEFITS|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|NON CONTRACTED|COMMERCIAL OTHER 1|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|PHCS|GROUP AND PENSION|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Aetna|AETNA PPO|10.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Tricare|TRICARE EAST REGION|10.50||||||| 9585233|ERX|0250|FLUTICASONE 110 MCG INHAL|Humana Medicare Advantage|HUMANA MA|1,354.25||||||| 9585233|ERX|0250|FLUTICASONE 110 MCG INHAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,354.25||||||| 9585233|ERX|0250|FLUTICASONE 110 MCG INHAL|Managed Medicare|HEALTHSPRING MA|1,354.25||||||| 9585233|ERX|0250|FLUTICASONE 110 MCG INHAL|United Healthcare|UNITED HEALTHCARE OTHER|1,354.25||||||| 9585233|ERX|0250|FLUTICASONE 110 MCG INHAL|Medicare|MEDICARE ACUTE|1,354.25||||||| 9585233|ERX|0250|FLUTICASONE 110 MCG INHAL|Veterans Affairs|VETERANS ADMINISTRATION|1,354.25||||||| 9585365|ERX|0250|EPIPEN 0.3MG/0.3ML SYRING|Managed Medicare|HEALTHSPRING MA|726.25||||||| 9585423|ERX|0250|FLOVENT 220 MCG INHALER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,103.50||| 9585423|ERX|0250|FLOVENT 220 MCG INHALER|Humana Medicare Advantage|HUMANA MA|2,103.50||||||| 9585423|ERX|0250|FLOVENT 220 MCG INHALER|Medicare|MEDICARE ACUTE|2,103.50||||||| 9585423|ERX|0250|FLOVENT 220 MCG INHALER|Blue Cross PPO Specialty|BCBSTX PPO|2,103.50||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Optum Behavioral Health|BH OPTUM UHC|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Multiplan|WEB TPA|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Cigna Behavioral Health|BH CIGNA|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Humana Medicare Advantage|HUMANA MA|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Medicaid|MEDICAID|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Magellan Behavioral Health|BH MAGELLAN|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Access Direct Platinum|ANDREWS CENTER|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Tricare|TRICARE EAST REGION|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|135.25||||||| 9585688|ERX|0250|QUETIAPINE 400MG TABLET|Medicare|MEDICARE ACUTE|135.25||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Medicaid|COUNTY INDIGENT HEALTH OTHER|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Medicare|MEDICARE ACUTE|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Managed Medicaid|MEDICAID AMERIGROUP|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Humana Medicare Advantage|HUMANA MA|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Aenta Medicare Advantage|AETNA MEDICARE MA|10.50||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|United Medicare Advantage|UHC MEDICARE GOLD MA|10.50||||||| 9586058|ERX|0250|PROMETHAZINE SYRUP 12.5MG|Medicare|MEDICARE ACUTE|10.50||||||| 9586058|ERX|0250|PROMETHAZINE SYRUP 12.5MG|Blue Cross PPO Specialty|BCBSTX PPO|10.50||||||| 9586058|ERX|0250|PROMETHAZINE SYRUP 12.5MG|Humana Medicare Advantage|HUMANA MA|10.50||||||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Workers Compensation|UT EMPLOYEE INJURY|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Blue Cross PPO Specialty|BCBSTX OTHER|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Aetna|AETNA OTHER|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Aetna|AETNA PPO|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Blue Cross PPO Specialty|BCBSTX PPO|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Blue Cross HMO Specialty|BCBSTX HMO|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Cigna|CIGNA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|United Medicare Advantage|UHC AARP MCR HMO MA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Humana Medicare Advantage|HUMANA MA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|PHCS|GROUP AND PENSION|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|United Healthcare|UNITED HEALTHCARE OTHER|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|United Healthcare|AARP|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Managed Medicare|BCBS MEDICARE PPO MA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Medicare|MEDICARE ACUTE|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Managed Medicare|HEALTHSPRING MA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|NON CONTRACTED|COMMERCIAL OTHER 1|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|United Healthcare|UNITED HEALTHCARE|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Tricare|TRICARE EAST REGION|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|PHCS|HUMANA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Cigna|CIGNA OTHER|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||11.25||| 9586231|ERX|0250|.IDOCAINE 1% (PF), 5ML AM|United Healthcare|TML GROUP BENEFITS|||||11.25||| 9586256|ERX|0250|CAFFEINE CITRATE 60MG/3ML|Blue Cross PPO Specialty|BCBSTX PPO|140.50||||||| 9586256|ERX|0250|CAFFEINE CITRATE 60MG/3ML|Medicare|MEDICARE ACUTE|||||140.50||| 9586256|ERX|0250|CAFFEINE CITRATE 60MG/3ML|United Healthcare|UNITED HEALTHCARE|||||140.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|12.50||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Cigna|CIGNA OTHER|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Medicare Advantage|UHC AARP MCR HMO MA|12.50||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|12.50||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Cigna|CIGNA|12.50||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Access Direct Platinum|HEALTHFIRST TPA|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Aetna Value Network|AETNA VALUE NETWORK|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|MEDICAID SUPERIOR|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Medicaid|MEDICAID HMO|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Aetna|AETNA PPO|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicare|HEALTHSPRING MA|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicare|BCBS MEDICARE PPO MA|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Healthcare|UNITED HEALTHCARE OTHER|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Aetna|AETNA OTHER|12.50||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicare|WELLCARE CHOICE MA|12.50||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Tricare|TRICARE EAST REGION|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicare|OTHER INSTITUTIONS|||||12.50||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Medicaid|MEDICAID|12.50||||||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|United Healthcare|TML GROUP BENEFITS|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|United Healthcare|UNITED HEALTHCARE|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|United Healthcare|GEHA|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Aenta Medicare Advantage|AETNA MEDICARE MA|71.62||||||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|United Healthcare|UNITED HEALTHCARE OTHER|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|United Healthcare|UNITED HEALTHCARE|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Cigna|CIGNA|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|NON CONTRACTED|COMMERCIAL OTHER 1|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Managed Medicare|HEALTHSPRING MA|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|PHCS|HUMANA|71.62||||||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Workers Compensation|TRAVELERS INSURANCE COMPANY|71.62||||||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Blue Cross PPO Specialty|BCBSTX PPO|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Managed Medicaid|MEDICAID UNITED HEALTHCARE|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|ChampVA|CHAMPVA CENTER|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Veterans Affairs|VETERANS ADMINISTRATION|71.62||||||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Managed Medicare|OTHER INSTITUTIONS|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Managed Medicaid|MEDICAID AMERIGROUP|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Blue Cross PPO Specialty|BCBSTX OTHER|71.62||||||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Aetna|AETNA PPO|71.62||||||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Managed Medicaid|MEDICAID SUPERIOR|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Blue Cross HMO Specialty|BCBSTX HMO|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Workers Compensation|WORKERS COMPENSATION OTHER|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Managed Medicare|BCBS MEDICARE PPO MA|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|United Medicare Advantage|UHC MEDICARE GOLD MA|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Aetna|AETNA OTHER|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Workers Compensation|TEXAS MUTUAL INSURANCE|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Access Direct Platinum|HEALTHFIRST TPA UMR|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Humana Medicare Advantage|HUMANA MA|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Cigna|CIGNA OTHER|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|United Medicare Advantage|UHC AARP MCR HMO MA|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Access Direct Platinum|HEALTHFIRST TPA|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Medicaid|MEDICAID|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Medicare|MEDICARE ACUTE|71.62||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Medicare|MEDICARE PART B ONLY IP|71.62||||||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Medicaid|SMITH COUNTY JAIL|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||71.62||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Medicaid|CRIME VICTIMS COMPENSATION|71.62||||||| 9586355|ERX|0250|LIDOCAINE-EPI 1%-1:200,00|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||71.62||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Aetna Value Network|AETNA VALUE NETWORK|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Aetna|AETNA PPO|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Cigna|CIGNA|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|PHCS|GROUP AND PENSION|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|PHCS|HUMANA INSURANCE|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Cigna|CIGNA OTHER|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Medicaid|MEDICAID|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Medicare|MEDICARE ACUTE|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Medicaid|MEDICAID HMO|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|United Healthcare|TML GROUP BENEFITS|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Access Direct Platinum|HEALTHFIRST TPA|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9586363|ERX|0250|FENTANYL-ROPIV 2MCG/ML-0.|Tricare|TRICARE EAST REGION|2.50||||||| 9586389|ERX|0250|FOSFOMYCIN 3 G POWDER PKT|Medicare|MEDICARE ACUTE|476.30||||||| 9586389|ERX|0250|FOSFOMYCIN 3 G POWDER PKT|Humana Medicare Advantage|HUMANA MA|476.30||||||| 9586389|ERX|0250|FOSFOMYCIN 3 G POWDER PKT|United Medicare Advantage|UHC AARP MCR HMO MA|476.30||||||| 9586389|ERX|0250|FOSFOMYCIN 3 G POWDER PKT|United Medicare Advantage|UHC MEDICARE GOLD MA|476.30||||||| 9586389|ERX|0250|FOSFOMYCIN 3 G POWDER PKT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|476.30||||||| 9586389|ERX|0250|FOSFOMYCIN 3 G POWDER PKT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|476.30||||||| 9586389|ERX|0250|FOSFOMYCIN 3 G POWDER PKT|Managed Medicare|HEALTHSPRING MA|476.30||||||| 9586413|ERX|0250|AZTREONAM 75 MG/1 ML NEB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||524.82||| 9586421|ERX|0250|ZENPEP 3000 CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.65||||||| 9586447|ERX|0250|ZENPEP 15000 CAPSULE|Humana Medicare Advantage|HUMANA MA|0.35||||||| 9586454|ERX|0250|ZENPEP 20000 CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|41.76||||||| 9586454|ERX|0250|ZENPEP 20000 CAPSULE|Managed Medicare|HEALTHSPRING MA|||||41.76||| 9586462|ERX|0250|ZENPEP 25000 CAPSULE|Medicare|MEDICARE ACUTE|51.68||||||| 9586470|ERX|0250|ZENPEP 40000 CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||82.48||| 9586470|ERX|0250|ZENPEP 40000 CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||82.48||| 9586470|ERX|0250|ZENPEP 40000 CAPSULE|Humana Medicare Advantage|HUMANA MA|82.48||||||| 9586470|ERX|0250|ZENPEP 40000 CAPSULE|Medicaid|MEDICAID|82.48||||||| 9586470|ERX|0250|ZENPEP 40000 CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|82.48||||||| 95865|EAP|0922|EMG LARYNX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||723.35||| 95865|EAP|0922|EMG LARYNX|Managed Medicare|BCBS MEDICARE PPO MA|||||723.35||| 95865|EAP|0922|EMG LARYNX|Blue Cross HMO Specialty|BCBSTX HMO|||||6.29||| 95865|EAP|0922|EMG LARYNX|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.29||| 95865|EAP|0922|EMG LARYNX|United Healthcare|UNITED HEALTHCARE OTHER|723.35||||723.35||| 95865|EAP|0922|EMG LARYNX|Medicare|MEDICARE ACUTE|6.29||||6.29||| 95865|EAP|0922|EMG LARYNX|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||6.29||| 95865|EAP|0922|EMG LARYNX|Managed Medicare|HEALTHSPRING MA|||||676.18||| 95865|EAP|0922|EMG LARYNX|Humana Medicare Advantage|HUMANA MA|||||723.35||| 95865|EAP|0922|EMG LARYNX|United Medicare Advantage|UHC MEDICARE GOLD MA|||||676.18||| 95865|EAP|0922|EMG LARYNX|Veterans Affairs|VETERANS ADMINISTRATION|723.35||||||| 95865|EAP|0922|EMG LARYNX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.29||||6.29||| 95865|EAP|0922|EMG LARYNX|Blue Cross PPO Specialty|BCBSTX PPO|723.35||||723.35||| 95865|EAP|0922|EMG LARYNX|Managed Medicaid|MEDICAID AMERIGROUP|||||723.35||| 9586538|ERX|0250|CREON 24000 CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|40.43||||||| 9586538|ERX|0250|CREON 24000 CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40.43||||||| 9586538|ERX|0250|CREON 24000 CAPSULE|Humana Medicare Advantage|HUMANA MA|40.43||||||| 9586538|ERX|0250|CREON 24000 CAPSULE|Medicaid|SMITH COUNTY INDIGENT HEALTH|40.43||||||| 9586538|ERX|0250|CREON 24000 CAPSULE|Medicare|MEDICARE ACUTE|40.43||||||| 9586538|ERX|0250|CREON 24000 CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|40.43||||||| 9586538|ERX|0250|CREON 24000 CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|40.43||||||| 9586546|ERX|0250|ZENPEP 5000 CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.02||||||| 9586546|ERX|0250|ZENPEP 5000 CAPSULE|Medicaid|MEDICAID|13.02||||||| 9586546|ERX|0250|ZENPEP 5000 CAPSULE|Humana Medicare Advantage|HUMANA MA|13.02||||||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|ChampVA|CHAMPVA CENTER|||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|United Medicare Advantage|UHC MEDICARE GOLD MA|137.60||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|137.60||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Workers Compensation|WORKERS COMPENSATION OTHER|||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|United Medicare Advantage|UHC AARP WELLMED HMO MA|137.60||||||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|United Medicare Advantage|UHC AARP MCR HMO MA|137.60||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Managed Medicaid|MEDICAID AMERIGROUP|||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Aetna|AETNA PPO|||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Managed Medicaid|MEDICAID SUPERIOR|||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|137.60||||||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Blue Cross HMO Specialty|BCBSTX HMO|137.60||||||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Blue Cross PPO Specialty|BCBSTX PPO|137.60||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Aenta Medicare Advantage|AETNA MEDICARE MA|||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Managed Medicare|HEALTHSPRING MA|||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|United Healthcare|UNITED HEALTHCARE|137.60||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Texas Workforce Commission|DIS DETER SERV (DDS)|137.60||||||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|137.60||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Humana Medicare Advantage|HUMANA MA|137.60||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Medicare|MEDICARE ACUTE|137.60||||137.60||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|United Healthcare|UNITED HEALTHCARE|||||137.60||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Medicare|MEDICARE ACUTE|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Tricare|TRICARE EAST REGION|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Humana Medicare Advantage|HUMANA MA|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Cigna Behavioral Health|BH CIGNA|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Access Direct Platinum|ANDREWS CENTER|564.93||||||| 9586637|ERX|0250|VILANTEROL-FLUTICASONE 20|Managed Medicaid|MEDICAID AMERIGROUP|564.93||||||| 9586645|ERX|0250|UMECLIDINIUM 62.5 MCG INH|Medicare|MEDICARE ACUTE|343.40||||||| 9586645|ERX|0250|UMECLIDINIUM 62.5 MCG INH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|343.40||||||| 9586660|ERX|0250|PREVNAR 13 VACCINE 0.5 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|795.15||||||| 9586660|ERX|0250|PREVNAR 13 VACCINE 0.5 ML|Blue Cross PPO Specialty|BCBSTX PPO|795.15||||||| 95867|EAP|0922|EMG CRANIAL UNILATERAL|Medicaid|MEDICAID|1,739.95||||||| 95867|EAP|0922|EMG CRANIAL UNILATERAL|Aetna|BOON CHAPMAN|15.13||||||| 95867|EAP|0922|EMG CRANIAL UNILATERAL|Humana Medicare Advantage|HUMANA MA|15.13||||||| 95867|EAP|0922|EMG CRANIAL UNILATERAL|Access Direct Platinum|HEALTHFIRST TPA|1,739.95||||||| 95867|EAP|0922|EMG CRANIAL UNILATERAL|ChampVA|CHAMPVA CENTER|15.13||||||| 95867|EAP|0922|EMG CRANIAL UNILATERAL|Blue Cross PPO Specialty|BCBSTX PPO|1,739.95||||||| 95867|EAP|0922|EMG CRANIAL UNILATERAL|United Healthcare|UNITED HEALTHCARE|1,739.95||||||| 95867|EAP|0922|EMG CRANIAL UNILATERAL|Medicare|MEDICARE ACUTE|1,739.95||||||| 95868|EAP|0922|EMG CRANIAL BILATERAL|Blue Cross PPO Specialty|BCBSTX PPO|1,626.48||||1,739.95||| 95868|EAP|0922|EMG CRANIAL BILATERAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.13||||||| 95868|EAP|0922|EMG CRANIAL BILATERAL|Humana Medicare Advantage|HUMANA MA|15.13||||||| 95868|EAP|0922|EMG CRANIAL BILATERAL|Managed Medicare|HEALTHSPRING MA|15.13||||||| 95868|EAP|0922|EMG CRANIAL BILATERAL|Cigna|CIGNA|15.13||||||| 95868|EAP|0922|EMG CRANIAL BILATERAL|Medicare|MEDICARE ACUTE|1,739.95||||1,739.95||| 95869|EAP|0922|FREE RUN THORACIS EMG|United Medicare Advantage|UHC MEDICARE GOLD MA|6.35||||||| 95869|EAP|0922|FREE RUN THORACIS EMG|Managed Medicare|HEALTHSPRING MA|730.25||||||| 95869|EAP|0922|FREE RUN THORACIS EMG|Blue Cross HMO Specialty|BCBSTX HMO|730.25||||||| 95869|EAP|0922|FREE RUN THORACIS EMG|Medicare|MEDICARE ACUTE|730.25||||||| 95869|EAP|0922|FREE RUN THORACIS EMG|Managed Medicare|BCBS MEDICARE PPO MA|6.35||||||| 95869|EAP|0922|FREE RUN THORACIS EMG|Humana Medicare Advantage|HUMANA MA|730.25||||||| 95869|EAP|0922|FREE RUN THORACIS EMG|Blue Cross PPO Specialty|BCBSTX PPO|730.25||||||| 95869|EAP|0922|FREE RUN THORACIS EMG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|730.25||||||| 95869|EAP|0922|FREE RUN THORACIS EMG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|730.25||||||| 95869|EAP|0922|FREE RUN THORACIS EMG|United Healthcare|UNITED HEALTHCARE|730.25||||||| 9587023|ERX|0250|FLUTICASONE FUROATE 100 M|Medicare|MEDICARE ACUTE|393.15||||||| 9587023|ERX|0250|FLUTICASONE FUROATE 100 M|Medicaid|BH TEXAS CHILDRENS MEDICAID|393.15||||||| 9587056|ERX|0250|FLUTICASONE FUROATE 200 M|Managed Medicaid|MEDICAID AMERIGROUP|5.00||||||| 9587064|ERX|0250|UMECLIDINIUM-VILANT 62.5-|Medicare|MEDICARE ACUTE|477.90||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|42.98||||42.98||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Aetna|AETNA OTHER|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Medicare|MEDICARE PART B ONLY IP|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|United Healthcare|UNITED HEALTHCARE|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Aetna|AETNA PPO|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|United Healthcare|UNITED HEALTHCARE|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Humana Medicare Advantage|HUMANA MA|42.98||||||| 9587098|ERX|0250|RITONAVIR 100 MG TABLET|Medicare|MEDICARE ACUTE|42.98||||||| 9587106|ERX|0250|PEMBROLIZUMAB 100 MG/4 ML|Medicare|MEDICARE ACUTE|178.55||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Aetna|AETNA OTHER|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Managed Medicaid|MEDICAID SUPERIOR|||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Cigna|CIGNA|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Aenta Medicare Advantage|AETNA MEDICARE MA|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Humana Medicare Advantage|HUMANA MA|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Blue Cross HMO Specialty|BCBSTX HMO|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Blue Cross PPO Specialty|BCBSTX PPO|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Aetna|AETNA PPO|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Medicaid|SMITH COUNTY JAIL|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Veterans Affairs|VETERANS ADMINISTRATION|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|United Medicare Advantage|UHC MEDICARE GOLD MA|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|PHCS|HUMANA|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Medicare|MEDICARE ACUTE|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Managed Medicare|BCBS MEDICARE PPO MA|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Managed Medicare|ETMC AFFILIATE HOSPITALS|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|UTMB|UTMB CORRECTIONAL MANAGED CARE|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Tricare|TRICARE EAST REGION|||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|United Healthcare|UNITED HEALTHCARE OTHER|||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Medicare|MEDICARE PART B ONLY IP|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Access Direct Platinum|HEALTHFIRST TPA UMR|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|United Healthcare|UNITED HEALTHCARE|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Medicaid|CRIME VICTIMS COMPENSATION|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Medicaid|MEDICAID|98.02||||||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Managed Medicare|HEALTHSPRING MA|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|NON CONTRACTED|COMMERCIAL OTHER 1|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Blue Cross PPO Specialty|BCBSTX OTHER|98.02||||98.02||| 9587114|ERX|0250|LABETALOL 20 MG/4 ML SYRI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|98.02||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|ChampVA|CHAMPVA CENTER|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|Medicaid|SMITH COUNTY INDIGENT HEALTH|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|Medicare|MEDICARE ACUTE|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|Medicaid|MEDICAID|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|Managed Medicare|HEALTHSPRING MA|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|Humana Medicare Advantage|HUMANA MA|8.80||||||| 9587130|ERX|0250|SELENIUM 200 MCG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|8.80||||||| 9587163|ERX|0250|TALC,STERILE POWDER, 2 G|United Medicare Advantage|UHC MEDICARE GOLD MA|3.50||||||| 9587163|ERX|0250|TALC,STERILE POWDER, 2 G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.50||||||| 9587163|ERX|0250|TALC,STERILE POWDER, 2 G|Medicare|MEDICARE ACUTE|3.50||||||| 9587163|ERX|0250|TALC,STERILE POWDER, 2 G|Access Direct Platinum|HEALTHFIRST TPA UMR|3.50||||||| 9587197|ERX|0250|PATIROMER CALCIUM SORBITE|Managed Medicare|BCBS MEDICARE PPO MA|136.80||||||| 9587205|ERX|0250|LIDOCAINE 3.5% OPHT GEL D|Blue Cross PPO Specialty|BCBSTX PPO|||||1.16||| 9587205|ERX|0250|LIDOCAINE 3.5% OPHT GEL D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.16||| 9587205|ERX|0250|LIDOCAINE 3.5% OPHT GEL D|United Healthcare|UNITED HEALTHCARE|||||1.16||| 9587205|ERX|0250|LIDOCAINE 3.5% OPHT GEL D|United Medicare Advantage|UHC AARP MCR HMO MA|1.16||||||| 9587205|ERX|0250|LIDOCAINE 3.5% OPHT GEL D|Medicare|MEDICARE ACUTE|||||1.16||| 9587205|ERX|0250|LIDOCAINE 3.5% OPHT GEL D|Blue Cross HMO Specialty|BCBSTX HMO|||||1.16||| 9587205|ERX|0250|LIDOCAINE 3.5% OPHT GEL D|Access Direct Platinum|HEALTHFIRST TPA|||||1.16||| 9587205|ERX|0250|LIDOCAINE 3.5% OPHT GEL D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.16||| 9587213|ERX|0250|RIVAROXABAN 2.5 MG TABLET|Medicare|MEDICARE ACUTE|43.33||||||| 9587213|ERX|0250|RIVAROXABAN 2.5 MG TABLET|Managed Medicare|HEALTHSPRING MA|43.33||||43.33||| 9587213|ERX|0250|RIVAROXABAN 2.5 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|43.33||||||| 9587213|ERX|0250|RIVAROXABAN 2.5 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|43.33||||||| 9587213|ERX|0250|RIVAROXABAN 2.5 MG TABLET|Humana Medicare Advantage|HUMANA MA|43.33||||||| 9587213|ERX|0250|RIVAROXABAN 2.5 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|43.33||||43.33||| 9587213|ERX|0250|RIVAROXABAN 2.5 MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|43.33||||||| 9587213|ERX|0250|RIVAROXABAN 2.5 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.33||||||| 9587213|ERX|0250|RIVAROXABAN 2.5 MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||43.33||| 9587239|ERX|0250|ULIPRISTAL 30 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||178.75||| 9587239|ERX|0250|ULIPRISTAL 30 MG TABLET|Cigna|CIGNA|||||178.75||| 9587247|ERX|0250|NICARDIPINE 20MG/200ML DE|Veterans Affairs|VETERANS ADMINISTRATION|5.00||||||| 9587247|ERX|0250|NICARDIPINE 20MG/200ML DE|Medicare|MEDICARE ACUTE|5.00||||||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|17.60||||||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Workers Compensation|UT EMPLOYEE INJURY|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Tricare|TRICARE FOR LIFE|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|NON CONTRACTED|COMMERCIAL OTHER 1|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|United Healthcare|UNITED HEALTHCARE OTHER|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Medicaid|MEDICAID|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Medicaid|SMITH COUNTY INDIGENT HEALTH|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Managed Medicare|BCBS MEDICARE PPO MA|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|United Healthcare|GEHA|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Veterans Affairs|VETERANS ADMINISTRATION|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Access Direct Platinum|HEALTHFIRST TPA UMR|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Tricare|TRICARE EAST REGION|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Managed Medicare|HEALTHSPRING MA|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Managed Medicare|MA PART B ONLY IP|17.60||||||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Medicare|MEDICARE ACUTE|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Medicaid|SMITH COUNTY JAIL|17.60||||||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|United Healthcare|UNITED HEALTHCARE|17.60||||||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Blue Cross PPO Specialty|BCBSTX PPO|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Blue Cross HMO Specialty|BCBSTX HMO|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Aetna|AETNA PPO|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Cigna|CIGNA|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Managed Medicaid|MEDICAID SUPERIOR|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Managed Medicaid|MEDICAID AMERIGROUP|||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Humana Medicare Advantage|HUMANA MA|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|United Medicare Advantage|UHC MEDICARE GOLD MA|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|United Medicare Advantage|UHC AARP MCR HMO MA|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.60||||17.60||| 9587270|ERX|0250|MAALOX-V.LIDOCAINE(GI COM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.60||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Medicare|MEDICARE ACUTE|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Medicaid|MEDICAID|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|NON CONTRACTED|COMMERCIAL OTHER 1|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Access Direct Platinum|HEALTHFIRST TPA|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|United Medicare Advantage|UHC MEDICARE GOLD MA|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Blue Cross HMO Specialty|BCBSTX HMO|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Blue Cross PPO Specialty|BCBSTX PPO|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Humana Medicare Advantage|HUMANA MA|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|Aetna|BOON CHAPMAN|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|United Medicare Advantage|UHC AARP MCR HMO MA|0.63||||||| 9587288|ERX|0250|MULTITRACE-5 CONC 1ML VIA|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.63||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Cigna|CIGNA|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Aenta Medicare Advantage|AETNA MEDICARE MA|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Blue Cross PPO Specialty|BCBSTX PPO|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Blue Cross PPO Specialty|BCBSTX OTHER|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|United Medicare Advantage|UHC AARP MCR HMO MA|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Humana Medicare Advantage|HUMANA MA|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Tricare|TRICARE EAST REGION|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|NON CONTRACTED|COMMERCIAL OTHER 1|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Medicaid|MEDICAID|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|United Healthcare|TML GROUP BENEFITS|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Medicare|MEDICARE ACUTE|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Managed Medicare|HEALTHSPRING MA|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|United Medicare Advantage|UHC MEDICARE GOLD MA|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|United Healthcare|UNITED HEALTHCARE OTHER|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Managed Medicare|BCBS MEDICARE PPO MA|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Blue Cross HMO Specialty|BCBSTX HMO|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL-PO|Workers Compensation|WORKERS COMPENSATION OTHER|6.50||||||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Managed Medicare|BCBS MEDICARE PPO MA|||||97.92||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|United Healthcare|UNITED HEALTHCARE|||||97.92||| 95874|EAP|0761||Managed Medicare|HEALTHSPRING MA|||||2.35||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Medicare|MEDICARE ACUTE|||||97.92||| 95874|EAP|0761||Medicare|MEDICARE ACUTE|||||2.35||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||97.92||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|United Medicare Advantage|UHC AARP MCR HMO MA|||||97.92||| 95874|EAP|0761||United Medicare Advantage|UHC AARP MCR HMO MA|||||2.35||| 95874|EAP|0761||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.35||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Blue Cross HMO Specialty|BCBSTX HMO|||||97.92||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||97.92||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Blue Cross PPO Specialty|BCBSTX PPO|||||97.92||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Blue Cross PPO Specialty|BCBSTX OTHER|||||97.92||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||97.92||| 95874|EAP|0761||Blue Cross PPO Specialty|BCBSTX PPO|||||2.35||| 95874|EAP|0761||Blue Cross HMO Specialty|BCBSTX HMO|||||2.35||| 95874|EAP|0761||Aetna|AETNA OTHER|||||2.35||| 95874|EAP|0761||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.35||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||97.92||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Aetna|AETNA OTHER|||||97.92||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Humana Medicare Advantage|HUMANA MA|||||97.92||| 95874|EAP|0761||ChampVA|CHAMPVA CENTER|||||2.35||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|ChampVA|CHAMPVA CENTER|||||97.92||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||97.92||| 95874|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||2.35||| 95874|EAP|0761||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.35||| 95874|EAP|0761||United Healthcare|UNITED HEALTHCARE|||||2.35||| 95874|EAP|0510|GUIDE NERV DESTR, NEEDLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||97.92||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||149.17||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|Managed Medicaid|MEDICAID SUPERIOR|||||149.17||| 95885|EAP|0761||Managed Medicaid|MEDICAID AMERIGROUP|||||3.58||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|Managed Medicaid|MEDICAID AMERIGROUP|||||149.17||| 95885|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||3.58||| 95885|EAP|0761||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.58||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|Cigna|CIGNA|||||149.17||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||149.17||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||149.17||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||149.17||| 95885|EAP|0761||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.58||| 95885|EAP|0761||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.58||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||149.17||| 95885|EAP|0761||Medicare|MEDICARE ACUTE|||||3.58||| 95885|EAP|0761||United Healthcare|UNITED HEALTHCARE|||||3.58||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|Medicare|MEDICARE ACUTE|||||149.17||| 95885|EAP|0761||Blue Cross PPO Specialty|BCBSTX PPO|||||3.58||| 95885|EAP|0761||Tricare|TRICARE EAST REGION|||||3.58||| 95885|EAP|0761||Workers Compensation|UT EMPLOYEE INJURY|||||3.58||| 95885|EAP|0510|NEEDLE EMG EA EXT W/PARAS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||149.17||| 95885|EAP|0761||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.58||| 95885|EAP|0761||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.58||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Blue Cross HMO Specialty|BCBSTX HMO|||||179.17||| 95886|EAP|0761||Tricare|TRICARE EAST REGION|||||4.30||| 95886|EAP|0761||United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|United Medicare Advantage|UHC AARP MCR HMO MA|||||179.17||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Medicare|MEDICARE ACUTE|||||179.17||| 95886|EAP|0761||Managed Medicare|HEALTHSPRING MA|||||4.30||| 95886|EAP|0761||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.30||| 95886|EAP|0761||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|United Healthcare|UNITED HEALTHCARE|||||179.17||| 95886|EAP|0761||NON CONTRACTED|COMMERCIAL OTHER 1|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||179.17||| 95886|EAP|0761||United Healthcare|UNITED HEALTHCARE OTHER|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Workers Compensation|UT EMPLOYEE INJURY|||||179.17||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|United Healthcare|UNITED HEALTHCARE OTHER|||||179.17||| 95886|EAP|0761||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.30||| 95886|EAP|0761||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Blue Cross PPO Specialty|BCBSTX PPO|||||179.17||| 95886|EAP|0761||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||179.17||| 95886|EAP|0761||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||179.17||| 95886|EAP|0761||Medicare|MEDICARE ACUTE|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||179.17||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Humana Medicare Advantage|HUMANA MA|||||179.17||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||179.17||| 95886|EAP|0761||Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.30||| 95886|EAP|0761||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||179.17||| 95886|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Managed Medicaid|MEDICAID SUPERIOR|||||179.17||| 95886|EAP|0761||Cigna|CIGNA|||||4.30||| 95886|EAP|0761||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.30||| 95886|EAP|0761||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.30||| 95886|EAP|0761||Managed Medicaid|MEDICAID AMERIGROUP|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||179.17||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Managed Medicaid|MEDICAID AMERIGROUP|||||179.17||| 95886|EAP|0761||Managed Medicaid|MEDICAID SUPERIOR|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||304.59||| 95886|EAP|0761||Cigna|CIGNA OTHER|||||4.30||| 95886|EAP|0761||Aetna|AETNA PPO|||||4.30||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Managed Medicare|HEALTHSPRING MA|||||179.17||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Cigna|CIGNA|||||179.17||| 95886|EAP|0510|NEEDLE EMG EA EXTREM W/PA|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||179.17||| 95886|EAP|0761||Blue Cross PPO Specialty|BCBSTX PPO|||||4.30||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|Veterans Affairs|VETERANS ADMINISTRATION|400.80||||||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.34||||||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|Humana Medicare Advantage|HUMANA MA|3.34||||||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|United Medicare Advantage|UHC MEDICARE GOLD MA|367.40||||400.80||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.34||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|Blue Cross PPO Specialty|BCBSTX PPO|3.34||||400.80||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|Workers Compensation|WORKERS COMPENSATION OTHER|3.34||||||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|Medicare|MEDICARE ACUTE|400.80||||3.34||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|United Healthcare|UNITED HEALTHCARE|400.80||||||| 95887|EAP|0922|FREE RUN CN EMG W/STIMULA|NON CONTRACTED|COMMERCIAL OTHER 1|||||400.80||| 9589151|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Cigna|CIGNA OTHER|||||0.10||| 9589151|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.10||| 9589151|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||0.10||| 9589151|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Medicare|MEDICARE ACUTE|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|0.10||||0.10||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Access Direct Platinum|HEALTHFIRST TPA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Workers Compensation|TEXAS MUTUAL INSURANCE|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||0.10||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Cigna|CIGNA OTHER|0.10||||0.10||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Aetna|AETNA PPO|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Cigna|CIGNA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||0.10||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|ChampVA|CHAMPVA CENTER|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||0.10||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Multiplan|WEB TPA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicare|HEALTHSPRING MA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Medicaid|MEDICAID|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Medicaid|CRIME VICTIMS COMPENSATION|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Medicare|MEDICARE PART B ONLY IP|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9589169|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Medicaid|MEDICAID HMO|0.10||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|United Healthcare|UNITED HEALTHCARE|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Medicaid|MEDICAID HMO|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|PHCS|HUMANA INSURANCE|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|PHCS|GROUP AND PENSION|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Tricare|TRICARE FOR LIFE|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Managed Medicare|BCBS MEDICARE PPO MA|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Tricare|TRICARE EAST REGION|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|United Healthcare|UNITED HEALTHCARE OTHER|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Medicaid|MEDICAID|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Blue Cross PPO Specialty|BCBSTX OTHER|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Blue Cross HMO Specialty|BCBSTX HMO|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Aetna|AETNA PPO|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Cigna|CIGNA OTHER|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Managed Medicaid|MEDICAID AMERIGROUP|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Medicare|MEDICARE ACUTE|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|NON CONTRACTED|COMMERCIAL OTHER 1|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Cigna|CIGNA|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Aetna Value Network|AETNA VALUE NETWORK|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Access Direct Platinum|HEALTHFIRST TPA UMR|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Blue Cross PPO Specialty|BCBSTX PPO|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Managed Medicaid|MEDICAID SUPERIOR|1.15||||1.15||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|United Healthcare|TML GROUP BENEFITS|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.15||||||| 9589342|ERX|0250|OXYTOCIN 30 UNITS IN NS 5|Access Direct Platinum|HEALTHFIRST TPA|1.15||||||| 9589367|ERX|0250|MULITVITAMIN A-D-E-K TABL|Medicare|MEDICARE ACUTE|8.80||||||| 9589409|ERX|0250|ROTIGOTINE 2MG PATCH|Humana Medicare Advantage|HUMANA MA|1.24||||1.24||| 9589409|ERX|0250|ROTIGOTINE 2MG PATCH|Medicare|MEDICARE ACUTE|1.24||||||| 9589417|ERX|0250|ROTIGOTINE 4MG PATCH|Humana Medicare Advantage|HUMANA MA|1.24||||||| 9589417|ERX|0250|ROTIGOTINE 4MG PATCH|Medicare|MEDICARE ACUTE|1.24||||||| 9589458|ERX|0250|SODIUM CHLORIDE 0.45%, 10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.85||||||| 9589458|ERX|0250|SODIUM CHLORIDE 0.45%, 10|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.85||||||| 9589458|ERX|0250|SODIUM CHLORIDE 0.45%, 10|Humana Medicare Advantage|HUMANA MA|0.85||||||| 9589458|ERX|0250|SODIUM CHLORIDE 0.45%, 10|Medicare|MEDICARE ACUTE|0.85||||||| 9589458|ERX|0250|SODIUM CHLORIDE 0.45%, 10|Managed Medicaid|MEDICAID AMERIGROUP|0.85||||||| 9589458|ERX|0250|SODIUM CHLORIDE 0.45%, 10|Blue Cross PPO Specialty|BCBSTX PPO|0.85||||||| 9589482|ERX|0250|BUPRENORPHINE 8 MG TABLET|Medicare|MEDICARE ACUTE|49.07||||||| 9589482|ERX|0250|BUPRENORPHINE 8 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|49.07||||||| 9589482|ERX|0250|BUPRENORPHINE 8 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|49.07||||||| 9589482|ERX|0250|BUPRENORPHINE 8 MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|49.07||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|United Medicare Advantage|UHC AARP MCR HMO MA|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Blue Cross PPO Specialty|BCBSTX PPO|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Blue Cross HMO Specialty|BCBSTX HMO|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Aenta Medicare Advantage|AETNA MEDICARE MA|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Humana Medicare Advantage|HUMANA MA|22.25||||22.25||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Managed Medicaid|MEDICAID SUPERIOR|||||22.25||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|22.25||||22.25||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|United Medicare Advantage|UHC MEDICARE GOLD MA|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Managed Medicare|HEALTHSPRING MA|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|United Healthcare|UNITED HEALTHCARE OTHER|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Medicaid|SMITH COUNTY INDIGENT HEALTH|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|UTMB|UTMB CORRECTIONAL MANAGED CARE|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Veterans Affairs|VETERANS ADMINISTRATION|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Medicare|MEDICARE ACUTE|22.25||||22.25||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|22.25||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Medicaid|MEDICAID|22.25||||||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||130.50||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||130.50||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|||||130.50||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|||||130.50||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|Medicaid|MEDICAID HMO|||||130.50||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|United Healthcare|UNITED HEALTHCARE|||||130.50||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|130.50||||||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|130.50||||130.50||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||130.50||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|Humana Medicare Advantage|HUMANA MA|130.50||||||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|Medicare|MEDICARE PART B ONLY IP|130.50||||||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||130.50||| 9589755|ERX|0250|RALTEGRAVIR 400 MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||130.50||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Humana Medicare Advantage|HUMANA MA|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Aetna|AETNA OTHER|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Aetna|AETNA PPO|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Managed Medicare|HEALTHSPRING MA|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Medicare|MEDICARE ACUTE|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|United Healthcare|UNITED HEALTHCARE|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|United Medicare Advantage|UHC AARP WELLMED HMO MA|262.25||||||| 9589789|ERX|0250|DARUNAVIR 800 MG TABLET|Medicare|MEDICARE PART B ONLY IP|262.25||||||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.88||||||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|Medicare|MEDICARE ACUTE|6.88||||6.88||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|Managed Medicare|HEALTHSPRING MA|6.88||||||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|United Healthcare|UNITED HEALTHCARE OTHER|6.88||||||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|United Medicare Advantage|UHC MEDICARE GOLD MA|6.88||||||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|Access Direct Platinum|HEALTHFIRST TPA UMR|6.88||||||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.88||||||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|Humana Medicare Advantage|HUMANA MA|6.88||||||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.88||||6.88||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.88||||||| 9589847|ERX|0250|TALC, STERILE POWDER, 4 G|Blue Cross PPO Specialty|BCBSTX PPO|6.88||||||| 959|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|138,617.19|17735.86|43159.18|16151.64|||| 959|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|126,956.38|43159.18|43159.18|16151.64|||| 959|DRG||OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC|Tricare|TRICARE EAST REGION|115,050.26|16151.64|43159.18|16151.64|||| 9590050|ERX|0250|PANTOPRAZOLE 80 MG/160 ML|Medicare|MEDICARE ACUTE|0.92||||||| 9590050|ERX|0250|PANTOPRAZOLE 80 MG/160 ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.92||| 9590050|ERX|0250|PANTOPRAZOLE 80 MG/160 ML|Humana Medicare Advantage|HUMANA MA|0.92||||||| 9590050|ERX|0250|PANTOPRAZOLE 80 MG/160 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.92||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Access Direct Platinum|ANDREWS CENTER|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|151.25||||151.25||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|151.25||||151.25||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Medicaid|MEDICAID HMO|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Aetna|BH AETNA|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Magellan Behavioral Health|BH MAGELLAN|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Optum Behavioral Health|BH OPTUM UHC|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Humana Medicare Advantage|HUMANA MA|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Medicaid|MEDICAID|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Medicare|MEDICARE ACUTE|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|151.25||||||| 9590076|ERX|0250|LURASIDONE 40 MG TABLET|Cigna Behavioral Health|BH CIGNA|151.25||||||| 9590084|ERX|0250|LURASIDONE 20 MG TABLET|Medicaid|MEDICAID|151.25||||||| 9590084|ERX|0250|LURASIDONE 20 MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|151.25||||||| 9590084|ERX|0250|LURASIDONE 20 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||151.25||| 9590084|ERX|0250|LURASIDONE 20 MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||151.25||| 9590084|ERX|0250|LURASIDONE 20 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|151.25||||||| 9590084|ERX|0250|LURASIDONE 20 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|151.25||||151.25||| 9590084|ERX|0250|LURASIDONE 20 MG TABLET|Medicare|MEDICARE ACUTE|||||151.25||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|United Medicare Advantage|UHC MEDICARE GOLD MA|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Blue Cross PPO Specialty|BCBSTX PPO|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Aenta Medicare Advantage|AETNA MEDICARE MA|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Cigna|CIGNA|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Blue Cross HMO Specialty|BCBSTX HMO|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Tricare|TRICARE EAST REGION|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Managed Medicare|BCBS MEDICARE PPO MA|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|Medicare|MEDICARE ACUTE|297.50||||||| 9590100|ERX|0250|CARDIOPLEGIC - DEL NIDO W|NON CONTRACTED|COMMERCIAL OTHER 1|297.50||||||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.60||||||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.60||||||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.60||||||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|Medicare|MEDICARE ACUTE|0.60||||0.60||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.60||||||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.60||||||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.60||||||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.60||||||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.60||||||| 9590118|ERX|0250|VORTIOXETINE 10 MG TABLET|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.60||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|United Medicare Advantage|UHC AARP MCR HMO MA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Veterans Affairs|VETERANS ADMINISTRATION|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Access Direct Platinum|HEALTHFIRST TPA UMR|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Access Direct Platinum|HEALTHFIRST TPA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Blue Cross PPO Specialty|BCBSTX OTHER|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Managed Medicaid|MEDICAID SUPERIOR|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Aetna|AETNA PPO|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Aenta Medicare Advantage|AETNA MEDICARE MA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Cigna|CIGNA OTHER|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|United Healthcare|UNITED HEALTHCARE|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|PHCS|GROUP AND PENSION|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Tricare|TRICARE EAST REGION|||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|NON CONTRACTED|COMMERCIAL OTHER 1|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Managed Medicare|HEALTHSPRING MA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Cigna|CIGNA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|United Healthcare|UNITED HEALTHCARE|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|United Healthcare|UNITED HEALTHCARE OTHER|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|PHCS|HUMANA INSURANCE|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Managed Medicare|BCBS MEDICARE PPO MA|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Managed Medicaid|MEDICAID AMERIGROUP|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Blue Cross HMO Specialty|BCBSTX HMO|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Medicaid|MEDICAID|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Medicaid|LAW ENFORCEMENT OTHER|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|United Healthcare|TML GROUP BENEFITS|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Medicare|MEDICARE PART B ONLY IP|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Aetna|AETNA OTHER|0.15||||||| 9590126|ERX|0250|NITROGLYCERIN 1 MG/10 D5W|Cigna|CIGNA|||||0.15||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Blue Cross PPO Specialty|BCBSTX PPO|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Managed Medicaid|MEDICAID SUPERIOR|||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Managed Medicare|HEALTHSPRING MA|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Medicare|MEDICARE ACUTE|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Managed Medicare|BCBS MEDICARE PPO MA|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|United Healthcare|UNITED HEALTHCARE OTHER|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|United Healthcare|UNITED HEALTHCARE|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Medicaid|MEDICAID|73.25||||||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|NON CONTRACTED|COMMERCIAL OTHER 1|||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Humana Medicare Advantage|HUMANA MA|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Cigna|CIGNA|73.25||||||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Blue Cross HMO Specialty|BCBSTX HMO|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Aetna Value Network|AETNA VALUE NETWORK|||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Access Direct Platinum|HEALTHFIRST TPA UMR|||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|United Medicare Advantage|UHC MEDICARE GOLD MA|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Veterans Affairs|VETERANS ADMINISTRATION|73.25||||||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|United Medicare Advantage|UHC AARP MCR HMO MA|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|73.25||||73.25||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Aetna|AETNA PPO|73.25||||||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Aenta Medicare Advantage|AETNA MEDICARE MA|73.25||||73.25||| 9590159|ERX|0250|CISATRACURIUM 10 MG/ML, 2|Medicare|MEDICARE ACUTE|540.75||||||| 9590159|ERX|0250|CISATRACURIUM 10 MG/ML, 2|Managed Medicaid|MEDICAID SUPERIOR|||||540.75||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|United Medicare Advantage|UHC AARP MCR HMO MA|88.25||||||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|United Healthcare|UNITED HEALTHCARE OTHER|88.25||||||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|88.25||||||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Managed Medicare|HEALTHSPRING MA|88.25||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Medicare|MEDICARE ACUTE|88.25||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|United Medicare Advantage|UHC MEDICARE GOLD MA|88.25||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Blue Cross PPO Specialty|BCBSTX PPO|88.25||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|UTMB|UTMB CORRECTIONAL MANAGED CARE|88.25||||||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|United Healthcare|UNITED HEALTHCARE|88.25||||||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|88.25||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Blue Cross HMO Specialty|BCBSTX HMO|88.25||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Blue Cross PPO Specialty|BCBSTX OTHER|88.25||||||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Humana Medicare Advantage|HUMANA MA|88.25||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Managed Medicaid|MEDICAID SUPERIOR|88.25||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Cigna|CIGNA|||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|88.25||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|88.25||||||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||88.25||| 9590167|ERX|0250|INDOMETHACIN 50MG SUPPOSI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||88.25||| 9590191|ERX|0250|SETRALINE 20MG/ML SOLN, 3|Managed Medicaid|MEDICAID AMERIGROUP|181.50||||||| 9590191|ERX|0250|SETRALINE 20MG/ML SOLN, 3|Blue Cross PPO Specialty|BCBSTX PPO|181.50||||||| 9590191|ERX|0250|SETRALINE 20MG/ML SOLN, 3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|181.50||||||| 9590191|ERX|0250|SETRALINE 20MG/ML SOLN, 3|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|181.50||||||| 9590217|ERX|0250|GUANFACINE ER 4MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.73||||||| 9590217|ERX|0250|GUANFACINE ER 4MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.73||||||| 9590217|ERX|0250|GUANFACINE ER 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.73||||||| 9590217|ERX|0250|GUANFACINE ER 4MG TABLET|Tricare|TRICARE EAST REGION|0.73||||||| 9590217|ERX|0250|GUANFACINE ER 4MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.73||||||| 9590217|ERX|0250|GUANFACINE ER 4MG TABLET|Aetna|BH AETNA|0.73||||||| 9590217|ERX|0250|GUANFACINE ER 4MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.73||||||| 9590217|ERX|0250|GUANFACINE ER 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Humana Medicare Advantage|HUMANA MA|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Medicaid|MEDICAID|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Tricare|TRICARE EAST REGION|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Cigna|CIGNA|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.73||||||| 9590225|ERX|0250|GUANFACINE ER 2MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Medicaid|MEDICAID|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Managed Medicare|JACKSONVILLE ACCESS|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Tricare|TRICARE EAST REGION|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Access Direct Platinum|ANDREWS CENTER|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Cigna|CIGNA|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Cigna Behavioral Health|BH CIGNA|0.73||||||| 9590233|ERX|0250|GUANFACINE ER 1MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.73||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Humana Medicare Advantage|HUMANA MA|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Cigna|CIGNA OTHER|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Aetna|AETNA OTHER|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Aetna|AETNA PPO|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|United Medicare Advantage|UHC AARP WELLMED HMO MA|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Workers Compensation|UT EMPLOYEE INJURY|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Medicare|MEDICARE ACUTE|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Managed Medicare|HEALTHSPRING MA|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|United Healthcare|UNITED HEALTHCARE|62.25||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|62.25||||||| 9590266|ERX|0250|CLONIDINE ER 0.1MG TABLET|Medicare|MEDICARE ACUTE|0.34||||||| 9590266|ERX|0250|CLONIDINE ER 0.1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.34||||||| 9590266|ERX|0250|CLONIDINE ER 0.1MG TABLET|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.34||||||| 9590266|ERX|0250|CLONIDINE ER 0.1MG TABLET|Magellan Behavioral Health|BH MAGELLAN|0.34||||||| 9590274|ERX|0250|VILAZADONE 20MG TABLET|Optum Behavioral Health|BH OPTUM UHC|47.50||||||| 9590282|ERX|0250|LISDEXAMFETAMINE 20MG CAP|Access Direct Platinum|HEALTHFIRST TPA UMR|54.25||||||| 9590282|ERX|0250|LISDEXAMFETAMINE 20MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|54.25||||||| 9590282|ERX|0250|LISDEXAMFETAMINE 20MG CAP|Managed Medicaid|MEDICAID AMERIGROUP|54.25||||||| 9590282|ERX|0250|LISDEXAMFETAMINE 20MG CAP|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|54.25||||||| 9590290|ERX|0250|LISDEXAMFETAMINE 40MG CAP|Medicaid|MEDICAID|54.25||||||| 9590290|ERX|0250|LISDEXAMFETAMINE 40MG CAP|Medicaid|BH TEXAS CHILDRENS MEDICAID|54.25||||||| 9590290|ERX|0250|LISDEXAMFETAMINE 40MG CAP|United Healthcare|UNITED HEALTHCARE OTHER|54.25||||||| 9590290|ERX|0250|LISDEXAMFETAMINE 40MG CAP|Blue Cross PPO Specialty|BCBSTX PPO|54.25||||||| 9590290|ERX|0250|LISDEXAMFETAMINE 40MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|54.25||||||| 9590290|ERX|0250|LISDEXAMFETAMINE 40MG CAP|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|54.25||||||| 9590290|ERX|0250|LISDEXAMFETAMINE 40MG CAP|Managed Medicaid|MEDICAID AMERIGROUP|54.25||||||| 9590308|ERX|0250|LISDEXAMFETAMINE 30MG CAP|Managed Medicaid|MEDICAID AMERIGROUP|54.25||||||| 9590308|ERX|0250|LISDEXAMFETAMINE 30MG CAP|Blue Cross PPO Specialty|BCBSTX PPO|54.25||||||| 9590308|ERX|0250|LISDEXAMFETAMINE 30MG CAP|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|54.25||||||| 9590308|ERX|0250|LISDEXAMFETAMINE 30MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|54.25||||||| 9590308|ERX|0250|LISDEXAMFETAMINE 30MG CAP|Access Direct Platinum|HEALTHFIRST TPA UMR|54.25||||||| 9590308|ERX|0250|LISDEXAMFETAMINE 30MG CAP|Access Direct Platinum|ANDREWS CENTER|54.25||||||| 9590357|ERX|0250|PRAZOSIN 5MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.50||||||| 9590357|ERX|0250|PRAZOSIN 5MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||||| 9590365|ERX|0250|AMPHETIMINE/DEXTROAM XR 5|Managed Medicaid|MEDICAID AMERIGROUP|44.25||||||| 9590365|ERX|0250|AMPHETIMINE/DEXTROAM XR 5|Blue Cross PPO Specialty|BCBSTX PPO|44.25||||||| 9590365|ERX|0250|AMPHETIMINE/DEXTROAM XR 5|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|44.25||||||| 9590365|ERX|0250|AMPHETIMINE/DEXTROAM XR 5|Medicaid|BH TEXAS CHILDRENS MEDICAID|44.25||||||| 9590381|ERX|0250|CLINDAMYCIN 1% TOP GEL 30|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|540.75||||||| 9590381|ERX|0250|CLINDAMYCIN 1% TOP GEL 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|540.75||||||| 9590381|ERX|0250|CLINDAMYCIN 1% TOP GEL 30|Managed Medicaid|MEDICAID SUPERIOR|540.75||||||| 9590381|ERX|0250|CLINDAMYCIN 1% TOP GEL 30|Access Direct Platinum|ANDREWS CENTER|540.75||||||| 9590381|ERX|0250|CLINDAMYCIN 1% TOP GEL 30|Managed Medicaid|MEDICAID AMERIGROUP|540.75||||||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|United Healthcare|UNITED HEALTHCARE OTHER|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Tricare|TRICARE EAST REGION|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|United Healthcare|UNITED HEALTHCARE|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Managed Medicare|HEALTHSPRING MA|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Managed Medicare|BCBS MEDICARE PPO MA|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Medicare|MEDICARE PART B ONLY IP|27.25||||||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Medicare|MEDICARE ACUTE|27.25||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Aenta Medicare Advantage|AETNA MEDICARE MA|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.25||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Blue Cross HMO Specialty|BCBSTX HMO|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Cigna|CIGNA OTHER|27.25||||||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Managed Medicaid|MEDICAID AMERIGROUP|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Access Direct Platinum|HEALTHFIRST TPA UMR|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|United Medicare Advantage|UHC AARP MCR HMO MA|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Workers Compensation|WORKERS COMPENSATION OTHER|27.25||||||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.25||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Humana Medicare Advantage|HUMANA MA|27.25||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.25||||27.25||| 9590407|ERX|0250|HEPARIN LOCK 10 UNIT/ML 5|Blue Cross PPO Specialty|BCBSTX PPO|||||27.25||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Access Direct Platinum|HEALTHFIRST TPA UMR|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Veterans Affairs|VETERANS ADMINISTRATION|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|United Medicare Advantage|UHC MEDICARE GOLD MA|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Cigna|CIGNA|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Blue Cross PPO Specialty|BCBSTX OTHER|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Medicaid|MEDICAID|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Medicare|MEDICARE PART B ONLY IP|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Medicare|MEDICARE ACUTE|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Blue Cross PPO Specialty|BCBSTX PPO|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Managed Medicare|HEALTHSPRING MA|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Managed Medicare|BCBS MEDICARE PPO MA|||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Blue Cross HMO Specialty|BCBSTX HMO|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|United Healthcare|UNITED HEALTHCARE OTHER|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Humana Medicare Advantage|HUMANA MA|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|United Healthcare|UNITED HEALTHCARE|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Aenta Medicare Advantage|AETNA MEDICARE MA|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Managed Medicaid|MEDICAID AMERIGROUP|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Optum Behavioral Health|BH OPTUM UHC|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|United Medicare Advantage|UHC AARP MCR HMO MA|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.86||||0.86||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Access Direct Platinum|ANDREWS CENTER|0.86||||||| 9590431|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)|Access Direct Platinum|HEALTHFIRST TPA|||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|NON CONTRACTED|COMMERCIAL OTHER 1|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|PHCS|HUMANA|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Tricare|TRICARE EAST REGION|||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Managed Medicare|HEALTHSPRING MA|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Managed Medicare|BCBS MEDICARE PPO MA|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Medicare|MEDICARE ACUTE|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Aetna|AETNA OTHER|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Aenta Medicare Advantage|AETNA MEDICARE MA|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Blue Cross HMO Specialty|BCBSTX HMO|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Aetna|AETNA PPO|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Medicaid|MEDICAID|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Blue Cross PPO Specialty|BCBSTX PPO|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Humana Medicare Advantage|HUMANA MA|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|United Healthcare|UNITED HEALTHCARE|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Managed Medicaid|MEDICAID AMERIGROUP|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|United Medicare Advantage|UHC MEDICARE GOLD MA|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|United Medicare Advantage|UHC AARP MCR HMO MA|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Veterans Affairs|VETERANS ADMINISTRATION|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Access Direct Platinum|HEALTHFIRST TPA UMR|0.86||||0.86||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.86||||||| 9590449|ERX|0250|EMPAGLIFLOZIN(JARDIANCE)2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.86||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Veterans Affairs|VETERANS ADMINISTRATION|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Managed Medicaid|MEDICAID SUPERIOR|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Managed Medicaid|MEDICAID AMERIGROUP|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Humana Medicare Advantage|HUMANA MA|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Blue Cross HMO Specialty|BCBSTX HMO|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Cigna|CIGNA|||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Blue Cross PPO Specialty|BCBSTX PPO|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|United Medicare Advantage|UHC AARP MCR HMO MA|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Aetna|AETNA QHP HMO|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Aetna|AETNA PPO|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Aetna|AETNA OTHER|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Medicaid|MEDICAID|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Medicare|MEDICARE PART B ONLY IP|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Medicare|MEDICARE ACUTE|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Managed Medicare|HEALTHSPRING MA|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Managed Medicare|BCBS MEDICARE PPO MA|0.83||||0.83||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|United Healthcare|UNITED HEALTHCARE|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|PHCS|HUMANA|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|United Healthcare|GEHA|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|United Healthcare|UNITED HEALTHCARE OTHER|0.83||||||| 9590456|ERX|0250|LINAGLIPTIN(TRADJENTA) 5M|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||0.83||| 9590464|ERX|0250|LEVONORGESTREL 1.5MG TABL|United Healthcare|UNITED HEALTHCARE|||||210.75||| 9590464|ERX|0250|LEVONORGESTREL 1.5MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|||||210.75||| 9590464|ERX|0250|LEVONORGESTREL 1.5MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||210.75||| 9590464|ERX|0250|LEVONORGESTREL 1.5MG TABL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||210.75||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Workers Compensation|TRAVELERS INSURANCE COMPANY|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Workers Compensation|WORKERS COMPENSATION OTHER|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Veterans Affairs|VETERANS ADMINISTRATION|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Access Direct Platinum|HEALTHFIRST TPA UMR|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Access Direct Platinum|HEALTHFIRST TPA|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|202.75||||202.75||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|United Medicare Advantage|UHC MEDICARE GOLD MA|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|United Medicare Advantage|UHC AARP MCR HMO MA|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Aenta Medicare Advantage|AETNA MEDICARE MA|202.75||||202.75||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Blue Cross HMO Specialty|BCBSTX HMO|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Blue Cross PPO Specialty|BCBSTX PPO|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Blue Cross PPO Specialty|BCBSTX OTHER|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|202.75||||202.75||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Cigna|CIGNA|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Managed Medicaid|MEDICAID SUPERIOR|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Managed Medicaid|MEDICAID AMERIGROUP|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Managed Medicare|WELLCARE CHOICE MA|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Managed Medicare|HEALTHSPRING MA|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Humana Medicare Advantage|HUMANA MA|202.75||||202.75||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||202.75||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Managed Medicare|BCBS MEDICARE PPO MA|202.75||||202.75||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Medicare|MEDICARE PART B ONLY IP|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Medicare|MEDICARE ACUTE|202.75||||202.75||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Medicaid|MEDICAID|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Medicaid|COUNTY INDIGENT HEALTH OTHER|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|NON CONTRACTED|COMMERCIAL OTHER 1|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|Rusk State Hospital|RUSK STATE HOSP|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|UTMB|UTMB CORRECTIONAL MANAGED CARE|202.75||||||| 9590498|ERX|0250|VENELEX OINTMENT 60GM TUB|United Healthcare|UNITED HEALTHCARE OTHER|202.75||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Access Direct Platinum|HEALTHFIRST TPA UMR|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Blue Cross HMO Specialty|BCBSTX HMO|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|United Healthcare|UNITED HEALTHCARE|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|United Healthcare|UNITED HEALTHCARE OTHER|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|United Healthcare|TML GROUP BENEFITS|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|NON CONTRACTED|COMMERCIAL OTHER 1|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Medicaid|MEDICAID|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Medicaid|CRIME VICTIMS COMPENSATION|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Medicare|MEDICARE ACUTE|360.50||||360.50||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Managed Medicare|WELLCARE CHOICE MA|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Managed Medicare|HEALTHSPRING MA|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Managed Medicare|BCBS MEDICARE PPO MA|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Managed Medicaid|MEDICAID AMERIGROUP|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Managed Medicaid|MEDICAID UNITED HEALTHCARE|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Cigna|CIGNA|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Humana Medicare Advantage|HUMANA MA|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Blue Cross PPO Specialty|BCBSTX PPO|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Aetna|AETNA QHP HMO|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Aetna|AETNA PPO|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|UTMB|UTMB CORRECTIONAL MANAGED CARE|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Aenta Medicare Advantage|AETNA MEDICARE MA|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|United Medicare Advantage|UHC MEDICARE GOLD MA|360.50||||360.50||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|United Medicare Advantage|UHC AARP MCR HMO MA|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Workers Compensation|WORKERS COMPENSATION OTHER|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Workers Compensation|TEXAS MUTUAL INSURANCE|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Veterans Affairs|VETERANS ADMINISTRATION|360.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Rusk State Hospital|RUSK STATE HOSP|360.50||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.02||||0.02||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|United Healthcare|UNITED HEALTHCARE|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Medicaid|MEDICAID|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Medicare|MEDICARE ACUTE|0.02||||0.02||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.02||||0.02||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Cigna|CIGNA|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Cigna|CIGNA OTHER|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.02||||||| 9590571|ERX|0250|PHYTONADIONE 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.02||||||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|NON CONTRACTED|COMMERCIAL OTHER 1|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|United Healthcare|UNITED HEALTHCARE OTHER|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|United Healthcare|TML GROUP BENEFITS|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|United Healthcare|UNITED HEALTHCARE|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Tricare|TRICARE FOR LIFE|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.77||||||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Medicaid|MEDICAID HMO|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Medicare|MEDICARE ACUTE|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Medicare|MEDICARE PART B ONLY IP|1.77||||||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Managed Medicaid|MEDICAID AMERIGROUP|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Managed Medicare|BCBS MEDICARE PPO MA|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Managed Medicaid|MEDICAID SUPERIOR|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Managed Medicare|HEALTHSPRING MA|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Cigna|CIGNA|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Cigna|CIGNA|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Humana Medicare Advantage|HUMANA MA|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|ChampVA|CHAMPVA CENTER|1.77||||||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Medicaid|MEDICAID|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Blue Cross HMO Specialty|BCBSTX HMO|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Blue Cross PPO Specialty|BCBSTX PPO|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Aetna Value Network|AETNA VALUE NETWORK|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Tricare|TRICARE EAST REGION|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|PHCS|GROUP AND PENSION|1.77||||||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Aetna|BOON CHAPMAN|1.77||||||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Aetna|AETNA PPO|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Aetna|AETNA OTHER|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Aenta Medicare Advantage|AETNA MEDICARE MA|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.77||||||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|United Medicare Advantage|UHC MEDICARE GOLD MA|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|United Medicare Advantage|UHC AARP MCR HMO MA|1.77||||||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Access Direct Platinum|HEALTHFIRST TPA|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Access Direct Platinum|HEALTHFIRST TPA UMR|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Veterans Affairs|VETERANS ADMINISTRATION|1.77||||1.77||| 9590605|ERX|0250|NEOSTIGMINE 3MG/3ML SYRIN|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.77||| 9590639|ERX|0250|PHENYLEPH-SHARK LIVER-CCB|Multiplan|WEB TPA|9.25||||||| 95907|EAP|0922|NERVE CONDUCTION STUDIES|Medicare|MEDICARE ACUTE|1,006.80||||||| 95907|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicare|HEALTHSPRING MA|8.39||||||| 95907|EAP|0922|NERVE CONDUCTION STUDIES|Humana Medicare Advantage|HUMANA MA|||||1,006.80||| 95907|EAP|0922|NERVE CONDUCTION STUDIES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,006.80||||||| 9590753|ERX|0250|THEOPHYLLINE SR 400MG TAB|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9590753|ERX|0250|THEOPHYLLINE SR 400MG TAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||||| 9590753|ERX|0250|THEOPHYLLINE SR 400MG TAB|Humana Medicare Advantage|HUMANA MA|0.10||||0.10||| 9590753|ERX|0250|THEOPHYLLINE SR 400MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|NON CONTRACTED|COMMERCIAL OTHER 1|0.36||||||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.36||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.36||||||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Blue Cross PPO Specialty|BCBSTX PPO|||||0.36||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.36||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Humana Medicare Advantage|HUMANA MA|0.36||||||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Managed Medicaid|MEDICAID AMERIGROUP|||||0.36||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Managed Medicaid|MEDICAID SUPERIOR|||||0.36||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.36||||||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Medicaid|MEDICAID|0.36||||0.36||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Medicare|MEDICARE ACUTE|0.36||||0.36||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicare|HEALTHSPRING MA|1,514.40||||1,514.40||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicare|BCBS MEDICARE PPO MA|12.62||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,514.40||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.62||||1,514.40||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC MEDICARE GOLD MA|12.62||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,514.40||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Aenta Medicare Advantage|AETNA MEDICARE MA|1,388.20||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Veterans Affairs|VETERANS ADMINISTRATION|1,514.40||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Workers Compensation|WORKERS COMPENSATION OTHER|1,514.40||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross PPO Specialty|BCBSTX PPO|1,514.40||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Humana Medicare Advantage|HUMANA MA|1,514.40||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Access Direct Platinum|HEALTHFIRST TPA UMR|12.62||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Tricare|TRICARE EAST REGION|12.62||||||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.62||||||| 95908|EAP|0510|NERVE CONDUCTION STUDIES|Medicare|MEDICARE ACUTE|||||2.85||| 95908|EAP|0922|NERVE CONDUCTION STUDIES|Medicare|MEDICARE ACUTE|1,514.40||||||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|Veterans Affairs|VETERANS ADMINISTRATION|12.62||||||| 95909|EAP|0510|NRV CNDJ TST 5-6 STUDIES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.85||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC MEDICARE GOLD MA|1,514.40||||||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.62||||||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC AARP MCR HMO MA|1,514.40||||||| 95909|EAP|0510|NRV CNDJ TST 5-6 STUDIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.85||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,514.40||||||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross HMO Specialty|BCBSTX HMO|1,514.40||||||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross PPO Specialty|BCBSTX OTHER|1,514.40||||||| 95909|EAP|0510|NRV CNDJ TST 5-6 STUDIES|Cigna|CIGNA|||||2.85||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|Humana Medicare Advantage|HUMANA MA|1,514.40||||||| 95909|EAP|0510|NRV CNDJ TST 5-6 STUDIES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.85||| 95909|EAP|0510|NRV CNDJ TST 5-6 STUDIES|Managed Medicaid|MEDICAID AMERIGROUP|||||2.85||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|United Healthcare|UNITED HEALTHCARE|12.62||||||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicare|HEALTHSPRING MA|1,514.40||||||| 95909|EAP|0922|NERVE CONDUCTION STUDIES|Medicare|MEDICARE ACUTE|1,514.40||||||| 95909|EAP|0510|NRV CNDJ TST 5-6 STUDIES|Medicare|MEDICARE ACUTE|||||2.85||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Managed Medicare|HEALTHSPRING MA|101.62||||||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||101.62||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|101.62||||101.62||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Cigna|CIGNA|101.62||||||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Blue Cross HMO Specialty|BCBSTX HMO|101.62||||||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Tricare|TRICARE EAST REGION|101.62||||||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Blue Cross PPO Specialty|BCBSTX PPO|101.62||||101.62||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|United Healthcare|UNITED HEALTHCARE|101.62||||||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||101.62||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|101.62||||101.62||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|United Medicare Advantage|UHC MEDICARE GOLD MA|101.62||||||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|United Medicare Advantage|UHC AARP MCR HMO MA|101.62||||101.62||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Workers Compensation|WORKERS COMPENSATION OTHER|101.62||||||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Medicare|MEDICARE ACUTE|101.62||||101.62||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Workers Compensation|BROOKSHIRES WORKERS COMP|101.62||||||| 9590910|ERX|0250|MINERAL OIL, STERILE, 10M|Medicaid|MEDICAID|101.62||||||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Cigna|CIGNA|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Medicare|MEDICARE ACUTE|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Managed Medicare|HEALTHSPRING MA|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Humana Medicare Advantage|HUMANA MA|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||492.46||| 9590928|ERX|0250|ALPROSTADIL 20 MCG VIAL|Cigna|CIGNA OTHER|||||492.46||| 9590985|ERX|0250|SODIUM BICARB 4.2%, 5 ML|Medicare|MEDICARE ACUTE|109.33||||109.33||| 9590985|ERX|0250|SODIUM BICARB 4.2%, 5 ML|Blue Cross PPO Specialty|BCBSTX PPO|||||109.33||| 95910|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC MEDICARE GOLD MA|1,131.60||||||| 95910|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC AARP MCR HMO MA|1,131.60||||||| 95910|EAP|0761||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.57||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Workers Compensation|UT EMPLOYEE INJURY|||||315.42||| 95910|EAP|0761||Workers Compensation|UT EMPLOYEE INJURY|||||7.57||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||315.42||| 95910|EAP|0761||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.57||| 95910|EAP|0761||Managed Medicaid|MEDICAID SUPERIOR|||||7.57||| 95910|EAP|0761||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.57||| 95910|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.43||||||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||315.42||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Managed Medicaid|MEDICAID SUPERIOR|||||315.42||| 95910|EAP|0761||Cigna|CIGNA|||||7.57||| 95910|EAP|0761||Aetna|AETNA PPO|||||7.57||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||315.42||| 95910|EAP|0761||Managed Medicaid|MEDICAID AMERIGROUP|||||7.57||| 95910|EAP|0761||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.57||| 95910|EAP|0761||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.57||| 95910|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,131.60||||||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Blue Cross PPO Specialty|BCBSTX PPO|||||315.42||| 95910|EAP|0761||Blue Cross PPO Specialty|BCBSTX PPO|||||7.57||| 95910|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross PPO Specialty|BCBSTX PPO|1,131.60||||||| 95910|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.43||||||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Blue Cross HMO Specialty|BCBSTX HMO|||||315.42||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Medicare|MEDICARE ACUTE|||||315.42||| 95910|EAP|0922|NERVE CONDUCTION STUDIES|Humana Medicare Advantage|HUMANA MA|1,037.30||||||| 95910|EAP|0761||Medicare|MEDICARE ACUTE|||||7.57||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Humana Medicare Advantage|HUMANA MA|||||315.42||| 95910|EAP|0922|NERVE CONDUCTION STUDIES|Medicare|MEDICARE ACUTE|9.43||||9.43||| 95910|EAP|0761||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.57||| 95910|EAP|0761||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.57||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||315.42||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Managed Medicaid|MEDICAID AMERIGROUP|||||315.42||| 95910|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicare|HEALTHSPRING MA|9.43||||||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||315.42||| 95910|EAP|0510|NRV CNDJ TEST 7-8 STUDIES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||315.42||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Medicaid|MEDICAID|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Medicare|MEDICARE ACUTE|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Managed Medicare|BCBS MEDICARE PPO MA|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|United Healthcare|UNITED HEALTHCARE OTHER|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|United Healthcare|UNITED HEALTHCARE|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Rusk State Hospital|RUSK STATE HOSP|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|PHCS|HUMANA|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|NON CONTRACTED|COMMERCIAL OTHER 1|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Blue Cross PPO Specialty|BCBSTX PPO|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|United Healthcare|TML GROUP BENEFITS|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Aenta Medicare Advantage|AETNA MEDICARE MA|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Humana Medicare Advantage|HUMANA MA|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Managed Medicaid|MEDICAID SUPERIOR|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Blue Cross HMO Specialty|BCBSTX HMO|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Workers Compensation|TEXAS MUTUAL INSURANCE|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|United Medicare Advantage|UHC MEDICARE GOLD MA|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|Veterans Affairs|VETERANS ADMINISTRATION|0.85||||||| 9591066|ERX|0250|MIDAZOLAM 100 MG/100 ML N|United Medicare Advantage|UHC AARP MCR HMO MA|0.85||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|United Medicare Advantage|UHC MEDICARE GOLD MA|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Workers Compensation|WORKERS COMPENSATION OTHER|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Workers Compensation|TEXAS MUTUAL INSURANCE|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Veterans Affairs|VETERANS ADMINISTRATION|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Blue Cross HMO Specialty|BCBSTX HMO|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Tricare|TRICARE EAST REGION|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|UTMB|UTMB CORRECTIONAL MANAGED CARE|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Rusk State Hospital|RUSK STATE HOSP|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Managed Medicare|WELLCARE CHOICE MA|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Managed Medicare|HEALTHSPRING MA|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|United Medicare Advantage|UHC AARP MCR HMO MA|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Managed Medicare|BCBS MEDICARE PPO MA|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Medicare|MEDICARE ACUTE|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|United Healthcare|TML GROUP BENEFITS|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Medicaid|MEDICAID|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Medicaid|COUNTY INDIGENT HEALTH OTHER|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Aenta Medicare Advantage|AETNA MEDICARE MA|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Humana Medicare Advantage|HUMANA MA|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Blue Cross PPO Specialty|BCBSTX PPO|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|Managed Medicaid|MEDICAID SUPERIOR|101.50||||||| 9591074|ERX|0250|NOREPINEPHRINE 8 MG/250 M|NON CONTRACTED|COMMERCIAL OTHER 1|101.50||||||| 95911|EAP|0761||Medicare|MEDICARE ACUTE|||||13.66||| 95911|EAP|0761||Tricare|TRICARE EAST REGION|||||13.66||| 95911|EAP|0510|NRV CNDJ TEST 9-10 STUDIE|Managed Medicare|HEALTHSPRING MA|||||569.17||| 95911|EAP|0510|NRV CNDJ TEST 9-10 STUDIE|Blue Cross HMO Specialty|BCBSTX HMO|||||569.17||| 95911|EAP|0761||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||13.66||| 95911|EAP|0761||Cigna|CIGNA OTHER|||||13.66||| 95911|EAP|0510|NRV CNDJ TEST 9-10 STUDIE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||569.17||| 95911|EAP|0922|NERVE CONDUCTION STUDIES|Humana Medicare Advantage|HUMANA MA|12.62||||||| 95911|EAP|0761||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||13.66||| 95911|EAP|0761||Managed Medicaid|MEDICAID AMERIGROUP|||||13.66||| 95911|EAP|0510|NRV CNDJ TEST 9-10 STUDIE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||569.17||| 95911|EAP|0510|NRV CNDJ TEST 9-10 STUDIE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||569.17||| 95911|EAP|0761||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||13.66||| 95911|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross PPO Specialty|BCBSTX PPO|1,388.20||||1,514.40||| 95912|EAP|0761||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.66||| 95912|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC MEDICARE GOLD MA|1,514.40||||||| 95912|EAP|0510|NRV CNDJ TEST 11-12 STUDI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||569.17||| 95912|EAP|0761||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||13.66||| 95912|EAP|0761||Managed Medicaid|MEDICAID AMERIGROUP|||||13.66||| 95912|EAP|0510|NRV CNDJ TEST 11-12 STUDI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||569.17||| 95912|EAP|0510|NRV CNDJ TEST 11-12 STUDI|Humana Medicare Advantage|HUMANA MA|||||569.17||| 95912|EAP|0510|NRV CNDJ TEST 11-12 STUDI|Cigna|CIGNA|||||569.17||| 95912|EAP|0510|NRV CNDJ TEST 11-12 STUDI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||569.17||| 95912|EAP|0761||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.66||| 95912|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross HMO Specialty|BCBSTX HMO|||||12.62||| 95912|EAP|0761||Blue Cross PPO Specialty|BCBSTX PPO|||||13.66||| 95912|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross PPO Specialty|BCBSTX PPO|||||1,514.40||| 95912|EAP|0922|NERVE CONDUCTION STUDIES|NON CONTRACTED|COMMERCIAL OTHER 1|12.62||||||| 95912|EAP|0510|NRV CNDJ TEST 11-12 STUDI|Medicare|MEDICARE ACUTE|||||569.17||| 95912|EAP|0761||Medicare|MEDICARE ACUTE|||||13.66||| 95912|EAP|0510|NRV CNDJ TEST 11-12 STUDI|United Healthcare|UNITED HEALTHCARE|||||569.17||| 95912|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicare|HEALTHSPRING MA|12.62||||||| 95912|EAP|0761||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||13.66||| 95912|EAP|0761||Tricare|TRICARE EAST REGION|||||13.66||| 95912|EAP|0761||United Healthcare|UNITED HEALTHCARE|||||13.66||| 95912|EAP|0510|NRV CNDJ TEST 11-12 STUDI|United Healthcare|UNITED HEALTHCARE OTHER|||||569.17||| 95912|EAP|0922|NERVE CONDUCTION STUDIES|Medicare|MEDICARE ACUTE|12.62||||12.62||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,388.20||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Medicare|MEDICARE ACUTE|1,514.40||||12.62||| 95913|EAP|0761||Medicare|MEDICARE ACUTE|||||13.66||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicare|HEALTHSPRING MA|1,388.20||||||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|Managed Medicare|HEALTHSPRING MA|||||569.17||| 95913|EAP|0761||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||13.66||| 95913|EAP|0761||Managed Medicare|HEALTHSPRING MA|||||13.66||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicare|BCBS MEDICARE PPO MA|||||1,514.40||| 95913|EAP|0761||Tricare|TRICARE EAST REGION|||||13.66||| 95913|EAP|0761||United Healthcare|UNITED HEALTHCARE OTHER|||||13.66||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|United Healthcare|UNITED HEALTHCARE OTHER|1,514.40||||1,514.40||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||569.17||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|United Healthcare|UNITED HEALTHCARE|1,514.40||||||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|Medicare|MEDICARE ACUTE|||||569.17||| 95913|EAP|0761||NON CONTRACTED|COMMERCIAL OTHER 1|||||13.66||| 95913|EAP|0761||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||13.66||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|Blue Cross HMO Specialty|BCBSTX HMO|||||569.17||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross HMO Specialty|BCBSTX HMO|1,514.40||||12.62||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||569.17||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Blue Cross PPO Specialty|BCBSTX PPO|1,514.40||||12.62||| 95913|EAP|0761||Aenta Medicare Advantage|AETNA MEDICARE MA|||||13.66||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Aenta Medicare Advantage|AETNA MEDICARE MA|||||12.62||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||569.17||| 95913|EAP|0761||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||13.66||| 95913|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||13.66||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Humana Medicare Advantage|HUMANA MA|12.62||||1,514.40||| 95913|EAP|0761||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.66||| 95913|EAP|0761||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||13.66||| 95913|EAP|0761||Managed Medicaid|MEDICAID AMERIGROUP|||||13.66||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.62||||||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Managed Medicaid|MEDICAID AMERIGROUP|||||1,514.40||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.66||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|Managed Medicaid|MEDICAID SUPERIOR|||||569.17||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||569.17||| 95913|EAP|0761||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||13.66||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.62||||||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|United Medicare Advantage|UHC AARP MCR HMO MA|||||569.17||| 95913|EAP|0761||United Medicare Advantage|UHC MEDICARE GOLD MA|||||13.66||| 95913|EAP|0761||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.66||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC MEDICARE GOLD MA|12.62||||1,514.40||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,388.20||||||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||12.62||| 95913|EAP|0510|NRV CNDJ TEST 13 OR MORE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||569.17||| 95913|EAP|0922|NERVE CONDUCTION STUDIES|Access Direct Platinum|HEALTHFIRST TPA UMR|1,514.40||||||| 95925|EAP|0920|SSEPS UPPER LIMBS|Humana Medicare Advantage|HUMANA MA|||||1,623.60||| 95930|EAP|0920|VISUAL EVOKED POTENTIAL T|Cigna|CIGNA|||||12.68||| 95930|EAP|0920|VISUAL EVOKED POTENTIAL T|Aetna|AETNA PPO|||||1,521.60||| 95930|EAP|0920|VISUAL EVOKED POTENTIAL (|Medicare|MEDICARE ACUTE|2,137.30||||||| 95930|EAP|0920|VISUAL EVOKED POTENTIAL T|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1,521.60||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|United Medicare Advantage|UHC MEDICARE GOLD MA|15.17||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|United Medicare Advantage|UHC AARP WELLMED HMO MA|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|United Medicare Advantage|UHC AARP MCR HMO MA|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Humana Medicare Advantage|HUMANA MA|1,820.40||||1,820.40||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Aenta Medicare Advantage|AETNA MEDICARE MA|15.17||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Medicaid|MEDICAID|15.17||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|United Healthcare|UNITED HEALTHCARE|||||1,820.40||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Medicare|MEDICARE ACUTE|1,820.40||||1,668.70||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|United Healthcare|UNITED HEALTHCARE|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Managed Medicare|HEALTHSPRING MA|1,668.70||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Managed Medicare|BCBS MEDICARE PPO MA|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Blue Cross PPO Specialty|BCBSTX PPO|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Blue Cross HMO Specialty|BCBSTX HMO|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Cigna|CIGNA|15.17||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Managed Medicaid|MEDICAID AMERIGROUP|15.17||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|United Healthcare|UNITED HEALTHCARE OTHER|1,820.40||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|Managed Medicaid|MEDICAID SUPERIOR|15.17||||||| 95939|EAP|0920|MOTOR EVOKED POTENTIAL UP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,820.40||||1,820.40||| 95951|EAP|0740|VIDEO EEG <12 HOURS|Humana Medicare Advantage|HUMANA MA|51.17||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Medicare|MEDICARE ACUTE|70.55||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|United Healthcare|UNITED HEALTHCARE OTHER|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Medicaid|MEDICAID|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Managed Medicare|HEALTHSPRING MA|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Medicare|MEDICARE ACUTE|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Managed Medicare|BCBS MEDICARE PPO MA|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|United Medicare Advantage|UHC MEDICARE GOLD MA|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|70.55||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Aenta Medicare Advantage|AETNA MEDICARE MA|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Blue Cross PPO Specialty|BCBSTX PPO|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Humana Medicare Advantage|HUMANA MA|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Managed Medicaid|MEDICAID SUPERIOR|70.34||||||| 95956|EAP|0740|EEG MONITOR TECHNOL ATTEN|Cigna|CIGNA|70.34||||||| 95961|EAP|0740|CORTICAL MAPPING|Blue Cross PPO Specialty|BCBSTX PPO|17.07||||||| 95961|EAP|0740|ELECTRODE STIMULATION,BRI|Medicare|MEDICARE ACUTE|17.07||||24.50||| 95961|EAP|0740|CORTICAL MAPPING|Humana Medicare Advantage|HUMANA MA|17.07||||||| 95962|EAP|0740|ELECTRODE STIM,BRAIN ADD-|Medicare|MEDICARE ACUTE|||||12.25||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.35||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.35||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.35||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.35||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.35||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.35||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|Humana Medicare Advantage|HUMANA MA|||||2.35||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|United Healthcare|UNITED HEALTHCARE|||||2.35||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|Medicare|MEDICARE ACUTE|||||2.35||| 95970|EAP|0761|ANALYZE NEUROSTIM, NO PRO|Managed Medicare|OTHER INSTITUTIONS|||||2.35||| 95972|EAP|0361|ALYS CPLX SP/PN NPGT W/PR|Medicare|MEDICARE ACUTE|||||3.53||| 95972|EAP|0361|ALYS CPLX SP/PN NPGT W/PR|Blue Cross PPO Specialty|BCBSTX PPO|||||3.53||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Humana Medicare Advantage|HUMANA MA|||||41.67||| 95983|EAP|0360||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.00||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|United Medicare Advantage|UHC AARP MCR HMO MA|||||41.67||| 95983|EAP|0360||United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.00||| 95983|EAP|0360||Humana Medicare Advantage|HUMANA MA|||||1.00||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||41.67||| 95983|EAP|0360||Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.00||| 95983|EAP|0360||Aetna|AETNA PPO|||||1.00||| 95983|EAP|0360||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.00||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Blue Cross HMO Specialty|BCBSTX HMO|||||41.67||| 95983|EAP|0360||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.00||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Blue Cross PPO Specialty|BCBSTX OTHER|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Aetna|AETNA QHP HMO|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Blue Cross PPO Specialty|BCBSTX PPO|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||41.67||| 95983|EAP|0360||Blue Cross PPO Specialty|BCBSTX PPO|||||1.00||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Managed Medicare|OTHER INSTITUTIONS|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Managed Medicare|HEALTHSPRING MA|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Managed Medicare|BCBS MEDICARE PPO MA|||||41.67||| 95983|EAP|0360||Managed Medicare|OTHER INSTITUTIONS|||||1.00||| 95983|EAP|0360||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.00||| 95983|EAP|0360||Managed Medicare|HEALTHSPRING MA|||||1.00||| 95983|EAP|0360||Managed Medicare|BCBS MEDICARE PPO MA|||||1.00||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|United Healthcare|UNITED HEALTHCARE|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|United Healthcare|TML GROUP BENEFITS|||||41.67||| 95983|EAP|0360||United Healthcare|UNITED HEALTHCARE OTHER|||||1.00||| 95983|EAP|0360||United Healthcare|UNITED HEALTHCARE|||||1.00||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|PHCS|HUMANA INSURANCE|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|PHCS|HUMANA|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|NON CONTRACTED|COMMERCIAL OTHER 1|||||41.67||| 95983|EAP|0510|ELECTRONIC ANALYSIS IMPT|Medicare|MEDICARE ACUTE|41.67||||41.67||| 95983|EAP|0360||Medicare|MEDICARE ACUTE|||||1.00||| 95983|EAP|0360||PHCS|HUMANA|||||1.00||| 95984|EAP|0360||United Healthcare|UNITED HEALTHCARE|||||0.50||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Medicare|MEDICARE ACUTE|20.83||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|PHCS|HUMANA INSURANCE|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|PHCS|HUMANA|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|NON CONTRACTED|COMMERCIAL OTHER 1|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|United Healthcare|UNITED HEALTHCARE|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|United Healthcare|TML GROUP BENEFITS|||||20.83||| 95984|EAP|0360||United Healthcare|UNITED HEALTHCARE OTHER|||||0.50||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Managed Medicare|OTHER INSTITUTIONS|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Managed Medicare|HEALTHSPRING MA|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Managed Medicare|BCBS MEDICARE PPO MA|||||20.83||| 95984|EAP|0360||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.50||| 95984|EAP|0360||Managed Medicare|HEALTHSPRING MA|||||0.50||| 95984|EAP|0360||Managed Medicare|BCBS MEDICARE PPO MA|||||0.50||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||20.83||| 95984|EAP|0360||PHCS|HUMANA|||||0.50||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|United Medicare Advantage|UHC AARP MCR HMO MA|||||20.83||| 95984|EAP|0360||Humana Medicare Advantage|HUMANA MA|||||0.50||| 95984|EAP|0360||United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.50||| 95984|EAP|0360||Medicare|MEDICARE ACUTE|||||0.50||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Humana Medicare Advantage|HUMANA MA|||||20.83||| 95984|EAP|0360||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.50||| 95984|EAP|0360||Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.50||| 95984|EAP|0360||Aetna|AETNA PPO|||||0.50||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Blue Cross HMO Specialty|BCBSTX HMO|||||20.83||| 95984|EAP|0360||Blue Cross PPO Specialty|BCBSTX PPO|||||0.50||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Blue Cross PPO Specialty|BCBSTX OTHER|||||20.83||| 95984|EAP|0510|ELECTRONIC ANALYSIS IMPLT|Blue Cross PPO Specialty|BCBSTX PPO|||||20.83||| 95984|EAP|0360||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.50||| 95984|EAP|0360||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.50||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|United Medicare Advantage|UHC MEDICARE GOLD MA|643.20||||||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|Aenta Medicare Advantage|AETNA MEDICARE MA|5.36||||||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|Medicare|MEDICARE ACUTE|643.20||||||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|Managed Medicare|HEALTHSPRING MA|643.20||||||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|Medicaid|MEDICAID|5.36||||||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|Humana Medicare Advantage|HUMANA MA|643.20||||||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|Cigna|CIGNA|643.20||||||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|United Medicare Advantage|UHC AARP MCR HMO MA|643.20||||||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.36||||||| 96105|EAP|0444|APHASIA ASSESSMENT PER HR|Veterans Affairs|VETERANS ADMINISTRATION|5.36||||||| 96125|EAP|0440|COGNITIVE EVAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|United Healthcare|UNITED HEALTHCARE|5.29||||||| 96125|EAP|0918||United Healthcare|UNITED HEALTHCARE OTHER|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|NON CONTRACTED|COMMERCIAL OTHER 1|5.29||||5.29||| 96125|EAP|0440|COGNITIVE EVAL|Medicare|MEDICARE ACUTE|5.29||||5.29||| 96125|EAP|0918||Medicare|MEDICARE ACUTE|5.29||||||| 96125|EAP|0918||Managed Medicare|HEALTHSPRING MA|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Medicaid|MEDICAID|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|PHCS|GROUP AND PENSION|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Blue Cross HMO Specialty|BCBSTX HMO|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Blue Cross PPO Specialty|BCBSTX PPO|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Blue Cross PPO Specialty|BCBSTX OTHER|5.29||||||| 96125|EAP|0918||Medicaid|MEDICAID|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.29||||||| 96125|EAP|0918||Aenta Medicare Advantage|AETNA MEDICARE MA|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Aenta Medicare Advantage|AETNA MEDICARE MA|5.29||||5.29||| 96125|EAP|0440|COGNITIVE EVAL|Managed Medicare|HEALTHSPRING MA|5.29||||5.29||| 96125|EAP|0440|COGNITIVE EVAL|Aetna|AETNA PPO|5.29||||||| 96125|EAP|0918||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.29||||||| 96125|EAP|0918||Humana Medicare Advantage|HUMANA MA|5.29||||5.29||| 96125|EAP|0440|COGNITIVE EVAL|Humana Medicare Advantage|HUMANA MA|5.29||||5.29||| 96125|EAP|0440|COGNITIVE EVAL|United Medicare Advantage|UHC MEDICARE GOLD MA|5.29||||5.29||| 96125|EAP|0440|COGNITIVE EVAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Cigna|CIGNA|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|United Medicare Advantage|UHC AARP WELLMED HMO MA|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|United Medicare Advantage|UHC AARP MCR HMO MA|5.29||||5.29||| 96125|EAP|0918||United Medicare Advantage|UHC MEDICARE GOLD MA|5.29||||||| 96125|EAP|0918||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.29||| 96125|EAP|0440|COGNITIVE EVAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.29||||5.29||| 96125|EAP|0918||Access Direct Platinum|HEALTHFIRST TPA|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Workers Compensation|WORKERS COMPENSATION OTHER|5.29||||||| 96125|EAP|0440|COGNITIVE EVAL|Veterans Affairs|VETERANS ADMINISTRATION|5.29||||||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|134,501.75|23218.37|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|162,212.44|20765.4|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|122,167.40|16209.34|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|Blue Cross PPO Specialty|BCBSTX PPO|149,462.58|10675.155|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|Medicare|MEDICARE ACUTE|77,641.37|16237.5|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|419,260.94|18679.04|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|419,777.44|18719.54|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|Veterans Affairs|VETERANS ADMINISTRATION|103,790.97|16550.38|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|98,824.11|16379.86|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|Humana Medicare Advantage|HUMANA MA|197,220.10|16240.81|30214.38|10675.155|||| 963|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC|Cigna|CIGNA|73,333.05|30214.38|30214.38|10675.155|||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Multiplan|WEB TPA|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Tricare|TRICARE FOR LIFE|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Tricare|TRICARE EAST REGION|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|United Healthcare|UNITED HEALTHCARE OTHER|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|United Healthcare|UNITED HEALTHCARE|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Managed Medicare|OTHER INSTITUTIONS|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Managed Medicare|BCBS MEDICARE PPO MA|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|7.78||||||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Medicaid|SMITH COUNTY JAIL|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Medicaid|MEDICAID|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Aetna|AETNA PPO|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Aenta Medicare Advantage|AETNA MEDICARE MA|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Aetna|AETNA OTHER|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.78||||||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Blue Cross HMO Specialty|BCBSTX HMO|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Blue Cross PPO Specialty|BCBSTX PPO|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Managed Medicaid|MEDICAID SUPERIOR|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Managed Medicaid|MEDICAID AMERIGROUP|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Humana Medicare Advantage|HUMANA MA|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Medicare|MEDICARE ACUTE|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Cigna|CIGNA|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Medicare|MEDICARE PART B ONLY IP|7.78||||||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Cigna|CIGNA OTHER|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|United Medicare Advantage|UHC MEDICARE GOLD MA|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|United Medicare Advantage|UHC AARP WELLMED HMO MA|7.78||||||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Medicaid|MEDICAID HMO|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|United Healthcare|GOLDEN RULE|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Medicaid|CRIME VICTIMS COMPENSATION|7.78||||||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|United Medicare Advantage|UHC AARP MCR HMO MA|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|NON CONTRACTED|COMMERCIAL OTHER 1|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Managed Medicare|HEALTHSPRING MA|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Access Direct Platinum|HEALTHFIRST TPA|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Veterans Affairs|VETERANS ADMINISTRATION|7.78||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Workers Compensation|GALLAGHER BASSETT|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Workers Compensation|UT EMPLOYEE INJURY|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Workers Compensation|WORKERS COMPENSATION OTHER|||||7.78||| 96360|EAP|0260|IV HYDRA 31-90 INITIAL 1S|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||7.78||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Workers Compensation|WORKERS COMPENSATION OTHER|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Veterans Affairs|VETERANS ADMINISTRATION|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Workers Compensation|TEXAS MUTUAL INSURANCE|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Workers Compensation|UT EMPLOYEE INJURY|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Access Direct Platinum|HEALTHFIRST TPA UMR|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Access Direct Platinum|HEALTHFIRST TPA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|United Medicare Advantage|UHC MEDICARE GOLD MA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.89||||||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|United Medicare Advantage|UHC AARP MCR HMO MA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Cigna|CIGNA OTHER|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Humana Medicare Advantage|HUMANA MA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicaid|MEDICAID SUPERIOR|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Blue Cross PPO Specialty|BCBSTX PPO|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|ChampVA|CHAMPVA CENTER|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicaid|MEDICAID AMERIGROUP|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Aetna Value Network|AETNA VALUE NETWORK|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Aenta Medicare Advantage|AETNA MEDICARE MA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Aetna|AETNA OTHER|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Aetna|AETNA PPO|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Aetna|BOON CHAPMAN|3.89||||||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Blue Cross PPO Specialty|BCBSTX OTHER|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicare|MEDICARE PART B ONLY IP|3.89||||||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicare|MEDICARE ACUTE|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|MEDICAID HMO|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Blue Cross HMO Specialty|BCBSTX HMO|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|MEDICAID|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|LAW ENFORCEMENT OTHER|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|CRIME VICTIMS COMPENSATION|3.89||||||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Cigna|CIGNA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|MEDICAID BCBSTX|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.89||||||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|SUPERIOR HEALTHPLAN CHIP|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicare|MA PART B ONLY IP|3.89||||||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|United Healthcare|UNITED HEALTHCARE|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|United Healthcare|UNITED HEALTHCARE OTHER|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Rusk State Hospital|RUSK STATE HOSP|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|PHCS|HUMANA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|PHCS|HUMANA INSURANCE|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Tricare|TRICARE EAST REGION|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Tricare|TRICARE FOR LIFE|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|United Healthcare|TML GROUP BENEFITS|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|NON CONTRACTED|COMMERCIAL OTHER 2|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|NON CONTRACTED|COMMERCIAL OTHER 1|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicare|WELLCARE CHOICE MA|3.89||||||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicare|HEALTHSPRING MA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicare|BCBS MEDICARE PPO MA|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Medicaid|SMITH COUNTY JAIL|3.89||||3.89||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|PHCS|GROUP AND PENSION|3.89||||||| 96361|EAP|0260|IV HYDRA EA ADDTL HR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.89||||3.89||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|NON CONTRACTED|COMMERCIAL OTHER 1|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Rusk State Hospital|RUSK STATE HOSP|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|PHCS|HUMANA|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|PHCS|GROUP AND PENSION|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Tricare|TRICARE EAST REGION|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|United Healthcare|UNITED HEALTHCARE OTHER|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|United Healthcare|TML GROUP BENEFITS|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|United Healthcare|UNITED HEALTHCARE|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicare|MA PART B ONLY IP|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicare|BCBS MEDICARE PPO MA|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicaid|SMITH COUNTY JAIL|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicaid|MEDICAID HMO|||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicaid|MEDICAID|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicaid|CRIME VICTIMS COMPENSATION|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicaid|SMITH COUNTY INDIGENT HEALTH|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicaid|COUNTY INDIGENT HEALTH OTHER|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicaid|SUPERIOR HEALTHPLAN CHIP|11.25||||11.25||| 96365|EAP|0260|IV INF FOR THER/PROPH/DX|Medicare|MEDICARE ACUTE|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicare|WELLCARE CHOICE MA|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicare|MEDICARE PART B ONLY IP|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicare|OTHER INSTITUTIONS|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicare|MEDICARE ACUTE|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Aenta Medicare Advantage|AETNA MEDICARE MA|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Aetna|AETNA PPO|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Aetna|AETNA OTHER|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|United Healthcare|AARP|11.25||||||| 96365|EAP|0260|IV INF FOR THER/PROPH/DX|United Healthcare|UNITED HEALTHCARE|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Aetna|BOON CHAPMAN|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Brinson Benefits|THE HEALTH PLAN SMITH CO|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Blue Cross HMO Specialty|BCBSTX HMO|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Blue Cross PPO Specialty|BCBSTX PPO|11.25||||11.25||| 96365|EAP|0260|IV INF FOR THER/PROPH/DX|Blue Cross PPO Specialty|BCBSTX PPO|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicare|HEALTHSPRING MA|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Blue Cross PPO Specialty|BCBSTX OTHER|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicaid|MEDICAID AMERIGROUP|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Humana Medicare Advantage|HUMANA MA|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|United Medicare Advantage|UHC AARP WELLMED HMO MA|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Access Direct Platinum|HEALTHFIRST TPA|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|PHCS|HUMANA INSURANCE|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Veterans Affairs|VETERANS ADMINISTRATION|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Workers Compensation|WORKERS COMPENSATION OTHER|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Workers Compensation|TEXAS MUTUAL INSURANCE|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|United Medicare Advantage|UHC MEDICARE GOLD MA|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|United Medicare Advantage|UHC AARP MCR HMO MA|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Cigna|CIGNA|11.25||||||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Cigna|CIGNA OTHER|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Cigna|CIGNA|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicaid|MEDICAID SUPERIOR|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Access Direct Platinum|HEALTHFIRST TPA UMR|11.25||||11.25||| 96365|EAP|0260|IV INF THER/PROPH/DX 1ST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.25||||11.25||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Access Direct Platinum|HEALTHFIRST TPA UMR|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Veterans Affairs|VETERANS ADMINISTRATION|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Workers Compensation|WORKERS COMPENSATION OTHER|||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Access Direct Platinum|HEALTHFIRST TPA|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|United Medicare Advantage|UHC AARP MCR HMO MA|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Cigna|CIGNA|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Cigna|CIGNA|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Humana Medicare Advantage|HUMANA MA|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Managed Medicaid|MEDICAID AMERIGROUP|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Managed Medicaid|MEDICAID SUPERIOR|||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Blue Cross PPO Specialty|BCBSTX PPO|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Blue Cross HMO Specialty|BCBSTX HMO|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Cigna|CIGNA OTHER|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Aenta Medicare Advantage|AETNA MEDICARE MA|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|United Medicare Advantage|UHC MEDICARE GOLD MA|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Aetna|AETNA PPO|||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Aetna|BOON CHAPMAN|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Medicare|MEDICARE ACUTE|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Medicare|MEDICARE PART B ONLY IP|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Managed Medicare|BCBS MEDICARE PPO MA|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|United Healthcare|UNITED HEALTHCARE OTHER|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|United Healthcare|UNITED HEALTHCARE|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|United Healthcare|UNITED HEALTHCARE|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Managed Medicare|HEALTHSPRING MA|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|United Healthcare|TML GROUP BENEFITS|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Tricare|TRICARE EAST REGION|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Medicaid|MEDICAID|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|NON CONTRACTED|COMMERCIAL OTHER 1|4.07||||4.07||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Medicaid|SMITH COUNTY JAIL|4.07||||||| 96366|EAP|0260|IV INF THER PROP/DX EA HO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4.07||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Medicare|MEDICARE PART B ONLY IP|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|NON CONTRACTED|COMMERCIAL OTHER 1|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|United Healthcare|UNITED HEALTHCARE OTHER|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|United Healthcare|TML GROUP BENEFITS|3.90||||||| 96367|EAP|0260|IV INF THERAPY ADL SEQ UP|United Healthcare|UNITED HEALTHCARE|||||5.29||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Managed Medicare|HEALTHSPRING MA|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Managed Medicare|BCBS MEDICARE PPO MA|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Medicaid|SMITH COUNTY JAIL|3.90||||||| 96367|EAP|0260|IV INF THERAPY ADL SEQ UP|Medicare|MEDICARE ACUTE|||||5.29||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Aetna|AETNA PPO|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Blue Cross PPO Specialty|BCBSTX OTHER|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Managed Medicaid|MEDICAID SUPERIOR|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Medicaid|MEDICAID|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|United Healthcare|UNITED HEALTHCARE|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|United Healthcare|UNITED HEALTHCARE|||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|United Medicare Advantage|UHC MEDICARE GOLD MA|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Veterans Affairs|VETERANS ADMINISTRATION|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Access Direct Platinum|HEALTHFIRST TPA|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Medicare|MEDICARE ACUTE|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|United Medicare Advantage|UHC AARP MCR HMO MA|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Cigna|CIGNA|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Humana Medicare Advantage|HUMANA MA|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.90||||||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Managed Medicaid|MEDICAID AMERIGROUP|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Blue Cross PPO Specialty|BCBSTX PPO|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Blue Cross HMO Specialty|BCBSTX HMO|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Aenta Medicare Advantage|AETNA MEDICARE MA|3.90||||3.90||| 96367|EAP|0450|IV INF THER PROPH ADDL SE|Access Direct Platinum|HEALTHFIRST TPA UMR|3.90||||3.90||| 96368|EAP|0450|IV INF CONCURRENT MED|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|United Medicare Advantage|UHC MEDICARE GOLD MA|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Humana Medicare Advantage|HUMANA MA|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Managed Medicaid|MEDICAID AMERIGROUP|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Blue Cross HMO Specialty|BCBSTX HMO|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|United Medicare Advantage|UHC AARP MCR HMO MA|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Blue Cross PPO Specialty|BCBSTX PPO|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Aenta Medicare Advantage|AETNA MEDICARE MA|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|Medicaid|SMITH COUNTY JAIL|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|Medicaid|MEDICAID|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|Access Direct Platinum|HEALTHFIRST TPA UMR|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Managed Medicare|HEALTHSPRING MA|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|Managed Medicare|BCBS MEDICARE PPO MA|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|United Healthcare|UNITED HEALTHCARE OTHER|||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|United Healthcare|UNITED HEALTHCARE|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|Tricare|TRICARE EAST REGION|3.89||||||| 96368|EAP|0450|IV INF CONCURRENT MED|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Medicare|MEDICARE ACUTE|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Veterans Affairs|VETERANS ADMINISTRATION|3.89||||3.89||| 96368|EAP|0450|IV INF CONCURRENT MED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.89||||3.89||| 96372|EAP|0450|INJECT-IM/SQ ONLY|PHCS|HUMANA|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|PHCS|GROUP AND PENSION|3.11||||||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Rusk State Hospital|RUSK STATE HOSP|3.11||||||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|PHCS|HUMANA|||||1.60||| 96372|EAP|0450|INJECT-IM/SQ ONLY|NON CONTRACTED|COMMERCIAL OTHER 4|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|NON CONTRACTED|COMMERCIAL OTHER 2|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|NON CONTRACTED|COMMERCIAL OTHER 1|3.11||||3.11||| 96372|EAP|0260||Tricare|TRICARE EAST REGION|||||1.60||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Tricare|TRICARE EAST REGION|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Multiplan|WEB TPA|||||1.60||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicare|MEDICARE PART B ONLY IP|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicare|MEDICARE ACUTE|3.11||||3.11||| 96372|EAP|0510|THER/PROPH/DIAG INJ SC/IM|Medicare|MEDICARE ACUTE|||||66.67||| 96372|EAP|0361|THER/PROPH/DIAG INJ SC/IM|Medicare|MEDICARE ACUTE|||||1.79||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Tricare|TRICARE FOR LIFE|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Tricare|TRICARE EAST REGION|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|United Healthcare|UNITED HEALTHCARE OTHER|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|United Healthcare|UNITED HEALTHCARE|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|United Healthcare|TML GROUP BENEFITS|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|United Healthcare|GEHA|||||3.11||| 96372|EAP|0260|INJECT-IM/SQ ONLY|United Healthcare|UNITED HEALTHCARE|||||5.20||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Healthcare|UNITED HEALTHCARE OTHER|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Healthcare|UNITED HEALTHCARE|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Healthcare|UNITED HEALTHCARE|||||113.34||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Managed Medicare|BCBS MEDICARE PPO MA|||||1.60||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.60||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||66.67||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Managed Medicare|HEALTHSPRING MA|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Managed Medicare|BCBS MEDICARE PPO MA|3.11||||3.11||| 96372|EAP|0260||Medicare|MEDICARE ACUTE|||||1.60||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Medicare|MEDICARE ACUTE|||||66.67||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.11||||||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid|MEDICAID HMO|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid|LAW ENFORCEMENT OTHER|3.11||||||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid|BH TEXAS CHILDRENS MEDICAID|3.11||||3.11||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Aetna|AETNA OTHER|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Aetna|AETNA PPO|||||66.67||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Aetna|AETNA PPO|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Aetna|AETNA OTHER|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Aenta Medicare Advantage|AETNA MEDICARE MA|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.11||||3.11||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||113.34||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Aetna Value Network|AETNA VALUE NETWORK|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||66.67||| 96372|EAP|0361|THER/PROPH/DIAG INJ SC/IM|Blue Cross PPO Specialty|BCBSTX PPO|||||1.79||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Blue Cross PPO Specialty|BCBSTX PPO|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Blue Cross PPO Specialty|BCBSTX OTHER|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.11||||||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||113.34||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||113.34||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||66.67||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.11||||3.11||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||66.67||| 96372|EAP|0361|THER/PROPH/DIAG INJ SC/IM|Blue Cross HMO Specialty|BCBSTX HMO|||||1.79||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid|MEDICAID|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Blue Cross HMO Specialty|BCBSTX HMO|3.11||||3.11||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Blue Cross PPO Specialty|BCBSTX PPO|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Blue Cross HMO Specialty|BCBSTX HMO|||||1.60||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Blue Cross HMO Specialty|BCBSTX HMO|||||66.67||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Medicaid|SMITH COUNTY JAIL|3.11||||3.11||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Blue Cross PPO Specialty|BCBSTX OTHER|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||113.34||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Managed Medicaid|MEDICAID SUPERIOR|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Managed Medicaid|MEDICAID AMERIGROUP|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.11||||3.11||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Managed Medicare|HEALTHSPRING MA|||||66.67||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Cigna|CIGNA OTHER|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Cigna|CIGNA|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Cigna|CIGNA|||||3.11||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Cigna|CIGNA|||||113.34||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Cigna|CIGNA|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Humana Medicare Advantage|HUMANA MA|||||66.67||| 96372|EAP|0260||Humana Medicare Advantage|HUMANA MA|||||1.60||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Humana Medicare Advantage|HUMANA MA|3.11||||3.11||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Healthcare|AARP|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Medicare Advantage|UHC AARP MCR HMO MA|||||1.60||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Medicare Advantage|UHC AARP MCR HMO MA|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Medicare Advantage|UHC MEDICARE GOLD MA|113.34||||66.67||| 96372|EAP|0510|THER/PROPH/DIAG INJ SC/IM|Tricare|TRICARE EAST REGION|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||113.34||| 96372|EAP|0450|INJECT-IM/SQ ONLY|United Medicare Advantage|UHC MEDICARE GOLD MA|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.11||||3.11||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|NON CONTRACTED|COMMERCIAL OTHER 1|||||66.67||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Multiplan|WEB TPA|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|United Medicare Advantage|UHC AARP MCR HMO MA|3.11||||3.11||| 96372|EAP|0510|THER/PROPH/DIAG INJ SC/IM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||66.67||| 96372|EAP|0510|THER/PROPH/DIAG INJ SC/IM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.60||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|PHCS|HUMANA INSURANCE|||||66.67||| 96372|EAP|0260||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.60||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|PHCS|HUMANA INSURANCE|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Access Direct Platinum|HEALTHFIRST TPA|||||3.11||| 96372|EAP|0510|THER/PROPH/DIAG INJ SC/IM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||66.67||| 96372|EAP|0260|THER/PROPH/DIAG INJ SC/IM|Veterans Affairs|VETERANS ADMINISTRATION|||||66.67||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Workers Compensation|WORKERS COMPENSATION OTHER|3.11||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Workers Compensation|UT EMPLOYEE INJURY|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Workers Compensation|BROOKSHIRES WORKERS COMP|||||3.11||| 96372|EAP|0450|INJECT-IM/SQ ONLY|Veterans Affairs|VETERANS ADMINISTRATION|3.11||||3.11||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|ZURICH COMPANY|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|GALLAGHER BASSETT|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|UT EMPLOYEE INJURY|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|TRAVELERS INSURANCE COMPANY|3.46||||||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|WORKERS COMP PHYSICIAN|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|WORKERS COMPENSATION OTHER|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|TEXAS MUTUAL INSURANCE|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Access Direct Platinum|HEALTHFIRST TPA UMR|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Access Direct Platinum|HEALTHFIRST TPA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Medicare Advantage|UHC MEDICARE GOLD MA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Medicare Advantage|UHC AARP WELLMED HMO MA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Humana Medicare Advantage|HUMANA MA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Cigna|CIGNA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Cigna|CIGNA OTHER|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicaid|MEDICAID SUPERIOR|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicaid|MEDICAID AMERIGROUP|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Blue Cross PPO Specialty|BCBSTX PPO|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Blue Cross HMO Specialty|BCBSTX HMO|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Aetna Value Network|AETNA VALUE NETWORK|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Aenta Medicare Advantage|AETNA MEDICARE MA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Aetna|AETNA PPO|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Aetna|AETNA OTHER|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|SUPERIOR HEALTHPLAN CHIP|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|CRIME VICTIMS COMPENSATION|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|ChampVA|CHAMPVA CENTER|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|MEDICAID BCBSTX|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Blue Cross PPO Specialty|BCBSTX OTHER|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|SMITH COUNTY JAIL|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|LAW ENFORCEMENT OTHER|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|MEDICAID|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|MEDICAID HMO|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicare|MEDICARE PART B ONLY IP|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicare|MEDICARE ACUTE|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicare|HEALTHSPRING MA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Medicare Advantage|UHC AARP MCR HMO MA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicare|WELLCARE CHOICE MA|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicare|OTHER INSTITUTIONS|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicare|ETMC REHABILITATION HOSPITAL|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Managed Medicare|BCBS MEDICARE PPO MA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Healthcare|TML GROUP BENEFITS|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Workers Compensation|BROOKSHIRES WORKERS COMP|3.46||||||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Healthcare|UNITED HEALTHCARE|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Healthcare|GOLDEN RULE|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Healthcare|AARP|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Healthcare|GEHA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|United Healthcare|UNITED HEALTHCARE OTHER|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Veterans Affairs|VETERANS ADMINISTRATION|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Multiplan|NALC|3.46||||||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Multiplan|WEB TPA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|NON CONTRACTED|COMMERCIAL OTHER 4|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|NON CONTRACTED|COMMERCIAL OTHER 2|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|NON CONTRACTED|COMMERCIAL OTHER 1|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Rusk State Hospital|RUSK STATE HOSP|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|PHCS|GROUP AND PENSION|3.46||||||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|PHCS|HUMANA|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|PHCS|HUMANA INSURANCE|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|PHCS|MULTIPLAN PHCS|||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Tricare|TRICARE FOR LIFE|3.46||||3.46||| 96374|EAP|0260|IV PUSH-1ST MED INITL 1ST|Tricare|TRICARE EAST REGION|3.46||||3.46||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Rusk State Hospital|RUSK STATE HOSP|2.88||||||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|PHCS|MULTIPLAN PHCS|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|PHCS|HUMANA INSURANCE|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|PHCS|HUMANA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Tricare|TRICARE FOR LIFE|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Tricare|TRICARE EAST REGION|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Multiplan|NALC|2.88||||||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|NON CONTRACTED|COMMERCIAL OTHER 4|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|NON CONTRACTED|COMMERCIAL OTHER 1|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|NON CONTRACTED|COMMERCIAL OTHER 2|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Healthcare|GOLDEN RULE|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Healthcare|AARP|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Healthcare|UNITED HEALTHCARE OTHER|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Healthcare|TML GROUP BENEFITS|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Healthcare|UNITED HEALTHCARE|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Healthcare|GEHA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicare|HEALTHSPRING MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicare|OTHER INSTITUTIONS|2.88||||||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicare|BCBS MEDICARE PPO MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicare|MA PART B ONLY IP|2.88||||||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicare|MEDICARE ACUTE|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicare|MEDICARE PART B ONLY IP|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|MEDICAID|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|MEDICAID HMO|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|SMITH COUNTY JAIL|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|CRIME VICTIMS COMPENSATION|2.88||||||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|MEDICAID BCBSTX|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid|LAW ENFORCEMENT OTHER|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Aenta Medicare Advantage|AETNA MEDICARE MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Aetna|AETNA PPO|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Aetna|BOON CHAPMAN|2.88||||||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Aetna|AETNA OTHER|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Aetna Value Network|AETNA VALUE NETWORK|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|ChampVA|CHAMPVA CENTER|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicare|WELLCARE CHOICE MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Blue Cross PPO Specialty|BCBSTX PPO|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Blue Cross PPO Specialty|BCBSTX OTHER|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Blue Cross HMO Specialty|BCBSTX HMO|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicaid|MEDICAID SUPERIOR|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Managed Medicaid|MEDICAID AMERIGROUP|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Cigna|CIGNA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Cigna|CIGNA OTHER|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Humana Medicare Advantage|HUMANA MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Multiplan|WEB TPA|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|PHCS|GROUP AND PENSION|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Medicare Advantage|UHC AARP MCR HMO MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|United Medicare Advantage|UHC MEDICARE GOLD MA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Access Direct Platinum|HEALTHFIRST TPA UMR|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Access Direct Platinum|HEALTHFIRST TPA|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Veterans Affairs|VETERANS ADMINISTRATION|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Workers Compensation|GALLAGHER BASSETT|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Workers Compensation|TEXAS MUTUAL INSURANCE|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Workers Compensation|WORKERS COMPENSATION OTHER|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Workers Compensation|TRAVELERS INSURANCE COMPANY|2.88||||||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Workers Compensation|UT EMPLOYEE INJURY|2.88||||2.88||| 96375|EAP|0260|IV PUSH-EA ADDTL NEW MED|Workers Compensation|ZURICH COMPANY|||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Workers Compensation|TEXAS MUTUAL INSURANCE|2.88||||||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Workers Compensation|WORKERS COMPENSATION OTHER|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Veterans Affairs|VETERANS ADMINISTRATION|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Access Direct Platinum|HEALTHFIRST TPA UMR|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Access Direct Platinum|HEALTHFIRST TPA|2.88||||||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|United Medicare Advantage|UHC AARP MCR HMO MA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Cigna|CIGNA OTHER|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Cigna|CIGNA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Cigna|CIGNA|||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Managed Medicaid|MEDICAID SUPERIOR|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Managed Medicaid|MEDICAID AMERIGROUP|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Blue Cross HMO Specialty|BCBSTX HMO|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Blue Cross PPO Specialty|BCBSTX PPO|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Blue Cross PPO Specialty|BCBSTX OTHER|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Aetna|AETNA OTHER|||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Aenta Medicare Advantage|AETNA MEDICARE MA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Aetna|BOON CHAPMAN|2.88||||||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Aetna|AETNA PPO|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Medicaid|SMITH COUNTY JAIL|2.88||||||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Humana Medicare Advantage|HUMANA MA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|United Medicare Advantage|UHC MEDICARE GOLD MA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Medicaid|MEDICAID HMO|||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Medicaid|MEDICAID|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Medicaid|LAW ENFORCEMENT OTHER|2.88||||||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Managed Medicare|WELLCARE CHOICE MA|2.88||||||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Managed Medicare|MA PART B ONLY IP|2.88||||||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Managed Medicare|HEALTHSPRING MA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Workers Compensation|ZURICH COMPANY|||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Managed Medicare|BCBS MEDICARE PPO MA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|United Healthcare|UNITED HEALTHCARE OTHER|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|United Healthcare|UNITED HEALTHCARE|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Tricare|TRICARE EAST REGION|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Tricare|TRICARE FOR LIFE|||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Medicare|MEDICARE PART B ONLY IP|2.88||||||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|Medicare|MEDICARE ACUTE|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|PHCS|HUMANA|2.88||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|PHCS|GROUP AND PENSION|2.88||||||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.88||| 96376|EAP|0450|IV PUSH-REPEAT SAME MED|NON CONTRACTED|COMMERCIAL OTHER 1|2.88||||2.88||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|NON CONTRACTED|COMMERCIAL OTHER 1|77,980.75|77980.75|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|United Healthcare|UNITED HEALTHCARE OTHER|139,062.67|21303.07|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|United Healthcare|UNITED HEALTHCARE|21,814.82|9484.81|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|102,758.55|9479.31|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|Medicaid|MEDICAID HMO|79,579.64|6707.86|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|Medicare|MEDICARE ACUTE|85,975.52|9479.31|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110,170.62|285.76|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|Blue Cross PPO Specialty|BCBSTX PPO|64,302.45|8513.12|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|Managed Medicaid|MEDICAID SUPERIOR|149,566.95|18120.82|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|Managed Medicaid|MEDICAID AMERIGROUP|156,577.24|21554.99|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|38,882.30|12179.2|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|46,809.96|9456.65|77980.75|285.76|||| 964|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W CC|Workers Compensation|WORKERS COMPENSATION OTHER|91,064.23|13676.565|77980.75|285.76|||| 96401|EAP|0260|CHEMO ANTI-NEOPL SQ/IM|Humana Medicare Advantage|HUMANA MA|||||66.67||| 96401|EAP|0260|CHEMO ANTI-NEOPL SQ/IM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||66.67||| 96401|EAP|0260|CHEMO ANTI-NEOPL SQ/IM|Blue Cross PPO Specialty|BCBSTX PPO|||||66.67||| 96401|EAP|0260|CHEMO ANTI-NEOPL SQ/IM|Blue Cross PPO Specialty|BCBSTX OTHER|||||66.67||| 96401|EAP|0260|CHEMO ANTI-NEOPL SQ/IM|Blue Cross HMO Specialty|BCBSTX HMO|||||66.67||| 96401|EAP|0260|CHEMO ANTI-NEOPL SQ/IM|Medicare|MEDICARE ACUTE|||||1.60||| 96401|EAP|0260|CHEMO ANTI-NEOPL SQ/IM|United Healthcare|UNITED HEALTHCARE OTHER|||||66.67||| 96401|EAP|0260|CHEMO ANTI-NEOPL SQ/IM|NON CONTRACTED|COMMERCIAL OTHER 1|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|NON CONTRACTED|COMMERCIAL OTHER 1|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|United Healthcare|UNITED HEALTHCARE OTHER|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|United Healthcare|UNITED HEALTHCARE|||||1.60||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|United Healthcare|UNITED HEALTHCARE|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Managed Medicare|BCBS MEDICARE PPO MA|||||113.34||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.60||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Managed Medicare|HEALTHSPRING MA|||||1.60||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Medicare|MEDICARE PART B ONLY IP|||||1.60||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Medicare|MEDICARE ACUTE|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|United Medicare Advantage|UHC AARP MCR HMO MA|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.60||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|United Medicare Advantage|UHC MEDICARE GOLD MA|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Veterans Affairs|VETERANS ADMINISTRATION|||||1.60||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.60||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Aenta Medicare Advantage|AETNA MEDICARE MA|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|PHCS|HUMANA|||||1.60||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Aetna|AETNA PPO|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Aetna Value Network|AETNA VALUE NETWORK|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Blue Cross PPO Specialty|BCBSTX PPO|||||1.60||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Blue Cross HMO Specialty|BCBSTX HMO|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Managed Medicaid|MEDICAID SUPERIOR|||||113.34||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Cigna|CIGNA|||||66.67||| 96402|EAP|0260|CHEMO HORMON ANTINEOPL SQ|Humana Medicare Advantage|HUMANA MA|||||66.67||| 96413|EAP|0330|CHEMO IV INFUSION 1ST HR|Humana Medicare Advantage|HUMANA MA|||||7.74||| 96413|EAP|0330|CHEMO IV INFUSION 1ST HR|Managed Medicare|BCBS MEDICARE PPO MA|||||7.74||| 96415|EAP|0330|CHEMO IV INFUSION ADDL HR|Managed Medicare|BCBS MEDICARE PPO MA|||||1.60||| 96417|EAP|0330|CHEMO IV INFUSION ADDL SE|Humana Medicare Advantage|HUMANA MA|||||1.60||| 96420|EAP|0330|IR-CHEMO IA PUSH TECHNIQU|Medicare|MEDICARE ACUTE|||||1,186.80||| 96420|EAP|0330|IR-CHEMO IA PUSH TECHNIQU|Managed Medicare|HEALTHSPRING MA|||||1,186.80||| 96420|EAP|0330|IR-CHEMO IA PUSH TECHNIQU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,186.80||| 96450|EAP|0331|XR-CHEMOTHERAPY INTO CNS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.80||||||| 96450|EAP|0331|XR-CHEMOTHERAPY INTO CNS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.80||||||| 96450|EAP|0331|XR-CHEMOTHERAPY INTO CNS|Blue Cross HMO Specialty|BCBSTX HMO|14.72||||||| 96450|EAP|0331|XR-CHEMOTHERAPY INTO CNS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.80||||||| 96450|EAP|0331|XR-CHEMOTHERAPY INTO CNS|United Healthcare|UNITED HEALTHCARE|12.80||||||| 96450|EAP|0331|XR-CHEMOTHERAPY INTO CNS|NON CONTRACTED|COMMERCIAL OTHER 1|12.80||||14.72||| 965|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC|Medicare|MEDICARE ACUTE|73,651.35|6315.52|6420.01|6315.52|||| 965|DRG||OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|81,548.36|6420.01|6420.01|6315.52|||| 969|DRG||HIV W EXTENSIVE O.R. PROCEDURE W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|513,734.90|857.28|54288.38|857.28|||| 969|DRG||HIV W EXTENSIVE O.R. PROCEDURE W MCC|Medicare|MEDICARE ACUTE|798,781.73|54288.38|54288.38|857.28|||| 97|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|129,882.03|21111.36|26438.88|2131.99|||| 97|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|322,632.48|21317.48|26438.88|2131.99|||| 97|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC|Medicare|MEDICARE ACUTE|349,278.82|21317.48|26438.88|2131.99|||| 97|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|73,920.35|26438.88|26438.88|2131.99|||| 97|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|378,978.83|2131.99|26438.88|2131.99|||| 970|DRG||HIV W EXTENSIVE O.R. PROCEDURE W/O MCC|United Healthcare|UNITED HEALTHCARE OTHER|57,203.88|34525.61|34525.61|34525.61|||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Cigna|CIGNA OTHER|325.95||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Cigna|CIGNA|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Cigna|CIGNA OTHER|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Cigna|CIGNA|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|ChampVA|CHAMPVA CENTER|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Humana Medicare Advantage|HUMANA MA|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Humana Medicare Advantage|HUMANA MA|333.90||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Managed Medicaid|MEDICAID SUPERIOR|3.18||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|333.90||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Managed Medicaid|MEDICAID AMERIGROUP|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Managed Medicaid|MEDICAID SUPERIOR|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.18||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Managed Medicaid|MEDICAID AMERIGROUP|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Aetna|AETNA PPO|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Aenta Medicare Advantage|AETNA MEDICARE MA|333.90||||3.18||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Aenta Medicare Advantage|AETNA MEDICARE MA|325.95||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Aetna|AETNA QHP HMO|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Aetna|AETNA OTHER|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Aetna|AETNA PPO|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Blue Cross PPO Specialty|BCBSTX PPO|333.90||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Blue Cross PPO Specialty|BCBSTX OTHER|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Blue Cross PPO Specialty|BCBSTX PPO|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Blue Cross PPO Specialty|BCBSTX OTHER|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Blue Cross HMO Specialty|BCBSTX HMO|3.18||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Blue Cross HMO Specialty|BCBSTX HMO|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Medicare Advantage|UHC MEDICARE GOLD MA|333.90||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Medicare Advantage|UHC AARP WELLMED HMO MA|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Medicare Advantage|UHC AARP MCR HMO MA|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|United Medicare Advantage|UHC MEDICARE GOLD MA|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|United Medicare Advantage|UHC AARP WELLMED HMO MA|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|United Medicare Advantage|UHC AARP MCR HMO MA|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Workers Compensation|BROOKSHIRES WORKERS COMP|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Workers Compensation|WORKERS COMPENSATION OTHER|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Workers Compensation|TRAVELERS INSURANCE COMPANY|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Workers Compensation|TEXAS MUTUAL INSURANCE|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Workers Compensation|BROOKSHIRES WORKERS COMP|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Workers Compensation|TEXAS MUTUAL INSURANCE|325.95||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Veterans Affairs|VETERANS ADMINISTRATION|333.90||||3.18||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|333.90||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Access Direct Platinum|HEALTHFIRST TPA UMR|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|333.90||||3.18||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Access Direct Platinum|HEALTHFIRST TPA|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Access Direct Platinum|HEALTHFIRST TPA UMR|325.95||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.18||||3.18||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Managed Medicare|MA PART B ONLY IP|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Veterans Affairs|VETERANS ADMINISTRATION|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Workers Compensation|WORKERS COMPENSATION OTHER|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Managed Medicare|HEALTHSPRING MA|333.90||||3.18||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Managed Medicare|BCBS MEDICARE PPO MA|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Managed Medicare|HEALTHSPRING MA|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Managed Medicare|BCBS MEDICARE PPO MA|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Medicaid|SUPERIOR HEALTHPLAN CHIP|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|333.90||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Medicaid|SMITH COUNTY JAIL|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Medicaid|MEDICAID|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Brinson Benefits|THE HEALTH PLAN SMITH CO|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Medicaid|CRIME VICTIMS COMPENSATION|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.18||||3.18||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Medicaid|MEDICAID|3.18||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Medicaid|LAW ENFORCEMENT OTHER|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Medicaid|CRIME VICTIMS COMPENSATION|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|333.90||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Medicare|MEDICARE PART B ONLY IP|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Medicare|MEDICARE ACUTE|333.90||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Aetna|BOON CHAPMAN|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Medicare|MEDICARE PART B ONLY IP|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Medicare|MEDICARE ACUTE|333.90||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Multiplan|WEB TPA|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|PHCS|HUMANA|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Aetna|AETNA OTHER|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|PHCS|GROUP AND PENSION|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|PHCS|HUMANA INSURANCE|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|PHCS|HUMANA INSURANCE|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|PHCS|HUMANA|325.95||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|NON CONTRACTED|COMMERCIAL OTHER 2|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|NON CONTRACTED|COMMERCIAL OTHER 1|325.95||||3.18||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Rusk State Hospital|RUSK STATE HOSP|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Rusk State Hospital|RUSK STATE HOSP|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|NON CONTRACTED|COMMERCIAL OTHER 1|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Healthcare|UNITED HEALTHCARE OTHER|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Cigna|CIGNA|3.18||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Healthcare|UNITED HEALTHCARE|333.90||||3.18||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Healthcare|UNITED HEALTHCARE|3.18||||3.18||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Cigna|CIGNA|333.90||||3.18||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Healthcare|TML GROUP BENEFITS|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Healthcare|GOLDEN RULE|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|United Healthcare|GEHA|333.90||||333.90||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|United Healthcare|UNITED HEALTHCARE OTHER|3.18||||3.18||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|United Healthcare|UNITED HEALTHCARE|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|United Healthcare|UNITED HEALTHCARE|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|United Healthcare|TML GROUP BENEFITS|333.90||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|United Healthcare|GEHA|||||333.90||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Tricare|TRICARE FOR LIFE|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|Tricare|TRICARE EAST REGION|333.90||||3.18||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|Tricare|TRICARE EAST REGION|333.90||||||| 97110|EAP|0420|THERAPEUTIC EXERCISE 15 M|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.18||||||| 97110|EAP|0430|THERAPEUTIC EXERCISE 15 M|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.18||||3.18||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Tricare|TRICARE EAST REGION|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Tricare|TRICARE FOR LIFE|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|325.95||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|United Healthcare|UNITED HEALTHCARE ERS|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|United Healthcare|UNITED HEALTHCARE OTHER|3.18||||325.95||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|United Healthcare|UNITED HEALTHCARE|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|United Healthcare|GEHA|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|United Healthcare|TML GROUP BENEFITS|333.90||||3.18||| 97112|EAP|0430|NEURO RE-ED 15 MIN|United Healthcare|UNITED HEALTHCARE|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|United Healthcare|UNITED HEALTHCARE|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|United Healthcare|TML GROUP BENEFITS|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|PHCS|HUMANA|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|PHCS|GROUP AND PENSION|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|PHCS|HUMANA|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Rusk State Hospital|RUSK STATE HOSP|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|NON CONTRACTED|COMMERCIAL OTHER 1|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicare|MEDICARE PART B ONLY IP|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicare|MEDICARE ACUTE|333.90||||3.18||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Medicare|MEDICARE PART B ONLY IP|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Medicare|MEDICARE ACUTE|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Multiplan|WEB TPA|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|SMITH COUNTY JAIL|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|MEDICAID BCBSTX|||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|MEDICAID|3.18||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|LAW ENFORCEMENT OTHER|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Medicaid|MEDICAID|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Medicaid|CRIME VICTIMS COMPENSATION|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.18||||3.18||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Managed Medicare|HEALTHSPRING MA|333.90||||325.95||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Managed Medicare|BCBS MEDICARE PPO MA|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Managed Medicare|HEALTHSPRING MA|333.90||||3.18||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|333.90||||3.18||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Access Direct Platinum|HEALTHFIRST TPA UMR|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Access Direct Platinum|HEALTHFIRST TPA|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|333.90||||3.18||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Access Direct Platinum|HEALTHFIRST TPA UMR|325.95||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Access Direct Platinum|HEALTHFIRST TPA|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Workers Compensation|WORKERS COMPENSATION OTHER|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Workers Compensation|TRAVELERS INSURANCE COMPANY|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Managed Medicare|BCBS MEDICARE PPO MA|325.95||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.18||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Workers Compensation|TEXAS MUTUAL INSURANCE|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|333.90||||3.18||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Workers Compensation|BROOKSHIRES WORKERS COMP|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Workers Compensation|WORKERS COMPENSATION OTHER|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Veterans Affairs|VETERANS ADMINISTRATION|333.90||||3.18||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Veterans Affairs|VETERANS ADMINISTRATION|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|United Medicare Advantage|UHC MEDICARE GOLD MA|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|CRIME VICTIMS COMPENSATION|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|United Medicare Advantage|UHC AARP WELLMED HMO MA|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|United Medicare Advantage|UHC AARP MCR HMO MA|333.90||||333.90||| 97112|EAP|0430|NEURO RE-ED 15 MIN|United Medicare Advantage|UHC MEDICARE GOLD MA|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|MEDICAID HMO|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|333.90||||333.90||| 97112|EAP|0430|NEURO RE-ED 15 MIN|United Medicare Advantage|UHC AARP MCR HMO MA|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Blue Cross HMO Specialty|BCBSTX HMO|3.18||||333.90||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Blue Cross HMO Specialty|BCBSTX HMO|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Medicaid|SUPERIOR HEALTHPLAN CHIP|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Blue Cross PPO Specialty|BCBSTX PPO|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Blue Cross PPO Specialty|BCBSTX OTHER|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Blue Cross PPO Specialty|BCBSTX PPO|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Blue Cross PPO Specialty|BCBSTX OTHER|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|NON CONTRACTED|COMMERCIAL OTHER 1|333.90||||3.18||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|333.90||||3.18||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|PHCS|HUMANA INSURANCE|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Aenta Medicare Advantage|AETNA MEDICARE MA|333.90||||3.18||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Aenta Medicare Advantage|AETNA MEDICARE MA|333.90||||3.18||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Aetna|BOON CHAPMAN|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|United Healthcare|UNITED HEALTHCARE OTHER|3.18||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Aetna|AETNA QHP HMO|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Aetna|AETNA PPO|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Aetna|AETNA OTHER|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Aetna|AETNA PPO|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Aetna|AETNA OTHER|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Managed Medicaid|MEDICAID UNITED HEALTHCARE|333.90||||3.18||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Tricare|TRICARE EAST REGION|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Managed Medicaid|MEDICAID SUPERIOR|333.90||||333.90||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|333.90||||3.18||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Managed Medicaid|MEDICAID AMERIGROUP|333.90||||325.95||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|333.90||||333.90||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Managed Medicaid|MEDICAID SUPERIOR|3.18||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Managed Medicaid|MEDICAID AMERIGROUP|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Humana Medicare Advantage|HUMANA MA|333.90||||3.18||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Humana Medicare Advantage|HUMANA MA|333.90||||3.18||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Cigna|CIGNA OTHER|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|Cigna|CIGNA|333.90||||||| 97112|EAP|0430|NEURO RE-ED 15 MIN|Cigna|CIGNA OTHER|333.90||||||| 97112|EAP|0420|THER PX 1/> AREAS NEURO R|ChampVA|CHAMPVA CENTER|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Cigna|CIGNA OTHER|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Cigna|CIGNA|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|ChampVA|CHAMPVA CENTER|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Humana Medicare Advantage|HUMANA MA|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Managed Medicaid|MEDICAID AMERIGROUP|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Aenta Medicare Advantage|AETNA MEDICARE MA|3.18||||325.95||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Aetna|BOON CHAPMAN|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Aetna|AETNA QHP HMO|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Aetna|AETNA PPO|325.95||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Aetna|AETNA OTHER|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.18||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Blue Cross PPO Specialty|BCBSTX PPO|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Blue Cross PPO Specialty|BCBSTX OTHER|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|325.95||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Blue Cross HMO Specialty|BCBSTX HMO|333.90||||325.95||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Medicare Advantage|UHC MEDICARE GOLD MA|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Medicare Advantage|UHC AARP MCR HMO MA|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Workers Compensation|BROOKSHIRES WORKERS COMP|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Workers Compensation|WORKERS COMPENSATION OTHER|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Workers Compensation|TRAVELERS INSURANCE COMPANY|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Workers Compensation|TEXAS MUTUAL INSURANCE|325.95||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Veterans Affairs|VETERANS ADMINISTRATION|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.18||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA UMR|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.18||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.18||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Managed Medicare|HEALTHSPRING MA|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|333.90||||325.95||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Managed Medicare|BCBS MEDICARE PPO MA|3.18||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicaid|SMITH COUNTY JAIL|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicaid|MEDICAID BCBSTX|||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicaid|MEDICAID|3.18||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Aetna Value Network|AETNA VALUE NETWORK|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicaid|LAW ENFORCEMENT OTHER|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicaid|CRIME VICTIMS COMPENSATION|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.18||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicare|MEDICARE PART B ONLY IP|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Medicare|MEDICARE ACUTE|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Multiplan|WEB TPA|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|PHCS|HUMANA INSURANCE|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|PHCS|GROUP AND PENSION|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Managed Medicaid|MEDICAID SUPERIOR|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Cigna|CIGNA|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|PHCS|HUMANA|3.18||||325.95||| 97116|EAP|0420|GAIT TRAINING 15 MIN|NON CONTRACTED|COMMERCIAL OTHER 2|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|NON CONTRACTED|COMMERCIAL OTHER 1|3.18||||325.95||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Rusk State Hospital|RUSK STATE HOSP|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE ERS|3.18||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE OTHER|3.18||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE|3.18||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Healthcare|TML GROUP BENEFITS|3.18||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Healthcare|GOLDEN RULE|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|United Healthcare|GEHA|333.90||||||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Tricare|TRICARE EAST REGION|333.90||||3.18||| 97116|EAP|0420|GAIT TRAINING 15 MIN|Tricare|TRICARE FOR LIFE|333.90||||333.90||| 97116|EAP|0420|GAIT TRAINING 15 MIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.18||||325.95||| 97129|EAP|0430|COGNITIVE DEVELOPMENT 15|Medicare|MEDICARE ACUTE|1.54||||||| 97129|EAP|0430|COGNITIVE DEVELOPMENT 15|Managed Medicare|HEALTHSPRING MA|1.54||||||| 97129|EAP|0430|COGNITIVE DEVELOPMENT 15|Veterans Affairs|VETERANS ADMINISTRATION|1.54||||||| 97140|EAP|0420|LYMPHEDEMA MGMT 15 MIN|Blue Cross PPO Specialty|BCBSTX PPO|1.98||||||| 97140|EAP|0420|LYMPHEDEMA MGMT 15 MIN|Humana Medicare Advantage|HUMANA MA|207.90||||||| 97140|EAP|0420|LYMPHEDEMA MGMT 15 MIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|207.90||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicaid|LAW ENFORCEMENT OTHER|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.96||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicaid|SUPERIOR HEALTHPLAN CHIP|405.90||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicaid|SMITH COUNTY JAIL|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicaid|SMITH COUNTY INDIGENT HEALTH|405.90||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicaid|MEDICAID BCBSTX|||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicaid|MEDICAID|3.96||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Managed Medicare|MA PART B ONLY IP|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Managed Medicare|HEALTHSPRING MA|3.96||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Managed Medicare|BCBS MEDICARE PPO MA|405.90||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Tricare|TRICARE FOR LIFE|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|UTMB|UTMB CORRECTIONAL MANAGED CARE|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Healthcare|UNITED HEALTHCARE ERS|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Healthcare|UNITED HEALTHCARE|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Healthcare|UNITED HEALTHCARE|3.96||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Healthcare|TML GROUP BENEFITS|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Healthcare|GOLDEN RULE|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Healthcare|GEHA|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|PHCS|HUMANA|3.96||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|PHCS|HUMANA INSURANCE|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Rusk State Hospital|RUSK STATE HOSP|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|NON CONTRACTED|COMMERCIAL OTHER 1|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|NON CONTRACTED|COMMERCIAL OTHER 2|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicare|MEDICARE ACUTE|3.96||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Multiplan|WEB TPA|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicare|MEDICARE PART B ONLY IP|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.96||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Access Direct Platinum|HEALTHFIRST TPA UMR|3.96||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.96||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Access Direct Platinum|HEALTHFIRST TPA|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|PHCS|GROUP AND PENSION|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Workers Compensation|TEXAS MUTUAL INSURANCE|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Workers Compensation|WORKERS COMPENSATION OTHER|415.80||||405.90||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Workers Compensation|UT EMPLOYEE INJURY|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Workers Compensation|TRAVELERS INSURANCE COMPANY|405.90||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Workers Compensation|BROOKSHIRES WORKERS COMP|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Veterans Affairs|VETERANS ADMINISTRATION|405.90||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Healthcare|UNITED HEALTHCARE OTHER|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Medicare Advantage|UHC MEDICARE GOLD MA|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.96||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Medicare Advantage|UHC AARP WELLMED HMO MA|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|United Medicare Advantage|UHC AARP MCR HMO MA|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Tricare|TRICARE EAST REGION|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.96||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Managed Medicaid|MEDICAID SUPERIOR|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Managed Medicaid|MEDICAID AMERIGROUP|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Managed Medicaid|MEDICAID UNITED HEALTHCARE|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Cigna|CIGNA OTHER|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Cigna|CIGNA|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Cigna|CIGNA|3.96||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|ChampVA|CHAMPVA CENTER|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Medicaid|CRIME VICTIMS COMPENSATION|3.96||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Humana Medicare Advantage|HUMANA MA|3.96||||405.90||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Aetna Value Network|AETNA VALUE NETWORK|415.80||||||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|415.80||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Aetna|AETNA OTHER|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Aenta Medicare Advantage|AETNA MEDICARE MA|3.96||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Aetna|AETNA QHP HMO|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Aetna|AETNA PPO|415.80||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Blue Cross HMO Specialty|BCBSTX HMO|3.96||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Blue Cross PPO Specialty|BCBSTX PPO|415.80||||405.90||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Blue Cross PPO Specialty|BCBSTX OTHER|405.90||||415.80||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.96||||3.96||| 97161|EAP|0424|PT EVAL LOW COMPLEXITY 20|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.96||||415.80||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Blue Cross PPO Specialty|BCBSTX PPO|534.45||||521.73||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Blue Cross PPO Specialty|BCBSTX OTHER|534.45||||564.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Brinson Benefits|THE HEALTH PLAN SMITH CO|534.45||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Blue Cross HMO Specialty|BCBSTX HMO|534.45||||549.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Aenta Medicare Advantage|AETNA MEDICARE MA|534.45||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Aetna|AETNA PPO|5.09||||564.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Aetna|AETNA OTHER|534.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|534.45||||521.73||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Cigna|CIGNA OTHER|549.45||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Cigna|CIGNA|534.45||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Cigna|CIGNA|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|ChampVA|CHAMPVA CENTER|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Managed Medicaid|MEDICAID SUPERIOR|534.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|534.45||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Managed Medicaid|MEDICAID AMERIGROUP|534.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|United Medicare Advantage|UHC MEDICARE GOLD MA|534.45||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|534.45||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|United Medicare Advantage|UHC AARP WELLMED HMO MA|549.45||||549.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|534.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Workers Compensation|WORKERS COMPENSATION OTHER|549.45||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Workers Compensation|TEXAS MUTUAL INSURANCE|536.73||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Veterans Affairs|VETERANS ADMINISTRATION|534.45||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|564.45||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|United Medicare Advantage|UHC AARP MCR HMO MA|534.45||||549.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST TPA UMR|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|534.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST TPA|534.45||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Medicare|MEDICARE PART B ONLY IP|534.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Medicare|MEDICARE ACUTE|534.45||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|534.45||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|PHCS|HUMANA|564.45||||564.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|PHCS|HUMANA INSURANCE|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|NON CONTRACTED|COMMERCIAL OTHER 1|5.09||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|United Healthcare|UNITED HEALTHCARE OTHER|5.09||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Humana Medicare Advantage|HUMANA MA|534.45||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|United Healthcare|UNITED HEALTHCARE|534.45||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|United Healthcare|TML GROUP BENEFITS|564.45||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|United Healthcare|GOLDEN RULE|534.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|United Healthcare|GEHA|||||564.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Aetna|AETNA QHP HMO|536.73||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Tricare|TRICARE EAST REGION|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Tricare|TRICARE FOR LIFE|534.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.09||||534.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Managed Medicare|OTHER INSTITUTIONS|||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.09||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Managed Medicare|HEALTHSPRING MA|534.45||||5.09||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Managed Medicare|ETMC AFFILIATE HOSPITALS|5.09||||564.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Managed Medicare|BCBS MEDICARE PPO MA|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|564.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Medicaid|SMITH COUNTY JAIL|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Medicaid|MOLINA HEALTHCARE OF TEXAS|536.73||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Medicaid|MEDICAID|5.09||||564.45||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Medicaid|LAW ENFORCEMENT OTHER|5.09||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Medicaid|CRIME VICTIMS COMPENSATION|534.45||||||| 97162|EAP|0424|PT EVAL MODERATE COMPLEXI|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.09||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Medicaid|MEDICAID HMO|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Medicaid|MEDICAID|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Medicaid|CRIME VICTIMS COMPENSATION|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Managed Medicare|HEALTHSPRING MA|637.55||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|UTMB|UTMB CORRECTIONAL MANAGED CARE|637.55||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|United Healthcare|UNITED HEALTHCARE OTHER|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|United Healthcare|TML GROUP BENEFITS|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Medicare|MEDICARE PART B ONLY IP|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Medicare|MEDICARE ACUTE|6.22||||6.22||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Access Direct Platinum|HEALTHFIRST TPA UMR|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Access Direct Platinum|HEALTHFIRST TPA|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|NON CONTRACTED|COMMERCIAL OTHER 1|637.55||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Workers Compensation|WORKERS COMPENSATION OTHER|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Workers Compensation|TEXAS MUTUAL INSURANCE|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Veterans Affairs|VETERANS ADMINISTRATION|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|United Medicare Advantage|UHC MEDICARE GOLD MA|637.55||||653.10||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|United Medicare Advantage|UHC AARP MCR HMO MA|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Managed Medicare|BCBS MEDICARE PPO MA|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Managed Medicaid|MEDICAID SUPERIOR|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Managed Medicaid|MEDICAID AMERIGROUP|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Humana Medicare Advantage|HUMANA MA|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Aenta Medicare Advantage|AETNA MEDICARE MA|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Aetna|BOON CHAPMAN|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Aetna|AETNA PPO|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Aetna|AETNA OTHER|6.22||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Blue Cross HMO Specialty|BCBSTX HMO|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Blue Cross PPO Specialty|BCBSTX PPO|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Blue Cross PPO Specialty|BCBSTX OTHER|653.10||||||| 97163|EAP|0424|PT EVAL HIGH COMPLEXITY 4|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|637.55||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Blue Cross PPO Specialty|BCBSTX PPO|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Aenta Medicare Advantage|AETNA MEDICARE MA|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Aetna|AETNA PPO|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Cigna|CIGNA|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|United Medicare Advantage|UHC MEDICARE GOLD MA|2.31||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Humana Medicare Advantage|HUMANA MA|2.31||||2.20||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.31||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|United Medicare Advantage|UHC AARP MCR HMO MA|2.31||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Workers Compensation|WORKERS COMPENSATION OTHER|2.31||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Veterans Affairs|VETERANS ADMINISTRATION|225.50||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Blue Cross HMO Specialty|BCBSTX HMO|2.31||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.31||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Access Direct Platinum|HEALTHFIRST TPA UMR|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Medicare|MEDICARE ACUTE|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|United Healthcare|UNITED HEALTHCARE OTHER|2.31||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|United Healthcare|UNITED HEALTHCARE|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Managed Medicare|HEALTHSPRING MA|225.50||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Managed Medicare|BCBS MEDICARE PPO MA|2.20||||||| 97164|EAP|0424|PT RE-EVAL OF EST PLAN 20|Medicaid|MEDICAID|2.20||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Medicaid|SMITH COUNTY JAIL|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Medicaid|MEDICAID|3.96||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Managed Medicare|HEALTHSPRING MA|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Managed Medicare|BCBS MEDICARE PPO MA|3.96||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Tricare|TRICARE EAST REGION|405.90||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Healthcare|UNITED HEALTHCARE OTHER|405.90||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Healthcare|UNITED HEALTHCARE|415.80||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Healthcare|UNITED HEALTHCARE|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Healthcare|GOLDEN RULE|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Healthcare|GEHA|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|PHCS|GROUP AND PENSION|405.90||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|PHCS|HUMANA|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|NON CONTRACTED|COMMERCIAL OTHER 2|||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|NON CONTRACTED|COMMERCIAL OTHER 1|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Medicare|MEDICARE PART B ONLY IP|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|415.80||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Access Direct Platinum|HEALTHFIRST TPA UMR|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.96||||405.90||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Access Direct Platinum|HEALTHFIRST TPA|3.96||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Workers Compensation|TEXAS MUTUAL INSURANCE|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Workers Compensation|WORKERS COMPENSATION OTHER|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Medicare|MEDICARE ACUTE|3.96||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Workers Compensation|TRAVELERS INSURANCE COMPANY|3.96||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Workers Compensation|BROOKSHIRES WORKERS COMP|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Veterans Affairs|VETERANS ADMINISTRATION|3.96||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Medicare Advantage|UHC MEDICARE GOLD MA|3.96||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Medicare Advantage|UHC AARP MCR HMO MA|415.80||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Managed Medicaid|MEDICAID AMERIGROUP|415.80||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|United Healthcare|TML GROUP BENEFITS|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|UTMB|UTMB CORRECTIONAL MANAGED CARE|415.80||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Managed Medicaid|MEDICAID SUPERIOR|3.96||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Humana Medicare Advantage|HUMANA MA|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Cigna|CIGNA OTHER|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Cigna|CIGNA|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Cigna|CIGNA|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|ChampVA|CHAMPVA CENTER|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Aetna Value Network|AETNA VALUE NETWORK|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.96||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Aetna|AETNA OTHER|415.80||||||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Aenta Medicare Advantage|AETNA MEDICARE MA|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Aetna|AETNA QHP HMO|415.80||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Aetna|AETNA PPO|415.80||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Blue Cross HMO Specialty|BCBSTX HMO|415.80||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Blue Cross PPO Specialty|BCBSTX PPO|415.80||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Blue Cross PPO Specialty|BCBSTX OTHER|3.96||||415.80||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.96||||3.96||| 97165|EAP|0434|OT EVAL LOW COMPLEXITY 30|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.96||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Blue Cross PPO Specialty|BCBSTX PPO|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Blue Cross PPO Specialty|BCBSTX OTHER|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Brinson Benefits|THE HEALTH PLAN SMITH CO|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Blue Cross HMO Specialty|BCBSTX HMO|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Aenta Medicare Advantage|AETNA MEDICARE MA|5.09||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Aetna|AETNA PPO|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Aetna|AETNA OTHER|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Cigna|CIGNA OTHER|534.45||||5.09||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Cigna|CIGNA|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Cigna|CIGNA|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Humana Medicare Advantage|HUMANA MA|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Managed Medicaid|MEDICAID SUPERIOR|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|534.45||||5.09||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Managed Medicaid|MEDICAID AMERIGROUP|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|United Medicare Advantage|UHC AARP WELLMED HMO MA|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|United Medicare Advantage|UHC AARP MCR HMO MA|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Workers Compensation|TEXAS MUTUAL INSURANCE|521.73||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Workers Compensation|BROOKSHIRES WORKERS COMP|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Veterans Affairs|VETERANS ADMINISTRATION|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|534.45||||5.09||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST TPA UMR|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Workers Compensation|WORKERS COMPENSATION OTHER|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|United Medicare Advantage|UHC MEDICARE GOLD MA|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Access Direct Platinum|HEALTHFIRST TPA|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Medicare|MEDICARE PART B ONLY IP|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Medicare|MEDICARE ACUTE|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|PHCS|HUMANA INSURANCE|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|PHCS|GROUP AND PENSION|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|PHCS|HUMANA|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Rusk State Hospital|RUSK STATE HOSP|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|NON CONTRACTED|COMMERCIAL OTHER 1|534.45||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|United Healthcare|UNITED HEALTHCARE OTHER|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|United Healthcare|UNITED HEALTHCARE|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|United Healthcare|UNITED HEALTHCARE|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Aetna|AETNA QHP HMO|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|United Healthcare|TML GROUP BENEFITS|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|United Healthcare|GEHA|||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Tricare|TRICARE FOR LIFE|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Tricare|TRICARE EAST REGION|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.09||||5.09||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Managed Medicare|HEALTHSPRING MA|534.45||||521.73||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Managed Medicare|ETMC AFFILIATE HOSPITALS|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Managed Medicare|BCBS MEDICARE PPO MA|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Medicaid|SUPERIOR HEALTHPLAN CHIP|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Medicaid|SMITH COUNTY INDIGENT HEALTH|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Medicaid|MEDICAID|5.09||||534.45||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Medicaid|LAW ENFORCEMENT OTHER|534.45||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Medicaid|CRIME VICTIMS COMPENSATION|5.09||||||| 97166|EAP|0434|OT EVAL MODERATE COMPLEXI|Medicaid|COUNTY INDIGENT HEALTH OTHER|5.09||||||| 97167|EAP|0434|OT EVAL HIGH COMPLEXITY 6|Medicaid|MEDICAID|637.55||||||| 97167|EAP|0434|OT EVAL HIGH COMPLEXITY 6|Medicare|MEDICARE ACUTE|653.10||||||| 97167|EAP|0434|OT EVAL HIGH COMPLEXITY 6|United Medicare Advantage|UHC MEDICARE GOLD MA|653.10||||||| 97167|EAP|0434|OT EVAL HIGH COMPLEXITY 6|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|637.55||||||| 97167|EAP|0434|OT EVAL HIGH COMPLEXITY 6|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.22||||||| 97167|EAP|0434|OT EVAL HIGH COMPLEXITY 6|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|637.55||||||| 97167|EAP|0434|OT EVAL HIGH COMPLEXITY 6|Humana Medicare Advantage|HUMANA MA|637.55||||||| 97167|EAP|0434|OT EVAL HIGH COMPLEXITY 6|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|637.55||||||| 97167|EAP|0434|OT EVAL HIGH COMPLEXITY 6|Blue Cross PPO Specialty|BCBSTX PPO|653.10||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|Blue Cross PPO Specialty|BCBSTX PPO|2.31||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|Aenta Medicare Advantage|AETNA MEDICARE MA|2.20||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|Humana Medicare Advantage|HUMANA MA|2.20||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|225.50||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|Managed Medicaid|MEDICAID SUPERIOR|2.31||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|United Medicare Advantage|UHC AARP MCR HMO MA|2.31||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|225.50||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|Medicare|MEDICARE ACUTE|2.20||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|Managed Medicare|HEALTHSPRING MA|225.50||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|Medicaid|SMITH COUNTY JAIL|2.20||||||| 97168|EAP|0434|OT RE-EVAL OF ESTAB PLAN|Medicaid|MEDICAID|2.31||||||| 974|DRG||HIV W MAJOR RELATED CONDITION W MCC|Medicare|MEDICARE ACUTE|262,128.58|16263.51|36043.3|15956.55|||| 974|DRG||HIV W MAJOR RELATED CONDITION W MCC|Medicaid|MEDICAID|92,801.17|22668.74|36043.3|15956.55|||| 974|DRG||HIV W MAJOR RELATED CONDITION W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|258,081.85|15956.55|36043.3|15956.55|||| 974|DRG||HIV W MAJOR RELATED CONDITION W MCC|Humana Medicare Advantage|HUMANA MA|55,048.82|15957.19|36043.3|15956.55|||| 974|DRG||HIV W MAJOR RELATED CONDITION W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|213,530.88|18078.89|36043.3|15956.55|||| 974|DRG||HIV W MAJOR RELATED CONDITION W MCC|Managed Medicaid|MEDICAID AMERIGROUP|128,480.58|36043.3|36043.3|15956.55|||| 975|DRG||HIV W MAJOR RELATED CONDITION W CC|Rusk State Hospital|RUSK STATE HOSP|153,822.65|75373.1|75373.1|7815.93|||| 975|DRG||HIV W MAJOR RELATED CONDITION W CC|Medicaid|MEDICAID|92,500.90|7815.93|75373.1|7815.93|||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|United Medicare Advantage|UHC AARP MCR HMO MA|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|United Medicare Advantage|UHC MEDICARE GOLD MA|330.25||||||| 97532|EAP|0430||United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.54||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Aenta Medicare Advantage|AETNA MEDICARE MA|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Aetna|AETNA PPO|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Blue Cross HMO Specialty|BCBSTX HMO|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Blue Cross PPO Specialty|BCBSTX PPO|330.25||||||| 97532|EAP|0430||Humana Medicare Advantage|HUMANA MA|1.54||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Humana Medicare Advantage|HUMANA MA|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|330.25||||||| 97532|EAP|0430||Medicaid|MEDICAID|1.54||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Medicaid|MEDICAID|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Managed Medicare|HEALTHSPRING MA|330.25||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|330.25||||||| 97532|EAP|0430||Medicare|MEDICARE ACUTE|1.54||||||| 97532|EAP|0440|COGNITIVE DEVELOPMENT - 1|Medicare|MEDICARE ACUTE|330.25||||||| 97533|EAP|0430|SENSORY INTEGRATION 15 MI|Medicare|MEDICARE ACUTE|166.05||||||| 97533|EAP|0430|SENSORY INTEGRATION 15 MI|United Healthcare|UNITED HEALTHCARE|170.10||||||| 97533|EAP|0430|SENSORY INTEGRATION 15 MI|Cigna|CIGNA|1.62||||||| 97533|EAP|0430|SENSORY INTEGRATION 15 MI|Humana Medicare Advantage|HUMANA MA|170.10||||||| 97533|EAP|0430|SENSORY INTEGRATION 15 MI|Aenta Medicare Advantage|AETNA MEDICARE MA|170.10||||||| 97533|EAP|0430|SENSORY INTEGRATION 15 MI|Aetna|AETNA OTHER|170.10||||||| 97533|EAP|0430|SENSORY INTEGRATION 15 MI|Veterans Affairs|VETERANS ADMINISTRATION|170.10||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Medicare Advantage|UHC MEDICARE GOLD MA|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Medicare Advantage|UHC AARP MCR HMO MA|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|United Medicare Advantage|UHC MEDICARE GOLD MA|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|United Medicare Advantage|UHC AARP MCR HMO MA|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.18||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA UMR|325.95||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|333.90||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.18||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA UMR|325.95||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Workers Compensation|BROOKSHIRES WORKERS COMP|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Workers Compensation|WORKERS COMPENSATION OTHER|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Workers Compensation|TRAVELERS INSURANCE COMPANY|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Workers Compensation|TEXAS MUTUAL INSURANCE|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Workers Compensation|WORKERS COMPENSATION OTHER|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Workers Compensation|TRAVELERS INSURANCE COMPANY|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Workers Compensation|BROOKSHIRES WORKERS COMP|325.95||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Veterans Affairs|VETERANS ADMINISTRATION|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Veterans Affairs|VETERANS ADMINISTRATION|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Blue Cross PPO Specialty|BCBSTX PPO|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Blue Cross PPO Specialty|BCBSTX OTHER|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Blue Cross PPO Specialty|BCBSTX PPO|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Blue Cross PPO Specialty|BCBSTX OTHER|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Blue Cross HMO Specialty|BCBSTX HMO|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Aetna Value Network|AETNA VALUE NETWORK|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Aetna Value Network|AETNA VALUE NETWORK|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.18||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Aenta Medicare Advantage|AETNA MEDICARE MA|333.90||||325.95||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Aenta Medicare Advantage|AETNA MEDICARE MA|3.18||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Aetna|BOON CHAPMAN|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Aetna|AETNA QHP HMO|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Aetna|AETNA PPO|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Aetna|AETNA OTHER|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Aetna|AETNA PPO|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Aetna|AETNA OTHER|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Managed Medicaid|MEDICAID SUPERIOR|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Managed Medicaid|MEDICAID AMERIGROUP|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|333.90||||325.95||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|333.90||||325.95||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|333.90||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Managed Medicaid|MEDICAID AMERIGROUP|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Humana Medicare Advantage|HUMANA MA|3.18||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Humana Medicare Advantage|HUMANA MA|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Cigna|CIGNA OTHER|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Cigna|CIGNA|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Cigna|CIGNA|325.95||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Managed Medicaid|MEDICAID SUPERIOR|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Cigna|CIGNA OTHER|333.90||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Cigna|CIGNA|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Cigna|CIGNA|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|ChampVA|CHAMPVA CENTER|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Aetna|AETNA QHP HMO|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Managed Medicare|OTHER INSTITUTIONS|||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.18||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Managed Medicare|HEALTHSPRING MA|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Managed Medicare|BCBS MEDICARE PPO MA|3.18||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.18||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Managed Medicare|HEALTHSPRING MA|333.90||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Managed Medicare|BCBS MEDICARE PPO MA|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicaid|MEDICAID HMO|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Blue Cross HMO Specialty|BCBSTX HMO|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicaid|MEDICAID|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicaid|LAW ENFORCEMENT OTHER|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.18||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicaid|CRIME VICTIMS COMPENSATION|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.18||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Medicaid|SMITH COUNTY JAIL|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Medicaid|MEDICAID|3.18||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Workers Compensation|TEXAS MUTUAL INSURANCE|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Medicaid|CRIME VICTIMS COMPENSATION|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Tricare|TRICARE FOR LIFE|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Tricare|TRICARE EAST REGION|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Tricare|TRICARE FOR LIFE|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Tricare|TRICARE EAST REGION|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Workers Compensation|UT EMPLOYEE INJURY|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE OTHER|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE|3.18||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Healthcare|TML GROUP BENEFITS|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Healthcare|GOLDEN RULE|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|United Healthcare|GEHA|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE OTHER|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST TPA|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|United Healthcare|UNITED HEALTHCARE|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|United Healthcare|TML GROUP BENEFITS|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|United Healthcare|GEHA|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|PHCS|HUMANA|333.90||||333.90||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|PHCS|HUMANA INSURANCE|325.95||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|PHCS|GROUP AND PENSION|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|PHCS|HUMANA INSURANCE|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|PHCS|HUMANA|333.90||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|333.90||||325.95||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|PHCS|GROUP AND PENSION|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|NON CONTRACTED|COMMERCIAL OTHER 2|333.90||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|NON CONTRACTED|COMMERCIAL OTHER 1|3.18||||3.18||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Rusk State Hospital|RUSK STATE HOSP|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Rusk State Hospital|RUSK STATE HOSP|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|NON CONTRACTED|COMMERCIAL OTHER 2|||||3.18||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|NON CONTRACTED|COMMERCIAL OTHER 1|333.90||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicare|MEDICARE PART B ONLY IP|3.18||||||| 97535|EAP|0420|HOME MGMT TRAINING 15 MIN|Medicare|MEDICARE ACUTE|333.90||||333.90||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Medicare|MEDICARE PART B ONLY IP|3.18||||||| 97535|EAP|0430|SELF CARE TRAINING 15 MIN|Medicare|MEDICARE ACUTE|333.90||||333.90||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|PHCS|HUMANA INSURANCE|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|NON CONTRACTED|COMMERCIAL OTHER 1|||||693.38||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|United Healthcare|UNITED HEALTHCARE OTHER|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|United Healthcare|UNITED HEALTHCARE|||||693.38||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Tricare|TRICARE FOR LIFE|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Tricare|TRICARE EAST REGION|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Medicaid|MEDICAID|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Medicaid|MEDICAID HMO|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Managed Medicare|HEALTHSPRING MA|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Managed Medicare|BCBS MEDICARE PPO MA|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Cigna|CIGNA OTHER|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Cigna|CIGNA|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Humana Medicare Advantage|HUMANA MA|6.45||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Managed Medicaid|MEDICAID SUPERIOR|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Managed Medicaid|MEDICAID AMERIGROUP|||||6.45||| 97597|EAP|0450|DEBRIDE SELECTIVE 1ST 20S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||565.80||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Aenta Medicare Advantage|AETNA MEDICARE MA|693.38||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Aetna|AETNA PPO|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Blue Cross HMO Specialty|BCBSTX HMO|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|United Healthcare|UNITED HEALTHCARE|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Medicare|MEDICARE ACUTE|741.75||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Blue Cross PPO Specialty|BCBSTX PPO|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Blue Cross PPO Specialty|BCBSTX OTHER|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Veterans Affairs|VETERANS ADMINISTRATION|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Workers Compensation|WORKERS COMPENSATION OTHER|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|Access Direct Platinum|HEALTHFIRST TPA|||||741.75||| 97597|EAP|0450|DEBRIDE SELECTIVE 1ST 20S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||565.80||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|United Medicare Advantage|UHC MEDICARE GOLD MA|||||741.75||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.45||| 97597|EAP|0761|DEBRIDE SELECT FIRST 20SQ|United Medicare Advantage|UHC AARP MCR HMO MA|741.75||||741.75||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|United Medicare Advantage|UHC MEDICARE GOLD MA|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.61||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|United Medicare Advantage|UHC AARP MCR HMO MA|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Access Direct Platinum|HEALTHFIRST TPA|||||5.61||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Veterans Affairs|VETERANS ADMINISTRATION|||||603.08||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Blue Cross PPO Specialty|BCBSTX PPO|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.61||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Blue Cross PPO Specialty|BCBSTX OTHER|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Blue Cross HMO Specialty|BCBSTX HMO|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Aetna|AETNA PPO|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Aenta Medicare Advantage|AETNA MEDICARE MA|645.15||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Managed Medicaid|MEDICAID SUPERIOR|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.61||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Managed Medicaid|MEDICAID AMERIGROUP|||||5.61||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Humana Medicare Advantage|HUMANA MA|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Cigna|CIGNA|||||5.61||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.61||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Managed Medicare|HEALTHSPRING MA|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Managed Medicare|BCBS MEDICARE PPO MA|||||5.61||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||5.61||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|United Healthcare|UNITED HEALTHCARE|||||645.15||| 97598|EAP|0761|DEBRIDE SELECT EA ADDL 20|Medicare|MEDICARE ACUTE|||||603.08||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.25||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Medicare|MEDICARE ACUTE|||||603.75||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|United Healthcare|UNITED HEALTHCARE|||||603.75||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Cigna|CIGNA|||||5.25||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||603.75||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Managed Medicaid|MEDICAID SUPERIOR|||||603.75||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||603.75||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Aetna|AETNA PPO|||||603.75||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||603.75||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Blue Cross HMO Specialty|BCBSTX HMO|||||603.75||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Blue Cross PPO Specialty|BCBSTX PPO|||||5.25||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Veterans Affairs|VETERANS ADMINISTRATION|||||5.25||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.25||| 97605|EAP|0761|NEG PRESS WOUND THPY 50CM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.25||| 97606|EAP|0761|NEG PRES WOUND THPY >50CM|Veterans Affairs|VETERANS ADMINISTRATION|||||6.55||| 97606|EAP|0761|NEG PRES WOUND THPY >50CM|Blue Cross PPO Specialty|BCBSTX PPO|||||753.25||| 97606|EAP|0761|NEG PRES WOUND THPY >50CM|Managed Medicaid|MEDICAID SUPERIOR|||||753.25||| 97606|EAP|0761|NEG PRES WOUND THPY >50CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||753.25||| 97606|EAP|0761|NEG PRES WOUND THPY >50CM|Cigna|CIGNA|||||6.55||| 97606|EAP|0761|NEG PRES WOUND THPY >50CM|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||6.55||| 97606|EAP|0761|NEG PRES WOUND THPY >50CM|Medicare|MEDICARE ACUTE|||||753.25||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|NON CONTRACTED|COMMERCIAL OTHER 1|||||12.19||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Managed Medicare|HEALTHSPRING MA|||||1,401.85||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Medicare|MEDICARE ACUTE|||||1,401.85||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Humana Medicare Advantage|HUMANA MA|||||1,401.85||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.19||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Aetna|AETNA PPO|||||12.19||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.19||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Blue Cross PPO Specialty|BCBSTX PPO|||||12.19||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,401.85||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,401.85||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,401.85||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.19||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||12.19||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Access Direct Platinum|HEALTHFIRST TPA|||||12.19||| 97607|EAP|0761|NEG PRE WOUND <=50SQ CM|Veterans Affairs|VETERANS ADMINISTRATION|||||12.19||| 977|DRG||HIV W OR W/O OTHER RELATED CONDITION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|264,083.13|12427.33|12427.33|8568.23|||| 977|DRG||HIV W OR W/O OTHER RELATED CONDITION|United Medicare Advantage|UHC AARP MCR HMO MA|38,564.01|8568.23|12427.33|8568.23|||| 977|DRG||HIV W OR W/O OTHER RELATED CONDITION|Tricare|TRICARE FOR LIFE|78,519.36|10002.64|12427.33|8568.23|||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1.65||||177.38||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicaid|CRIME VICTIMS COMPENSATION|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.65||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicaid|MEDICAID HMO|189.75||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.65||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicare|WELLCARE CHOICE MA|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.65||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicare|JACKSONVILLE ACCESS|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicare|HEALTHSPRING MA|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicare|BCBS MEDICARE PPO MA|1.65||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Multiplan|WEB TPA|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicare|MEDICARE PART B ONLY IP|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicare|MEDICARE ACUTE|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|PHCS|HUMANA INSURANCE|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|PHCS|HUMANA|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Rusk State Hospital|RUSK STATE HOSP|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|NON CONTRACTED|COMMERCIAL OTHER 1|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Tricare|TRICARE EAST REGION|189.75||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|UTMB|UTMB CORRECTIONAL MANAGED CARE|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|United Healthcare|UNITED HEALTHCARE OTHER|189.75||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|United Healthcare|TML GROUP BENEFITS|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Workers Compensation|BROOKSHIRES WORKERS COMP|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Workers Compensation|TEXAS MUTUAL INSURANCE|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Veterans Affairs|VETERANS ADMINISTRATION|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Workers Compensation|ZURICH COMPANY|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Workers Compensation|WORKERS COMPENSATION OTHER|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Workers Compensation|UT EMPLOYEE INJURY|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Workers Compensation|TRAVELERS INSURANCE COMPANY|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|United Healthcare|UNITED HEALTHCARE|189.75||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.65||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Access Direct Platinum|HEALTHFIRST TPA UMR|189.75||||177.38||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Tricare|TRICARE FOR LIFE|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Access Direct Platinum|HEALTHFIRST TPA|1.65||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|United Medicare Advantage|UHC MEDICARE GOLD MA|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|PHCS|GROUP AND PENSION|177.38||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|189.75||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|United Medicare Advantage|UHC AARP WELLMED HMO MA|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|United Medicare Advantage|UHC AARP MCR HMO MA|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Blue Cross HMO Specialty|BCBSTX HMO|189.75||||177.38||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.65||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicare|MA PART B ONLY IP|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Blue Cross PPO Specialty|BCBSTX PPO|189.75||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Blue Cross PPO Specialty|BCBSTX OTHER|177.38||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Aenta Medicare Advantage|AETNA MEDICARE MA|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Aetna|BOON CHAPMAN|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicaid|MEDICAID|1.65||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Aetna|BH AETNA|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Aetna|AETNA QHP HMO|177.38||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Aetna|AETNA PPO|189.75||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Aetna|AETNA OTHER|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Medicaid|SMITH COUNTY JAIL|1.65||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|189.75||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicaid|MEDICAID UNITED HEALTHCARE|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicaid|MEDICAID SUPERIOR|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicaid|MEDICAID AMERIGROUP|189.75||||1.65||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|ChampVA|CHAMPVA CENTER|1.65||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Cigna|CIGNA OTHER|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Cigna|CIGNA|189.75||||177.38||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Cigna|CIGNA|189.75||||||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Humana Medicare Advantage|HUMANA MA|189.75||||189.75||| 97802|EAP|0942|MEDICAL NUTR ASSMT INDIV|Magellan Behavioral Health|BH MAGELLAN|1.65||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Humana Medicare Advantage|HUMANA MA|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Cigna|CIGNA OTHER|420.90||||420.90||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Cigna|CIGNA|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Managed Medicaid|MEDICAID SUPERIOR|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Managed Medicaid|MEDICAID AMERIGROUP|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Aetna|BOON CHAPMAN|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Aetna|AETNA PPO|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Aetna|AETNA OTHER|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Blue Cross PPO Specialty|BCBSTX PPO|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Blue Cross HMO Specialty|BCBSTX HMO|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|United Medicare Advantage|UHC MEDICARE GOLD MA|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|United Medicare Advantage|UHC AARP WELLMED HMO MA|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|United Medicare Advantage|UHC AARP MCR HMO MA|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Access Direct Platinum|HEALTHFIRST TPA UMR|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Access Direct Platinum|HEALTHFIRST TPA|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Veterans Affairs|VETERANS ADMINISTRATION|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Blue Cross PPO Specialty|BCBSTX OTHER|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Workers Compensation|WORKERS COMPENSATION OTHER|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Workers Compensation|TEXAS MUTUAL INSURANCE|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|United Healthcare|UNITED HEALTHCARE OTHER|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Aenta Medicare Advantage|AETNA MEDICARE MA|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|United Healthcare|UNITED HEALTHCARE|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|United Healthcare|TML GROUP BENEFITS|393.45||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Tricare|TRICARE EAST REGION|393.45||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Aetna|AETNA QHP HMO|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|PHCS|HUMANA|393.45||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|PHCS|GROUP AND PENSION|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Rusk State Hospital|RUSK STATE HOSP|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|NON CONTRACTED|COMMERCIAL OTHER 1|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Medicare|MEDICARE ACUTE|420.90||||3.66||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Medicare|MEDICARE PART B ONLY IP|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|ChampVA|CHAMPVA CENTER|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Managed Medicare|WELLCARE CHOICE MA|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Managed Medicare|HEALTHSPRING MA|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Managed Medicare|ETMC AFFILIATE HOSPITALS|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Managed Medicare|BCBS MEDICARE PPO MA|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Medicaid|SMITH COUNTY JAIL|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Medicaid|MEDICAID HMO|420.90||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Medicaid|MEDICAID|3.66||||||| 97803|EAP|0942|MED NUTRT RE-ASSMT INDV 1|Medicaid|CRIME VICTIMS COMPENSATION|3.66||||||| 98|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W CC|Medicare|MEDICARE ACUTE|125,938.60|12011.71|12564.9|71.44|||| 98|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W CC|Blue Cross PPO Specialty|BCBSTX PPO|154,615.54|12564.9|12564.9|71.44|||| 98|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40,295.46|71.44|12564.9|71.44|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Workers Compensation|ZURICH COMPANY|114,860.03|37813.76|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|63,071.42|26443.19|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Managed Medicare|BCBS MEDICARE PPO MA|127,770.42|25897.76|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|252,473.97|26443.19|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Humana Medicare Advantage|HUMANA MA|107,223.86|21242.04|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Managed Medicare|HEALTHSPRING MA|189,054.17|25925.48|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|130,565.37|33172.59|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|395,346.57|56158.1|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|128,362.33|238.14|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|163,712.04|14158.14|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|221,492.58|149489.845|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|718,888.39|48000.97|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|139,607.21|25358.575|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|166,796.06|16257.71|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|172,443.57|25897.76|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Medicaid|MEDICAID HMO|184,758.20|14439.64|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Medicare|MEDICARE PART B ONLY IP|48,636.79|4140.62|149489.845|238.14|||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Medicare|MEDICARE ACUTE|179,351.67|25925.04|149489.845|238.14|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Medicare|MEDICARE PART B ONLY IP|41,648.10|6814.73|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Medicare|MEDICARE ACUTE|114,707.16|14661.76|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|NON CONTRACTED|COMMERCIAL OTHER 1|86,763.59|86763.59|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Blue Cross PPO Specialty|BCBSTX PPO|42,509.66|16655.19|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Blue Cross HMO Specialty|BCBSTX HMO|101,124.40|14158.14|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Managed Medicaid|MEDICAID SUPERIOR|110,043.13|13272.63|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|207,353.56|20216.11|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Managed Medicaid|MEDICAID AMERIGROUP|73,526.97|8736.61|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Humana Medicare Advantage|HUMANA MA|148,816.81|14666.06|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Managed Medicare|HEALTHSPRING MA|80,762.23|14661.76|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Managed Medicare|BCBS MEDICARE PPO MA|47,163.30|14662.64|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|97,365.03|19377.34|86763.59|6814.73|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Workers Compensation|WORKERS COMPENSATION OTHER|81,871.76|21367.5|86763.59|6814.73|||| 983|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|59,561.01|10454.24|18817.63|9056.85|||| 983|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|62,011.02|9056.85|18817.63|9056.85|||| 983|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|103,046.80|10831.34|18817.63|9056.85|||| 983|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|United Medicare Advantage|UHC AARP MCR HMO MA|95,231.22|10454.24|18817.63|9056.85|||| 983|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|49,622.62|10474.03|18817.63|9056.85|||| 983|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|83,709.82|18817.63|18817.63|9056.85|||| 983|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|46,687.09|10496.59|18817.63|9056.85|||| 983|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|Medicare|MEDICARE ACUTE|65,741.40|9518.52|18817.63|9056.85|||| 987|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Medicare|MEDICARE ACUTE|144,973.70|19583.235|39457.67|264.5|||| 987|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|United Healthcare|TML GROUP BENEFITS|148,015.97|39457.67|39457.67|264.5|||| 987|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|United Medicare Advantage|UHC AARP MCR HMO MA|157,220.44|19960.43|39457.67|264.5|||| 987|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Managed Medicare|HEALTHSPRING MA|230,466.85|19960.43|39457.67|264.5|||| 987|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Humana Medicare Advantage|HUMANA MA|136,065.79|16754.715|39457.67|264.5|||| 987|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|175,417.96|22628.35|39457.67|264.5|||| 987|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|163,590.39|264.5|39457.67|264.5|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Workers Compensation|BROOKSHIRES WORKERS COMP|159,721.60|15318.12|26061.8|9699.83|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Veterans Affairs|VETERANS ADMINISTRATION|31,516.64|10929.99|26061.8|9699.83|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95,887.36|20656.07|26061.8|9699.83|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Humana Medicare Advantage|HUMANA MA|101,556.69|10909.21|26061.8|9699.83|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Tricare|TRICARE EAST REGION|68,537.84|9699.83|26061.8|9699.83|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|129,847.88|10909.21|26061.8|9699.83|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|United Healthcare|UNITED HEALTHCARE OTHER|103,638.55|26061.8|26061.8|9699.83|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Medicaid|MEDICAID|231,838.05|14233.895|26061.8|9699.83|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Medicare|MEDICARE ACUTE|169,535.30|10909.21|26061.8|9699.83|||| 989|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|Medicare|MEDICARE ACUTE|33,488.78|7658.925|7718.76|7066.35|||| 989|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|299,107.16|7718.76|7718.76|7066.35|||| 989|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|53,642.48|7317.42|7718.76|7066.35|||| 989|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|46,362.97|7066.35|7718.76|7066.35|||| 99|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.00||| 99|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||2.00||| 99|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| 99|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| 99|EAP|0510||Cigna|CIGNA OTHER|||||2.00||| 99|EAP|0510||Cigna|CIGNA|||||2.00||| 99|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||2.00||| 99|EAP|0510||Aetna|BOON CHAPMAN|||||2.00||| 99|EAP|0510||Aetna|AETNA QHP HMO|||||2.00||| 99|EAP|0510||Aetna|AETNA PPO|||||2.00||| 99|EAP|0510||Aetna|AETNA OTHER|||||2.00||| 99|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| 99|EAP|0510||PHCS|HUMANA INSURANCE|||||2.00||| 99|EAP|0510||PHCS|HUMANA|||||2.00||| 99|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| 99|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| 99|EAP|0510||United Healthcare|ZZZZZ UNITED HEALTHCARE|||||2.00||| 99|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 99|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.00||| 99|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||2.00||| 99|EAP|0510||United Healthcare|AARP|||||2.00||| 99|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||2.00||| 99|EAP|0510||Medicaid|MEDICAID|||||2.00||| 99|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|39,510.82|107.16|107.16|107.16|||| 99001|EAP|0300|HANDLING FEE FOR TDH|Medicare|MEDICARE ACUTE|0.25||||||| 99001|EAP|0300|HANDLING FEE FOR TDH|Blue Cross PPO Specialty|BCBSTX PPO|0.25||||0.25||| 99001|EAP|0300|HANDLING FEE FOR TDH|Aenta Medicare Advantage|AETNA MEDICARE MA|0.25||||||| 99001|EAP|0300|HANDLING FEE FOR TDH|Medicaid|MEDICAID|0.25||||||| 99001|EAP|0300|HANDLING FEE FOR TDH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.25||||||| 99001|EAP|0300|HANDLING FEE FOR TDH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.25||||||| 99001|EAP|0300|HANDLING FEE FOR TDH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.25||||||| 99001|EAP|0300|HANDLING FEE FOR TDH|Managed Medicaid|MEDICAID AMERIGROUP|||||0.25||| 99001|EAP|0300|HANDLING FEE FOR TDH|Humana Medicare Advantage|HUMANA MA|28.75||||||| 99001|EAP|0300|HANDLING FEE FOR TDH|Workers Compensation|ZURICH COMPANY|||||0.25||| 99001|EAP|0300|HANDLING FEE FOR TDH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.25||| 99001|EAP|0300|HANDLING FEE FOR TDH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.25||||||| 99001|EAP|0300|HANDLING FEE FOR TDH|United Medicare Advantage|UHC AARP MCR HMO MA|28.75||||||| 99151|EAP|0370|MOD SED SAME PHYS <5 1ST|Managed Medicaid|MEDICAID AMERIGROUP|||||483.75||| 99151|EAP|0370|MOD SED SAME PHYS <5 1ST|Blue Cross PPO Specialty|BCBSTX PPO|||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Tricare|TRICARE EAST REGION|||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Tricare|TRICARE EAST REGION|517.50||||||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|UTMB|UTMB CORRECTIONAL MANAGED CARE|483.75||||4.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|United Healthcare|UNITED HEALTHCARE OTHER|517.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|United Healthcare|TML GROUP BENEFITS|517.50||||||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|United Healthcare|UNITED HEALTHCARE OTHER|517.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|NON CONTRACTED|COMMERCIAL OTHER 1|483.75||||483.75||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|NON CONTRACTED|COMMERCIAL OTHER 1|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|PHCS|HUMANA INSURANCE|517.50||||||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Medicare|MEDICARE ACUTE|517.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Medicare|MEDICARE PART B ONLY IP|483.75||||||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Medicare|MEDICARE ACUTE|4.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.50||||4.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Managed Medicare|HEALTHSPRING MA|4.50||||4.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Managed Medicare|BCBS MEDICARE PPO MA|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Managed Medicare|BCBS MEDICARE PPO MA|517.50||||||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Medicaid|SMITH COUNTY JAIL|||||4.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Medicaid|MEDICAID|||||483.75||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Medicaid|CRIME VICTIMS COMPENSATION|517.50||||||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Medicaid|MEDICAID|517.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|United Medicare Advantage|UHC MEDICARE GOLD MA|517.50||||||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.50||||4.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|United Medicare Advantage|UHC AARP MCR HMO MA|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|United Medicare Advantage|UHC AARP MCR HMO MA|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|United Medicare Advantage|UHC MEDICARE GOLD MA|517.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|4.50||||4.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Access Direct Platinum|HEALTHFIRST TPA UMR|4.50||||||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Access Direct Platinum|HEALTHFIRST TPA UMR|||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Workers Compensation|WORKERS COMPENSATION OTHER|||||4.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Veterans Affairs|VETERANS ADMINISTRATION|517.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Managed Medicare|HEALTHSPRING MA|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|517.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Aenta Medicare Advantage|AETNA MEDICARE MA|||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Aenta Medicare Advantage|AETNA MEDICARE MA|||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Aetna|AETNA PPO|||||4.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Aetna|AETNA OTHER|||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Aetna|AETNA PPO|||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Aetna|AETNA OTHER|517.50||||||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Blue Cross HMO Specialty|BCBSTX HMO|483.75||||4.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Medicare|UTSW MC KIDNEY PROGRAM|||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|United Healthcare|UNITED HEALTHCARE|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Blue Cross HMO Specialty|BCBSTX HMO|517.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Blue Cross PPO Specialty|BCBSTX PPO|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Blue Cross PPO Specialty|BCBSTX PPO|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|UTMB|UTMB CORRECTIONAL MANAGED CARE|517.50||||||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Cigna|CIGNA|||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Cigna|CIGNA OTHER|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Cigna|CIGNA|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|ChampVA|CHAMPVA CENTER|517.50||||||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Humana Medicare Advantage|HUMANA MA|517.50||||4.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Humana Medicare Advantage|HUMANA MA|517.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Managed Medicaid|MEDICAID SUPERIOR|||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.50||||517.50||| 99152|EAP|0370|MOD SED SAME PHYS >5 1ST|Managed Medicaid|MEDICAID AMERIGROUP|483.75||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Managed Medicaid|MEDICAID UNITED HEALTHCARE|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Managed Medicaid|MEDICAID SUPERIOR|517.50||||||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|517.50||||517.50||| 99152|EAP|0371|MOD SED SAME PHYS/QHP 5/>|Managed Medicaid|MEDICAID AMERIGROUP|517.50||||517.50||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Managed Medicaid|MEDICAID SUPERIOR|||||215.05||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Managed Medicaid|MEDICAID AMERIGROUP|||||201.03||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Managed Medicaid|MEDICAID AMERIGROUP|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Managed Medicaid|MEDICAID AMERIGROUP|240.35||||240.35||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Humana Medicare Advantage|HUMANA MA|||||1.87||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Humana Medicare Advantage|HUMANA MA|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Cigna|CIGNA OTHER|240.35||||||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Cigna|CIGNA|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|ChampVA|CHAMPVA CENTER|240.35||||||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Blue Cross PPO Specialty|BCBSTX PPO|215.05||||1.87||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Blue Cross PPO Specialty|BCBSTX PPO|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Blue Cross PPO Specialty|BCBSTX PPO|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Blue Cross HMO Specialty|BCBSTX HMO|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Aetna|AETNA PPO|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Aetna|AETNA OTHER|240.35||||||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||215.05||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|240.35||||240.35||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.87||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Veterans Affairs|VETERANS ADMINISTRATION|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Veterans Affairs|VETERANS ADMINISTRATION|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Aetna|AETNA PPO|||||240.35||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.87||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|240.35||||240.35||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Blue Cross HMO Specialty|BCBSTX HMO|||||1.87||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|United Medicare Advantage|UHC MEDICARE GOLD MA|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|United Medicare Advantage|UHC AARP MCR HMO MA|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|United Medicare Advantage|UHC MEDICARE GOLD MA|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|United Medicare Advantage|UHC AARP MCR HMO MA|240.35||||240.35||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Medicaid|MEDICAID|||||1.87||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Medicaid|MEDICAID|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Humana Medicare Advantage|HUMANA MA|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Medicaid|MEDICAID|240.35||||240.35||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Managed Medicare|HEALTHSPRING MA|||||1.87||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Managed Medicare|HEALTHSPRING MA|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Managed Medicare|BCBS MEDICARE PPO MA|240.35||||||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Managed Medicare|HEALTHSPRING MA|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Managed Medicaid|MEDICAID SUPERIOR|240.35||||||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Medicare|UTSW MC KIDNEY PROGRAM|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|Medicare|MEDICARE ACUTE|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Medicare|MEDICARE ACUTE|240.35||||240.35||| 99153|EAP|0370|MOD SED SAME PHYS EA ADL|Medicare|MEDICARE ACUTE|||||201.03||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|NON CONTRACTED|COMMERCIAL OTHER 1|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|NON CONTRACTED|COMMERCIAL OTHER 1|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|PHCS|HUMANA INSURANCE|240.35||||||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|United Healthcare|UNITED HEALTHCARE|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EAC|United Healthcare|UNITED HEALTHCARE|||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|United Healthcare|UNITED HEALTHCARE OTHER|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|United Healthcare|UNITED HEALTHCARE|240.35||||240.35||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|Tricare|TRICARE EAST REGION|240.35||||||| 99153|EAP|0371|MOD SED SAME PHYS/QHP EA|UTMB|UTMB CORRECTIONAL MANAGED CARE|240.35||||||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|United Healthcare|UNITED HEALTHCARE OTHER|4.66||||||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|United Healthcare|UNITED HEALTHCARE|535.90||||||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|Medicare|MEDICARE PART B ONLY IP|535.90||||||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|Medicare|MEDICARE ACUTE|4.66||||4.66||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|United Medicare Advantage|UHC MEDICARE GOLD MA|||||535.90||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.66||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.66||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|Workers Compensation|TEXAS MUTUAL INSURANCE|4.66||||||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.66||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|Blue Cross PPO Specialty|BCBSTX PPO|500.95||||535.90||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|Humana Medicare Advantage|HUMANA MA|||||4.66||| 99156|EAP|0370|MOD SED DIF PHYS >5 1ST 3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.66||||||| 99157|EAP|0370|MOD SED DIF PHYS EA ADL 1|Humana Medicare Advantage|HUMANA MA|||||2.20||| 99157|EAP|0370|MOD SED DIF PHYS EA ADL 1|Blue Cross PPO Specialty|BCBSTX PPO|||||2.53||| 99157|EAP|0370|MOD SED DIF PHYS EA ADL 1|Workers Compensation|TEXAS MUTUAL INSURANCE|2.20||||||| 99157|EAP|0370|MOD SED DIF PHYS EA ADL 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.20||| 99157|EAP|0370|MOD SED DIF PHYS EA ADL 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.20||| 99157|EAP|0370|MOD SED DIF PHYS EA ADL 1|Medicare|MEDICARE ACUTE|236.50||||2.20||| 99157|EAP|0370|MOD SED DIF PHYS EA ADL 1|United Healthcare|UNITED HEALTHCARE OTHER|2.20||||||| 99195|EAP|0300|PHLEBOTOMY FEE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||119.17||| 99195|EAP|0300|PHLEBOTOMY FEE|Medicare|MEDICARE ACUTE|||||119.17||| 99195|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||119.17||| 99195|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST TPA|||||119.17||| 99195|EAP|0940|THERAPEUTIC PHLEBOT|Veterans Affairs|VETERANS ADMINISTRATION|2.12||||||| 99195|EAP|0300|PHLEBOTOMY FEE|Aetna|AETNA OTHER|||||119.17||| 99195|EAP|0300|PHLEBOTOMY FEE|Blue Cross PPO Specialty|BCBSTX PPO|||||119.17||| 99195|EAP|0940|THERAPEUTIC PHLEBOT|Blue Cross PPO Specialty|BCBSTX PPO|2.12||||||| 99195|EAP|0940|THERAPEUTIC PHLEBOT|Humana Medicare Advantage|HUMANA MA|243.80||||||| 99195|EAP|0300|PHLEBOTOMY FEE|Humana Medicare Advantage|HUMANA MA|||||119.17||| 992|EAP|0510||Cigna|CIGNA OTHER|||||2.00||| 992|EAP|0510||Cigna|CIGNA|||||2.25||| 992|EAP|0510||Cigna|CIGNA|||||1.50||| 992|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 992|EAP|0510||Aetna|AETNA OTHER|||||2.00||| 992|EAP|0510||Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.25||| 992|EAP|0510||Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.00||| 992|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||2.25||| 992|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.00||| 992|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||2.00||| 992|EAP|0510||Veterans Affairs|VETERANS ADMINISTRATION|||||2.25||| 992|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.25||| 992|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| 992|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| 992|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.25||| 992|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.00||| 992|EAP|0510||Aetna|AETNA PPO|||||2.00||| 992|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| 992|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.25||| 992|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 992|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| 992|EAP|0510||Cigna|CIGNA|||||2.00||| 992|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.25||| 992|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.00||| 992|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||2.00||| 992|EAP|0510||PHCS|HUMANA|||||2.00||| 992|EAP|0510||Rusk State Hospital|RUSK STATE HOSP|||||2.25||| 992|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.25||| 992|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| 992|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| 992|EAP|0510||Multiplan|WEB TPA|||||2.25||| 992|EAP|0510||Multiplan|WEB TPA|||||2.00||| 992|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.25||| 992|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.00||| 9920|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.50||| 9920|EAP|0510||Medicaid|SMITH COUNTY JAIL|||||1.50||| 9920|EAP|0510||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.50||| 9920|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||2.00||| 9920|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||1.50||| 9920|EAP|0510||Multiplan|WEB TPA|||||1.75||| 9920|EAP|0510||Multiplan|NALC|||||1.75||| 9920|EAP|0510||PHCS|HUMANA|||||1.75||| 9920|EAP|0510||PHCS|HUMANA|||||2.00||| 9920|EAP|0510||PHCS|HUMANA|||||1.50||| 9920|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| 9920|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| 9920|EAP|0510||Tricare|TRICARE FOR LIFE|||||1.75||| 9920|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.25||| 9920|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 9920|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| 9920|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.25||| 9920|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.00||| 9920|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.75||| 9920|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.50||| 9920|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||1.75||| 9920|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||1.50||| 9920|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| 9920|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| 9920|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| 9920|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.50||| 9920|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| 9920|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| 9920|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.50||| 9920|EAP|0510||Workers Compensation|UT EMPLOYEE INJURY|||||1.50||| 9920|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.00||| 9920|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.50||| 9920|EAP|0510||United Healthcare|ZZZZZ UNITED HEALTHCARE|||||1.75||| 9920|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.25||| 9920|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||1.50||| 9920|EAP|0510||Aetna|AETNA PPO|||||1.75||| 9920|EAP|0510||Aetna|AETNA PPO|||||1.50||| 9920|EAP|0510||Aetna|AETNA OTHER|||||1.75||| 9920|EAP|0510||Aetna|AETNA OTHER|||||1.50||| 9920|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| 9920|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| 9920|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| 9920|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.50||| 9920|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||2.00||| 9920|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| 9920|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.75||| 9920|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| 9920|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| 9920|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 9920|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.00||| 9920|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.50||| 9920|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.75||| 9920|EAP|0510||Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| 9920|EAP|0510||Cigna|CIGNA OTHER|||||2.00||| 9920|EAP|0510||Cigna|CIGNA OTHER|||||1.50||| 9920|EAP|0510||Cigna|CIGNA|||||2.00||| 9920|EAP|0510||Cigna|CIGNA|||||1.75||| 9920|EAP|0510||Cigna|CIGNA|||||1.50||| 99202|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 99202|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 99202|EAP|0510|E&M NP L2|Blue Cross PPO Specialty|BCBSTX PPO|||||4.09||| 99202|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 99202|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| 99202|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| 99202|EAP|0510|E&M NP L2|Veterans Affairs|VETERANS ADMINISTRATION|||||490.80||| 99202|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| 99202|EAP|0510|E&M NP L2|Access Direct Platinum|HEALTHFIRST TPA UMR|||||490.80||| 99202|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE|||||1.50||| 99202|EAP|0510||United Healthcare|ZZZZZ UNITED HEALTHCARE|||||1.50||| 99202|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.50||| 99203|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.75||| 99203|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.50||| 99203|EAP|0510||Medicaid|SMITH COUNTY JAIL|||||1.50||| 99203|EAP|0510||Medicaid|SMITH COUNTY INDIGENT HEALTH|||||1.50||| 99203|EAP|0510||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.50||| 99203|EAP|0510||Medicaid|MEDICAID HMO|||||1.50||| 99203|EAP|0510||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.75||| 99203|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.50||| 99203|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||1.50||| 99203|EAP|0510||PHCS|HUMANA INSURANCE|||||1.75||| 99203|EAP|0510||PHCS|GROUP AND PENSION|||||1.50||| 99203|EAP|0510||PHCS|HUMANA|||||1.50||| 99203|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| 99203|EAP|0510||Medicare|MEDICARE ACUTE|4.70||||4.70||| 99203|EAP|0510||Medicare|MEDICARE ACUTE|4.70||||1.75||| 99203|EAP|0510||Medicare|MEDICARE ACUTE|4.70||||1.50||| 99203|EAP|0510||Tricare|TRICARE EAST REGION|||||1.50||| 99203|EAP|0510||United Healthcare|ZZZZZ UNITED HEALTHCARE|||||1.75||| 99203|EAP|0510||United Healthcare|UNITED HEALTHCARE ERS|||||1.50||| 99203|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| 99203|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.75||| 99203|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.50||| 99203|EAP|0510||United Healthcare|GOLDEN RULE|||||1.50||| 99203|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||1.75||| 99203|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.50||| 99203|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||1.50||| 99203|EAP|0510||United Healthcare|GEHA|||||1.50||| 99203|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| 99203|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| 99203|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.50||| 99203|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| 99203|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.50||| 99203|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| 99203|EAP|0510||Veterans Affairs|VETERANS ADMINISTRATION|||||4.70||| 99203|EAP|0510||Veterans Affairs|VETERANS ADMINISTRATION|||||1.75||| 99203|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| 99203|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| 99203|EAP|0510||Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||1.50||| 99203|EAP|0510||Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||1.50||| 99203|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||1.50||| 99203|EAP|0510||Cigna|CIGNA|||||1.75||| 99203|EAP|0510||PHCS|GROUP AND PENSION|||||1.75||| 99203|EAP|0510||Cigna|CIGNA|||||1.50||| 99203|EAP|0510||Cigna|CIGNA OTHER|||||1.50||| 99203|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.50||| 99203|EAP|0510||Managed Medicaid|MEDICAID SUPERIOR|||||5.64||| 99203|EAP|0510||Medicaid|MEDICAID|||||1.50||| 99203|EAP|0510||Aetna|BOON CHAPMAN|||||1.50||| 99203|EAP|0510||Aetna|AETNA PPO|||||1.75||| 99203|EAP|0510||Aetna|AETNA PPO|||||1.50||| 99203|EAP|0510||Aetna|AETNA OTHER|||||1.75||| 99203|EAP|0510||Aetna|AETNA OTHER|||||1.50||| 99203|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| 99203|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| 99203|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| 99203|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 99203|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| 99203|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||1.75||| 99203|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| 99203|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||1.50||| 99203|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.75||| 99203|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 99203|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| 99204|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| 99204|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|7.10||||7.10||| 99204|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|7.10||||2.00||| 99204|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||2.00||| 99204|EAP|0510||Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.00||| 99204|EAP|0510||Aetna|AETNA PPO|||||2.00||| 99204|EAP|0510||Aetna|AETNA OTHER|||||2.00||| 99204|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.00||| 99204|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.00||| 99204|EAP|0510||Cigna|CIGNA OTHER|||||2.00||| 99204|EAP|0510||Cigna|CIGNA|||||2.00||| 99204|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||2.00||| 99204|EAP|0510||Veterans Affairs|VETERANS ADMINISTRATION|||||2.00||| 99204|EAP|0510||Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||2.00||| 99204|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| 99204|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| 99204|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| 99204|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| 99204|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.00||| 99204|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||2.00||| 99204|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.00||| 99204|EAP|0510||United Healthcare|ZZZZZ UNITED HEALTHCARE|||||2.00||| 99204|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| 99204|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 99204|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.00||| 99204|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| 99204|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||2.00||| 99204|EAP|0510||United Healthcare|GEHA|||||2.00||| 99204|EAP|0510||Multiplan|WEB TPA|||||2.00||| 99204|EAP|0510||Medicare|MEDICARE ACUTE|||||2.00||| 99204|EAP|0510||PHCS|HUMANA INSURANCE|||||2.00||| 99204|EAP|0510||PHCS|HUMANA|||||2.00||| 99204|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| 99204|EAP|0510||PHCS|GROUP AND PENSION|||||2.00||| 99204|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 2|||||2.00||| 99204|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| 99204|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.00||| 99204|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||2.00||| 99204|EAP|0510||Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| 99204|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| 99204|EAP|0510||Medicaid|SMITH COUNTY JAIL|||||2.00||| 99204|EAP|0510||Medicaid|MEDICAID|||||2.00||| 99205|EAP|0510||PHCS|HUMANA INSURANCE|||||2.25||| 99205|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.25||| 99205|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.25||| 99205|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.25||| 99205|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.25||| 99205|EAP|0510||United Healthcare|GEHA|||||2.25||| 99205|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.25||| 99205|EAP|0510||Veterans Affairs|VETERANS ADMINISTRATION|||||2.25||| 99205|EAP|0510||Cigna|CIGNA|||||2.25||| 99205|EAP|0510||Aetna|AETNA PPO|||||2.25||| 99205|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.25||| 99205|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.25||| 99205|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| 99205|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||2.25||| 99205|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||2.25||| 9921|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| 9921|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| 9921|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| 9921|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| 9921|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||1.75||| 9921|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| 9921|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.75||| 9921|EAP|0510||Aetna Value Network|AETNA VALUE NETWORK|||||2.00||| 9921|EAP|0510||Aetna|AETNA QHP HMO|||||1.75||| 9921|EAP|0510||Aetna|AETNA PPO|||||2.00||| 9921|EAP|0510||Aetna|AETNA PPO|||||1.75||| 9921|EAP|0510||Aetna|AETNA OTHER|||||2.00||| 9921|EAP|0510||Aetna|AETNA OTHER|||||1.75||| 9921|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| 9921|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.00||| 9921|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.75||| 9921|EAP|0510||Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| 9921|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||2.00||| 9921|EAP|0510||Cigna|CIGNA OTHER|||||2.00||| 9921|EAP|0510||Cigna|CIGNA OTHER|||||1.75||| 9921|EAP|0510||Cigna|CIGNA|||||2.25||| 9921|EAP|0510||Cigna|CIGNA|||||2.00||| 9921|EAP|0510||Cigna|CIGNA|||||1.75||| 9921|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.00||| 9921|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||2.00||| 9921|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||1.75||| 9921|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.50||| 9921|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.75||| 9921|EAP|0510||Veterans Affairs|VETERANS ADMINISTRATION|||||2.00||| 9921|EAP|0510||Workers Compensation|WORKERS COMPENSATION OTHER|||||1.75||| 9921|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| 9921|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| 9921|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| 9921|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.25||| 9921|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| 9921|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| 9921|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| 9921|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| 9921|EAP|0510||United Healthcare|ZZZZZ UNITED HEALTHCARE|||||1.75||| 9921|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 9921|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| 9921|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.00||| 9921|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.75||| 9921|EAP|0510||Cigna|CIGNA OTHER|||||1.25||| 9921|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.75||| 9921|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.50||| 9921|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||2.00||| 9921|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||1.75||| 9921|EAP|0510||Managed Medicaid|MEDICAID AMERIGROUP|||||2.00||| 9921|EAP|0510||United Healthcare|GOLDEN RULE|||||1.75||| 9921|EAP|0510||United Healthcare|GEHA|||||2.00||| 9921|EAP|0510||United Healthcare|GEHA|||||1.75||| 9921|EAP|0510||United Healthcare|AARP|||||2.00||| 9921|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| 9921|EAP|0510||United Healthcare|AARP|||||1.75||| 9921|EAP|0510||Multiplan|NALC|||||2.00||| 9921|EAP|0510||Multiplan|GILSBAR INC|||||2.00||| 9921|EAP|0510||Medicare|MEDICARE ACUTE|||||2.00||| 9921|EAP|0510||Medicare|MEDICARE ACUTE|||||1.75||| 9921|EAP|0510||PHCS|MULTIPLAN PHCS|||||2.00||| 9921|EAP|0510||PHCS|HUMANA INSURANCE|||||2.00||| 9921|EAP|0510||PHCS|HUMANA INSURANCE|||||1.75||| 9921|EAP|0510||Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.00||| 9921|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 9921|EAP|0510||PHCS|HUMANA|||||2.00||| 9921|EAP|0510||PHCS|HUMANA|||||1.75||| 9921|EAP|0510||PHCS|GROUP AND PENSION|||||2.00||| 9921|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| 9921|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.50||| 9921|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| 9921|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| 9921|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.25||| 9921|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| 9921|EAP|0510||Medicaid|SMITH COUNTY JAIL|||||2.00||| 9921|EAP|0510||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| 9921|EAP|0510||Medicaid|LAW ENFORCEMENT OTHER|||||2.00||| 9921|EAP|0510||Medicaid|MEDICAID|||||2.00||| 9921|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.00||| 9921|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.75||| 9921|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||2.00||| 9921|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||1.75||| 99211|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.25||| 99211|EAP|0761||NON CONTRACTED|COMMERCIAL OTHER 1|||||4.01||| 99211|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicare|MEDICARE ACUTE|||||1.25||| 99211|EAP|0510||Medicare|MEDICARE ACUTE|||||2.73||| 99211|EAP|0760|DRAIN/TUBE REMOVAL|Medicare|MEDICARE ACUTE|||||1.25||| 99211|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||3.47||| 99211|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.73||| 99211|EAP|0761|TREATMENT ROOM 0-30 MIN B|United Healthcare|UNITED HEALTHCARE|||||4.98||| 99211|EAP|0761||United Healthcare|UNITED HEALTHCARE|||||481.20||| 99211|EAP|0761||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.01||| 99211|EAP|0510|OFFICE/OUTPATIENT VISIT,|Cigna|CIGNA|||||1.25||| 99211|EAP|0761||Cigna|CIGNA|||||481.20||| 99211|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||327.60||| 99211|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.25||| 99211|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||416.40||| 99211|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.73||| 99211|EAP|0761|TREATMENT ROOM 0-30 MIN B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.98||| 99211|EAP|0761||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.01||| 99211|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||416.40||| 99211|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.25||| 99211|EAP|0760|DRAIN/TUBE REMOVAL|Blue Cross PPO Specialty|BCBSTX PPO|||||1.25||| 99211|EAP|0761|TREATMENT ROOM 0-30 MIN B|Blue Cross PPO Specialty|BCBSTX PPO|||||4.15||| 99212|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||490.80||| 99212|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| 99212|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.09||| 99212|EAP|0510||Medicaid|MEDICAID HMO|||||4.09||| 99212|EAP|0510||Medicaid|MEDICAID|||||490.80||| 99212|EAP|0510||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||490.80||| 99212|EAP|0510||Managed Medicare|OTHER INSTITUTIONS|||||4.09||| 99212|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||490.80||| 99212|EAP|0510||Managed Medicare|BCBS MEDICARE PPO MA|||||4.09||| 99212|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| 99212|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||490.80||| 99212|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||490.80||| 99212|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||4.09||| 99212|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| 99212|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||490.80||| 99212|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.09||||490.80||| 99212|EAP|0510||Cigna|CIGNA|||||1.50||| 99212|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||490.80||| 99212|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.50||| 99212|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||490.80||| 99212|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 99212|EAP|0510||Veterans Affairs|VETERANS ADMINISTRATION|||||490.80||| 99212|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||4.09||| 99212|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||4.09||| 99212|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||490.80||| 99212|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.09||| 99212|EAP|0510||PHCS|HUMANA|||||1.50||| 99212|EAP|0510||Aetna|AETNA PPO|||||1.50||| 99212|EAP|0510||Aetna|AETNA PPO|||||490.80||| 99212|EAP|0510||Managed Medicaid|MEDICAID SUPERIOR|||||490.80||| 99212|EAP|0510||Medicare|MEDICARE ACUTE|490.80||||490.80||| 99212|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||490.80||| 99212|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| 99212|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 99212|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||490.80||| 99212|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||1.50||| 99212|EAP|0510||Cigna|CIGNA OTHER|||||4.09||| 99212|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| 99212|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.50||| 99212|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.50||| 99212|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.50||| 99212|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||1.50||| 99212|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA|||||490.80||| 99212|EAP|0510||PHCS|HUMANA INSURANCE|||||490.80||| 99212|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||490.80||| 99212|EAP|0510||Aenta Medicare Advantage|AETNA MEDICARE MA|||||490.80||| 99213|EAP|0510||Aetna|BOON CHAPMAN|||||1.75||| 99213|EAP|0510||Tricare|TRICARE EAST REGION|||||1.75||| 99213|EAP|0510||Cigna|CIGNA|||||1.75||| 99213|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.70||| 99213|EAP|0510||Managed Medicaid|MEDICAID AMERIGROUP|||||4.70||| 99213|EAP|0510||Aetna|ZZZZZ AETNA|||||1.75||| 99213|EAP|0510||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||4.70||| 99213|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| 99213|EAP|0510||United Healthcare|GOLDEN RULE|||||1.75||| 99213|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||4.70||| 99213|EAP|0510||Medicaid|CRIME VICTIMS COMPENSATION|||||1.75||| 99213|EAP|0510||Multiplan|GILSBAR INC|||||1.75||| 99213|EAP|0510||Managed Medicaid|MEDICAID AMERIGROUP|||||1.75||| 99213|EAP|0510||Medicaid|MEDICAID|||||4.70||| 99213|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| 99213|EAP|0510||Medicaid|SMITH COUNTY JAIL|||||4.70||| 99213|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||1.75||| 99213|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|4.70||||1.75||| 99213|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.64||| 99213|EAP|0510||Aetna|AETNA PPO|||||5.64||| 99213|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||5.64||| 99213|EAP|0510||Aetna|AETNA PPO|||||1.75||| 99213|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| 99213|EAP|0510||PHCS|HUMANA INSURANCE|||||1.75||| 99213|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.70||| 99213|EAP|0510||Managed Medicaid|MEDICAID SUPERIOR|||||5.64||| 99213|EAP|0510||Managed Medicare|OTHER INSTITUTIONS|||||4.70||| 99213|EAP|0510||Cigna|CIGNA|||||5.17||| 99213|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| 99213|EAP|0510||Veterans Affairs|VETERANS ADMINISTRATION|||||4.70||| 99213|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.75||| 99213|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.75||| 99213|EAP|0510||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.75||| 99213|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.75||| 99213|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||5.64||| 99213|EAP|0510||Cigna|CIGNA OTHER|||||1.75||| 99213|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| 99213|EAP|0510||Cigna|CIGNA|||||4.70||| 99213|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.75||| 99213|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||1.75||| 99213|EAP|0510||Medicare|MEDICARE ACUTE|5.64||||1.75||| 99213|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.70||| 99213|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.64||| 99213|EAP|0510||Cigna|CIGNA OTHER|||||5.64||| 99213|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.64||| 99213|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||5.64||| 99213|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.64||| 99213|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||5.64||| 99213|EAP|0510||Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||1.75||| 99213|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|4.70||||5.64||| 99213|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||1.75||| 99213|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||1.75||| 99213|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||5.64||| 99213|EAP|0510||Aetna Value Network|AETNA VALUE NETWORK|||||1.75||| 99213|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.75||| 99213|EAP|0510||Medicaid|MEDICAID|||||1.75||| 99213|EAP|0510||United Healthcare|AARP|||||1.75||| 99213|EAP|0510||Aetna|AETNA OTHER|||||1.75||| 99213|EAP|0510||Workers Compensation|TEXAS MUTUAL INSURANCE|||||1.75||| 99213|EAP|0510||Medicare|UTSW MC KIDNEY PROGRAM|||||1.75||| 99213|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.75||| 99213|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.75||| 99213|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| 99213|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.64||| 99213|EAP|0510||Multiplan|WEB TPA|||||1.75||| 99213|EAP|0510||Medicaid|SMITH COUNTY INDIGENT HEALTH|||||4.70||| 99213|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| 99213|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||4.70||| 99213|EAP|0510||Medicare|MEDICARE ACUTE|5.64||||5.64||| 99213|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.75||| 99213|EAP|0510||PHCS|HUMANA|||||1.75||| 99213|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| 99213|EAP|0510||Workers Compensation|WORKERS COMPENSATION OTHER|||||1.75||| 99213|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.64||| 99213|EAP|0510||United Healthcare|GEHA|||||1.75||| 99213|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||1.75||| 99214|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.00||| 99214|EAP|0510||Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| 99214|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| 99214|EAP|0510||Managed Medicare|HEALTHSPRING MA|||||2.00||| 99214|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||711.60||| 99214|EAP|0510||Medicaid|SMITH COUNTY JAIL|||||2.00||| 99214|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||711.60||| 99214|EAP|0510||Medicaid|MEDICAID|||||2.00||| 99214|EAP|0510||Managed Medicare|ETMC AFFILIATE HOSPITALS|||||2.00||| 99214|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.93||| 99214|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.00||| 99214|EAP|0510||PHCS|GROUP AND PENSION|||||2.00||| 99214|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||2.00||| 99214|EAP|0510||Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.00||| 99214|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.93||| 99214|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||711.60||| 99214|EAP|0510||Aetna|BOON CHAPMAN|||||2.00||| 99214|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|5.93||||2.00||| 99214|EAP|0510||Cigna|CIGNA|||||5.93||| 99214|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|5.93||||5.93||| 99214|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| 99214|EAP|0510||Cigna|CIGNA|||||2.00||| 99214|EAP|0510||Aetna|AETNA QHP HMO|||||2.00||| 99214|EAP|0510||Managed Medicaid|MEDICAID AMERIGROUP|||||5.93||| 99214|EAP|0510||Multiplan|WEB TPA|||||2.00||| 99214|EAP|0510||Veterans Affairs|VETERANS ADMINISTRATION|||||2.00||| 99214|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.93||| 99214|EAP|0510||Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||2.00||| 99214|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| 99214|EAP|0510||Texas Workforce Commission|DIS DETER SERV (DDS)|||||2.00||| 99214|EAP|0510||United Healthcare|UNITED HEALTHCARE ERS|||||2.00||| 99214|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| 99214|EAP|0510||Aetna Value Network|AETNA VALUE NETWORK|||||2.00||| 99214|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| 99214|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.00||| 99214|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| 99214|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||711.60||| 99214|EAP|0510||Aetna|AETNA OTHER|||||2.25||| 99214|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.00||| 99214|EAP|0510||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| 99214|EAP|0510||Humana Medicare Advantage|HUMANA MA|||||2.00||| 99214|EAP|0510||Cigna|CIGNA OTHER|||||2.00||| 99214|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.00||| 99214|EAP|0510||Aetna|AETNA PPO|||||2.00||| 99214|EAP|0510||Multiplan|PACIFICARE|||||2.00||| 99214|EAP|0510||Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| 99214|EAP|0510||Managed Medicaid|MEDICAID AMERIGROUP|||||2.00||| 99214|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| 99214|EAP|0510||Aetna|AETNA OTHER|||||2.00||| 99214|EAP|0510||Tricare|TRICARE EAST REGION|||||2.00||| 99214|EAP|0510||United Healthcare|TML GROUP BENEFITS|||||2.00||| 99214|EAP|0510||United Healthcare|GOLDEN RULE|||||2.00||| 99214|EAP|0510||United Healthcare|AARP|||||2.00||| 99214|EAP|0510||United Healthcare|GEHA|||||2.00||| 99214|EAP|0510||Workers Compensation|WORKERS COMPENSATION OTHER|||||2.00||| 99214|EAP|0510||Multiplan|NALC|||||2.00||| 99214|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 99214|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.00||| 99214|EAP|0510||Medicare|MEDICARE ACUTE|||||2.00||| 99214|EAP|0510||PHCS|HUMANA INSURANCE|||||2.00||| 99214|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| 99214|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||711.60||| 99214|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||652.30||| 99214|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.93||| 99214|EAP|0510||PHCS|MULTIPLAN PHCS|||||2.00||| 99214|EAP|0510||PHCS|MULTIPLAN PHCS OTHER|||||2.00||| 99214|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|||||2.00||| 99214|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| 99214|EAP|0510||Medicare|MEDICARE ACUTE|||||711.60||| 99214|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||5.93||| 99214|EAP|0510||PHCS|HUMANA|||||2.00||| 99215|EAP|0510|E&M EP L5|Blue Cross PPO Specialty|BCBSTX PPO|||||8.52||| 99215|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.25||| 99215|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.25||| 99215|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.25||| 99215|EAP|0510||PHCS|HUMANA|||||2.25||| 99215|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.25||| 99215|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.25||| 99215|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.25||| 99215|EAP|0510|E&M EP L5|Managed Medicaid|MEDICAID SUPERIOR|||||7.10||| 99215|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.25||| 99215|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| 99215|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||2.25||| 99215|EAP|0510||Cigna|CIGNA|||||2.25||| 99215|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.25||| 99215|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.25||| 99215|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||2.25||| 99222|EAP|0981|E&M INITIAL HOSP CARE MOD|Medicare|MEDICARE ACUTE|||||5.90||| 99222|EAP|0981|E&M INITIAL HOSP CARE MOD|Managed Medicaid|MEDICAID SUPERIOR|||||5.90||| 99223|EAP|0981|E&M INITIAL HOSPITAL CARE|Aetna|AETNA PPO|||||772.25||| 99231|EAP|0981|SUBSEQUENT HOSPITAL CARE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||157.75||| 99232|EAP|0981|E&M SUBSEQUENT HOSP CARE|Medicare|MEDICARE ACUTE|||||545.25||| 9924|EAP|0510||Aetna|AETNA PPO|||||2.00||| 9924|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.50||| 9924|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| 9924|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.75||| 9924|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.75||| 9924|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| 9924|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| 9924|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| 9924|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 9924|EAP|0510||Aetna|AETNA PPO|||||1.50||| 9924|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| 9924|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| 9924|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| 99242|EAP|0510|OFFICE CONSULTATION 30 MI|Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 99242|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| 99242|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 99242|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| 99242|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 99242|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| 99242|EAP|0510|OFFICE CONSULTATION 30 MI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| 99242|EAP|0510|OFFICE CONSULTATION 30 MI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| 99242|EAP|0510|OFFICE CONSULTATION 30 MI|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.50||| 99242|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| 99242|EAP|0510|OFFICE CONSULTATION 30 MI|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 99243|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aetna|AETNA OTHER|||||1.75||| 99243|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Cigna|CIGNA OTHER|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| 99243|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| 99243|EAP|0510|OFFICE CONSULTATION 40MIN|Managed Medicare|BCBS MEDICARE PPO MA|||||1.75||| 99243|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| 99243|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||1.75||| 99243|EAP|0510||Aetna|AETNA OTHER|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|United Healthcare|UNITED HEALTHCARE|||||1.75||| 99243|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Cigna|CIGNA|||||1.75||| 99243|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| 99243|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| 99243|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Veterans Affairs|VETERANS ADMINISTRATION|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aetna|AETNA PPO|||||1.75||| 99243|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.75||| 99243|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| 99243|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.75||| 99243|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Veterans Affairs|VETERANS ADMINISTRATION|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|United Healthcare|TML GROUP BENEFITS|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|NON CONTRACTED|COMMERCIAL OTHER 4|||||2.00||| 99244|EAP|0510||ChampVA|CHAMPVA CENTER|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Managed Medicaid|MEDICAID AMERIGROUP|||||2.00||| 99244|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||2.00||| 99244|EAP|0510||Cigna|CIGNA|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 99244|EAP|0510||PHCS|GROUP AND PENSION|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|PHCS|MULTIPLAN PHCS|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Multiplan|WEB TPA|||||2.00||| 99244|EAP|0510||United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|United Healthcare|UNITED HEALTHCARE|||||2.00||| 99244|EAP|0510||Medicaid|MEDICAID|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Medicaid|MEDICAID|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| 99244|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Medicaid|SMITH COUNTY JAIL|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| 99244|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| 99244|EAP|0510||Texas Workforce Commission|DIS DETER SERV (DDS)|||||2.00||| 99244|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| 99244|EAP|0510||Aetna|AETNA PPO|||||2.00||| 99244|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| 99244|EAP|0510||Aetna|BOON CHAPMAN|||||2.00||| 99244|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| 99244|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Aetna|AETNA OTHER|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Aetna|AETNA PPO|||||2.00||| 99244|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| 99244|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| 99244|EAP|0510|OFFICE CONSULTATION 60 MI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| 99244|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.00||| 99244|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| 99245|EAP|0510||Aetna Value Network|AETNA VALUE NETWORK|||||2.25||| 99245|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| 99245|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||2.25||| 99245|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.25||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID AMERIGROUP|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicare|HEALTHSPRING MA|8.68||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|MEDICAID HMO|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Cigna|CIGNA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|PHCS|HUMANA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|United Healthcare|UNITED HEALTHCARE|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|PHCS|HUMANA INSURANCE|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Tricare|TRICARE EAST REGION|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Workers Compensation|UT EMPLOYEE INJURY|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|United Healthcare|GEHA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Aetna|AETNA PPO|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Humana Medicare Advantage|HUMANA MA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Access Direct Platinum|HEALTHFIRST TPA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|ChampVA|CHAMPVA CENTER|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicare|BCBS MEDICARE PPO MA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.68||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID SUPERIOR|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross HMO Specialty|BCBSTX HMO|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|MEDICAID|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|United Medicare Advantage|UHC AARP MCR HMO MA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross PPO Specialty|BCBSTX PPO|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Veterans Affairs|VETERANS ADMINISTRATION|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|LAW ENFORCEMENT OTHER|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|United Healthcare|UNITED HEALTHCARE OTHER|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Workers Compensation|WORKERS COMPENSATION OTHER|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|SMITH COUNTY JAIL|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicare|MEDICARE PART B ONLY IP|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Workers Compensation|GALLAGHER BASSETT|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicare|MEDICARE ACUTE|8.68||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Cigna|CIGNA OTHER|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Aetna|AETNA OTHER|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.68||| 99281|EAP|0450|ER VISIT LEVEL 1|Tricare|TRICARE FOR LIFE|||||8.68||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Humana Medicare Advantage|HUMANA MA|||||376.50||| 99282|EAP|0450|ER VISIT LEVEL 2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Aetna|AETNA PPO|||||376.50||| 99282|EAP|0450|ER VISIT LEVEL 2|Cigna|CIGNA OTHER|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Aetna|AETNA PPO|||||3.45||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross HMO Specialty|BCBSTX HMO|||||376.50||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicaid|MEDICAID SUPERIOR|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Managed Medicaid|MEDICAID AMERIGROUP|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicaid|MEDICAID SUPERIOR|||||285.25||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID AMERIGROUP|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross PPO Specialty|BCBSTX PPO|||||376.50||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Blue Cross PPO Specialty|BCBSTX PPO|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||285.25||| 99282|EAP|0450|ER VISIT LEVEL 2|Aenta Medicare Advantage|AETNA MEDICARE MA|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3.45||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2|Access Direct Platinum|HEALTHFIRST TPA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Blue Cross HMO Specialty|BCBSTX HMO|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross PPO Specialty|BCBSTX PPO|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross PPO Specialty|BCBSTX PPO|||||285.25||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||376.50||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross PPO Specialty|BCBSTX PPO|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2|Aetna|AETNA OTHER|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Cigna|CIGNA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Cigna|CIGNA|||||285.25||| 99282|EAP|0450|ER VISIT LEVEL 2|Workers Compensation|UT EMPLOYEE INJURY|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2|Humana Medicare Advantage|HUMANA MA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|United Medicare Advantage|UHC AARP MCR HMO MA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Cigna|CIGNA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Workers Compensation|WORKERS COMP PHYSICIAN|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Humana Medicare Advantage|HUMANA MA|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2|United Healthcare|UNITED HEALTHCARE|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||376.50||| 99282|EAP|0450|ER VISIT LEVEL 2|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Managed Medicaid|MEDICAID SUPERIOR|10.08||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Veterans Affairs|VETERANS ADMINISTRATION|||||376.50||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Workers Compensation|WORKERS COMPENSATION OTHER|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Access Direct Platinum|HEALTHFIRST TPA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Humana Medicare Advantage|HUMANA MA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Workers Compensation|UT EMPLOYEE INJURY|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Multiplan|WEB TPA|||||376.50||| 99282|EAP|0450|ER VISIT LEVEL 2|Multiplan|WEB TPA|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Workers Compensation|TEXAS MUTUAL INSURANCE|||||376.50||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2|Workers Compensation|BROOKSHIRES WORKERS COMP|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID SUPERIOR|10.08||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Cigna|CIGNA OTHER|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Veterans Affairs|VETERANS ADMINISTRATION|||||3.45||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Medicare|MEDICARE ACUTE|||||376.50||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Medicare|MEDICARE ACUTE|||||3.45||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Medicare|MEDICARE ACUTE|||||285.25||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Blue Cross PPO Specialty|BCBSTX OTHER|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||376.50||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Medicare|MEDICARE ACUTE|10.08||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|PHCS|HUMANA|||||3.45||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicaid|MEDICAID AMERIGROUP|||||285.25||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicare|MEDICARE ACUTE|10.08||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|NON CONTRACTED|COMMERCIAL OTHER 2|10.08||||||| 99282|EAP|0450|ER VISIT LEVEL 2|Workers Compensation|WORKERS COMPENSATION OTHER|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Veterans Affairs|VETERANS ADMINISTRATION|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross HMO Specialty|BCBSTX HMO|||||285.25||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|United Healthcare|UNITED HEALTHCARE OTHER|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Aetna|AETNA PPO|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|United Healthcare|UNITED HEALTHCARE OTHER|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Aetna|AETNA PPO|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|NON CONTRACTED|COMMERCIAL OTHER 1|||||285.25||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Tricare|TRICARE FOR LIFE|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Medicaid|MEDICAID|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|United Healthcare|UNITED HEALTHCARE OTHER|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Tricare|TRICARE FOR LIFE|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|NON CONTRACTED|COMMERCIAL OTHER 1|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Medicaid|MEDICAID HMO|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|United Healthcare|UNITED HEALTHCARE|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|MEDICAID HMO|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|MEDICAID|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Medicaid|SMITH COUNTY JAIL|||||285.25||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.45||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Managed Medicare|HEALTHSPRING MA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross HMO Specialty|BCBSTX HMO|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicare|BCBS MEDICARE PPO MA|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||376.50||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicare|HEALTHSPRING MA|||||10.08||| 99282|EAP|0981|E&M EMERGENCY DEPARTMENT|Medicaid|SMITH COUNTY JAIL|||||376.50||| 99282|EAP|0450|ER VISIT LEVEL 2|Tricare|TRICARE EAST REGION|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Medicaid|SMITH COUNTY JAIL|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|SMITH COUNTY JAIL|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||10.08||| 99282|EAP|0450|ER VISIT LEVEL 2 W/PROC|Tricare|TRICARE EAST REGION|||||10.08||| 99283|EAP|0450|ER VISIT LEVEL 3|Humana Medicare Advantage|HUMANA MA|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Humana Medicare Advantage|HUMANA MA|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|ChampVA|CHAMPVA CENTER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|ChampVA|CHAMPVA CENTER|||||15.40||| 99283|EAP|0981|TRAUMA PHYSICIAN CHARGE|Managed Medicaid|MEDICAID AMERIGROUP|||||5.84||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Managed Medicaid|MEDICAID SUPERIOR|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Aenta Medicare Advantage|AETNA MEDICARE MA|15.40||||15.40||| 99283|EAP|0981|TRAUMA PHYSICIAN CHARGE|Managed Medicaid|MEDICAID SUPERIOR|||||5.84||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Blue Cross PPO Specialty|BCBSTX PPO|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Aetna|AETNA OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Blue Cross HMO Specialty|BCBSTX HMO|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross HMO Specialty|BCBSTX HMO|||||15.40||| 99283|EAP|0981|TRAUMA PHYSICIAN CHARGE|Blue Cross PPO Specialty|BCBSTX PPO|||||5.84||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Blue Cross PPO Specialty|BCBSTX OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross PPO Specialty|BCBSTX OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Aenta Medicare Advantage|AETNA MEDICARE MA|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Aetna|AETNA PPO|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID SUPERIOR|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Cigna|CIGNA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross PPO Specialty|BCBSTX PPO|15.40||||15.40||| 99283|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross PPO Specialty|BCBSTX PPO|||||506.75||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID AMERIGROUP|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.40||| 99283|EAP|0981|TRAUMA PHYSICIAN CHARGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.84||||||| 99283|EAP|0450|ER VISIT LEVEL 3|Cigna|CIGNA OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Cigna|CIGNA OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Aetna|AETNA OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|United Medicare Advantage|UHC AARP MCR HMO MA|15.40||||15.40||| 99283|EAP|0981|E&M EMERGENCY DEPARTMENT|Humana Medicare Advantage|HUMANA MA|||||506.75||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Cigna|CIGNA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Aetna Value Network|AETNA VALUE NETWORK|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Aetna|AETNA PPO|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Managed Medicaid|MEDICAID AMERIGROUP|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||15.40||| 99283|EAP|0981|E&M EMERGENCY DEPARTMENT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||506.75||| 99283|EAP|0450|ER VISIT LEVEL 3|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Tricare|TRICARE EAST REGION|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Tricare|TRICARE FOR LIFE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|LAW ENFORCEMENT OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID BCBSTX|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID CSHCN|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid|LAW ENFORCEMENT OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid|MEDICAID|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid|MEDICAID HMO|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid|SMITH COUNTY JAIL|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|OTHER INSTITUTIONS|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Managed Medicare|BCBS MEDICARE PPO MA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Managed Medicare|HEALTHSPRING MA|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|HEALTHSPRING MA|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|WELLCARE CHOICE MA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|BCBS MEDICARE PPO MA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid|MEDICAID BCBSTX|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|SMITH COUNTY JAIL|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID HMO|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Tricare|TRICARE EAST REGION|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|United Healthcare|UNITED HEALTHCARE OTHER|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|United Healthcare|GOLDEN RULE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|TML GROUP BENEFITS|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|UNITED HEALTHCARE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|United Healthcare|GEHA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|GOLDEN RULE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|NON CONTRACTED|COMMERCIAL OTHER 1|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|NON CONTRACTED|COMMERCIAL OTHER 2|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|NON CONTRACTED|COMMERCIAL OTHER 1|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|NON CONTRACTED|COMMERCIAL OTHER 2|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Multiplan|TRUSTMARK|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|UNITED HEALTHCARE OTHER|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Multiplan|NALC|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|United Healthcare|UNITED HEALTHCARE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Multiplan|MUTUAL OF OMAHA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|GEHA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|NON CONTRACTED|AFLAC|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|NON CONTRACTED|COMMERCIAL OTHER 4|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|PHCS|HUMANA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Multiplan|WEB TPA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|PHCS|HUMANA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Multiplan|WEB TPA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicare|MEDICARE PART B ONLY IP|||||15.40||| 99283|EAP|0981|TRAUMA PHYSICIAN CHARGE|United Healthcare|UNITED HEALTHCARE OTHER|||||5.84||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Medicare|MEDICARE ACUTE|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicare|MEDICARE ACUTE|15.40||||15.40||| 99283|EAP|0981|TRAUMA PHYSICIAN CHARGE|Veterans Affairs|VETERANS ADMINISTRATION|||||5.84||| 99283|EAP|0450|ER VISIT LEVEL 3|Tricare|TRICARE FOR LIFE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|UT EMPLOYEE INJURY|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|PHCS|HUMANA INSURANCE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Multiplan|PACIFICARE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|United Medicare Advantage|UHC MEDICARE GOLD MA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Workers Compensation|WORKERS COMPENSATION OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Workers Compensation|TEXAS MUTUAL INSURANCE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST TPA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Workers Compensation|BROOKSHIRES WORKERS COMP|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|TEXAS MUTUAL INSURANCE|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Access Direct Platinum|HEALTHFIRST TPA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|GALLAGHER BASSETT|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Veterans Affairs|VETERANS ADMINISTRATION|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Veterans Affairs|VETERANS ADMINISTRATION|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Access Direct Platinum|HEALTHFIRST TPA TYLER ISD|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|BROOKSHIRES WORKERS COMP|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|WORKERS COMP PHYSICIAN|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|WORKERS COMPENSATION OTHER|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST TPA UMR|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|United Medicare Advantage|UHC AARP MCR HMO MA|15.40||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Workers Compensation|UT EMPLOYEE INJURY|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3 W/PROC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||15.40||| 99283|EAP|0450|ER VISIT LEVEL 3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||15.40||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Aetna Value Network|AETNA VALUE NETWORK|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Aetna|AETNA PPO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Aetna|AETNA PPO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Aenta Medicare Advantage|AETNA MEDICARE MA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Aenta Medicare Advantage|AETNA MEDICARE MA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Blue Cross PPO Specialty|BCBSTX OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|UHC AARP MCR HMO MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross PPO Specialty|BCBSTX PPO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Blue Cross HMO Specialty|BCBSTX HMO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Humana Medicare Advantage|HUMANA MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross HMO Specialty|BCBSTX HMO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicaid|MEDICAID SUPERIOR|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Cigna|CIGNA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicaid|MEDICAID AMERIGROUP|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Cigna|CIGNA OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Cigna|CIGNA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross PPO Specialty|BCBSTX OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|ChampVA|CHAMPVA CENTER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Humana Medicare Advantage|HUMANA MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Medicare Advantage|UHC MEDICARE GOLD MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Aetna|BH AETNA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|UHC MEDICARE GOLD MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Access Direct Platinum|HEALTHFIRST TPA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Workers Compensation|WORKERS COMPENSATION OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Workers Compensation|GALLAGHER BASSETT|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Workers Compensation|WORKERS COMP PHYSICIAN|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Workers Compensation|TEXAS MUTUAL INSURANCE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Blue Cross PPO Specialty|BCBSTX PPO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Workers Compensation|WORKERS COMPENSATION OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Workers Compensation|BROOKSHIRES WORKERS COMP|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Veterans Affairs|VETERANS ADMINISTRATION|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Veterans Affairs|VETERANS ADMINISTRATION|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicare|MEDICARE PART B ONLY IP|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicare|MEDICARE ACUTE|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicare|MEDICARE ACUTE|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|PHCS|HUMANA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|PHCS|HUMANA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|United Healthcare|GEHA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Multiplan|WEB TPA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|NON CONTRACTED|COMMERCIAL OTHER 4|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|NON CONTRACTED|COMMERCIAL OTHER 2|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|NON CONTRACTED|COMMERCIAL OTHER 4|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|NON CONTRACTED|COMMERCIAL OTHER 1|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|United Healthcare|UNITED HEALTHCARE OTHER|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|United Healthcare|UNITED HEALTHCARE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Healthcare|UNITED HEALTHCARE ERS|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Healthcare|UNITED HEALTHCARE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Healthcare|TML GROUP BENEFITS|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Healthcare|GOLDEN RULE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Healthcare|GEHA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Tricare|TRICARE FOR LIFE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Tricare|TRICARE EAST REGION|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid|MEDICAID HMO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Access Direct Platinum|HEALTHFIRST TPA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Medicare Advantage|UHC AARP MCR HMO MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|ChampVA|CHAMPVA CENTER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid|MEDICAID|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid|LAW ENFORCEMENT OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|SMITH COUNTY JAIL|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|MEDICAID HMO|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|MEDICAID BCBSTX|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|LAW ENFORCEMENT OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicare|WELLCARE CHOICE MA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID AMERIGROUP|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicare|OTHER INSTITUTIONS|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Cigna|CIGNA OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID SUPERIOR|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicare|HEALTHSPRING MA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicare|BCBS MEDICARE PPO MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|MEDICAID|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicare|BCBS MEDICARE PPO MA|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid|SMITH COUNTY JAIL|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Aetna|AETNA OTHER|||||20.00||| 99284|EAP|0981|EMERGENCY DEPT VISIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3.64||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|United Healthcare|UNITED HEALTHCARE OTHER|20.00||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Tricare|TRICARE FOR LIFE|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicare|HEALTHSPRING MA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Tricare|TRICARE EAST REGION|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|NON CONTRACTED|COMMERCIAL OTHER 1|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|NON CONTRACTED|COMMERCIAL OTHER 2|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|NON CONTRACTED|AFLAC|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Medicaid|MEDICAID BCBSTX|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Multiplan|WEB TPA|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Rusk State Hospital|RUSK STATE HOSP|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4 W/PROC|Workers Compensation|UT EMPLOYEE INJURY|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Workers Compensation|UT EMPLOYEE INJURY|||||20.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Access Direct Platinum|HEALTHFIRST TPA UMR|||||20.00||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Multiplan|WEB TPA|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|PHCS|GROUP AND PENSION|||||3.64||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicare|MA PART B ONLY IP|24.72||||||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicare|OTHER INSTITUTIONS|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|United Healthcare|UNITED HEALTHCARE|||||726.25||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|Veterans Affairs|VETERANS ADMINISTRATION|||||3.64||| 99285|EAP|0450|ER VISIT LEVEL 5|United Healthcare|UNITED HEALTHCARE OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|PHCS|GROUP AND PENSION|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicare|BCBS MEDICARE PPO MA|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|United Healthcare|UNITED HEALTHCARE|||||3.64||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Tricare|TRICARE EAST REGION|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|MEDICAID HMO|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|SMITH COUNTY JAIL|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|LAW ENFORCEMENT OTHER|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicare|HEALTHSPRING MA|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|MEDICAID|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|MEDICAID BCBSTX|||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|MOLINA HEALTHCARE OF TEXAS|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|SMITH COUNTY INDIGENT HEALTH|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicare|ETMC REHABILITATION HOSPITAL|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicare|WELLCARE CHOICE MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicare|HEALTHSPRING MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicare|HEALTHSPRING MA|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Medicaid|LAW ENFORCEMENT OTHER|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicare|ETMC REHABILITATION HOSPITAL|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|BH TEXAS CHILDRENS MEDICAID|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicare|MEDICARE ACUTE|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|Managed Medicare|OTHER INSTITUTIONS|||||3.64||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|MEDICAID BCBSTX|||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|MOLINA HEALTHCARE OF TEXAS|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|BH TEXAS CHILDRENS MEDICAID|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|CRIME VICTIMS COMPENSATION|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|LAW ENFORCEMENT OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|COUNTY INDIGENT HEALTH OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|SUPERIOR HEALTHPLAN CHIP|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|SMITH COUNTY JAIL|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|MEDICAID HMO|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|SMITH COUNTY INDIGENT HEALTH|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Managed Medicare|HEALTHSPRING MA|||||1,084.75||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|MEDICAID|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|Managed Medicare|HEALTHSPRING MA|||||3.64||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Medicaid|MEDICAID|||||726.25||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Tricare|TRICARE EAST REGION|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Tricare|TRICARE FOR LIFE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Tricare|TRICARE FOR LIFE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Tricare|TRICARE EAST REGION|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Healthcare|UNITED HEALTHCARE OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Healthcare|TML GROUP BENEFITS|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Healthcare|GOLDEN RULE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Healthcare|GEHA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|United Healthcare|UNITED HEALTHCARE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|United Healthcare|TML GROUP BENEFITS|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid|SUPERIOR HEALTHPLAN CHIP|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Healthcare|AARP|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|PHCS|HUMANA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Optum Behavioral Health|BH OPTUM UHC|24.72||||||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|PHCS|HUMANA INSURANCE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|PHCS|HUMANA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|PHCS|MULTIPLAN PHCS|||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Rusk State Hospital|RUSK STATE HOSP|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|NON CONTRACTED|COMMERCIAL OTHER 4|||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|NON CONTRACTED|COMMERCIAL OTHER 2|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|NON CONTRACTED|COMMERCIAL OTHER 1|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|NON CONTRACTED|COMMERCIAL OTHER 1|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|NON CONTRACTED|COMMERCIAL OTHER 2|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|NON CONTRACTED|COMMERCIAL OTHER 4|||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Medicare|MEDICARE ACUTE|||||1,084.75||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Medicare|MEDICARE ACUTE|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,084.75||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Access Direct Platinum|HEALTHFIRST TPA UMR|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Veterans Affairs|VETERANS ADMINISTRATION|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicare|MEDICARE ACUTE|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Veterans Affairs|VETERANS ADMINISTRATION|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5|Workers Compensation|TRAVELERS INSURANCE COMPANY|24.72||||||| 99285|EAP|0450|ER VISIT LEVEL 5|Workers Compensation|WORKERS COMPENSATION OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|ZURICH COMPANY|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|BROOKSHIRES WORKERS COMP|24.72||||||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|TEXAS MUTUAL INSURANCE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|GALLAGHER BASSETT|||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|UT EMPLOYEE INJURY|24.72||||24.72||| 99285|EAP|0981|TRAUMA PHYSICIAN CHARGE|Workers Compensation|WORKERS COMPENSATION OTHER|3.64||||33.08||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|WORKERS COMPENSATION OTHER|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Workers Compensation|TEXAS MUTUAL INSURANCE|||||1,084.75||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Workers Compensation|GALLAGHER BASSETT|||||1,084.75||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross HMO Specialty|BCBSTX HMO|||||726.25||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Workers Compensation|WORKERS COMPENSATION OTHER|3.64||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5|Veterans Affairs|VETERANS ADMINISTRATION|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Access Direct Platinum|HEALTHFIRST TPA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Multiplan|NALC|24.72||||||| 99285|EAP|0450|ER VISIT LEVEL 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Workers Compensation|TRAVELERS INSURANCE COMPANY|24.72||||||| 99285|EAP|0450|ER VISIT LEVEL 5|Access Direct Platinum|HEALTHFIRST TPA UMR|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Medicare Advantage|UHC AARP MCR HMO MA|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,084.75||| 99285|EAP|0450|ER VISIT LEVEL 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Medicare Advantage|UHC AARP WELLMED HMO MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||726.25||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|Humana Medicare Advantage|HUMANA MA|||||3.64||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.64||| 99285|EAP|0450|ER VISIT LEVEL 5|NON CONTRACTED|COMMERCIAL OTHER 1|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Magellan Behavioral Health|BH MAGELLAN|||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicaid|MEDICAID AMERIGROUP|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Cigna|CIGNA OTHER|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Managed Medicaid|MEDICAID AMERIGROUP|||||1,084.75||| 99285|EAP|0450|ER VISIT LEVEL 5|Cigna|CIGNA OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|ChampVA|CHAMPVA CENTER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Access Direct Platinum|HEALTHFIRST TPA|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Cigna|CIGNA OTHER|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5|Cigna|CIGNA|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Cigna|CIGNA|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5|ChampVA|CHAMPVA CENTER|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Cigna|CIGNA|||||1,084.75||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||726.25||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,084.75||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Managed Medicaid|MEDICAID SUPERIOR|||||1,084.75||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicaid|MEDICAID SUPERIOR|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Healthcare|UNITED HEALTHCARE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||726.25||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicaid|MEDICAID SUPERIOR|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5|United Medicare Advantage|UHC AARP MCR HMO MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Magellan Behavioral Health|BH MAGELLAN|||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|United Medicare Advantage|UHC MEDICARE GOLD MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Humana Medicare Advantage|HUMANA MA|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.64||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Managed Medicaid|MEDICAID AMERIGROUP|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|Managed Medicaid|MEDICAID SUPERIOR|||||3.64||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicare|MEDICARE PART B ONLY IP|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID SUPERIOR|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID AMERIGROUP|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Cigna|CIGNA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|United Medicare Advantage|UHC MEDICARE GOLD MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Blue Cross HMO Specialty|BCBSTX HMO|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross HMO Specialty|BCBSTX HMO|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Blue Cross HMO Specialty|BCBSTX HMO|||||1,084.75||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Blue Cross PPO Specialty|BCBSTX PPO|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Humana Medicare Advantage|HUMANA MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Blue Cross PPO Specialty|BCBSTX OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross PPO Specialty|BCBSTX PPO|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross PPO Specialty|BCBSTX OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Aetna|BOON CHAPMAN|24.72||||||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Brinson Benefits|THE HEALTH PLAN SMITH CO|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Humana Medicare Advantage|HUMANA MA|||||726.25||| 99285|EAP|0981|EMERGENCY DEPT VISIT 99|Blue Cross PPO Specialty|BCBSTX PPO|||||3.64||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Blue Cross PPO Specialty|BCBSTX PPO|||||1,084.75||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Medicaid|MEDICAID|||||1,084.75||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Aetna|AETNA QHP HMO|24.72||||||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross PPO Specialty|BCBSTX PPO|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Aetna|AETNA PPO|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Aetna|AETNA OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Aetna|AETNA QHP HMO|24.72||||||| 99285|EAP|0450|ER VISIT LEVEL 5|Aetna|AETNA PPO|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Aetna Value Network|AETNA VALUE NETWORK|||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.72||||24.72||| 99285|EAP|0981|EMERGENCY DEPT VISIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,084.75||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.72||||24.72||| 99285|EAP|0981|E&M EMERGENCY DEPARTMENT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||726.25||| 99285|EAP|0450|ER VISIT LEVEL 5|Aetna|AETNA OTHER|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5|Aenta Medicare Advantage|AETNA MEDICARE MA|24.72||||24.72||| 99285|EAP|0450|ER VISIT LEVEL 5 W/PROC|Aenta Medicare Advantage|AETNA MEDICARE MA|24.72||||24.72||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Medicaid|MEDICAID|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Tricare|TRICARE FOR LIFE|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|United Healthcare|UNITED HEALTHCARE OTHER|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Aetna|AETNA OTHER|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Medicare|MEDICARE ACUTE|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Blue Cross PPO Specialty|BCBSTX PPO|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Veterans Affairs|VETERANS ADMINISTRATION|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Cigna|CIGNA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Aenta Medicare Advantage|AETNA MEDICARE MA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Access Direct Platinum|HEALTHFIRST TPA UMR|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Medicare|MEDICARE PART B ONLY IP|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|United Healthcare|UNITED HEALTHCARE|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Managed Medicaid|MEDICAID SUPERIOR|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|NON CONTRACTED|COMMERCIAL OTHER 1|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Managed Medicare|HEALTHSPRING MA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|UTMB|UTMB CORRECTIONAL MANAGED CARE|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|United Healthcare|TML GROUP BENEFITS|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|PHCS|GROUP AND PENSION|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Blue Cross PPO Specialty|BCBSTX OTHER|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|PHCS|HUMANA INSURANCE|||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Workers Compensation|BROOKSHIRES WORKERS COMP|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Workers Compensation|TEXAS MUTUAL INSURANCE|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Access Direct Platinum|HEALTHFIRST TPA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Cigna|CIGNA|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Workers Compensation|WORKERS COMPENSATION OTHER|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Humana Medicare Advantage|HUMANA MA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Blue Cross HMO Specialty|BCBSTX HMO|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Managed Medicaid|MEDICAID AMERIGROUP|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|United Medicare Advantage|UHC AARP MCR HMO MA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Aetna|AETNA PPO|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|PHCS|HUMANA|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Aetna Value Network|AETNA VALUE NETWORK|||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|United Healthcare|UNITED HEALTHCARE|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|United Healthcare|GOLDEN RULE|||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Tricare|TRICARE EAST REGION|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Medicaid|SMITH COUNTY INDIGENT HEALTH|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Rusk State Hospital|RUSK STATE HOSP|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Medicaid|SMITH COUNTY JAIL|||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Medicaid|MOLINA HEALTHCARE OF TEXAS|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Medicaid|CRIME VICTIMS COMPENSATION|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Medicaid|COUNTY INDIGENT HEALTH OTHER|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|United Medicare Advantage|UHC MEDICARE GOLD MA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Managed Medicare|WELLCARE CHOICE MA|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Managed Medicare|BCBS MEDICARE PPO MA|20.50||||20.50||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|20.50||||||| 99291|EAP|0450|CRITICAL CARE 1ST 30 - 74|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.50||||20.50||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Managed Medicare|HEALTHSPRING MA|12.83||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.40||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Medicare|MEDICARE ACUTE|12.83||||12.83||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|United Medicare Advantage|UHC MEDICARE GOLD MA|12.83||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|United Medicare Advantage|UHC AARP MCR HMO MA|7.40||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.40||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Blue Cross HMO Specialty|BCBSTX HMO|12.83||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Aetna|AETNA PPO|7.40||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Managed Medicaid|MEDICAID SUPERIOR|12.83||||12.83||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.83||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Humana Medicare Advantage|HUMANA MA|12.83||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Blue Cross PPO Specialty|BCBSTX PPO|7.40||||12.83||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Medicare|MEDICARE ACUTE|7.40||||12.83||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7.40||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Medicaid|SMITH COUNTY JAIL|||||12.83||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Medicaid|MEDICAID|7.40||||7.40||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|United Medicare Advantage|UHC MEDICARE GOLD MA|7.40||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Humana Medicare Advantage|HUMANA MA|7.40||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Aetna Value Network|AETNA VALUE NETWORK|||||7.40||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Blue Cross PPO Specialty|BCBSTX PPO|12.83||||12.83||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|United Healthcare|UNITED HEALTHCARE|7.40||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.40||||||| 99292|EAP|0450|CRITICAL CARE EA ADDL 30|Medicaid|MEDICAID|7.40||||12.83||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Cigna|CIGNA|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|United Medicare Advantage|UHC AARP MCR HMO MA|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|PHCS|HUMANA|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Tricare|TRICARE EAST REGION|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|United Healthcare|GEHA|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Medicare|MEDICARE ACUTE|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|United Healthcare|UNITED HEALTHCARE OTHER|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Medicaid|SMITH COUNTY JAIL|||||0.90||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Managed Medicare|HEALTHSPRING MA|37.50||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|NON CONTRACTED|COMMERCIAL OTHER 1|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Veterans Affairs|VETERANS ADMINISTRATION|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Humana Medicare Advantage|HUMANA MA|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Blue Cross HMO Specialty|BCBSTX HMO|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.90||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Blue Cross PPO Specialty|BCBSTX PPO|||||37.50||| 99406|EAP|0510|BEHAV CHNG SMOKING 3-10 M|Blue Cross PPO Specialty|BCBSTX OTHER|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Managed Medicaid|MEDICAID SUPERIOR|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Humana Medicare Advantage|HUMANA MA|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Tricare|TRICARE EAST REGION|||||63.75||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Managed Medicare|HEALTHSPRING MA|||||63.75||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Medicaid|MEDICAID|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|United Healthcare|UNITED HEALTHCARE OTHER|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|United Healthcare|UNITED HEALTHCARE|||||0.90||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Medicare|MEDICARE ACUTE|37.50||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Veterans Affairs|VETERANS ADMINISTRATION|37.50||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37.50||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|United Medicare Advantage|UHC AARP MCR HMO MA|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Cigna|CIGNA|||||0.90||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Managed Medicaid|MEDICAID AMERIGROUP|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Blue Cross HMO Specialty|BCBSTX HMO|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Blue Cross PPO Specialty|BCBSTX PPO|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Blue Cross PPO Specialty|BCBSTX OTHER|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||37.50||| 99407|EAP|0510|BEHAV CHNG SMOKING > 10 M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||37.50||| 99495|EAP|0510|TRANS CARE MGMT 14 DAY DI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||129.58||| 99495|EAP|0510|TRANS CARE MGMT 14 DAY DI|Medicare|MEDICARE ACUTE|||||129.58||| A4550|EAP|0272|SURGICAL TRAYS|Managed Medicare|HEALTHSPRING MA|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|PHCS|HUMANA|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Aetna Value Network|AETNA VALUE NETWORK|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Blue Cross PPO Specialty|BCBSTX PPO|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Blue Cross HMO Specialty|BCBSTX HMO|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Humana Medicare Advantage|HUMANA MA|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Managed Medicaid|MEDICAID AMERIGROUP|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Tricare|TRICARE EAST REGION|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|United Medicare Advantage|UHC AARP MCR HMO MA|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|United Healthcare|AARP|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|United Healthcare|UNITED HEALTHCARE|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|United Healthcare|UNITED HEALTHCARE OTHER|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Medicare|MEDICARE ACUTE|||||1.10||| A4550|EAP|0272|SURGICAL TRAYS|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.10||| A4641|EAP|0636|TC 99M 0-25MCI RX|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|109.25||||||| A4641|EAP|0636|TC 99M 0-25MCI RX|Blue Cross PPO Specialty|BCBSTX PPO|||||109.25||| A4646|EAP|0371||Medicare|MEDICARE ACUTE|240.35||||240.35||| A4648|EAP|0278|IMPLANTABLE TISSUE MARKER|United Medicare Advantage|UHC AARP MCR HMO MA|||||273.38||| A4648|EAP|0278|IMPLANTABLE TISSUE MARKER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||273.38||| A4648|EAP|0278|IMPLANTABLE TISSUE MARKER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||273.38||| A4648|EAP|0278|IMPLANTABLE TISSUE MARKER|Medicare|MEDICARE ACUTE|526.50||||273.38||| A4648|EAP|0278|FIDUCIAL TISSUE MARKER I|Medicare|MEDICARE ACUTE|526.50||||526.50||| A4648|EAP|0278|IMPLANTABLE TISSUE MARKER|Managed Medicare|HEALTHSPRING MA|||||273.38||| A4648|EAP|0278|FIDUCIAL TISSUE MARKER I|Blue Cross PPO Specialty|BCBSTX PPO|||||526.50||| A4648|EAP|0278|FIDUCIAL TISSUE MARKER I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||526.50||| A4648|EAP|0278|FIDUCIAL TISSUE MARKER I|Humana Medicare Advantage|HUMANA MA|||||526.50||| A4648|EAP|0278|IMPLANTABLE TISSUE MARKER|Humana Medicare Advantage|HUMANA MA|||||273.38||| A4648|EAP|0278|IMPLANTABLE TISSUE MARKER|Veterans Affairs|VETERANS ADMINISTRATION|||||273.38||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|UNITED HEALTHCARE ERS|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|UNITED HEALTHCARE OTHER|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|UNITED HEALTHCARE|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|UNITED HEALTHCARE|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|TML GROUP BENEFITS|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Medicare|MEDICARE PART B ONLY IP|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Medicaid|MEDICAID|3,477.50||||||| A6010|EAP|0278||Medicare|MEDICARE ACUTE|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicare|HEALTHSPRING MA|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicare|BCBS MEDICARE PPO MA|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Brinson Benefits|THE HEALTH PLAN SMITH CO|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Blue Cross HMO Specialty|BCBSTX HMO|3,477.50||||3,477.50||| A6010|EAP|0278||Blue Cross PPO Specialty|BCBSTX PPO|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Aenta Medicare Advantage|AETNA MEDICARE MA|3,477.50||||3,477.50||| A6010|EAP|0278||Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,477.50||| A6010|EAP|0278||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Aetna|AETNA QHP HMO|||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Blue Cross PPO Specialty|BCBSTX PPO|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Aetna|AETNA PPO|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Aetna|AETNA OTHER|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|NON CONTRACTED|COMMERCIAL OTHER 1|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Medicare|MEDICARE ACUTE|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicaid|MEDICAID SUPERIOR|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicaid|MEDICAID AMERIGROUP|3,477.50||||||| A6010|EAP|0278||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Cigna|CIGNA|3,477.50||||||| A6010|EAP|0278||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Tricare|TRICARE EAST REGION|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3,477.50||| A6010|EAP|0278||Workers Compensation|WORKERS COMPENSATION OTHER|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Workers Compensation|WORKERS COMPENSATION OTHER|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Workers Compensation|TEXAS MUTUAL INSURANCE|3,477.50||||||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|Humana Medicare Advantage|HUMANA MA|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|United Medicare Advantage|UHC MEDICARE GOLD MA|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|United Medicare Advantage|UHC AARP MCR HMO MA|3,477.50||||3,477.50||| A6010|EAP|0623|COLLAGEN BASED WOUND FILL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,477.50||||||| A6010|EAP|0278||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,477.50||||3,477.50||| A6010|EAP|0278||Humana Medicare Advantage|HUMANA MA|3,477.50||||3,477.50||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicaid|MEDICAID AMERIGROUP|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Humana Medicare Advantage|HUMANA MA|25.93||||25.93||| A6011|EAP|0272||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|United Medicare Advantage|UHC AARP WELLMED HMO MA|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|United Medicare Advantage|UHC AARP MCR HMO MA|25.93||||25.93||| A6011|EAP|0272||Workers Compensation|WORKERS COMPENSATION OTHER|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Workers Compensation|WORKERS COMPENSATION OTHER|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Workers Compensation|TEXAS MUTUAL INSURANCE|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.93||||25.93||| A6011|EAP|0272||Humana Medicare Advantage|HUMANA MA|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicaid|MEDICAID SUPERIOR|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Aetna|AETNA QHP HMO|||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Aetna|AETNA PPO|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Aetna|AETNA OTHER|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.93||||25.93||| A6011|EAP|0272||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Aenta Medicare Advantage|AETNA MEDICARE MA|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Blue Cross HMO Specialty|BCBSTX HMO|25.93||||25.93||| A6011|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Blue Cross PPO Specialty|BCBSTX PPO|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Brinson Benefits|THE HEALTH PLAN SMITH CO|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicare|BCBS MEDICARE PPO MA|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Medicare|MEDICARE PART B ONLY IP|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Medicare|MEDICARE ACUTE|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|United Medicare Advantage|UHC MEDICARE GOLD MA|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|NON CONTRACTED|COMMERCIAL OTHER 1|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|UNITED HEALTHCARE OTHER|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|UNITED HEALTHCARE ERS|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|UNITED HEALTHCARE|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|UNITED HEALTHCARE|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Medicaid|MEDICAID|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|United Healthcare|TML GROUP BENEFITS|25.93||||||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Tricare|TRICARE EAST REGION|25.93||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||25.93||| A6011|EAP|0623|COLLAGEN BASED WOUND FILL|Managed Medicare|HEALTHSPRING MA|25.93||||||| A6011|EAP|0272||Medicare|MEDICARE ACUTE|25.93||||25.93||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Managed Medicare|BCBS MEDICARE PPO MA|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|NON CONTRACTED|COMMERCIAL OTHER 1|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Medicaid|MEDICAID|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Medicare|MEDICARE ACUTE|2.38||||2.38||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Managed Medicare|HEALTHSPRING MA|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Blue Cross PPO Specialty|BCBSTX PPO|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Aenta Medicare Advantage|AETNA MEDICARE MA|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Aetna|AETNA PPO|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Humana Medicare Advantage|HUMANA MA|2.38||||2.38||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|Veterans Affairs|VETERANS ADMINISTRATION|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|United Medicare Advantage|UHC AARP MCR HMO MA|2.38||||||| A7041|EAP|0270|WATER SEAL DRAIN CONTAINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.38||| A9500|EAP|0636|TC99M SESTAMIBI|Medicare|MEDICARE ACUTE|462.75||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Veterans Affairs|VETERANS ADMINISTRATION|462.75||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Humana Medicare Advantage|HUMANA MA|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Aetna|AETNA OTHER|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Blue Cross PPO Specialty|BCBSTX PPO|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Managed Medicare|HEALTHSPRING MA|||||462.75||| A9500|EAP|0636|TC99M SESTAMIBI|Managed Medicare|BCBS MEDICARE PPO MA|||||462.75||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Access Direct Platinum|HEALTHFIRST TPA UMR|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Managed Medicaid|MEDICAID SUPERIOR|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Blue Cross PPO Specialty|BCBSTX OTHER|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|United Healthcare|UNITED HEALTHCARE|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|United Healthcare|GEHA|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|United Healthcare|GOLDEN RULE|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|UTMB|UTMB CORRECTIONAL MANAGED CARE|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|NON CONTRACTED|COMMERCIAL OTHER 1|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Medicare|UTSW MC KIDNEY PROGRAM|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Medicaid|SMITH COUNTY JAIL|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Medicaid|LAW ENFORCEMENT OTHER|520.50||||||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Medicaid|COUNTY INDIGENT HEALTH OTHER|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Medicare|MEDICARE ACUTE|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Medicaid|MEDICAID|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Managed Medicare|HEALTHSPRING MA|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Managed Medicare|BCBS MEDICARE PPO MA|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Tricare|TRICARE FOR LIFE|520.50||||||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Tricare|TRICARE EAST REGION|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Managed Medicare|OTHER INSTITUTIONS|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|United Healthcare|UNITED HEALTHCARE|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Blue Cross HMO Specialty|BCBSTX HMO|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Medicare|MEDICARE PART B ONLY IP|520.50||||||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Blue Cross PPO Specialty|BCBSTX PPO|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Aenta Medicare Advantage|AETNA MEDICARE MA|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Aetna|BOON CHAPMAN|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Aetna|AETNA PPO|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|United Healthcare|UNITED HEALTHCARE OTHER|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Aetna|AETNA OTHER|520.50||||||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Managed Medicaid|MEDICAID AMERIGROUP|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Cigna|CIGNA OTHER|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Cigna|CIGNA|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Humana Medicare Advantage|HUMANA MA|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Access Direct Platinum|HEALTHFIRST TPA|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Veterans Affairs|VETERANS ADMINISTRATION|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|United Medicare Advantage|UHC MEDICARE GOLD MA|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|520.50||||520.50||| A9502|EAP|0636|TC99M MYOVIEW PER STUDY|United Medicare Advantage|UHC AARP MCR HMO MA|520.50||||520.50||| A9505|EAP|0636|THALLIUM 1MCI RX|Blue Cross PPO Specialty|BCBSTX PPO|||||402.75||| A9505|EAP|0636|THALLIUM 1MCI RX|NON CONTRACTED|COMMERCIAL OTHER 1|402.75||||||| A9505|EAP|0636|THALLIUM 1MCI RX|Medicaid|MEDICAID|402.75||||||| A9505|EAP|0636|THALLIUM 1MCI RX|Humana Medicare Advantage|HUMANA MA|||||402.75||| A9516|EAP|0636|I123 NAI 100 UCI RX|United Healthcare|UNITED HEALTHCARE OTHER|||||335.75||| A9516|EAP|0636|I123 NAI 100 UCI RX|United Healthcare|UNITED HEALTHCARE|||||335.75||| A9516|EAP|0636|I123 CAP 200 UCI RX|United Healthcare|UNITED HEALTHCARE OTHER|||||6.71||| A9516|EAP|0636|I123 CAP 200 UCI RX|United Healthcare|UNITED HEALTHCARE|||||6.71||| A9516|EAP|0636|I123 CAP 200 UCI RX|Managed Medicare|HEALTHSPRING MA|||||6.71||| A9516|EAP|0636|I123 NAI 100 UCI RX|Access Direct Platinum|HEALTHFIRST TPA UMR|||||335.75||| A9516|EAP|0636|I123 CAP 200 UCI RX|Blue Cross HMO Specialty|BCBSTX HMO|||||6.71||| A9516|EAP|0636|I123 NAI 100 UCI RX|Managed Medicaid|MEDICAID SUPERIOR|||||335.75||| A9516|EAP|0636|I123 CAP 200 UCI RX|Managed Medicaid|MEDICAID SUPERIOR|||||6.71||| A9516|EAP|0636|I123 CAP 200 UCI RX|Humana Medicare Advantage|HUMANA MA|||||6.71||| A9516|EAP|0636|I123 NAI 100 UCI RX|Humana Medicare Advantage|HUMANA MA|||||335.75||| A9516|EAP|0636|I123 CAP 200 UCI RX|Blue Cross PPO Specialty|BCBSTX PPO|||||6.71||| A9516|EAP|0636|I123 NAI 100 UCI RX|Blue Cross HMO Specialty|BCBSTX HMO|||||335.75||| A9516|EAP|0636|I123 CAP 200 UCI RX|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.71||| A9516|EAP|0636|I123 NAI 100 UCI RX|Blue Cross PPO Specialty|BCBSTX PPO|||||335.75||| A9516|EAP|0636|I123 CAP 200 UCI RX|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.71||| A9516|EAP|0636|I123 NAI 100 UCI RX|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||335.75||| A9516|EAP|0636|I123 CAP 200 UCI RX|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.71||| A9516|EAP|0636|I123 NAI 100 UCI RX|Managed Medicare|HEALTHSPRING MA|||||335.75||| A9516|EAP|0636|I123 CAP 200 UCI RX|Medicare|MEDICARE ACUTE|||||6.71||| A9516|EAP|0636|I123 NAI 100 UCI RX|Medicare|MEDICARE ACUTE|||||335.75||| A9516|EAP|0636|I123 NAI 100 UCI RX|United Medicare Advantage|UHC MEDICARE GOLD MA|||||335.75||| A9521|EAP|0636|CERETEC RX|Medicare|MEDICARE ACUTE|2,483.25||||||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Aetna|AETNA PPO|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Aenta Medicare Advantage|AETNA MEDICARE MA|3.58||||||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Blue Cross PPO Specialty|BCBSTX PPO|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Veterans Affairs|VETERANS ADMINISTRATION|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|United Medicare Advantage|UHC AARP MCR HMO MA|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Medicaid|MEDICAID HMO|3.58||||||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Medicaid|MEDICAID|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.58||||||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|United Healthcare|UNITED HEALTHCARE|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Medicare|MEDICARE ACUTE|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|PHCS|GROUP AND PENSION|3.58||||||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|United Healthcare|UNITED HEALTHCARE OTHER|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Tricare|TRICARE EAST REGION|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|NON CONTRACTED|COMMERCIAL OTHER 1|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Tricare|TRICARE SOUTH PHYSICIAN|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Managed Medicare|BCBS MEDICARE PPO MA|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Managed Medicare|HEALTHSPRING MA|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Medicaid|SMITH COUNTY INDIGENT HEALTH|3.58||||||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|United Medicare Advantage|UHC MEDICARE GOLD MA|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Access Direct Platinum|HEALTHFIRST TPA|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Access Direct Platinum|HEALTHFIRST TPA UMR|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Blue Cross HMO Specialty|BCBSTX HMO|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Blue Cross PPO Specialty|BCBSTX OTHER|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Managed Medicaid|MEDICAID AMERIGROUP|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Managed Medicaid|MEDICAID SUPERIOR|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Aetna|AETNA OTHER|3.58||||||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Humana Medicare Advantage|HUMANA MA|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Cigna|CIGNA|3.58||||3.58||| A9537|EAP|0636|CHOLETEC RX NDC 0270-0083|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.58||||3.58||| A9538|EAP|0636|PYP TC 99M RX|Humana Medicare Advantage|HUMANA MA|||||285.50||| A9538|EAP|0636|PYP TC 99M RX|Cigna|CIGNA OTHER|285.50||||||| A9538|EAP|0636|PYP TC 99M RX|Medicare|MEDICARE ACUTE|||||285.50||| A9538|EAP|0636|PYP TC 99M RX|Medicaid|SMITH COUNTY INDIGENT HEALTH|285.50||||||| A9540|EAP|0636|MAA TC99M RX|United Medicare Advantage|UHC MEDICARE GOLD MA|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|United Medicare Advantage|UHC AARP WELLMED HMO MA|324.75||||||| A9540|EAP|0636|MAA TC99M RX|Veterans Affairs|VETERANS ADMINISTRATION|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Blue Cross PPO Specialty|BCBSTX PPO|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Aenta Medicare Advantage|AETNA MEDICARE MA|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Aetna|AETNA PPO|||||324.75||| A9540|EAP|0636|MAA TC99M RX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|324.75||||||| A9540|EAP|0636|MAA TC99M RX|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Medicaid|MEDICAID|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Rusk State Hospital|RUSK STATE HOSP|||||324.75||| A9540|EAP|0636|MAA TC99M RX|Medicare|MEDICARE PART B ONLY IP|324.75||||||| A9540|EAP|0636|MAA TC99M RX|Medicare|MEDICARE ACUTE|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|United Healthcare|UNITED HEALTHCARE|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|United Healthcare|UNITED HEALTHCARE OTHER|324.75||||||| A9540|EAP|0636|MAA TC99M RX|Medicaid|SMITH COUNTY JAIL|||||324.75||| A9540|EAP|0636|MAA TC99M RX|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||324.75||| A9540|EAP|0636|MAA TC99M RX|Humana Medicare Advantage|HUMANA MA|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Cigna|CIGNA|324.75||||||| A9540|EAP|0636|MAA TC99M RX|Managed Medicaid|MEDICAID AMERIGROUP|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Managed Medicare|HEALTHSPRING MA|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Managed Medicaid|MEDICAID UNITED HEALTHCARE|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Managed Medicaid|MEDICAID SUPERIOR|324.75||||||| A9540|EAP|0636|MAA TC99M RX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Blue Cross HMO Specialty|BCBSTX HMO|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|Access Direct Platinum|HEALTHFIRST TPA|324.75||||||| A9540|EAP|0636|MAA TC99M RX|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|324.75||||324.75||| A9540|EAP|0636|MAA TC99M RX|United Medicare Advantage|UHC AARP MCR HMO MA|324.75||||324.75||| A9541|EAP|0636|SULFUR COLLOID RX|UTMB|UTMB CORRECTIONAL MANAGED CARE|264.75||||||| A9541|EAP|0636|SULFUR COLLOID RX|Medicare|MEDICARE PART B ONLY IP|264.75||||||| A9541|EAP|0636|SULFUR COLLOID RX|PHCS|HUMANA|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|PHCS|GROUP AND PENSION|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|NON CONTRACTED|COMMERCIAL OTHER 1|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Tricare|TRICARE EAST REGION|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Medicare|MEDICARE ACUTE|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|United Healthcare|UNITED HEALTHCARE|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Medicaid|MEDICAID|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Managed Medicare|HEALTHSPRING MA|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Managed Medicare|BCBS MEDICARE PPO MA|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Humana Medicare Advantage|HUMANA MA|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Cigna|CIGNA|264.75||||||| A9541|EAP|0636|SULFUR COLLOID RX|Cigna|CIGNA|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Managed Medicaid|MEDICAID UNITED HEALTHCARE|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|United Healthcare|UNITED HEALTHCARE OTHER|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Managed Medicaid|MEDICAID SUPERIOR|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Managed Medicaid|MEDICAID AMERIGROUP|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Aetna|AETNA PPO|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Aenta Medicare Advantage|AETNA MEDICARE MA|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Blue Cross PPO Specialty|BCBSTX PPO|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Blue Cross HMO Specialty|BCBSTX HMO|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Access Direct Platinum|HEALTHFIRST TPA UMR|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Access Direct Platinum|HEALTHFIRST TPA|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|United Medicare Advantage|UHC MEDICARE GOLD MA|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Workers Compensation|ZURICH COMPANY|264.75||||||| A9541|EAP|0636|SULFUR COLLOID RX|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|264.75||||264.75||| A9541|EAP|0636|SULFUR COLLOID RX|United Medicare Advantage|UHC AARP MCR HMO MA|264.75||||264.75||| A9548|EAP|0636|INDIUM III DTPA I991230|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,423.25||| A9552|EAP|0343|FDG PER DOSE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,774.25||| A9552|EAP|0343|FDG PER DOSE|Managed Medicare|BCBS MEDICARE PPO MA|1,774.25||||1,774.25||| A9552|EAP|0343|FDG PER DOSE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,774.25||| A9552|EAP|0343|FDG PER DOSE|Managed Medicare|HEALTHSPRING MA|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Managed Medicare|OTHER INSTITUTIONS|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Medicaid|SMITH COUNTY JAIL|||||1,774.25||| A9552|EAP|0343|FDG PER DOSE|Medicaid|MEDICAID|1,774.25||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|United Healthcare|UNITED HEALTHCARE|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|United Healthcare|TML GROUP BENEFITS|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Tricare|TRICARE EAST REGION|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Rusk State Hospital|RUSK STATE HOSP|||||1,774.25||| A9552|EAP|0343|FDG PER DOSE|PHCS|HUMANA|||||1,774.25||| A9552|EAP|0343|FDG PER DOSE|PHCS|GROUP AND PENSION|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Medicare|MEDICARE ACUTE|2,040.39||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,774.25||| A9552|EAP|0343|FDG PER DOSE|United Healthcare|UNITED HEALTHCARE OTHER|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,774.25||| A9552|EAP|0343|FDG PER DOSE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,774.25||| A9552|EAP|0343|FDG PER DOSE|Veterans Affairs|VETERANS ADMINISTRATION|||||1,907.32||| A9552|EAP|0343|FDG PER DOSE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Managed Medicaid|MEDICAID SUPERIOR|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,774.25||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Managed Medicaid|MEDICAID AMERIGROUP|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Cigna|CIGNA OTHER|||||1,907.32||| A9552|EAP|0343|FDG PER DOSE|Humana Medicare Advantage|HUMANA MA|2,040.39||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Aetna|AETNA PPO|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Aetna Value Network|AETNA VALUE NETWORK|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Blue Cross PPO Specialty|BCBSTX PPO|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Cigna|CIGNA|||||2,040.39||| A9552|EAP|0343|FDG PER DOSE|Blue Cross HMO Specialty|BCBSTX HMO|||||2,040.39||| A9558|EAP|0636|XE 133 20 MCI RX|Aenta Medicare Advantage|AETNA MEDICARE MA|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Cigna|CIGNA|228.25||||||| A9558|EAP|0636|XE 133 20 MCI RX|Managed Medicaid|MEDICAID AMERIGROUP|||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Veterans Affairs|VETERANS ADMINISTRATION|228.25||||||| A9558|EAP|0636|XE 133 20 MCI RX|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|United Healthcare|UNITED HEALTHCARE OTHER|228.25||||||| A9558|EAP|0636|XE 133 20 MCI RX|Medicaid|SMITH COUNTY JAIL|||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Medicaid|MEDICAID|228.25||||||| A9558|EAP|0636|XE 133 20 MCI RX|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Managed Medicare|HEALTHSPRING MA|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|United Healthcare|UNITED HEALTHCARE|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Medicare|MEDICARE PART B ONLY IP|228.25||||||| A9558|EAP|0636|XE 133 20 MCI RX|United Medicare Advantage|UHC AARP MCR HMO MA|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Medicare|MEDICARE ACUTE|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|United Medicare Advantage|UHC MEDICARE GOLD MA|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Access Direct Platinum|HEALTHFIRST TPA|228.25||||||| A9558|EAP|0636|XE 133 20 MCI RX|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Managed Medicaid|MEDICAID UNITED HEALTHCARE|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Humana Medicare Advantage|HUMANA MA|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Blue Cross HMO Specialty|BCBSTX HMO|228.25||||||| A9558|EAP|0636|XE 133 20 MCI RX|Blue Cross PPO Specialty|BCBSTX PPO|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|228.25||||||| A9558|EAP|0636|XE 133 20 MCI RX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|228.25||||228.25||| A9558|EAP|0636|XE 133 20 MCI RX|Aetna|AETNA PPO|||||228.25||| A9560|EAP|0636|TC99 LABELED RBC RX|Managed Medicare|HEALTHSPRING MA|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|UTMB|UTMB CORRECTIONAL MANAGED CARE|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|United Healthcare|UNITED HEALTHCARE OTHER|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|Medicare|MEDICARE ACUTE|663.50||||663.50||| A9560|EAP|0636|TC99 LABELED RBC RX|United Medicare Advantage|UHC MEDICARE GOLD MA|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|Access Direct Platinum|HEALTHFIRST TPA UMR|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|Aenta Medicare Advantage|AETNA MEDICARE MA|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|Humana Medicare Advantage|HUMANA MA|663.50||||663.50||| A9560|EAP|0636|TC99 LABELED RBC RX|Blue Cross PPO Specialty|BCBSTX PPO|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|Cigna|CIGNA|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|United Medicare Advantage|UHC AARP MCR HMO MA|663.50||||||| A9560|EAP|0636|TC99 LABELED RBC RX|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|663.50||||663.50||| A9560|EAP|0636|TC99 LABELED RBC RX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|663.50||||663.50||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Aetna|AETNA PPO|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Aenta Medicare Advantage|AETNA MEDICARE MA|1.35||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|155.25||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Blue Cross PPO Specialty|BCBSTX PPO|1.35||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Humana Medicare Advantage|HUMANA MA|155.25||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Cigna|CIGNA OTHER|||||145.13||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Cigna|CIGNA|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||145.13||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Workers Compensation|WORKERS COMPENSATION OTHER|||||145.13||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Veterans Affairs|VETERANS ADMINISTRATION|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Managed Medicaid|MEDICAID UNITED HEALTHCARE|155.25||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Access Direct Platinum|HEALTHFIRST TPA|||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|United Medicare Advantage|UHC MEDICARE GOLD MA|155.25||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|United Medicare Advantage|UHC AARP MCR HMO MA|145.13||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|NON CONTRACTED|COMMERCIAL OTHER 1|||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|PHCS|HUMANA|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Multiplan|WEB TPA|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Blue Cross HMO Specialty|BCBSTX HMO|1.35||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Medicare|MEDICARE ACUTE|155.25||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|United Healthcare|UNITED HEALTHCARE|||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Tricare|TRICARE EAST REGION|||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Medicaid|MEDICAID|1.35||||155.25||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.35||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Managed Medicare|HEALTHSPRING MA|145.13||||1.35||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|United Healthcare|UNITED HEALTHCARE OTHER|||||145.13||| A9561|EAP|0343|TC-99M HDP PER DOSE NDC69|Managed Medicare|BCBS MEDICARE PPO MA|||||145.13||| A9562|EAP|0636|MAG-3|Managed Medicare|BCBS MEDICARE PPO MA|||||1,254.50||| A9562|EAP|0636|MAG-3|United Healthcare|UNITED HEALTHCARE OTHER|||||1,254.50||| A9562|EAP|0636|MAG-3|United Healthcare|UNITED HEALTHCARE|||||1,254.50||| A9562|EAP|0636|MAG-3|Medicare|MEDICARE ACUTE|1,254.50||||1,254.50||| A9562|EAP|0636|MAG-3|Managed Medicaid|MEDICAID SUPERIOR|||||1,254.50||| A9562|EAP|0636|MAG-3|Humana Medicare Advantage|HUMANA MA|||||1,254.50||| A9562|EAP|0636|MAG-3|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,254.50||| A9562|EAP|0636|MAG-3|Blue Cross PPO Specialty|BCBSTX PPO|||||1,254.50||| A9562|EAP|0636|MAG-3|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,254.50||| A9562|EAP|0636|MAG-3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,254.50||| A9562|EAP|0636|MAG-3|Aetna|AETNA PPO|||||1,254.50||| A9567|EAP|0636|DTPA TC RX|Managed Medicaid|MEDICAID SUPERIOR|291.50||||||| A9567|EAP|0636|DTPA TC RX|Managed Medicaid|MEDICAID UNITED HEALTHCARE|291.50||||||| A9567|EAP|0636|DTPA TC RX|UTMB|UTMB CORRECTIONAL MANAGED CARE|291.50||||||| A9567|EAP|0636|DTPA TC RX|United Healthcare|UNITED HEALTHCARE|291.50||||||| A9567|EAP|0636|DTPA TC RX|Humana Medicare Advantage|HUMANA MA|291.50||||||| A9570|EAP|0636|INDIUM III WBC RX|Medicare|MEDICARE ACUTE|1,879.50||||1,879.50||| A9570|EAP|0636|INDIUM III WBC RX|Humana Medicare Advantage|HUMANA MA|||||1,879.50||| A9570|EAP|0636|INDIUM III WBC RX|Blue Cross PPO Specialty|BCBSTX PPO|||||1,879.50||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|United Medicare Advantage|UHC MEDICARE GOLD MA|9.24||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|United Medicare Advantage|UHC AARP MCR HMO MA|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|United Medicare Advantage|UHC AARP MCR HMO MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Access Direct Platinum|HEALTHFIRST TPA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.24||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Access Direct Platinum|HEALTHFIRST TPA UMR|9.87||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.24||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Access Direct Platinum|HEALTHFIRST TPA|9.24||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Workers Compensation|UT EMPLOYEE INJURY|||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Workers Compensation|UT EMPLOYEE INJURY|||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Veterans Affairs|VETERANS ADMINISTRATION|9.24||||9.24||| A9576|EAP|0255|PROHANCE 5ML VIAL/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.24||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Managed Medicaid|MEDICAID SUPERIOR|9.87||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Managed Medicaid|MEDICAID SUPERIOR|9.87||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Veterans Affairs|VETERANS ADMINISTRATION|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Managed Medicaid|MEDICAID AMERIGROUP|9.87||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.87||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Managed Medicaid|MEDICAID SUPERIOR|9.87||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.24||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Managed Medicaid|MEDICAID AMERIGROUP|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Cigna|CIGNA|||||9.24||| A9576|EAP|0255|PROHANCE 10ML NDC0270-000|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.87||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Cigna|CIGNA OTHER|9.87||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Cigna|CIGNA|||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Cigna|CIGNA OTHER|9.87||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Access Direct Platinum|HEALTHFIRST TPA UMR|9.87||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Humana Medicare Advantage|HUMANA MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Humana Medicare Advantage|HUMANA MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.24||||9.24||| A9576|EAP|0255|PROHANCE 10ML NDC0270-000|Humana Medicare Advantage|HUMANA MA|9.87||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Aetna|AETNA OTHER|9.24||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Aetna|AETNA PPO|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Aetna|BOON CHAPMAN|9.87||||||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Aetna|AETNA PPO|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Aetna|AETNA PPO|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Aetna|AETNA QHP HMO|9.87||||||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Aenta Medicare Advantage|AETNA MEDICARE MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Aenta Medicare Advantage|AETNA MEDICARE MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.24||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Blue Cross HMO Specialty|BCBSTX HMO|9.87||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Blue Cross HMO Specialty|BCBSTX HMO|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Blue Cross PPO Specialty|BCBSTX OTHER|9.87||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Blue Cross PPO Specialty|BCBSTX PPO|9.87||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Blue Cross PPO Specialty|BCBSTX PPO|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.87||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Blue Cross PPO Specialty|BCBSTX OTHER|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Aenta Medicare Advantage|AETNA MEDICARE MA|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Blue Cross PPO Specialty|BCBSTX PPO|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Blue Cross PPO Specialty|BCBSTX OTHER|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Access Direct Platinum|HEALTHFIRST TPA UMR|9.87||||9.87||| A9576|EAP|0255|PROHANCE 10ML NDC0270-000|Blue Cross PPO Specialty|BCBSTX PPO|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Blue Cross HMO Specialty|BCBSTX HMO|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|ChampVA|CHAMPVA CENTER|9.87||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|United Medicare Advantage|UHC MEDICARE GOLD MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Aetna|AETNA OTHER|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Medicare|MEDICARE PART B ONLY IP|9.24||||||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.87||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Humana Medicare Advantage|HUMANA MA|9.24||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Cigna|CIGNA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Cigna|CIGNA|9.87||||9.87||| A9576|EAP|0255|PROHANCE 5ML VIAL/ML|Medicare|MEDICARE ACUTE|9.24||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Medicare|MEDICARE ACUTE|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Medicare|MEDICARE ACUTE|9.24||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Workers Compensation|WORKERS COMPENSATION OTHER|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|9.87||||||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.87||||9.24||| A9576|EAP|0255|PROHANCE 10ML NDC0270-000|Medicare|MEDICARE ACUTE|9.87||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Medicare|MEDICARE ACUTE|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Medicare|UTSW MC KIDNEY PROGRAM|||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Managed Medicaid|MEDICAID AMERIGROUP|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Medicaid|MEDICAID|9.87||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Veterans Affairs|VETERANS ADMINISTRATION|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Medicaid|MOLINA HEALTHCARE OF TEXAS|9.24||||||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Medicare|MEDICARE PART B ONLY IP|9.87||||||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Medicaid|MEDICAID|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Medicaid|SMITH COUNTY JAIL|9.24||||||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Medicaid|MEDICAID HMO|||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Medicaid|COUNTY INDIGENT HEALTH OTHER|9.24||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Managed Medicare|BCBS MEDICARE PPO MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Managed Medicare|HEALTHSPRING MA|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Managed Medicare|HEALTHSPRING MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Managed Medicare|BCBS MEDICARE PPO MA|9.87||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Medicaid|MEDICAID BCBSTX|||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|United Healthcare|UNITED HEALTHCARE|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|United Healthcare|UNITED HEALTHCARE OTHER|9.24||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|United Healthcare|GEHA|||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|United Healthcare|GEHA|||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|United Healthcare|UNITED HEALTHCARE|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|United Healthcare|UNITED HEALTHCARE OTHER|9.87||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|United Healthcare|UNITED HEALTHCARE OTHER|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|United Healthcare|TML GROUP BENEFITS|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|United Healthcare|UNITED HEALTHCARE|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.24||||||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.87||||||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|United Healthcare|GOLDEN RULE|9.24||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Texas Workforce Commission|DIS DETER SERV (DDS)|||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|United Medicare Advantage|UHC MEDICARE GOLD MA|9.87||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|PHCS|GROUP AND PENSION|||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|PHCS|HUMANA|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|PHCS|GROUP AND PENSION|||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|PHCS|HUMANA|9.24||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Tricare|TRICARE FOR LIFE|9.87||||9.87||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|Tricare|TRICARE EAST REGION|9.24||||9.87||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Tricare|TRICARE EAST REGION|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|Tricare|TRICARE FOR LIFE|9.87||||9.24||| A9576|EAP|0255|PROHANCE 20ML NDC0270-111|NON CONTRACTED|COMMERCIAL OTHER 1|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15ML VIAL/ML NDC|NON CONTRACTED|COMMERCIAL OTHER 1|9.87||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-11|Tricare|TRICARE EAST REGION|9.24||||9.24||| A9584|EAP|0636|I-123 IOFLUPANE|United Healthcare|UNITED HEALTHCARE|||||128.91||| A9584|EAP|0636|I-123 IOFLUPANE|Medicare|MEDICARE ACUTE|||||128.91||| A9584|EAP|0636|I-123 IOFLUPANE|Tricare|TRICARE EAST REGION|||||128.91||| A9584|EAP|0636|I-123 IOFLUPANE|Managed Medicare|OTHER INSTITUTIONS|||||128.91||| A9584|EAP|0636|I-123 IOFLUPANE|Blue Cross PPO Specialty|BCBSTX PPO|||||128.91||| A9584|EAP|0636|I-123 IOFLUPANE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||128.91||| A9584|EAP|0636|I-123 IOFLUPANE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||128.91||| A9584|EAP|0636|I-123 IOFLUPANE|Humana Medicare Advantage|HUMANA MA|||||128.91||| A9584|EAP|0636|I-123 IOFLUPANE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||128.91||| A9585|EAP|0636|GADAVIST 2ML VIAL 2068062|Managed Medicaid|MEDICAID AMERIGROUP|||||5.60||| A9585|EAP|0636|GADAVIST 2ML VIAL 2068062|ChampVA|CHAMPVA CENTER|||||5.60||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||266.96||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||266.96||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|United Healthcare|UNITED HEALTHCARE|||||3.07||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|PHCS|HUMANA|||||286.98||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|Multiplan|WEB TPA|||||266.96||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|Medicare|MEDICARE ACUTE|||||266.96||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||266.96||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||266.96||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|Blue Cross HMO Specialty|BCBSTX HMO|||||3.07||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|Blue Cross PPO Specialty|BCBSTX PPO|||||266.96||| A9587|EAP|0343|NM GALLIUM GA68 DOTATATE,|Humana Medicare Advantage|HUMANA MA|||||3.07||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|Blue Cross PPO Specialty|BCBSTX PPO|||||16.98||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|NON CONTRACTED|COMMERCIAL OTHER 1|||||16.98||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|Managed Medicare|HEALTHSPRING MA|||||1,825.35||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|Managed Medicare|BCBS MEDICARE PPO MA|||||1,952.70||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|United Healthcare|GEHA|||||1,952.70||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|United Healthcare|UNITED HEALTHCARE|||||16.98||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|Veterans Affairs|VETERANS ADMINISTRATION|||||16.98||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|Access Direct Platinum|HEALTHFIRST TPA UMR|||||16.98||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|Humana Medicare Advantage|HUMANA MA|||||1,825.35||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|Medicare|MEDICARE ACUTE|||||1,825.35||| A9588|EAP|0343|NM FLUCICLOVINE F-18 PER|United Healthcare|UNITED HEALTHCARE OTHER|||||16.98||| A9698|EAP|0621|SITZMARKERS- NON-RAD CONT|Aetna|AETNA PPO|||||409.58||| A9698|EAP|0621|SITZMARKERS- NON-RAD CONT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||409.58||| A9698|EAP|0621|SITZMARKERS- NON-RAD CONT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||409.58||| A9698|EAP|0621|SITZMARKERS- NON-RAD CONT|Managed Medicaid|MEDICAID SUPERIOR|||||409.58||| A9698|EAP|0621|SITZMARKERS- NON-RAD CONT|Access Direct Platinum|HEALTHFIRST TPA|||||409.58||| A9698|EAP|0621|SITZMARKERS- NON-RAD CONT|Medicare|MEDICARE ACUTE|||||409.58||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA OTHER|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA OTHER|17.36||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|BOON CHAPMAN|362.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA PPO|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA PPO|1,157.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA OTHER|17.36||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA OTHER|362.50||||362.50||| C1713|EAP|0278|IMPL ROD 12.5M 40M 10-P12|Aetna|AETNA PPO|192.50||||338.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA QHP HMO|115.73||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA QHP HMO|115.73||||2,893.25||| C1713|EAP|0278|MPL SPACER 8X15X14 10 DEG|Aetna|AETNA PPO|192.50||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA PPO|654.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA PPO|5,786.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA PPO|2,893.25||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA OTHER|17.36||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA QHP HMO|115.73||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,893.25||||2,893.25||| C1713|EAP|0278|IMPLANT ORBITAL FLOOR G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20,569.75||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12,979.25||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|2,893.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12,979.25||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|362.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,786.50||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP MCR HMO MA|17.36||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP MCR HMO MA|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP MCR HMO MA|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP MCR HMO MA|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|192.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,893.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP MCR HMO MA|2,893.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|17.36||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|654.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,157.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|162.24||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|210.00||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TEXAS MUTUAL INSURANCE|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|17.36||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|UT EMPLOYEE INJURY|||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|UT EMPLOYEE INJURY|||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TRAVELERS INSURANCE COMPANY|1,157.25||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|362.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TEXAS MUTUAL INSURANCE|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|BROOKSHIRES WORKERS COMP|||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|17,359.75||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMP PHYSICIAN|||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|2,893.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TEXAS MUTUAL INSURANCE|5,786.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|UT EMPLOYEE INJURY|||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|UT EMPLOYEE INJURY|||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TRAVELERS INSURANCE COMPANY|115.73||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|UT EMPLOYEE INJURY|||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|654.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TEXAS MUTUAL INSURANCE|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|GALLAGHER BASSETT|||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TEXAS MUTUAL INSURANCE|17.36||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|391.30||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|162.24||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|5,786.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|654.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.36||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|654.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|181.75||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|1,157.25||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.36||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|362.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UMR|1,157.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UMR|17.36||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.36||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.36||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TEXAS MUTUAL INSURANCE|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|BROOKSHIRES WORKERS COMP|||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12,979.25||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.36||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TEXAS MUTUAL INSURANCE|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UMR|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UMR|2,893.25||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UMR|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|12,979.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UMR|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|115.73||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|115.73||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|115.73||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|654.50||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|GALLAGHER BASSETT|||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA|362.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.36||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TEXAS MUTUAL INSURANCE|2,893.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMP PHYSICIAN|||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.36||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17.36||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.36||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID BCBSTX|||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID|17.36||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MOLINA HEALTHCARE OF TEXAS|181.75||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.36||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MOLINA HEALTHCARE OF TEXAS|115.73||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MOLINA HEALTHCARE OF TEXAS|362.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|CRIME VICTIMS COMPENSATION|1,157.25||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|SMITH COUNTY JAIL|2,893.25||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|LAW ENFORCEMENT OTHER|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|192.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|362.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID|2,893.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|162.24||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|SMITH COUNTY JAIL|1,157.25||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|LAW ENFORCEMENT OTHER|5,786.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP MCR HMO MA|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|SMITH COUNTY INDIGENT HEALTH|654.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID BCBSTX|||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17,359.75||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID BCBSTX|||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|CRIME VICTIMS COMPENSATION|654.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP WELLMED HMO MA|115.73||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP MCR HMO MA|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID|654.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MOLINA HEALTHCARE OF TEXAS|1,157.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|CRIME VICTIMS COMPENSATION|5,786.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID|17,359.75||||17,359.75||| C1713|EAP|0278|IMPL SPACER LLIF SP 375.8|Medicare|MEDICARE ACUTE|20,820.75||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|1,157.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|654.50||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|17.36||||367.50||| C1713|EAP|0278|SI JOINT SYST SIMMETRY ZY|Medicare|MEDICARE ACUTE|200.20||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE PART B ONLY IP|115.73||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE PART B ONLY IP|5,786.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE PART B ONLY IP|1,157.25||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE PART B ONLY IP|654.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|181.75||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE PART B ONLY IP|181.75||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.36||||17.36||| C1713|EAP|0278|IMPL SPACER 9M 45M SP 375|Medicare|MEDICARE ACUTE|20,820.75||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|192.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|192.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|192.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID|362.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|192.50||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|12,979.25||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|LAW ENFORCEMENT OTHER|1,157.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MOLINA HEALTHCARE OF TEXAS|17.36||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|5,786.50||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|17,359.75||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|1,157.25||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|20,569.75||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP MCR HMO MA|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID|1,157.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|200.20||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|362.50||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|654.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|192.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MOLINA HEALTHCARE OF TEXAS|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|5,786.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID|5,786.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|SMITH COUNTY JAIL|654.50||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|181.75||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|SMITH COUNTY JAIL|5,786.50||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC MEDICARE GOLD MA|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|LAW ENFORCEMENT OTHER|115.73||||115.73||| C1713|EAP|0278|IMPL SPACER 7M 50M 375.20|Medicare|MEDICARE ACUTE|20,820.75||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|20,820.75||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|17.36||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE PART B ONLY IP|17.36||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC AARP MCR HMO MA|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID HMO|||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|115.73||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|CRIME VICTIMS COMPENSATION|17.36||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|17.36||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|376.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|BROOKSHIRES WORKERS COMP|||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicaid|MEDICAID HMO|||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|5,786.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|17,359.75||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|12,979.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|2,893.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UMR|654.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.36||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|TEXAS MUTUAL INSURANCE|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.36||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA|654.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|115.73||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|2,893.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|654.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.36||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMP PHYSICIAN|||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17,359.75||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UMR|5,786.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,157.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|181.75||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|115.73||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|654.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|362.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|162.24||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|192.50||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Access Direct Platinum|HEALTHFIRST TPA UMR|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|181.75||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1,157.25||| C1713|EAP|0278|IMPL SPACER 9M 40M SP 375|Medicare|MEDICARE ACUTE|20,820.75||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|362.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|1,157.25||||17.36||| C1713|EAP|0278|IMPL ASSY PRIMALOK SP 800|Managed Medicare|HEALTHSPRING MA|227.50||||24,227.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|200.20||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|162.24||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,893.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Veterans Affairs|VETERANS ADMINISTRATION|362.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|5,786.50||||115.73||| C1713|EAP|0278|IMPL ROD 12.5M 40M 10-P12|Medicare|MEDICARE ACUTE|20,569.75||||338.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|17.36||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|162.24||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|115.73||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|20,569.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12,979.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|BCBS MEDICARE PPO MA|181.75||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE PART B ONLY IP|362.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|2,893.25||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5,786.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|2,893.25||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|1,157.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|HEALTHSPRING MA|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|115.73||||367.50||| C1713|EAP|0278|IMPL STEM HUM REV 12M 108|Medicare|MEDICARE ACUTE|20,569.75||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|362.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|UTMB|UTMB CORRECTIONAL MANAGED CARE|5,786.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,893.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|19,424.25||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.36||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,157.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|UTMB|UTMB CORRECTIONAL MANAGED CARE|654.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|UTMB|UTMB CORRECTIONAL MANAGED CARE|362.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|UTMB|UTMB CORRECTIONAL MANAGED CARE|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|UTMB|UTMB CORRECTIONAL MANAGED CARE|115.73||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE OTHER|5,786.50||||2,893.25||| C1713|EAP|0278|IMPL OSTEOMATCH PEEK ACSM|United Healthcare|UNITED HEALTHCARE ERS|500.76||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE OTHER|17.36||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE OTHER|17,359.75||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE OTHER|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE OTHER|654.50||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE PART B ONLY IP|12,979.25||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|5,786.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|TML GROUP BENEFITS|362.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Workers Compensation|WORKERS COMPENSATION OTHER|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|362.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|654.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE ERS|654.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|2,893.25||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|GEHA|17,359.75||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|TML GROUP BENEFITS|2,893.25||||115.73||| C1713|EAP|0278|SI JOINT SYST SIMMETRY ZY|United Healthcare|UNITED HEALTHCARE|115.73||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE OTHER|115.73||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE OTHER|2,893.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE OTHER|1,157.25||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Medicare|MEDICARE ACUTE|227.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|17.36||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|TML GROUP BENEFITS|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|GEHA|115.73||||||| C1713|EAP|0278|IMPL ROD 12.5M 40M 10-P12|United Healthcare|UNITED HEALTHCARE OTHER|362.50||||338.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE ERS|362.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|GEHA|17.36||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|UNITED HEALTHCARE|1,157.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|United Healthcare|TML GROUP BENEFITS|2,893.25||||17,359.75||| C1713|EAP|0278|IMPL CAGE 21M SMALL|United Healthcare|UNITED HEALTHCARE|192.50||||192.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE EAST REGION|162.24||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Rusk State Hospital|RUSK STATE HOSP|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Rusk State Hospital|RUSK STATE HOSP|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Rusk State Hospital|RUSK STATE HOSP|2,893.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Rusk State Hospital|RUSK STATE HOSP|1,157.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Rusk State Hospital|RUSK STATE HOSP|654.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Rusk State Hospital|RUSK STATE HOSP|362.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE EAST REGION|362.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Texas Workforce Commission|DIS DETER SERV (DDS)|||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE EAST REGION|1,157.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|HUMANA|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|HUMANA|12,979.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|HUMANA|5,786.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|HUMANA|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|HUMANA|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|GROUP AND PENSION|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna Value Network|AETNA VALUE NETWORK|181.75||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|GROUP AND PENSION|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|GROUP AND PENSION|115.73||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|GROUP AND PENSION|5,786.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE FOR LIFE|5,786.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|GROUP AND PENSION|17,359.75||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE FOR LIFE|1,157.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE FOR LIFE|654.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|HUMANA|17.36||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE EAST REGION|238.00||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|HUMANA|2,893.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE EAST REGION|17,359.75||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE EAST REGION|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA OTHER|17.36||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE EAST REGION|2,893.25||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|HUMANA|17,359.75||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE EAST REGION|17.36||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|PHCS|HUMANA|181.75||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Tricare|TRICARE EAST REGION|654.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 1|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA PPO|17.36||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Multiplan|WEB TPA|1,157.25||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Multiplan|WEB TPA|17.36||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Multiplan|WEB TPA|5,786.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Multiplan|WEB TPA|115.73||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Multiplan|WEB TPA|654.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 1|175.93||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 1|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 1|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aetna|AETNA PPO|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 2|115.73||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 2|115.73||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 1|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Rusk State Hospital|RUSK STATE HOSP|181.75||||17,359.75||| C1713|EAP|0278|SI JOINT SYST SIMMETRY ZY|Aetna|AETNA PPO|12,979.25||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 1|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 1|17.36||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 1|2,893.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 1|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 2|1,157.25||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 2|115.73||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 2|115.73||||12,979.25||| C1713|EAP|0278|PTC PROXIMAL BODY 741701|NON CONTRACTED|COMMERCIAL OTHER 1|195.47||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|NON CONTRACTED|COMMERCIAL OTHER 2|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|17.36||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|2,893.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|362.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA OTHER|2,893.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA OTHER|115.73||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA OTHER|1,157.25||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA OTHER|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA OTHER|115.73||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|17,359.75||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|17.36||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|1,157.25||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|297.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|20,820.75||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|162.24||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|17.36||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|1,157.25||||12,979.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|362.50||||5,786.50||| C1713|EAP|0278|IMPL ROD 12.5M 40M 10-P12|Humana Medicare Advantage|HUMANA MA|192.50||||338.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|22,713.50||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|20,820.75||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|654.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|181.75||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID AMERIGROUP|5,786.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID AMERIGROUP|17.36||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID AMERIGROUP|1,157.25||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID AMERIGROUP|362.50||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|162.24||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,893.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.36||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID SUPERIOR|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID SUPERIOR|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID SUPERIOR|2,893.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID SUPERIOR|17.36||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID SUPERIOR|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID SUPERIOR|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID SUPERIOR|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID SUPERIOR|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|200.20||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID SUPERIOR|17,359.75||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,786.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,893.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.36||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,157.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|654.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|362.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|162.24||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|115.73||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|5,786.50||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|2,893.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|17.36||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|1,157.25||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|654.50||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross HMO Specialty|BCBSTX HMO|181.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|5,786.50||||162.24||| C1713|EAP|0278|SI JOINT SYST SIMMETRY ZY|Blue Cross PPO Specialty|BCBSTX PPO|12,979.25||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|5,786.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|20,820.75||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|20,820.75||||181.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|17,359.75||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|162.24||||367.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|2,893.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|17.36||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|1,157.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|2,893.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|362.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Humana Medicare Advantage|HUMANA MA|20,569.75||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX OTHER|115.73||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX OTHER|17.36||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|362.50||||362.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX OTHER|1,157.25||||654.50||| C1713|EAP|0278|IMPLANT ORBITAL FLOOR G1|Blue Cross PPO Specialty|BCBSTX PPO|192.50||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX PPO|654.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross PPO Specialty|BCBSTX OTHER|5,786.50||||2,893.25||| C1713|EAP|0278|CERVICAL DISC 13X15 STAND|Blue Cross PPO Specialty|BCBSTX PPO|192.50||||217.00||| C1713|EAP|0278|IMPL ROD 12.5M 40M 10-P12|Blue Cross PPO Specialty|BCBSTX PPO|192.50||||338.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17,359.75||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,786.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|12,979.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2,893.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.36||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,157.25||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|654.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA OTHER|115.73||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|362.50||||1,157.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|181.75||||654.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Cigna|CIGNA|2,893.25||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Brinson Benefits|THE HEALTH PLAN SMITH CO|17.36||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|ChampVA|CHAMPVA CENTER|362.50||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|ChampVA|CHAMPVA CENTER|1,157.25||||||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|115.73||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|162.24||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|5,786.50||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|2,893.25||||17,359.75||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|17.36||||115.73||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|1,157.25||||5,786.50||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|654.50||||2,893.25||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|362.50||||17.36||| C1713|EAP|0278|IMPLANT SCREW,CAGE, ROD,|Aenta Medicare Advantage|AETNA MEDICARE MA|181.75||||654.50||| C1713|EAP|0278|IMPL ROD 12.5M 40M 10-P12|Aenta Medicare Advantage|AETNA MEDICARE MA|391.30||||338.25||| C1714|EAP|0278|CATH, TRANS ATHERECTOMY,|Tricare|TRICARE EAST REGION|156.00||||||| C1714|EAP|0278|CATH, TRANS ATHERECTOMY,|United Healthcare|UNITED HEALTHCARE|156.00||||||| C1714|EAP|0278|HAWK ONE H1-M|United Healthcare|UNITED HEALTHCARE OTHER|||||168.26||| C1714|EAP|0278|HAWK ONE H1-S|Managed Medicare|HEALTHSPRING MA|168.26||||168.26||| C1714|EAP|0278|CATH, TRANS ATHERECTOMY,|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||156.00||| C1714|EAP|0278|HAWK ONE H1-M|Managed Medicare|HEALTHSPRING MA|156.00||||168.26||| C1714|EAP|0278|HAWK ONE H1-S|Medicare|MEDICARE ACUTE|156.00||||168.26||| C1714|EAP|0278|HAWK ONE H1-M|Medicare|MEDICARE ACUTE|156.00||||168.26||| C1714|EAP|0278|CATH, TRANS ATHERECTOMY,|Medicaid|MEDICAID|156.00||||||| C1714|EAP|0278|CATH, TRANS ATHERECTOMY,|Medicare|MEDICARE ACUTE|156.00||||156.00||| C1714|EAP|0278|HAWK ONE H1-S|Access Direct Platinum|HEALTHFIRST TPA UMR|168.26||||||| C1714|EAP|0278|HAWK ONE H1-M|Veterans Affairs|VETERANS ADMINISTRATION|||||168.26||| C1714|EAP|0278|CATH, TRANS ATHERECTOMY,|Veterans Affairs|VETERANS ADMINISTRATION|||||156.00||| C1714|EAP|0278|CATH, TRANS ATHERECTOMY,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||156.00||| C1714|EAP|0278|HAWK ONE H1-M|United Medicare Advantage|UHC AARP MCR HMO MA|||||168.26||| C1714|EAP|0278|HAWK ONE H1-M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|156.00||||168.26||| C1714|EAP|0278|HAWK ONE H1-M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|156.00||||168.26||| C1714|EAP|0278|HAWK ONE H1-S|United Healthcare|UNITED HEALTHCARE OTHER|||||168.26||| C1714|EAP|0278|HAWK ONE H1-M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||168.26||| C1714|EAP|0278|HAWK ONE H1-S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|156.00||||168.26||| C1714|EAP|0278|HAWK ONE H1-M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|156.00||||168.26||| C1714|EAP|0278|HAWK ONE H1-S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|156.00||||168.26||| C1714|EAP|0278|HAWK ONE H1-M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||168.26||| C1714|EAP|0278|HAWK ONE H1-M|Aetna|AETNA PPO|||||168.26||| C1714|EAP|0278|HAWK ONE H1-S|Blue Cross PPO Specialty|BCBSTX OTHER|168.26||||||| C1714|EAP|0278|HAWK ONE H1-M|Blue Cross PPO Specialty|BCBSTX PPO|156.00||||168.26||| C1714|EAP|0278|HAWK ONE H1-M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||168.26||| C1714|EAP|0278|CATH, TRANS ATHERECTOMY,|Managed Medicaid|MEDICAID AMERIGROUP|156.00||||||| C1714|EAP|0278|HAWK ONE H1-M|Humana Medicare Advantage|HUMANA MA|||||168.26||| C1714|EAP|0278|CATH, TRANS ATHERECTOMY,|Humana Medicare Advantage|HUMANA MA|||||156.00||| C1714|EAP|0278|HAWK ONE H1-S|Humana Medicare Advantage|HUMANA MA|||||168.26||| C1715|EAP|0278|SMARTNEEDLE BRACHIALE SC-|Cigna|CIGNA|697.25||||||| C1715|EAP|0278|SMARTNEEDLE BRACHIALE SC-|Humana Medicare Advantage|HUMANA MA|||||697.25||| C1715|EAP|0278|SMARTNEEDLE BRACHIALE SC-|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||697.25||| C1715|EAP|0278|SMARTNEEDLE BRACHIALE SC-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|697.25||||||| C1715|EAP|0278|SMARTNEEDLE BRACHIALE SC-|United Medicare Advantage|UHC AARP WELLMED HMO MA|697.25||||||| C1715|EAP|0278|SMARTNEEDLE BRACHIALE SC-|United Medicare Advantage|UHC AARP MCR HMO MA|||||697.25||| C1715|EAP|0278|SMARTNEEDLE BRACHIALE SC-|Access Direct Platinum|HEALTHFIRST TPA|697.25||||||| C1715|EAP|0278|SMARTNEEDLE BRACHIALE SC-|Medicare|MEDICARE ACUTE|697.25||||697.25||| C1715|EAP|0278|SMARTNEEDLE BRACHIALE SC-|Managed Medicare|BCBS MEDICARE PPO MA|||||697.25||| C1721|EAP|0278|EVERA MRI XT DR 7123640|United Healthcare|UNITED HEALTHCARE|60,042.50||||36,514.50||| C1721|EAP|0278|EVERA MRI XT DR 7123640|United Healthcare|UNITED HEALTHCARE|||||36,514.50||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Managed Medicare|HEALTHSPRING MA|||||36,514.50||| C1721|EAP|0278|ELLIPSE NEXT GEN DR 36 DF|Managed Medicare|HEALTHSPRING MA|||||38,605.25||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Medicaid|MEDICAID|||||36,514.50||| C1721|EAP|0278|IMPL EVERA MRI XT DR DDMB|Medicare|MEDICARE ACUTE|60,042.50||||60,042.50||| C1721|EAP|0278|EVERA MRI S DR SYSTEM 712|Medicare|MEDICARE ACUTE|60,042.50||||46,987.25||| C1721|EAP|0278|DYNAGEN EL DR D152, 153|Medicare|MEDICARE ACUTE|36,514.50||||589.75||| C1721|EAP|0278|FORTIFY ASSURA N G DR-40|Medicare|MEDICARE ACUTE|60,042.50||||51,105.50||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Medicare|MEDICARE ACUTE|60,042.50||||36,514.50||| C1721|EAP|0279||Medicare|MEDICARE ACUTE|32.10||||32.10||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Veterans Affairs|VETERANS ADMINISTRATION|36,514.50||||||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||36,514.50||| C1721|EAP|0278|IMPL EVERA MRI XT DR DDMB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||60,042.50||| C1721|EAP|0278|IMPL EVERA MRI XT DR DDMB|United Medicare Advantage|UHC MEDICARE GOLD MA|36,514.50||||60,042.50||| C1721|EAP|0278|IMPL EVERA MRI XT DR DDMB|United Medicare Advantage|UHC AARP MCR HMO MA|60,042.50||||60,042.50||| C1721|EAP|0278|IMPL EVERA MRI XT DR DDMB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||60,042.50||| C1721|EAP|0278|IMPL EVERA MRI XT DR DDMB|Blue Cross PPO Specialty|BCBSTX PPO|36,514.50||||60,042.50||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Blue Cross PPO Specialty|BCBSTX OTHER|36,514.50||||||| C1721|EAP|0278|EVERA MRI S DR SYSTEM 712|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36,514.50||||46,987.25||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|60,042.50||||36,514.50||| C1721|EAP|0278|IMPL EVERA MRI XT DR DDMB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|60,042.50||||36,514.50||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Managed Medicaid|MEDICAID UNITED HEALTHCARE|60,042.50||||36,514.50||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38,605.25||||36,514.50||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Managed Medicaid|MEDICAID AMERIGROUP|||||36,514.50||| C1721|EAP|0278|EVERA MRI XT DR 7123640|Humana Medicare Advantage|HUMANA MA|36,514.50||||36,514.50||| C1721|EAP|0278|IMPL EVERA MRI XT DR DDMB|Humana Medicare Advantage|HUMANA MA|36,514.50||||60,042.50||| C1722|EAP|0278|IMPL VISIA AF MRI VR DVFB|Humana Medicare Advantage|HUMANA MA|||||564.55||| C1722|EAP|0278|IMPL VISIA AF MRI SURESCA|Humana Medicare Advantage|HUMANA MA|||||564.69||| C1722|EAP|0278|IMPL VISIA AF MRI VR DVFB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|564.55||||564.55||| C1722|EAP|0278|IMPL VISIA AF MRI VR DVFB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||564.55||| C1722|EAP|0278|IMPL VISIA AF MRI SURESCA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||564.69||| C1722|EAP|0278|IMPL VISIA AF MRI VR DVFB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||564.55||| C1722|EAP|0278|VISIA AF MRI SINGLE CHAMB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||431.37||| C1722|EAP|0278|IMPL VISIA AF MRI VR DVFB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||564.55||| C1722|EAP|0278|ICD FORTIFY VR40 1231-40Q|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,104.87||| C1722|EAP|0278|IMPL VISIA AF MRI VR DVFB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|564.55||||||| C1722|EAP|0278|IMPL VISIA AF MRI VR DVFB|Medicare|MEDICARE ACUTE|564.69||||564.55||| C1722|EAP|0278|IMPL VISIA AF MRI SURESCA|Medicare|MEDICARE ACUTE|36,265.50||||564.69||| C1722|EAP|0278|IMPL VISIA AF MRI VR DVFB|NON CONTRACTED|COMMERCIAL OTHER 1|564.55||||||| C1722|EAP|0278|IMPL VISIA AF MRI SURESCA|UTMB|UTMB CORRECTIONAL MANAGED CARE|564.69||||||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|United Healthcare|TML GROUP BENEFITS|12,357.75||||||| C1724|EAP|0278|CROWN STEALTH 1.5 CLASSIC|United Healthcare|UNITED HEALTHCARE|||||22,047.25||| C1724|EAP|0278|CROWN STEALTH 2.0 CLASSIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||22,047.25||| C1724|EAP|0278|CROWN 30 GRIT STEALTH 1.2|Managed Medicare|BCBS MEDICARE PPO MA|||||22,047.25||| C1724|EAP|0278|CORONARY CLASSIC CROWN 1.|Managed Medicare|HEALTHSPRING MA|12,357.75||||219.60||| C1724|EAP|0278|CROWN 30 GRIT STEALTH 3.0|Managed Medicare|HEALTHSPRING MA|12,357.75||||22,047.25||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||12,357.75||| C1724|EAP|0278|CROWN 30 GRIT STEALTH 1.5|Managed Medicare|HEALTHSPRING MA|12,357.75||||22,047.25||| C1724|EAP|0278|CORONARY CLASSIC CROWN 1.|Managed Medicare|BCBS MEDICARE PPO MA|||||219.60||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||12,357.75||| C1724|EAP|0278|CROWN STEALTH 2.0 CLASSIC|Managed Medicare|HEALTHSPRING MA|12,357.75||||22,047.25||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Managed Medicare|HEALTHSPRING MA|12,357.75||||12,357.75||| C1724|EAP|0278|CROWN STEALTH 1.5 CLASSIC|Medicare|MEDICARE ACUTE|22,047.25||||22,047.25||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Medicare|MEDICARE PART B ONLY IP|12,357.75||||||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Medicare|MEDICARE ACUTE|12,357.75||||12,357.75||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Medicaid|MEDICAID|12,357.75||||||| C1724|EAP|0278|CATH CROWN 360 DBP-125 MI|Medicare|MEDICARE ACUTE|18,889.75||||18,889.75||| C1724|EAP|0278|CORONARY CLASSIC CROWN 1.|Medicare|MEDICARE ACUTE|219.60||||219.60||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Veterans Affairs|VETERANS ADMINISTRATION|||||12,357.75||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|United Medicare Advantage|UHC MEDICARE GOLD MA|18,889.75||||12,357.75||| C1724|EAP|0278|CROWN 30 GRIT STEALTH 3.0|United Medicare Advantage|UHC MEDICARE GOLD MA|12,357.75||||22,047.25||| C1724|EAP|0278|CROWN STEALTH 2.0 CLASSIC|United Medicare Advantage|UHC AARP MCR HMO MA|12,357.75||||22,047.25||| C1724|EAP|0278|CROWN STEALTH 2.0 CLASSIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22,047.25||| C1724|EAP|0278|CORONARY CLASSIC CROWN 1.|United Medicare Advantage|UHC MEDICARE GOLD MA|12,357.75||||219.60||| C1724|EAP|0278|CROWN STEALTH 1.5 CLASSIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22,047.25||| C1724|EAP|0278|CROWN 30 GRIT STEALTH 3.0|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22,047.25||| C1724|EAP|0278|CORONARY CLASSIC CROWN 1.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||219.60||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|United Medicare Advantage|UHC AARP MCR HMO MA|12,357.75||||12,357.75||| C1724|EAP|0278|CROWN STEALTH 1.5 CLASSIC|Managed Medicare|HEALTHSPRING MA|12,357.75||||22,047.25||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|PHCS|HUMANA|||||12,357.75||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12,357.75||| C1724|EAP|0278|CORONARY CLASSIC CROWN 1.|Blue Cross PPO Specialty|BCBSTX PPO|12,357.75||||219.60||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Blue Cross PPO Specialty|BCBSTX PPO|18,889.75||||12,357.75||| C1724|EAP|0278|CROWN 30 GRIT STEALTH 1.5|Aenta Medicare Advantage|AETNA MEDICARE MA|12,357.75||||22,047.25||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|219.60||||12,357.75||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12,357.75||||12,357.75||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12,357.75||||||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Managed Medicaid|MEDICAID AMERIGROUP|||||12,357.75||| C1724|EAP|0278|CROWN STEALTH 2.0 CLASSIC|Humana Medicare Advantage|HUMANA MA|219.60||||22,047.25||| C1724|EAP|0278|CORONARY CLASSIC CROWN 1.|Humana Medicare Advantage|HUMANA MA|219.60||||219.60||| C1724|EAP|0278|CATHETER CROWN STEALTH 1.|Humana Medicare Advantage|HUMANA MA|12,357.75||||12,357.75||| C1724|EAP|0278|CROWN 30 GRIT STEALTH 1.5|Humana Medicare Advantage|HUMANA MA|219.60||||22,047.25||| C1725|EAP|0272|CATH TREK RX 5.0X15 10122|Cigna|CIGNA|1,104.25||||1,104.25||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Cigna|CIGNA|11.56||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Cigna|CIGNA|||||11.56||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Cigna|CIGNA|9.73||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Humana Medicare Advantage|HUMANA MA|11.56||||1,337.50||| C1725|EAP|0272|SPRINTER CATH 2.0X15 SPR2|Humana Medicare Advantage|HUMANA MA|11.56||||11.56||| C1725|EAP|0272|SPRINTER CATH 1.5X12 SPR1|Humana Medicare Advantage|HUMANA MA|11.56||||11.56||| C1725|EAP|0272|CATH MINI TREK RX 2.0X8 1|Humana Medicare Advantage|HUMANA MA|55.64||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|Humana Medicare Advantage|HUMANA MA|1,104.25||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Humana Medicare Advantage|HUMANA MA|1,104.25||||11.56||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|Humana Medicare Advantage|HUMANA MA|1,104.25||||1,396.50||| C1725|EAP|0272|BALL NC TREK 3.5X12 10124|Humana Medicare Advantage|HUMANA MA|1,262.60||||1,104.25||| C1725|EAP|0272|BALL NC TREK 2.75X15 1012|Humana Medicare Advantage|HUMANA MA|11.56||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Humana Medicare Advantage|HUMANA MA|11.56||||9.73||| C1725|EAP|0272|BALL INVATEC AMP 3.5X120X|Humana Medicare Advantage|HUMANA MA|87.74||||1,954.25||| C1725|EAP|0272|BALL INVATEC AHU 2X60X150|Humana Medicare Advantage|HUMANA MA|1,396.50||||1,954.25||| C1725|EAP|0272|BALL INVATEC ADM 5X40X130|Humana Medicare Advantage|HUMANA MA|50.59||||1,052.50||| C1725|EAP|0272|BALL EVERCROSS OTW 035 PT|Humana Medicare Advantage|HUMANA MA|50.59||||23.75||| C1725|EAP|0272|CATH MINI TREK RX 1.5X12|Humana Medicare Advantage|HUMANA MA|1,104.25||||1,104.25||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Humana Medicare Advantage|HUMANA MA|53.50||||53.50||| C1725|EAP|0272|SPRINTER CATH 2.5X12 SPR2|Humana Medicare Advantage|HUMANA MA|11.56||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Humana Medicare Advantage|HUMANA MA|1,337.50||||53.50||| C1725|EAP|0272|GUIDE CATH 6F AL75 LA6AL7|Humana Medicare Advantage|HUMANA MA|11.56||||389.75||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Humana Medicare Advantage|HUMANA MA|1,391.50||||1,104.25||| C1725|EAP|0272|CATH TREK RX 2.5X12 10122|Humana Medicare Advantage|HUMANA MA|1,460.25||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Humana Medicare Advantage|HUMANA MA|1,104.25||||11.56||| C1725|EAP|0272|CATH BALL SPRINTERRX 3.5X|Humana Medicare Advantage|HUMANA MA|1,104.25||||11.56||| C1725|EAP|0272|BALL SPRINTER OTW 1.25X15|Humana Medicare Advantage|HUMANA MA|1,104.25||||11.56||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Humana Medicare Advantage|HUMANA MA|1,104.25||||11.56||| C1725|EAP|0272|BALL NC TREK 3.0X12 10124|Humana Medicare Advantage|HUMANA MA|1,262.60||||1,104.25||| C1725|EAP|0272|BALL INVATEC AMP 3.5X80X1|Humana Medicare Advantage|HUMANA MA|11.56||||1,954.25||| C1725|EAP|0272|BALL NC TREK 2.5X15 10124|Humana Medicare Advantage|HUMANA MA|11.56||||1,104.25||| C1725|EAP|0272|BALL INVATEC AHU 2X120X15|Humana Medicare Advantage|HUMANA MA|11.56||||1,954.25||| C1725|EAP|0272|BALL INVATEC ADM 5X40X80|Humana Medicare Advantage|HUMANA MA|9.73||||1,052.50||| C1725|EAP|0272|BALL INVATEC ADM 6X40X130|Humana Medicare Advantage|HUMANA MA|1,104.25||||1,052.50||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Humana Medicare Advantage|HUMANA MA|18,163.25||||107.00||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Humana Medicare Advantage|HUMANA MA|160.50||||107.00||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Humana Medicare Advantage|HUMANA MA|107.00||||107.00||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|53.50||||1,337.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,337.50||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Managed Medicaid|MEDICAID AMERIGROUP|1,337.50||||1,337.50||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.56||||11.56||| C1725|EAP|0272|CATH, TRANSLUMIN NON-LASE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.56||||1,391.50||| C1725|EAP|0272|CATH SABER 4.0X10X150C 48|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,337.50||||12.84||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|Managed Medicaid|MEDICAID AMERIGROUP|1,337.50||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.56||||11.56||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Managed Medicaid|MEDICAID AMERIGROUP|1,337.50||||11.56||| C1725|EAP|0272|BALL NC TREK 3.0X8 101244|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,391.50||||1,104.25||| C1725|EAP|0272|BALL NC TREK 3.0X20 10124|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.56||||1,104.25||| C1725|EAP|0272|BALL NC TREK 3.0X20 10124|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.73||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,396.50||||9.73||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,052.50||||9.73||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||160.50||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Managed Medicaid|MEDICAID AMERIGROUP|||||107.00||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.00||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,262.60||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,337.50||||53.50||| C1725|EAP|0272|SPRINTER CATH 2.5X12 SPR2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.56||||53.50||| C1725|EAP|0272|CATH, TRANSLUMIN NON-LASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.56||||1,391.50||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44.67||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,396.50||||11.56||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,104.25||||1,396.50||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,104.25||||53.50||| C1725|EAP|0272|SPRINTER CATH 2.5X12 SPR2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.56||||11.56||| C1725|EAP|0272|SPRINTER CATH 3.0X15 SPR3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.56||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|53.50||||53.50||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.56||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.56||||11.56||| C1725|EAP|0272|BALL NC TREK 2.5X12 10124|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.73||||1,104.25||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Aenta Medicare Advantage|AETNA MEDICARE MA|53.50||||11.56||| C1725|EAP|0272|CATH, TRANSLUMIN NON-LASE|Aenta Medicare Advantage|AETNA MEDICARE MA|53.50||||1,391.50||| C1725|EAP|0272|CATH BALL SPRINTERRX 3.5X|Aenta Medicare Advantage|AETNA MEDICARE MA|53.50||||11.56||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Aenta Medicare Advantage|AETNA MEDICARE MA|53.50||||11.56||| C1725|EAP|0272|BALL NC TREK 2.5X8 101244|Aenta Medicare Advantage|AETNA MEDICARE MA|1,337.50||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Aenta Medicare Advantage|AETNA MEDICARE MA|11.56||||9.73||| C1725|EAP|0272|BALL INVATEC ADM 6X120X13|Aenta Medicare Advantage|AETNA MEDICARE MA|1,104.25||||1,052.50||| C1725|EAP|0272|BALL INVATEC ADM 4X200X13|Aenta Medicare Advantage|AETNA MEDICARE MA|9.73||||14.13||| C1725|EAP|0272|BALL INVATEC ADM 5X40X80|Aenta Medicare Advantage|AETNA MEDICARE MA|11.56||||1,052.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Aetna|AETNA PPO|1,337.50||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Aetna|AETNA OTHER|11.56||||||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Aetna|AETNA PPO|11.56||||11.56||| C1725|EAP|0272|BALL INVATEC AMP 4X80X150|Aetna|AETNA PPO|11.56||||1,954.25||| C1725|EAP|0272|BALL INVATEC ADM 4X40X130|Aetna|AETNA PPO|11.56||||1,052.50||| C1725|EAP|0272|BALL CUT RX ANGIOSCULPT 2|Aetna|AETNA OTHER|50.59||||||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Brinson Benefits|THE HEALTH PLAN SMITH CO|1,337.50||||||| C1725|EAP|0272|CATH TREK RX 3.0X20 10122|Blue Cross PPO Specialty|BCBSTX PPO|11.56||||1,104.25||| C1725|EAP|0272|BALL INVATEC ADM 5X40X80|Blue Cross PPO Specialty|BCBSTX PPO|9.73||||1,052.50||| C1725|EAP|0272|BALL NC TREK 3.5X8 101245|Blue Cross PPO Specialty|BCBSTX PPO|11.56||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|Blue Cross PPO Specialty|BCBSTX PPO|1,104.25||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Blue Cross PPO Specialty|BCBSTX PPO|53.50||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Blue Cross PPO Specialty|BCBSTX PPO|53.50||||1,337.50||| C1725|EAP|0272|SPRINTER CATH 2.0X20 SPR2|Blue Cross PPO Specialty|BCBSTX PPO|53.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Blue Cross PPO Specialty|BCBSTX PPO|53.50||||11.56||| C1725|EAP|0272|COUGAR 190CM GUID- CGRXT1|Blue Cross PPO Specialty|BCBSTX PPO|1,337.50||||609.25||| C1725|EAP|0272|CATH TREK RX 2.5X08 10122|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||1,104.25||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Blue Cross PPO Specialty|BCBSTX PPO|1,460.25||||1,104.25||| C1725|EAP|0272|CATH DIL 6M 20M 424-6020W|Blue Cross PPO Specialty|BCBSTX PPO|1,104.25||||1,262.60||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Blue Cross PPO Specialty|BCBSTX PPO|1,104.25||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Blue Cross PPO Specialty|BCBSTX OTHER|11.56||||9.73||| C1725|EAP|0272|CATH BALLOON DILATATION B|Blue Cross PPO Specialty|BCBSTX PPO|11.56||||3,114.50||| C1725|EAP|0272|CATH BALL SPRINTERRX 3.5X|Blue Cross PPO Specialty|BCBSTX OTHER|11.56||||9.73||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Blue Cross PPO Specialty|BCBSTX PPO|3,114.50||||11.56||| C1725|EAP|0272|BALL NC TREK 3.0X20 10124|Blue Cross PPO Specialty|BCBSTX PPO|11.56||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Blue Cross PPO Specialty|BCBSTX PPO|1,104.25||||9.73||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Blue Cross HMO Specialty|BCBSTX HMO|11.56||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Blue Cross HMO Specialty|BCBSTX HMO|11.56||||1,337.50||| C1725|EAP|0272|CATH TREK RX 2.5X12 10122|Blue Cross HMO Specialty|BCBSTX HMO|11.56||||1,104.25||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Blue Cross HMO Specialty|BCBSTX HMO|11.56||||11.56||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Blue Cross HMO Specialty|BCBSTX HMO|9.73||||9.73||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Blue Cross HMO Specialty|BCBSTX HMO|11.56||||11.56||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Blue Cross PPO Specialty|BCBSTX PPO|107.00||||187.25||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Blue Cross PPO Specialty|BCBSTX PPO|11.56||||11.56||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Blue Cross PPO Specialty|BCBSTX PPO|107.00||||107.00||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|United Medicare Advantage|UHC AARP MCR HMO MA|53.50||||1,337.50||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|United Medicare Advantage|UHC AARP MCR HMO MA|11.56||||11.56||| C1725|EAP|0272|BALL INVATEC ADM 5X200X13|United Medicare Advantage|UHC AARP MCR HMO MA|9.73||||14.13||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||11.56||| C1725|EAP|0272|BALL INVATEC ADM 6X40X130|United Medicare Advantage|UHC AARP MCR HMO MA|1,104.25||||1,052.50||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.56||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.56||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.50||||1,337.50||| C1725|EAP|0272|BALL INVATEC ADM 4X200X13|United Medicare Advantage|UHC MEDICARE GOLD MA|1,104.25||||14.13||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.50||||11.56||| C1725|EAP|0272|CATH BALL SPRINTERRX 3.5X|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,104.25||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|United Medicare Advantage|UHC MEDICARE GOLD MA|11.56||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X15 SPR2|United Medicare Advantage|UHC AARP MCR HMO MA|53.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 1.5X12 SPR1|United Medicare Advantage|UHC AARP MCR HMO MA|1,337.50||||11.56||| C1725|EAP|0272|BALL NC EUPHORA RX G1|United Medicare Advantage|UHC MEDICARE GOLD MA|11.56||||9.73||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||53.50||| C1725|EAP|0272|BALL INVATEC ADM 6X60X80|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.73||||1,052.50||| C1725|EAP|0272|GUIDE CATH 6F AL75 LA6AL7|United Medicare Advantage|UHC AARP MCR HMO MA|11.56||||389.75||| C1725|EAP|0272|SPRINTER CATH 2.5X12 SPR2|United Medicare Advantage|UHC AARP MCR HMO MA|53.50||||11.56||| C1725|EAP|0272|BALL INVATEC AMP 2.5X120X|United Medicare Advantage|UHC MEDICARE GOLD MA|11.56||||1,954.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|United Medicare Advantage|UHC AARP MCR HMO MA|11.56||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.5X12 SPR2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.5X12 SPR2|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||11.56||| C1725|EAP|0272|BALL EVERCROSS OTW 035 PT|United Medicare Advantage|UHC MEDICARE GOLD MA|9.73||||23.75||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,104.25||||11.56||| C1725|EAP|0272|SPRINTER CATH 1.5X15 SPR1|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|United Medicare Advantage|UHC AARP MCR HMO MA|53.50||||11.56||| C1725|EAP|0272|BALL INVATEC AMP 4X80X150|United Medicare Advantage|UHC AARP MCR HMO MA|11.56||||1,954.25||| C1725|EAP|0272|BALL NC TREK 2.5X15 10124|United Medicare Advantage|UHC AARP MCR HMO MA|11.56||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,104.25||||9.73||| C1725|EAP|0272|BALL INVATEC AMP 3.5X120X|United Medicare Advantage|UHC MEDICARE GOLD MA|11.56||||1,954.25||| C1725|EAP|0272|CATH MINI TREK RX 2.0X8 1|United Medicare Advantage|UHC AARP MCR HMO MA|11.56||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,337.50||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||1,337.50||| C1725|EAP|0272|BALL NC EUPHORA RX G1|United Medicare Advantage|UHC AARP MCR HMO MA|3,114.50||||9.73||| C1725|EAP|0272|BALL INVATEC AMP 2.5X150X|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,104.25||||23.75||| C1725|EAP|0272|BALL INVATEC ADM 4X150X13|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|50.59||||1,232.50||| C1725|EAP|0272|CATH BALL SPRINTERRX 3.5X|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||11.56||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|United Medicare Advantage|UHC MEDICARE GOLD MA|1,391.50||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|United Medicare Advantage|UHC AARP MCR HMO MA|53.50||||53.50||| C1725|EAP|0272|COUGAR 190CM GUID- CGRXT1|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||609.25||| C1725|EAP|0272|CATH MINI TREK RX 1.5X20|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.50||||1,104.25||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|107.00||||||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|United Medicare Advantage|UHC AARP MCR HMO MA|160.50||||107.00||| C1725|EAP|0278|CATH STEALTH CROWN 360 DB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||18,163.25||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.56||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,337.50||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,104.25||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Access Direct Platinum|HEALTHFIRST TPA UMR|11.56||||1,337.50||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Access Direct Platinum|HEALTHFIRST TPA UMR|9.73||||11.56||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.56||||1,104.25||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.56||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|Access Direct Platinum|HEALTHFIRST TPA|9.73||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.56||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|11.56||||||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,104.25||||11.56||| C1725|EAP|0272|CATH BALLOON DILATATION B|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.56||||3,114.50||| C1725|EAP|0272|BALL NC TREK 4.0X15 10124|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|1,104.25||||||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|50.59||||9.73||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.73||||9.73||| C1725|EAP|0272|BALL NC TREK 3.5X8 101245|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|11.56||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.73||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.56||||11.56||| C1725|EAP|0272|CATH TREK RX 30.X12 10122|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,104.25||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.73||||9.73||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||107.00||| C1725|EAP|0278|CATH STEALTH CROWN 360 DB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|18,163.25||||||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Veterans Affairs|VETERANS ADMINISTRATION|3,114.50||||1,337.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Veterans Affairs|VETERANS ADMINISTRATION|1,337.50||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||53.50||| C1725|EAP|0272|SPRINTER CATH 2.5X15 SPR2|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||53.50||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,104.25||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||53.50||| C1725|EAP|0272|SPRINTER CATH 1.5X15 SPR1|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||53.50||| C1725|EAP|0272|CATH, TRANSLUMIN NON-LASE|Veterans Affairs|VETERANS ADMINISTRATION|55.64||||53.50||| C1725|EAP|0272|CATH, TRANSLUMIN NON-LASE|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||1,391.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,104.25||||53.50||| C1725|EAP|0272|CATH TREK RX 2.5X12 10122|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||1,104.25||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Veterans Affairs|VETERANS ADMINISTRATION|1,104.25||||53.50||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||53.50||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|53.50||||53.50||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL1|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||53.50||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||107.00||| C1725|EAP|0272|BALL NC TREK 3.5X12 10124|Veterans Affairs|VETERANS ADMINISTRATION|11.56||||1,104.25||| C1725|EAP|0272|BALL NC TREK 3.0X20 10124|Veterans Affairs|VETERANS ADMINISTRATION|1,104.25||||1,104.25||| C1725|EAP|0272|BALL NC TREK 2.75X20 1012|Veterans Affairs|VETERANS ADMINISTRATION|1,104.25||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Veterans Affairs|VETERANS ADMINISTRATION|9.73||||9.73||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Veterans Affairs|VETERANS ADMINISTRATION|||||160.50||| C1725|EAP|0278|CATH STEALTH CROWN 360 DB|Veterans Affairs|VETERANS ADMINISTRATION|||||18,163.25||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|United Medicare Advantage|UHC MEDICARE GOLD MA|1,262.60||||1,396.50||| C1725|EAP|0272|CATH MINI TREK RX 2.0X30|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|CATH TREK RX 2.5X12 10122|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|CATH TREK RX 3.0X20 10122|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|BALL INVATEC AMP 3.5-4.0X|United Medicare Advantage|UHC MEDICARE GOLD MA|11.56||||23.75||| C1725|EAP|0272|BALL INVATEC ADM 5X200X13|Medicare|MEDICARE ACUTE|1,954.25||||14.13||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Medicare|MEDICARE ACUTE|11.56||||11.56||| C1725|EAP|0272|CATH, TRANSLUMIN NON-LASE|Medicare|MEDICARE ACUTE|1,104.25||||1,391.50||| C1725|EAP|0272|CATH BALL 5X60X130 ADM050|Medicare|MEDICARE ACUTE|3,114.50||||7,971.50||| C1725|EAP|0272|BALL SPRINTER OTW 1.25X15|United Medicare Advantage|UHC AARP MCR HMO MA|11.56||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X15 SPR2|Medicare|MEDICARE ACUTE|11.56||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X20 SPR2|Medicare|MEDICARE ACUTE|11.56||||11.56||| C1725|EAP|0272|BALL NC TREK 2.5X15 10124|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|SPRINTER CATH 2.5X20 SPR2|Medicare|MEDICARE ACUTE|53.50||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Medicare|MEDICARE ACUTE|53.50||||53.50||| C1725|EAP|0272|SPRINTER CATH 3.0X20 SPR3|Medicare|MEDICARE ACUTE|53.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.5X15 SPR2|Medicare|MEDICARE ACUTE|53.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.5X12 SPR2|Medicare|MEDICARE ACUTE|1,337.50||||11.56||| C1725|EAP|0272|BALL INVATEC ADM 5X40X80|United Medicare Advantage|UHC MEDICARE GOLD MA|44.67||||1,052.50||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||1,104.25||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Medicare|MEDICARE ACUTE|11.56||||11.56||| C1725|EAP|0272|SPRINTER CATH 1.5X12 SPR1|Medicare|MEDICARE ACUTE|389.75||||11.56||| C1725|EAP|0272|GUIDE CATH 6F AL75 LA6AL7|Medicare|MEDICARE ACUTE|609.25||||389.75||| C1725|EAP|0272|CATHETER BALLOON MAVERICK|Medicare|MEDICARE ACUTE|1,460.25||||1,460.25||| C1725|EAP|0272|CATH MINI TREK RX 2.0X8 1|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||1,104.25||| C1725|EAP|0272|CATH TREK RX 3.0X08 10122|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|CATH TREK RX 2.5X08 10122|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|CATH SAILOR 4X8 SAE040080|Medicare|MEDICARE ACUTE|1,104.25||||561.75||| C1725|EAP|0272|CATH MINI TREK RX 1.5X15|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|Medicare|MEDICARE ACUTE|1,262.60||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Medicare|MEDICARE ACUTE|11.56||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Medicare|MEDICARE ACUTE|11.56||||11.56||| C1725|EAP|0272|BALLOON CATH CB1413535120|Medicare|MEDICARE ACUTE|11.56||||44.67||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|Medicare|MEDICARE PART B ONLY IP|1,396.50||||||| C1725|EAP|0272|BALL NC TREK 4.5X20 10124|Medicare|MEDICARE ACUTE|1,396.50||||1,104.25||| C1725|EAP|0272|BALL NC TREK 3.0X8 101244|Medicare|MEDICARE ACUTE|11.56||||1,104.25||| C1725|EAP|0272|BALL NC TREK 3.0X15 10124|Medicare|MEDICARE PART B ONLY IP|1,104.25||||||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|United Medicare Advantage|UHC AARP MCR HMO MA|11.56||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|United Medicare Advantage|UHC AARP MCR HMO MA|1,104.25||||11.56||| C1725|EAP|0272|SPRINTER CATH 1.5X12 SPR1|United Medicare Advantage|UHC MEDICARE GOLD MA|1,337.50||||11.56||| C1725|EAP|0272|BALL NC TREK 3.0X15 10124|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|BALL NC TREK 3.0X12 10124|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|BALL NC TREK 2.5X12 10124|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Medicare|MEDICARE ACUTE|1,104.25||||9.73||| C1725|EAP|0272|BALL INVATEC ADM 6X20X80|Medicare|MEDICARE ACUTE|23.75||||1,052.50||| C1725|EAP|0272|BALL INVATEC ADM 5X150X13|Medicare|MEDICARE ACUTE|1,052.50||||1,232.50||| C1725|EAP|0272|SPRINTER CATH 3.0X15 SPR3|Medicare|MEDICARE ACUTE|53.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.5X10 SPR2|Medicare|MEDICARE ACUTE|11.56||||11.56||| C1725|EAP|0272|BALL SPRINTER OTW 1.25X15|Medicare|MEDICARE ACUTE|44.67||||11.56||| C1725|EAP|0272|BALL NC TREK 4.0X15 10124|Medicare|MEDICARE ACUTE|11.04||||1,104.25||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Medicare|MEDICARE PART B ONLY IP|1,337.50||||||| C1725|EAP|0272|BALL CUT RX ANGIOSCULPT 3|Medicare|MEDICARE ACUTE|50.59||||50.59||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Blue Cross HMO Specialty|BCBSTX HMO|11.56||||11.56||| C1725|EAP|0272|BALL NC TREK 2.0X15 10124|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|Medicare|MEDICARE ACUTE|11.56||||1,396.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Medicare|MEDICARE ACUTE|53.50||||1,337.50||| C1725|EAP|0272|SPRINTER CATH 1.5X15 SPR1|Medicare|MEDICARE ACUTE|11.56||||11.56||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Blue Cross PPO Specialty|BCBSTX OTHER|9.73||||9.73||| C1725|EAP|0272|CATH TREK RX 2.5X15 10122|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|BALL NC TREK 3.0X20 10124|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|BALL NC TREK 3.5X12 10124|Medicare|MEDICARE ACUTE|11.56||||1,104.25||| C1725|EAP|0272|BALL NC TREK 4.0X20 10124|Medicare|MEDICARE PART B ONLY IP|1,104.25||||||| C1725|EAP|0272|CATH BALL SPRINTERRX 3.5X|Medicare|MEDICARE ACUTE|11.56||||11.56||| C1725|EAP|0272|CATH MINI TREK RX 2.0X8 1|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|BALL INVATEC ADM 6X60X130|Medicare|MEDICARE ACUTE|9.73||||1,052.50||| C1725|EAP|0272|BALL NC TREK 2.5X20 10124|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|Blue Cross PPO Specialty|BCBSTX OTHER|11.56||||9.73||| C1725|EAP|0272|CATH TREK RX 5.0X15 10122|Blue Cross PPO Specialty|BCBSTX PPO|11.56||||1,104.25||| C1725|EAP|0272|BALL NC TREK 2.5X8 101244|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C1725|EAP|0272|CATH MINI TREK RX 1.5X12|Medicare|MEDICARE ACUTE|1,262.60||||1,104.25||| C1725|EAP|0272|CATH, TRANSLUMIN NON-LASE|Medicare|MEDICARE ACUTE|1,391.50||||55.64||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Medicare|MEDICARE ACUTE|160.50||||160.50||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Medicare|MEDICARE ACUTE|107.00||||107.00||| C1725|EAP|0278|CATH STEALTH CROWN 360 DB|Medicare|MEDICARE ACUTE|18,163.25||||18,163.25||| C1725|EAP|0272|CATH ANGIOPLASTY|Medicaid|MEDICAID|948.25||||9.73||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|Medicaid|MEDICAID|1,396.50||||9.73||| C1725|EAP|0272|SPRINTER CATH 2.5X15 SPR2|Blue Cross PPO Specialty|BCBSTX PPO|53.50||||11.56||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Medicaid|LAW ENFORCEMENT OTHER|9.73||||||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Medicaid|MEDICAID|11.56||||9.73||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Medicaid|MEDICAID|9.73||||9.73||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Medicaid|MEDICAID|1,337.50||||9.73||| C1725|EAP|0272|BALL NC TREK 3.5X12 10124|Aetna|AETNA OTHER|1,104.25||||||| C1725|EAP|0272|CATHETER BALLOON MAVERICK|Medicaid|SMITH COUNTY INDIGENT HEALTH|1,460.25||||||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|Medicaid|MEDICAID|11.56||||9.73||| C1725|EAP|0272|SPRINTER CATH 2.5X12 SPR2|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||11.56||| C1725|EAP|0272|BALL NC TREK 3.0X12 10124|Managed Medicare|HEALTHSPRING MA|11.56||||1,104.25||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Aetna|AETNA OTHER|11.56||||||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Aenta Medicare Advantage|AETNA MEDICARE MA|107.00||||||| C1725|EAP|0272|BALL NC TREK 4.0X15 10124|Managed Medicare|HEALTHSPRING MA|389.75||||1,104.25||| C1725|EAP|0272|SPRINTER CATH 2.0X15 SPR2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|53.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 1.5X12 SPR1|Managed Medicare|BCBS MEDICARE PPO MA|11.56||||11.56||| C1725|EAP|0272|BALL NC TREK 3.0X8 101244|Managed Medicare|HEALTHSPRING MA|1,104.25||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL3|Managed Medicare|HEALTHSPRING MA|53.50||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Managed Medicare|HEALTHSPRING MA|53.50||||11.56||| C1725|EAP|0272|BALL SPRINTER OTW 1.25X15|Managed Medicare|HEALTHSPRING MA|11.56||||11.56||| C1725|EAP|0272|CATH MINI TREK RX 1.5X12|Managed Medicare|HEALTHSPRING MA|53.50||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Aenta Medicare Advantage|AETNA MEDICARE MA|53.50||||11.56||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Managed Medicare|BCBS MEDICARE PPO MA|11.56||||9.73||| C1725|EAP|0272|SPRINTER CATH 2.0X20 SPR2|Managed Medicare|BCBS MEDICARE PPO MA|11.56||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Managed Medicare|HEALTHSPRING MA|53.50||||1,337.50||| C1725|EAP|0272|BALL INVATEC AMP 3.5X40X1|Managed Medicare|HEALTHSPRING MA|1,396.50||||1,954.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,052.50||||9.73||| C1725|EAP|0272|BALL INVATEC ADM 5X40X130|Managed Medicare|HEALTHSPRING MA|1,104.25||||1,052.50||| C1725|EAP|0272|SPRINTER CATH 2.0X6 SPR20|Managed Medicare|HEALTHSPRING MA|53.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Managed Medicare|HEALTHSPRING MA|53.50||||11.56||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1,396.50||| C1725|EAP|0272|CATH TREK RX 2.5X12 10122|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.56||||1,104.25||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||1,396.50||| C1725|EAP|0272|BALL INVATEC AHU 2X80X150|Managed Medicare|HEALTHSPRING MA|1,104.25||||1,954.25||| C1725|EAP|0272|SPRINTER CATH 1.5X15 SPR1|Managed Medicare|BCBS MEDICARE PPO MA|11.56||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Managed Medicare|HEALTHSPRING MA|53.50||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1,337.50||| C1725|EAP|0272|SPRINTER CATH 1.5X15 SPR1|Managed Medicare|HEALTHSPRING MA|53.50||||11.56||| C1725|EAP|0272|BALL NC TREK 4.5X15 10124|Managed Medicare|HEALTHSPRING MA|11.56||||1,104.25||| C1725|EAP|0272|BALL NC TREK 3.5X12 10124|Managed Medicare|BCBS MEDICARE PPO MA|11.56||||1,104.25||| C1725|EAP|0272|SPRINTER CATH 2.0X6 SPR20|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.56||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.56||||1,337.50||| C1725|EAP|0272|SPRINTER CATH 2.0X20 SPR2|Managed Medicare|HEALTHSPRING MA|53.50||||11.56||| C1725|EAP|0272|BALL INVATEC AMP 3.5X80X1|Managed Medicare|HEALTHSPRING MA|11.56||||1,954.25||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|53.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|53.50||||11.56||| C1725|EAP|0272|BALL INVATEC AMP 3.5X120X|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.73||||1,954.25||| C1725|EAP|0272|CATH BALL SPRINTERRX 3.5X|Managed Medicare|HEALTHSPRING MA|53.50||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER SPL301|Managed Medicare|BCBS MEDICARE PPO MA|11.56||||11.56||| C1725|EAP|0272|BALL INVATEC ADM 5X150X13|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,396.50||||1,232.50||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|53.50||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Managed Medicare|HEALTHSPRING MA|53.50||||53.50||| C1725|EAP|0272|GUIDE CATH 6F AL75 LA6AL7|Managed Medicare|BCBS MEDICARE PPO MA|11.56||||389.75||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.56||||11.56||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Managed Medicare|BCBS MEDICARE PPO MA|11.56||||11.56||| C1725|EAP|0272|BALL INVATEC AHU 2.5X30X1|Managed Medicare|HEALTHSPRING MA|1,104.25||||1,954.25||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|Managed Medicare|OTHER INSTITUTIONS|||||1,396.50||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Managed Medicare|BCBS MEDICARE PPO MA|11.56||||11.56||| C1725|EAP|0272|BALL INVATEC ADM 5X40X80|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.56||||1,052.50||| C1725|EAP|0272|BALL INVATEC ADM 4X200X13|Managed Medicare|HEALTHSPRING MA|9.73||||14.13||| C1725|EAP|0272|CATH, TRANSLUMIN NON-LASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|53.50||||1,391.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|53.50||||11.56||| C1725|EAP|0272|BALL INVATEC ADM 5X40X80|Managed Medicare|HEALTHSPRING MA|1,104.25||||1,052.50||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|Managed Medicare|HEALTHSPRING MA|1,337.50||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1,337.50||| C1725|EAP|0272|BALL INVATEC ADM 6X60X80|Managed Medicare|HEALTHSPRING MA|1,104.25||||1,052.50||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,337.50||||9.73||| C1725|EAP|0272|BALLOON CATH CB1413535120|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|53.50||||44.67||| C1725|EAP|0272|BALL NC TREK 2.0X15 10124|Managed Medicare|HEALTHSPRING MA|11.56||||1,104.25||| C1725|EAP|0272|BALL INVATEC AMP 3.5-4.0X|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,262.60||||23.75||| C1725|EAP|0272|BALL INVATEC ADM 6X60X130|Humana Medicare Advantage|HUMANA MA|1,104.25||||1,052.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||53.50||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Managed Medicare|HEALTHSPRING MA|11.56||||9.73||| C1725|EAP|0272|BALL NC TREK 2.0X15 10124|Humana Medicare Advantage|HUMANA MA|3,114.50||||1,104.25||| C1725|EAP|0272|BALL INVATEC ADM 5X80X130|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.56||||1,052.50||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Managed Medicare|HEALTHSPRING MA|107.00||||||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|160.50||||||| C1725|EAP|0278|VASCULAR BALLOON CATHETER|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||160.50||| C1725|EAP|0272|BALLOON ANGIOPLASTY CATHE|Multiplan|WEB TPA|||||1,396.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|NON CONTRACTED|COMMERCIAL OTHER 1|1,337.50||||53.50||| C1725|EAP|0272|BALL INVATEC AMP 3.0-3.5X|Humana Medicare Advantage|HUMANA MA|44.67||||23.75||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|NON CONTRACTED|COMMERCIAL OTHER 1|1,104.25||||53.50||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|NON CONTRACTED|COMMERCIAL OTHER 1|11.56||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|NON CONTRACTED|COMMERCIAL OTHER 1|53.50||||53.50||| C1725|EAP|0272|BALL NC EUPHORA RX G1|NON CONTRACTED|COMMERCIAL OTHER 1|9.73||||9.73||| C1725|EAP|0272|CATH, TRANSLUMIN NON-LASE|Humana Medicare Advantage|HUMANA MA|389.75||||1,391.50||| C1725|EAP|0272|CATH BALL SPRINTERRX 3.5X|NON CONTRACTED|COMMERCIAL OTHER 1|11.56||||11.56||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1,337.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|PHCS|HUMANA|9.73||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|PHCS|GROUP AND PENSION|53.50||||||| C1725|EAP|0272|BALL INVATEC ADM 5X80X130|Humana Medicare Advantage|HUMANA MA|1,104.25||||1,052.50||| C1725|EAP|0272|GUIDE CATH 6F AL75 LA6AL7|PHCS|HUMANA|389.75||||53.50||| C1725|EAP|0272|CATH TREK RX 3.0X20 10122|PHCS|HUMANA|1,104.25||||53.50||| C1725|EAP|0272|BALL NC TREK 2.5X12 10124|Humana Medicare Advantage|HUMANA MA|11.56||||1,104.25||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Tricare|TRICARE EAST REGION|1,337.50||||1,104.25||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Tricare|TRICARE FOR LIFE|11.56||||||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|Tricare|TRICARE EAST REGION|1,337.50||||11.56||| C1725|EAP|0272|BALL NC TREK 2.0X20 10124|Tricare|TRICARE EAST REGION|1,337.50||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|Tricare|TRICARE EAST REGION|1,337.50||||9.73||| C1725|EAP|0272|BALL SPRINTER OTW 1.25X15|Tricare|TRICARE EAST REGION|1,337.50||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|Humana Medicare Advantage|HUMANA MA|11.56||||11.56||| C1725|EAP|0272|BALL NC TREK 2.25X15 1012|Tricare|TRICARE EAST REGION|1,337.50||||1,104.25||| C1725|EAP|0272|CATHETER BALLOON MAVERICK|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,460.25||||||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.56||||||| C1725|EAP|0272|SPRINTER CATH 2.0X15 SPR2|United Healthcare|UNITED HEALTHCARE|53.50||||11.56||| C1725|EAP|0272|CATH MINI TREK RX 2.0X12|Cigna|CIGNA|11.56||||1,104.25||| C1725|EAP|0272|GUIDE CATH 6F AL75 LA6AL7|United Healthcare|UNITED HEALTHCARE OTHER|389.75||||11.56||| C1725|EAP|0272|SPRINTER CATH 2.0X12 SPR2|United Healthcare|UNITED HEALTHCARE|1,262.60||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|United Healthcare|GOLDEN RULE|11.56||||||| C1725|EAP|0272|BALL NC TREK 3.5X12 10124|United Healthcare|UNITED HEALTHCARE|11.56||||1,104.25||| C1725|EAP|0272|BALL NC EUPHORA RX G1|United Healthcare|UNITED HEALTHCARE|9.73||||9.73||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|United Healthcare|UNITED HEALTHCARE|53.50||||53.50||| C1725|EAP|0272|VASCULAR BALLOON CATHETER|United Healthcare|TML GROUP BENEFITS|1,337.50||||||| C1725|EAP|0272|CATH TREK RX 2.5X08 10122|United Healthcare|GOLDEN RULE|1,104.25||||||| C1725|EAP|0272|GUIDE CATH 6F AL75 LA6AL7|United Healthcare|UNITED HEALTHCARE|389.75||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|United Healthcare|UNITED HEALTHCARE OTHER|11.56||||11.56||| C1725|EAP|0272|CATH BALL SPRINTER RX 1.5|United Healthcare|UNITED HEALTHCARE|11.56||||11.56||| C1725|EAP|0272|CATH BALLS PRINTER/LS PL2|United Healthcare|TML GROUP BENEFITS|11.56||||||| C1725|EAP|0272|BALL NC EUPHORA RX G1|United Healthcare|UNITED HEALTHCARE OTHER|9.73||||9.73||| C1725|EAP|0272|SPRINTER CATH 2.5X15 SPR2|United Healthcare|UNITED HEALTHCARE OTHER|11.56||||11.56||| C1726|EAP|0272|TTS BALLOON|Rusk State Hospital|RUSK STATE HOSP|||||1,302.75||| C1726|EAP|0272|TTS BALLOON|Tricare|TRICARE EAST REGION|||||1,302.75||| C1726|EAP|0272|BILIARY BALLOON DILATOR|Managed Medicare|OTHER INSTITUTIONS|||||8.50||| C1726|EAP|0272|BILIARY BALLOON DILATOR|Managed Medicare|HEALTHSPRING MA|1,302.75||||8.50||| C1726|EAP|0272|TTS BALLOON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.50||||1,302.75||| C1726|EAP|0272|MIC-KEY TRANSGASTRIC FEED|Medicaid|MEDICAID HMO|||||2,537.25||| C1726|EAP|0272|ELIMINATOR BILLARY BALLOO|Medicare|MEDICARE ACUTE|45.48||||1,391.50||| C1726|EAP|0272|DIALATOR RENAL COOK 07500|Medicare|MEDICARE ACUTE|1,047.26||||1,302.75||| C1726|EAP|0272|FORTREX PTA BALLOON|Medicare|MEDICARE ACUTE|786.50||||1,302.75||| C1726|EAP|0272|BILIARY BALLOON DILATOR|Medicare|MEDICARE ACUTE|8.50||||8.50||| C1726|EAP|0272|TTS BALLOON|Medicare|MEDICARE ACUTE|1,302.75||||1,302.75||| C1726|EAP|0272|TTS BALLOON|Veterans Affairs|VETERANS ADMINISTRATION|1,302.75||||||| C1726|EAP|0272|TTS BALLOON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,302.75||||1,302.75||| C1726|EAP|0272|TTS BALLOON|Medicare|MEDICARE ACUTE|45.48||||1,302.75||| C1726|EAP|0272|TTS BALLOON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,302.75||| C1726|EAP|0272|TTS BALLOON|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,302.75||| C1726|EAP|0272|TTS BALLOON|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,302.75||| C1726|EAP|0272|TTS BALLOON|United Medicare Advantage|UHC AARP MCR HMO MA|1,302.75||||1,302.75||| C1726|EAP|0272|TTS BALLOON|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1,302.75||| C1726|EAP|0272|TTS BALLOON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,302.75||| C1726|EAP|0272|TTS BALLOON|United Medicare Advantage|UHC AARP MCR HMO MA|8.50||||1,302.75||| C1726|EAP|0272|TTS BALLOON|United Medicare Advantage|UHC MEDICARE GOLD MA|1,302.75||||1,302.75||| C1726|EAP|0272|TTS BALLOON|United Medicare Advantage|UHC MEDICARE GOLD MA|8.50||||1,302.75||| C1726|EAP|0272|TTS BALLOON|United Healthcare|UNITED HEALTHCARE OTHER|||||1,302.75||| C1726|EAP|0272|TTS BALLOON|Blue Cross PPO Specialty|BCBSTX PPO|1,302.75||||1,302.75||| C1726|EAP|0272|BILIARY BALLOON DILATOR|Blue Cross HMO Specialty|BCBSTX HMO|8.50||||||| C1726|EAP|0272|TTS BALLOON|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,302.75||| C1726|EAP|0272|BILIARY BALLOON DILATOR|Aetna|AETNA PPO|8.50||||||| C1726|EAP|0272|TTS BALLOON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,302.75||||1,302.75||| C1726|EAP|0272|BILIARY BALLOON DILATOR|Managed Medicaid|MEDICAID SUPERIOR|8.50||||||| C1726|EAP|0272|ELIMINATOR BILLARY BALLOO|Humana Medicare Advantage|HUMANA MA|8.50||||1,391.50||| C1726|EAP|0272|TTS BALLOON|Humana Medicare Advantage|HUMANA MA|1,302.75||||1,302.75||| C1726|EAP|0272|TTS BALLOON|Cigna|CIGNA|||||1,302.75||| C1727|EAP|0278||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||37.18||| C1727|EAP|0278||Blue Cross PPO Specialty|BCBSTX PPO|||||37.18||| C1727|EAP|0278||United Medicare Advantage|UHC AARP MCR HMO MA|||||37.18||| C1727|EAP|0278|BALLOON DILATION SINUS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|35.04||||||| C1727|EAP|0278|BALLOON DILATION SINUS|Medicare|MEDICARE ACUTE|35.04||||35.04||| C1727|EAP|0278||Medicare|MEDICARE ACUTE|35.04||||37.18||| C1727|EAP|0278|BALLOON DILATION SINUS|United Healthcare|UNITED HEALTHCARE OTHER|||||35.04||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|NON CONTRACTED|COMMERCIAL OTHER 1|1,391.50||||595.50||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|PHCS|GROUP AND PENSION|595.50||||||| C1729|EAP|0272|CATH, DRAINAGE G1|Tricare|TRICARE EAST REGION|1,391.50||||||| C1729|EAP|0272|CATH, DRAINAGE G1|United Healthcare|UNITED HEALTHCARE|1,391.50||||||| C1729|EAP|0272|CATH, DRAINAGE G1|United Healthcare|UNITED HEALTHCARE OTHER|1,391.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|United Healthcare|UNITED HEALTHCARE|595.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Managed Medicare|BCBS MEDICARE PPO MA|1,391.50||||595.50||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Managed Medicare|HEALTHSPRING MA|1,391.50||||595.50||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||595.50||| C1729|EAP|0272|CATH, DRAINAGE G1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,391.50||||||| C1729|EAP|0272|CATH, DRAINAGE G1|Medicaid|SMITH COUNTY INDIGENT HEALTH|1,391.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Medicaid|MEDICAID|595.50||||||| C1729|EAP|0272|CATH BILIARY DRAIN|Medicaid|MEDICAID|4.51||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Medicare|MEDICARE ACUTE|4.51||||595.50||| C1729|EAP|0272|SET PNEUMOTHORAX|Medicare|MEDICARE ACUTE|595.50||||8.37||| C1729|EAP|0272|CATH, DRAINAGE G1|Veterans Affairs|VETERANS ADMINISTRATION|1,391.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|595.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Access Direct Platinum|HEALTHFIRST TPA UMR|595.50||||||| C1729|EAP|0272|CATH BILIARY DRAIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.51||| C1729|EAP|0272|CATH, DRAINAGE G1|United Medicare Advantage|UHC MEDICARE GOLD MA|1,391.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|United Medicare Advantage|UHC MEDICARE GOLD MA|595.50||||||| C1729|EAP|0272|CATH BILIARY DRAIN|United Medicare Advantage|UHC MEDICARE GOLD MA|4.51||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|595.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||595.50||| C1729|EAP|0272|CATH, DRAINAGE G1|Medicare|MEDICARE ACUTE|1,391.50||||8.37||| C1729|EAP|0272|CATH, DRAINAGE G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,391.50||||||| C1729|EAP|0272|SET PNEUMOTHORAX|United Medicare Advantage|UHC AARP MCR HMO MA|8.37||||595.50||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|United Medicare Advantage|UHC AARP MCR HMO MA|595.50||||595.50||| C1729|EAP|0272|CATH, DRAINAGE G1|United Medicare Advantage|UHC AARP MCR HMO MA|1,391.50||||595.50||| C1729|EAP|0272|CATH, DRAINAGE G1|Medicaid|MEDICAID|1,391.50||||||| C1729|EAP|0272|CATH, DRAINAGE G1|Humana Medicare Advantage|HUMANA MA|1,391.50||||595.50||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Humana Medicare Advantage|HUMANA MA|595.50||||595.50||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Humana Medicare Advantage|HUMANA MA|4.51||||595.50||| C1729|EAP|0272|SET PNEUMOTHORAX|Humana Medicare Advantage|HUMANA MA|8.37||||595.50||| C1729|EAP|0272|MIC JEJUNAL FEEDING TUBE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|595.50||||8.49||| C1729|EAP|0272|CATH, DRAINAGE G1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,391.50||||8.49||| C1729|EAP|0272|CATH, DRAINAGE G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,391.50||||595.50||| C1729|EAP|0272|CATH, DRAINAGE G1|Managed Medicaid|MEDICAID AMERIGROUP|1,391.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|595.50||||595.50||| C1729|EAP|0272|SET PNEUMOTHORAX|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,391.50||||8.37||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Blue Cross PPO Specialty|BCBSTX PPO|4.51||||595.50||| C1729|EAP|0272|SET PNEUMOTHORAX|Blue Cross PPO Specialty|BCBSTX PPO|8.37||||595.50||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,391.50||||595.50||| C1729|EAP|0272|CATH, DRAINAGE G1|Blue Cross PPO Specialty|BCBSTX PPO|1,391.50||||595.50||| C1729|EAP|0272|CATH, DRAINAGE G1|Blue Cross PPO Specialty|BCBSTX OTHER|1,391.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Blue Cross PPO Specialty|BCBSTX PPO|595.50||||595.50||| C1729|EAP|0272|CATH, DRAINAGE G1|Blue Cross HMO Specialty|BCBSTX HMO|1,391.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Blue Cross HMO Specialty|BCBSTX HMO|595.50||||||| C1729|EAP|0272|CATH, DRAINAGE G1|Aenta Medicare Advantage|AETNA MEDICARE MA|1,391.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Aenta Medicare Advantage|AETNA MEDICARE MA|595.50||||||| C1729|EAP|0272|CATH NEPHROSTOMY DRAIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,391.50||||595.50||| C1729|EAP|0272|CATH BILIARY DRAIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|595.50||||4.51||| C1730|EAP|0272|INQUIRY QUAD 4 FR CATH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.47||||943.75||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.47||||36.11||| C1730|EAP|0272|DAIG FIXED QUAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.47||||5.05||| C1730|EAP|0272|CS-BWI BD710FJ282CT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|943.75||||3,316.25||| C1730|EAP|0272|6 FR (BW) FIXED QUAD CATH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,669.25||||6.05||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.47||||1,669.25||| C1730|EAP|0272|DAIG DEFLECT QUAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.47||||1,593.75||| C1730|EAP|0272|4 FR.(BW) FIXED QUAD CATH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.05||||6.05||| C1730|EAP|0272|INQUIRY QUAD 4 FR CATH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||943.75||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,669.25||| C1730|EAP|0272|DAIG FIXED QUAD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.05||| C1730|EAP|0272|CS-BWI BD710FJ282CT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,316.25||| C1730|EAP|0272|4 FR.(BW) FIXED QUAD CATH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.05||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Aetna|AETNA PPO|3,316.25||||1,669.25||| C1730|EAP|0272|LONG SHEATHS (60CM)|Aetna|AETNA PPO|3,316.25||||14.47||| C1730|EAP|0272|INQUIRY QUAD 4 FR CATH|Aetna|AETNA OTHER|||||943.75||| C1730|EAP|0272|DAIG FIXED QUAD|Aetna|AETNA OTHER|||||5.05||| C1730|EAP|0272|CS-BWI BD710FJ282CT|Blue Cross PPO Specialty|BCBSTX PPO|1,593.75||||3,316.25||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Blue Cross HMO Specialty|BCBSTX HMO|||||1,669.25||| C1730|EAP|0272|DAIG FIXED QUAD|Blue Cross HMO Specialty|BCBSTX HMO|||||5.05||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Blue Cross HMO Specialty|BCBSTX HMO|||||36.11||| C1730|EAP|0272|LONG SHEATHS (60CM)|Blue Cross PPO Specialty|BCBSTX PPO|36.11||||14.47||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Blue Cross PPO Specialty|BCBSTX PPO|14.47||||1,669.25||| C1730|EAP|0272|DAIG FIXED QUAD|Blue Cross PPO Specialty|BCBSTX PPO|943.75||||5.05||| C1730|EAP|0272|4 FR.(BW) FIXED QUAD CATH|Blue Cross PPO Specialty|BCBSTX PPO|3,316.25||||6.05||| C1730|EAP|0272|DAIG DEFLECT QUAD|Blue Cross HMO Specialty|BCBSTX HMO|||||1,593.75||| C1730|EAP|0272|6 FR (BW) FIXED QUAD CATH|Blue Cross HMO Specialty|BCBSTX HMO|||||6.05||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.11||||1,593.75||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Managed Medicaid|MEDICAID AMERIGROUP|||||36.11||| C1730|EAP|0272|LONG SHEATHS (60CM)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.11||||14.47||| C1730|EAP|0272|LONG SHEATHS (60CM)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14.47||||1,593.75||| C1730|EAP|0272|DAIG DEFLECT QUAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.47||||1,593.75||| C1730|EAP|0272|DAIG DEFLECT QUAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,593.75||||1,593.75||| C1730|EAP|0272|DAIG DEFLECT QUAD|Managed Medicaid|MEDICAID AMERIGROUP|||||1,593.75||| C1730|EAP|0272|DAIG DEFLECT QUAD|Cigna|CIGNA|||||1,593.75||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Humana Medicare Advantage|HUMANA MA|1,669.25||||1,669.25||| C1730|EAP|0272|LONG SHEATHS (60CM)|Humana Medicare Advantage|HUMANA MA|14.47||||14.47||| C1730|EAP|0272|INQUIRY QUAD 4 FR CATH|Humana Medicare Advantage|HUMANA MA|14.47||||943.75||| C1730|EAP|0272|DAIG FIXED QUAD|Humana Medicare Advantage|HUMANA MA|5.05||||5.05||| C1730|EAP|0272|CS-BWI BD710FJ282CT|Humana Medicare Advantage|HUMANA MA|3,316.25||||3,316.25||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|United Medicare Advantage|UHC AARP MCR HMO MA|36.11||||36.11||| C1730|EAP|0272|DAIG DEFLECT QUAD|United Medicare Advantage|UHC AARP MCR HMO MA|14.47||||1,593.75||| C1730|EAP|0272|DAIG FIXED QUAD|United Medicare Advantage|UHC MEDICARE GOLD MA|14.47||||5.05||| C1730|EAP|0272|LONG SHEATHS (60CM)|United Medicare Advantage|UHC MEDICARE GOLD MA|14.47||||14.47||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|United Medicare Advantage|UHC MEDICARE GOLD MA|14.47||||1,669.25||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.47||||1,669.25||| C1730|EAP|0272|INQUIRY QUAD 4 FR CATH|United Medicare Advantage|UHC MEDICARE GOLD MA|14.47||||943.75||| C1730|EAP|0272|DAIG FIXED QUAD|United Medicare Advantage|UHC AARP MCR HMO MA|36.11||||5.05||| C1730|EAP|0272|6 FR (BW) FIXED QUAD CATH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,316.25||||6.05||| C1730|EAP|0272|DAIG DEFLECT QUAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,113.75||||1,593.75||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|United Medicare Advantage|UHC MEDICARE GOLD MA|14.47||||36.11||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|United Medicare Advantage|UHC AARP MCR HMO MA|36.11||||1,669.25||| C1730|EAP|0272|DAIG DEFLECT QUAD|United Medicare Advantage|UHC MEDICARE GOLD MA|14.47||||1,593.75||| C1730|EAP|0272|INQUIRY QUAD 4 FR CATH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.47||||943.75||| C1730|EAP|0272|LONG SHEATHS (60CM)|United Medicare Advantage|UHC AARP MCR HMO MA|36.11||||14.47||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||1,669.25||| C1730|EAP|0272|CS-BWI BD710FJ282CT|United Medicare Advantage|UHC MEDICARE GOLD MA|1,669.25||||3,316.25||| C1730|EAP|0272|CS-BWI BD710FJ282CT|United Medicare Advantage|UHC AARP MCR HMO MA|1,593.75||||3,316.25||| C1730|EAP|0272|INQUIRY QUAD 4 FR CATH|United Medicare Advantage|UHC AARP MCR HMO MA|36.11||||943.75||| C1730|EAP|0272|DAIG FIXED QUAD|Access Direct Platinum|HEALTHFIRST TPA|||||5.05||| C1730|EAP|0272|DAIG FIXED QUAD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.05||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||36.11||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||36.11||| C1730|EAP|0272|LONG SHEATHS (60CM)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||14.47||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,669.25||| C1730|EAP|0272|DAIG FIXED QUAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,669.25||||5.05||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,669.25||||||| C1730|EAP|0272|DAIG FIXED QUAD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.05||| C1730|EAP|0272|DAIG DEFLECT QUAD|Humana Medicare Advantage|HUMANA MA|1,593.75||||1,593.75||| C1730|EAP|0272|DAIG FIXED QUAD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.05||||||| C1730|EAP|0272|CS-BWI BD710FJ282CT|Access Direct Platinum|HEALTHFIRST TPA|||||3,316.25||| C1730|EAP|0272|DAIG DEFLECT QUAD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,593.75||| C1730|EAP|0272|DAIG DEFLECT QUAD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,593.75||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Cigna|CIGNA|||||36.11||| C1730|EAP|0272|CS-BWI BD710FJ282CT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3,316.25||| C1730|EAP|0272|LONG SHEATHS (60CM)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||14.47||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Access Direct Platinum|HEALTHFIRST TPA|||||1,669.25||| C1730|EAP|0272|6 FR (BW) FIXED QUAD CATH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.05||| C1730|EAP|0272|CS-BWI BD710FJ282CT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,316.25||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Veterans Affairs|VETERANS ADMINISTRATION|943.75||||36.11||| C1730|EAP|0272|LONG SHEATHS (60CM)|Veterans Affairs|VETERANS ADMINISTRATION|943.75||||14.47||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Veterans Affairs|VETERANS ADMINISTRATION|943.75||||1,669.25||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.11||||36.11||| C1730|EAP|0272|DAIG FIXED QUAD|Veterans Affairs|VETERANS ADMINISTRATION|943.75||||5.05||| C1730|EAP|0272|DAIG DEFLECT QUAD|Veterans Affairs|VETERANS ADMINISTRATION|1,593.75||||1,593.75||| C1730|EAP|0272|DAIG DEFLECT QUAD|Blue Cross PPO Specialty|BCBSTX PPO|1,669.25||||1,593.75||| C1730|EAP|0272|INQUIRY QUAD 4 FR CATH|Medicare|MEDICARE ACUTE|1,669.25||||943.75||| C1730|EAP|0272|DAIG FIXED QUAD|Medicare|MEDICARE ACUTE|1,593.75||||5.05||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Blue Cross PPO Specialty|BCBSTX PPO|36.11||||36.11||| C1730|EAP|0272|DAIG DEFLECT QUAD|Medicare|MEDICARE ACUTE|3,316.25||||1,593.75||| C1730|EAP|0272|4 FR.(BW) FIXED QUAD CATH|Medicare|MEDICARE ACUTE|6.05||||6.05||| C1730|EAP|0272|DAIG FIXED QUAD|Medicare|MEDICARE PART B ONLY IP|5.05||||||| C1730|EAP|0272|LONG SHEATHS (60CM)|Medicare|MEDICARE ACUTE|943.75||||14.47||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Medicare|MEDICARE ACUTE|14.47||||36.11||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Medicare|MEDICARE ACUTE|36.11||||36.11||| C1730|EAP|0272|CS-BWI BD710FJ282CT|Medicare|MEDICARE ACUTE|6.05||||3,316.25||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Medicare|MEDICARE ACUTE|5.05||||1,669.25||| C1730|EAP|0272|DAIG DEFLECT QUAD|Managed Medicare|BCBS MEDICARE PPO MA|14.47||||1,593.75||| C1730|EAP|0272|DAIG DEFLECT QUAD|Managed Medicare|HEALTHSPRING MA|||||1,593.75||| C1730|EAP|0272|DAIG FIXED QUAD|Managed Medicare|HEALTHSPRING MA|||||5.05||| C1730|EAP|0272|LONG SHEATHS (60CM)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||14.47||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Aetna|AETNA OTHER|||||1,669.25||| C1730|EAP|0272|DAIG DEFLECT QUAD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,593.75||| C1730|EAP|0272|CS-BWI BD710FJ282CT|Managed Medicare|BCBS MEDICARE PPO MA|1,669.25||||3,316.25||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||36.11||| C1730|EAP|0272|LONG SHEATHS (60CM)|Aenta Medicare Advantage|AETNA MEDICARE MA|||||14.47||| C1730|EAP|0272|DAIG DEFLECT QUAD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,593.75||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Managed Medicare|HEALTHSPRING MA|||||1,669.25||| C1730|EAP|0272|LONG SHEATHS (60CM)|Managed Medicare|HEALTHSPRING MA|||||14.47||| C1730|EAP|0272|INQUIRY QUAD 4 FR CATH|Managed Medicare|HEALTHSPRING MA|||||943.75||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Managed Medicare|BCBS MEDICARE PPO MA|14.47||||1,669.25||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,669.25||| C1730|EAP|0272|LONG SHEATHS (60CM)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.47||||14.47||| C1730|EAP|0272|DAIG DEFLECT QUAD|United Healthcare|UNITED HEALTHCARE|||||1,593.75||| C1730|EAP|0272|CS-BWI BD710FJ282CT|United Healthcare|UNITED HEALTHCARE|||||3,316.25||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|United Healthcare|UNITED HEALTHCARE|1,669.25||||1,669.25||| C1730|EAP|0272|DYNAMIC XT QUAD M00420110|United Healthcare|UNITED HEALTHCARE OTHER|||||1,669.25||| C1730|EAP|0272|DAIG FIXED QUAD|United Healthcare|UNITED HEALTHCARE OTHER|||||5.05||| C1730|EAP|0272|LONG SHEATHS (60CM)|United Healthcare|UNITED HEALTHCARE|||||14.47||| C1730|EAP|0272|CS-BWI BD710FJ282CT|United Healthcare|UNITED HEALTHCARE OTHER|||||3,316.25||| C1730|EAP|0272|DAIG DEFLECT QUAD|United Healthcare|UNITED HEALTHCARE|5.05||||1,593.75||| C1730|EAP|0272|CS-BWI BD710FJ282CT|United Healthcare|UNITED HEALTHCARE|6.05||||3,316.25||| C1730|EAP|0272|LONG SHEATHS (60CM)|United Healthcare|UNITED HEALTHCARE|1,669.25||||14.47||| C1730|EAP|0272|4 FR.(BW) FIXED QUAD CATH|United Healthcare|UNITED HEALTHCARE OTHER|||||6.05||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|United Healthcare|UNITED HEALTHCARE|||||36.11||| C1730|EAP|0272|POLARISX DECAPOLAR 7004D|United Healthcare|UNITED HEALTHCARE OTHER|||||36.11||| C1731|EAP|0278|CATHETER PENTARAY|United Healthcare|UNITED HEALTHCARE|||||10,849.75||| C1731|EAP|0272|BSC DX-20 CATH M00420SL28|United Healthcare|UNITED HEALTHCARE OTHER|5,842.25||||||| C1731|EAP|0272|BSC DX-20 CATH M00420SL28|Managed Medicare|BCBS MEDICARE PPO MA|5,842.25||||||| C1731|EAP|0278|CATHETER PENTARAY|Managed Medicare|BCBS MEDICARE PPO MA|||||10,849.75||| C1731|EAP|0272|BSC DX-20 CATH M00420SL28|Medicare|MEDICARE ACUTE|5,842.25||||5,842.25||| C1731|EAP|0272|DUO DECA CATHETER|Medicare|MEDICARE ACUTE|9,586.75||||5,786.25||| C1731|EAP|0278|CATHETER PENTARAY|Medicare|MEDICARE ACUTE|10,849.75||||10,849.75||| C1731|EAP|0278|CATHETER PENTARAY|Veterans Affairs|VETERANS ADMINISTRATION|||||10,849.75||| C1731|EAP|0272|DUO DECA CATHETER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5,786.25||| C1731|EAP|0278|CATHETER PENTARAY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||10,849.75||| C1731|EAP|0272|CATH LASSO 2515 ECO VARI|Access Direct Platinum|HEALTHFIRST TPA|||||9,586.75||| C1731|EAP|0272|BSC DX-20 CATH M00420SL28|United Medicare Advantage|UHC AARP MCR HMO MA|5,842.25||||||| C1731|EAP|0272|BSC DX-20 CATH M00420SL28|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5,842.25||| C1731|EAP|0272|DUO DECA CATHETER|Medicare|MEDICARE ACUTE|5,786.25||||5,786.25||| C1731|EAP|0278|CATHETER PENTARAY|United Medicare Advantage|UHC AARP MCR HMO MA|||||10,849.75||| C1731|EAP|0278|CATHETER PENTARAY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10,849.75||||||| C1731|EAP|0278|CATHETER PENTARAY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10,849.75||| C1731|EAP|0272|DUO DECA CATHETER|Humana Medicare Advantage|HUMANA MA|5,842.25||||5,786.25||| C1731|EAP|0272|BSC DX-20 CATH M00420SL28|Humana Medicare Advantage|HUMANA MA|5,842.25||||5,842.25||| C1731|EAP|0278|CATHETER PENTARAY|Humana Medicare Advantage|HUMANA MA|10,849.75||||10,849.75||| C1731|EAP|0272|BSC DX-20 CATH M00420SL28|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5,842.25||| C1731|EAP|0272|BSC DX-20 CATH M00420SL28|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,842.25||||5,842.25||| C1731|EAP|0272|CATH LASSO 2515 ECO VARI|Blue Cross PPO Specialty|BCBSTX PPO|5,842.25||||9,586.75||| C1731|EAP|0272|BSC DX-20 CATH M00420SL28|Blue Cross PPO Specialty|BCBSTX PPO|5,842.25||||5,842.25||| C1731|EAP|0278|CATHETER PENTARAY|Blue Cross PPO Specialty|BCBSTX PPO|10,849.75||||10,849.75||| C1731|EAP|0278|CATHETER PENTARAY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||10,849.75||| C1731|EAP|0278|CATHETER PENTARAY|Aetna|AETNA PPO|10,849.75||||||| C1731|EAP|0278|CATHETER PENTARAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10,849.75||| C1731|EAP|0272|DUO DECA CATHETER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,786.25||| C1732|EAP|0278|ADVISOR HD GRID SENSOR EN|Aetna|AETNA PPO|||||104.32||| C1732|EAP|0278|ADVISOR HD GRID SENSOR EN|Blue Cross PPO Specialty|BCBSTX PPO|104.32||||104.32||| C1732|EAP|0278|ADVISOR HD GRID SENSOR EN|Humana Medicare Advantage|HUMANA MA|||||104.32||| C1732|EAP|0278|ADVISOR HD GRID SENSOR EN|United Medicare Advantage|UHC AARP MCR HMO MA|104.32||||104.32||| C1732|EAP|0278|ADVISOR HD GRID SENSOR EN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||104.32||| C1732|EAP|0278|ADVISOR HD GRID SENSOR EN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||104.32||| C1732|EAP|0278|ADVISOR HD GRID SENSOR EN|Veterans Affairs|VETERANS ADMINISTRATION|104.32||||||| C1732|EAP|0278|ADVISOR HD GRID SENSOR EN|Medicare|MEDICARE ACUTE|104.32||||104.32||| C1732|EAP|0278|ADVISOR HD GRID SENSOR EN|United Healthcare|UNITED HEALTHCARE|||||104.32||| C1733|EAP|0278|FREEZOR MAX CATH|United Healthcare|UNITED HEALTHCARE|||||126.38||| C1733|EAP|0272|ABLATION CATHETERS 8/10MM|Managed Medicare|HEALTHSPRING MA|||||8,131.25||| C1733|EAP|0272|ABLATION CATHETERS 8/10MM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8,131.25||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||26,018.25||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Managed Medicare|HEALTHSPRING MA|||||26,018.25||| C1733|EAP|0272|E-P ABLATION CATHETER|Medicare|MEDICARE ACUTE|4,032.75||||4,032.75||| C1733|EAP|0272|ABLATION CATHETERS 8/10MM|Medicare|MEDICARE ACUTE|8,131.25||||8,131.25||| C1733|EAP|0272|ABLATION CATHETERS 8/10MM|Medicare|MEDICARE PART B ONLY IP|8,131.25||||||| C1733|EAP|0272|E-P ABLATION CATHETER|Medicare|MEDICARE ACUTE|94.31||||4,032.75||| C1733|EAP|0278|FREEZOR MAX CATH|Medicare|MEDICARE ACUTE|26,018.25||||126.38||| C1733|EAP|0278|CATH NAVISTAR DS BI-DIR|Medicare|MEDICARE ACUTE|26,018.25||||11,100.25||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Medicare|MEDICARE ACUTE|26,018.25||||26,018.25||| C1733|EAP|0272|E-P ABLATION CATHETER|Veterans Affairs|VETERANS ADMINISTRATION|8,131.25||||4,032.75||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Veterans Affairs|VETERANS ADMINISTRATION|26,018.25||||26,018.25||| C1733|EAP|0272|E-P ABLATION CATHETER|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4,032.75||| C1733|EAP|0272|CATH NAVISTAR BI-DIRECT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||94.31||| C1733|EAP|0272|CATH NAVISTAR BI-DIRECT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|94.31||||||| C1733|EAP|0272|CATH NAVISTAR BI-DIRECT|Access Direct Platinum|HEALTHFIRST TPA|||||94.31||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Medicare|MEDICARE PART B ONLY IP|26,018.25||||||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||26,018.25||| C1733|EAP|0272|BSC 10MM ABLAT CATH M0044|United Medicare Advantage|UHC AARP MCR HMO MA|82.07||||||| C1733|EAP|0272|ABLATION CATHETERS 8/10MM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8,131.25||| C1733|EAP|0278|CATH NAVISTAR DS BI-DIR|United Medicare Advantage|UHC AARP MCR HMO MA|11,100.25||||11,100.25||| C1733|EAP|0272|CATH NAVISTAR BI-DIRECT|Medicare|MEDICARE ACUTE|82.07||||94.31||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|United Medicare Advantage|UHC AARP MCR HMO MA|26,018.25||||26,018.25||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||26,018.25||| C1733|EAP|0272|ABLATION CATHETERS 8/10MM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8,131.25||||8,131.25||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26,018.25||||||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|United Healthcare|UNITED HEALTHCARE|||||26,018.25||| C1733|EAP|0272|ABLATION CATHETERS 8/10MM|Humana Medicare Advantage|HUMANA MA|8,131.25||||8,131.25||| C1733|EAP|0272|CATH NAVISTAR BI-DIRECT|Humana Medicare Advantage|HUMANA MA|8,131.25||||94.31||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Humana Medicare Advantage|HUMANA MA|||||26,018.25||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Blue Cross PPO Specialty|BCBSTX PPO|||||26,018.25||| C1733|EAP|0272|E-P ABLATION CATHETER|Blue Cross PPO Specialty|BCBSTX PPO|||||4,032.75||| C1733|EAP|0272|CATH NAVISTAR BI-DIRECT|Blue Cross PPO Specialty|BCBSTX PPO|||||94.31||| C1733|EAP|0272|ABLATION CATHETERS 8/10MM|Blue Cross PPO Specialty|BCBSTX PPO|||||8,131.25||| C1733|EAP|0278|FREEZOR MAX CATH|Blue Cross PPO Specialty|BCBSTX PPO|||||126.38||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26,018.25||||26,018.25||| C1733|EAP|0272|ABLATION CATHETERS 8/10MM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,131.25||||8,131.25||| C1733|EAP|0272|CATH NAVISTAR BI-DIRECT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,131.25||||94.31||| C1733|EAP|0278|CATH CRYOABLATION AORTIC|Aenta Medicare Advantage|AETNA MEDICARE MA|||||26,018.25||| C1733|EAP|0272|CATH NAVISTAR BI-DIRECT|Aetna|AETNA OTHER|||||94.31||| C1750|EAP|0272|CATH TUNNELED DIALYSIS|Medicare|MEDICARE ACUTE|2,132.25||||||| C1751|EAP|0272||Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,893.25||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|Aenta Medicare Advantage|AETNA MEDICARE MA|2,893.25||||||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|Aetna|AETNA OTHER|||||2,893.25||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,893.25||| C1751|EAP|0272|GUIDE-NEURO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,296.50||| C1751|EAP|0272|GUIDE-NEURO|Blue Cross PPO Specialty|BCBSTX PPO|1,296.50||||1,296.50||| C1751|EAP|0272|GUIDE-NEURO|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,296.50||| C1751|EAP|0272||Blue Cross HMO Specialty|BCBSTX HMO|||||2,893.25||| C1751|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|2,893.25||||2,893.25||| C1751|EAP|0272||Cigna|CIGNA|||||2,893.25||| C1751|EAP|0272||Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,893.25||||2,893.25||| C1751|EAP|0272||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,893.25||||||| C1751|EAP|0272|GUIDE-NEURO|United Medicare Advantage|UHC MEDICARE GOLD MA|2,893.25||||1,296.50||| C1751|EAP|0272|GUIDE-NEURO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,296.50||||2,893.25||| C1751|EAP|0272||United Medicare Advantage|UHC AARP MCR HMO MA|2,893.25||||||| C1751|EAP|0272||United Medicare Advantage|UHC MEDICARE GOLD MA|2,893.25||||2,893.25||| C1751|EAP|0272||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,893.25||||2,893.25||| C1751|EAP|0272||Humana Medicare Advantage|HUMANA MA|2,893.25||||2,893.25||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|United Medicare Advantage|UHC AARP MCR HMO MA|2,893.25||||||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,893.25||| C1751|EAP|0272|GUIDE-NEURO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,296.50||||||| C1751|EAP|0272||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,893.25||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|Blue Cross PPO Specialty|BCBSTX PPO|2,893.25||||2,893.25||| C1751|EAP|0272||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2,893.25||| C1751|EAP|0272||Access Direct Platinum|HEALTHFIRST TPA UMR|2,893.25||||||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,893.25||||||| C1751|EAP|0272|GUIDE-NEURO|Veterans Affairs|VETERANS ADMINISTRATION|1,296.50||||||| C1751|EAP|0272||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,893.25||||2,893.25||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|Rusk State Hospital|RUSK STATE HOSP|2,893.25||||||| C1751|EAP|0272||Tricare|TRICARE FOR LIFE|||||2,893.25||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|United Healthcare|UNITED HEALTHCARE OTHER|2,893.25||||||| C1751|EAP|0272||United Healthcare|UNITED HEALTHCARE OTHER|2,893.25||||2,893.25||| C1751|EAP|0272||United Healthcare|UNITED HEALTHCARE|2,893.25||||2,893.25||| C1751|EAP|0272||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2,893.25||| C1751|EAP|0272||Managed Medicare|HEALTHSPRING MA|2,893.25||||||| C1751|EAP|0272||Managed Medicare|BCBS MEDICARE PPO MA|2,893.25||||||| C1751|EAP|0272|GUIDE-NEURO|Medicaid|SMITH COUNTY INDIGENT HEALTH|1,296.50||||||| C1751|EAP|0272||Medicaid|MEDICAID|2,893.25||||2,893.25||| C1751|EAP|0272||Medicaid|SMITH COUNTY INDIGENT HEALTH|2,893.25||||||| C1751|EAP|0272||Medicare|MEDICARE ACUTE|2,893.25||||2,893.25||| C1751|EAP|0272|GUIDE-NEURO|Medicare|MEDICARE ACUTE|1,296.50||||1,296.50||| C1751|EAP|0278|CATH, INF, PER/CENT/MIDLI|Medicare|MEDICARE ACUTE|2,893.25||||2,893.25||| C1752|EAP|0272|CATHETER TEMP DAILYSIS|Medicare|MEDICARE ACUTE|6.90||||||| C1752|EAP|0272|CATHETER TEMP DAILYSIS|Managed Medicare|HEALTHSPRING MA|6.90||||||| C1752|EAP|0272|CATHETER TEMP DAILYSIS|United Medicare Advantage|UHC MEDICARE GOLD MA|6.90||||||| C1752|EAP|0272|CATHETER TEMP DAILYSIS|Humana Medicare Advantage|HUMANA MA|6.90||||||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|Blue Cross PPO Specialty|BCBSTX PPO|3,611.25||||3,611.25||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|Blue Cross HMO Specialty|BCBSTX HMO|||||3,611.25||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,082.50||||3,611.25||| C1753|EAP|0272|IVUS CATH .035 IMAGING AA|Aenta Medicare Advantage|AETNA MEDICARE MA|5,082.50||||||| C1753|EAP|0272|IVUS CATH .035 IMAGING AA|Aetna|AETNA PPO|5,082.50||||||| C1753|EAP|0272|IVUS CATH .035 IMAGING AA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,082.50||||||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,082.50||||3,611.25||| C1753|EAP|0272|IVUS CATH .035 IMAGING AA|Cigna|CIGNA|5,082.50||||||| C1753|EAP|0272|IVUS CATH .035 IMAGING AA|Humana Medicare Advantage|HUMANA MA|5,082.50||||||| C1753|EAP|0272|IVUS CATH .035 IMAGING AA|Veterans Affairs|VETERANS ADMINISTRATION|5,082.50||||||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|United Medicare Advantage|UHC AARP MCR HMO MA|5,082.50||||3,611.25||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|United Medicare Advantage|UHC MEDICARE GOLD MA|5,082.50||||3,611.25||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|United Healthcare|UNITED HEALTHCARE|3,611.25||||||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,611.25||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|Managed Medicare|HEALTHSPRING MA|||||3,611.25||| C1753|EAP|0272|IVUS CATH .035 IMAGING AA|Managed Medicare|BCBS MEDICARE PPO MA|5,082.50||||||| C1753|EAP|0272|IVUS CATH .035 IMAGING AA|Medicare|MEDICARE ACUTE|5,082.50||||5,082.50||| C1753|EAP|0272|IVUS VOLCANO IMAGING PERI|Medicare|MEDICARE ACUTE|3,611.25||||3,611.25||| C1755|EAP|0272|CATHETER, INTRASPINAL G1|Medicare|MEDICARE ACUTE|5,786.50||||5,786.50||| C1755|EAP|0272|CATHETER, INTRASPINAL G1|United Medicare Advantage|UHC MEDICARE GOLD MA|5,786.50||||||| C1755|EAP|0272|CATHETER, INTRASPINAL G1|United Medicare Advantage|UHC AARP MCR HMO MA|5,786.50||||||| C1755|EAP|0272|CATHETER, INTRASPINAL G1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,786.50||||||| C1755|EAP|0272|CATHETER, INTRASPINAL G1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5,786.50||||||| C1755|EAP|0272|CATHETER, INTRASPINAL G1|Humana Medicare Advantage|HUMANA MA|5,786.50||||||| C1755|EAP|0272|CATHETER, INTRASPINAL G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,786.50||||||| C1755|EAP|0272|CATHETER, INTRASPINAL G1|Blue Cross PPO Specialty|BCBSTX PPO|5,786.50||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Blue Cross HMO Specialty|BCBSTX HMO|2,922.75||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Blue Cross PPO Specialty|BCBSTX PPO|2,922.75||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Aetna|AETNA PPO|2,922.75||||||| C1757|EAP|0278|CATHETER THROMBOLITIC SEP|Aetna|AETNA PPO|105.66||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,922.75||||||| C1757|EAP|0278|CATHETER THROMBOLITIC SEP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|105.66||||||| C1757|EAP|0278|CATHETER THROMBOLITIC SEP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|105.66||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Humana Medicare Advantage|HUMANA MA|2,922.75||||2,922.75||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Veterans Affairs|VETERANS ADMINISTRATION|2,922.75||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,922.75||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|United Medicare Advantage|UHC AARP MCR HMO MA|2,922.75||||||| C1757|EAP|0278|CATHETER THROMBOLITIC SEP|Blue Cross HMO Specialty|BCBSTX HMO|105.66||||||| C1757|EAP|0278|CATHETER THROMBOLITIC SEP|United Medicare Advantage|UHC MEDICARE GOLD MA|105.66||||||| C1757|EAP|0278|CATHETER THROMBOLITIC SEP|United Healthcare|UNITED HEALTHCARE OTHER|105.66||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|United Healthcare|UNITED HEALTHCARE OTHER|2,922.75||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Managed Medicare|HEALTHSPRING MA|2,922.75||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,922.75||||||| C1757|EAP|0272|CATH ART EMOLECTOMY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|284.25||||||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Medicare|MEDICARE ACUTE|3,197.75||||2,922.75||| C1757|EAP|0272|CATH ART EMOLECTOMY|Medicare|MEDICARE ACUTE|284.25||||284.25||| C1757|EAP|0272|EXPORT AP EXTRACTION EXPO|Medicare|MEDICARE ACUTE|2,922.75||||2,922.75||| C1757|EAP|0278|CATHETER ASPIR 8F INDIGO|Medicare|MEDICARE ACUTE|105.66||||158.90||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Medicaid|MEDICAID|278.75||||||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Medicaid|SUPERIOR HEALTHPLAN CHIP|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Medicaid|MOLINA HEALTHCARE OF TEXAS|278.75||||||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Medicare|MEDICARE ACUTE|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Managed Medicare|HEALTHSPRING MA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Managed Medicare|BCBS MEDICARE PPO MA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|PHCS|GROUP AND PENSION|278.75||||||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Tricare|TRICARE EAST REGION|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|NON CONTRACTED|COMMERCIAL OTHER 1|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|UTMB|UTMB CORRECTIONAL MANAGED CARE|278.75||||||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|United Healthcare|UNITED HEALTHCARE OTHER|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|United Healthcare|UNITED HEALTHCARE|||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|United Healthcare|UNITED HEALTHCARE|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|United Medicare Advantage|UHC AARP MCR HMO MA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|United Medicare Advantage|UHC MEDICARE GOLD MA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Access Direct Platinum|HEALTHFIRST TPA UMR|||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Access Direct Platinum|HEALTHFIRST TPA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|PHCS|HUMANA INSURANCE|278.75||||||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Medicare|MEDICARE PART B ONLY IP|278.75||||||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Veterans Affairs|VETERANS ADMINISTRATION|278.75||||||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Cigna|CIGNA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Humana Medicare Advantage|HUMANA MA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Managed Medicaid|MEDICAID SUPERIOR|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Managed Medicaid|MEDICAID AMERIGROUP|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Aenta Medicare Advantage|AETNA MEDICARE MA|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Aetna|AETNA OTHER|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Aetna|AETNA PPO|||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Aetna|BOON CHAPMAN|278.75||||||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Blue Cross PPO Specialty|BCBSTX PPO|278.75||||278.75||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Blue Cross PPO Specialty|BCBSTX OTHER|278.75||||||| C1758|EAP|0272|CATHETER URETERAL DIAG/TH|Blue Cross HMO Specialty|BCBSTX HMO|278.75||||278.75||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|Blue Cross PPO Specialty|BCBSTX PPO|3,199.50||||3,199.50||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,199.50||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||13,309.25||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|Aetna|AETNA PPO|3,199.50||||||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13,309.25||||13,309.25||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,199.50||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13,309.25||||||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Humana Medicare Advantage|HUMANA MA|||||13,309.25||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Veterans Affairs|VETERANS ADMINISTRATION|13,309.25||||13,309.25||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3,199.50||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||13,309.25||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||13,309.25||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Access Direct Platinum|HEALTHFIRST TPA|||||13,309.25||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,199.50||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|Humana Medicare Advantage|HUMANA MA|3,199.50||||3,199.50||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Aetna|AETNA PPO|||||13,309.25||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|United Medicare Advantage|UHC AARP MCR HMO MA|||||3,199.50||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,199.50||||||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||13,309.25||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13,309.25||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Blue Cross PPO Specialty|BCBSTX PPO|13,309.25||||13,309.25||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|United Medicare Advantage|UHC AARP MCR HMO MA|13,309.25||||13,309.25||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|United Healthcare|UNITED HEALTHCARE|||||13,309.25||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|United Healthcare|UNITED HEALTHCARE|||||3,199.50||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|Managed Medicare|BCBS MEDICARE PPO MA|||||3,199.50||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Managed Medicare|BCBS MEDICARE PPO MA|||||13,309.25||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Managed Medicare|HEALTHSPRING MA|||||13,309.25||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||13,309.25||| C1759|EAP|0272|CATHETER IC ECHOCARDIOGRA|Medicare|MEDICARE ACUTE|3,199.50||||3,199.50||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Medicare|MEDICARE PART B ONLY IP|13,309.25||||||| C1759|EAP|0278|FLEXVIEW INTRACARDIAC CAT|Medicare|MEDICARE ACUTE|13,309.25||||13,309.25||| C1759|EAP|0278|CATHETER IC ULTRASOUND|Medicare|MEDICARE ACUTE|13,309.25||||162.48||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Medicaid|CRIME VICTIMS COMPENSATION|10.66||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Medicaid|MEDICAID|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Medicaid|SMITH COUNTY INDIGENT HEALTH|10.66||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Medicaid|MEDICAID|240.35||||240.35||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Medicare|MEDICARE PART B ONLY IP|1,474.50||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Medicare|MEDICARE ACUTE|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Medicare|MEDICARE ACUTE|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Medicare|MEDICARE ACUTE|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Managed Medicare|BCBS MEDICARE PPO MA|10.66||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Managed Medicare|HEALTHSPRING MA|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Managed Medicare|HEALTHSPRING MA|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Managed Medicare|BCBS MEDICARE PPO MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|NON CONTRACTED|COMMERCIAL OTHER 1|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|NON CONTRACTED|COMMERCIAL OTHER 1|10.66||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|PHCS|HUMANA|||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|PHCS|HUMANA INSURANCE|1,474.50||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|PHCS|GROUP AND PENSION|||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Tricare|TRICARE FOR LIFE|1,474.50||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Tricare|TRICARE EAST REGION|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,474.50||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,474.50||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|United Healthcare|UNITED HEALTHCARE|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|United Healthcare|UNITED HEALTHCARE|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|United Healthcare|UNITED HEALTHCARE OTHER|10.66||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|United Healthcare|UNITED HEALTHCARE|240.35||||240.35||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|United Healthcare|UNITED HEALTHCARE OTHER|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|United Medicare Advantage|UHC MEDICARE GOLD MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|United Medicare Advantage|UHC AARP WELLMED HMO MA|1,474.50||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE|United Medicare Advantage|UHC MEDICARE GOLD MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|United Medicare Advantage|UHC AARP MCR HMO MA|10.66||||240.35||| C1760|EAP|0278|MYNX CLOSURE DEVICE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|United Medicare Advantage|UHC MEDICARE GOLD MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|United Medicare Advantage|UHC AARP MCR HMO MA|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|United Medicare Advantage|UHC MEDICARE GOLD MA|10.66||||10.66||| C1760|EAP|0278|PFO CLOSURE DEVICE 030 9-|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,474.50||||35,073.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|United Medicare Advantage|UHC AARP MCR HMO MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Access Direct Platinum|HEALTHFIRST TPA UMR|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|1,474.50||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Access Direct Platinum|HEALTHFIRST TPA|||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10.66||||10.66||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,474.50||||10.66||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Workers Compensation|WORKERS COMPENSATION OTHER|10.66||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Veterans Affairs|VETERANS ADMINISTRATION|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Veterans Affairs|VETERANS ADMINISTRATION|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Veterans Affairs|VETERANS ADMINISTRATION|1,474.50||||240.35||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Veterans Affairs|VETERANS ADMINISTRATION|10.66||||10.66||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|United Healthcare|UNITED HEALTHCARE|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Cigna|CIGNA|10.66||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Cigna|CIGNA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Cigna|CIGNA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Cigna|CIGNA|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|UTMB|UTMB CORRECTIONAL MANAGED CARE|10.66||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Humana Medicare Advantage|HUMANA MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Humana Medicare Advantage|HUMANA MA|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Humana Medicare Advantage|HUMANA MA|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Managed Medicaid|MEDICAID SUPERIOR|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Managed Medicaid|MEDICAID AMERIGROUP|10.66||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Rusk State Hospital|RUSK STATE HOSP|||||240.35||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Managed Medicaid|MEDICAID AMERIGROUP|10.66||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Managed Medicare|HEALTHSPRING MA|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.66||||10.66||| C1760|EAP|0278|PFO CLOSURE DEVICE 030 9-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,474.50||||35,073.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Aenta Medicare Advantage|AETNA MEDICARE MA|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Aenta Medicare Advantage|AETNA MEDICARE MA|10.66||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Medicare|MEDICARE ACUTE|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Aetna|AETNA QHP HMO|10.66||||||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Aetna|AETNA PPO|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Aetna|AETNA OTHER|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Aetna|AETNA PPO|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Medicaid|MEDICAID|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Aetna|AETNA OTHER|10.66||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Aetna|AETNA PPO|10.66||||10.66||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Medicaid|MEDICAID|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|240.35||||240.35||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Blue Cross HMO Specialty|BCBSTX HMO|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Blue Cross HMO Specialty|BCBSTX HMO|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Blue Cross HMO Specialty|BCBSTX HMO|857.43||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Blue Cross HMO Specialty|BCBSTX HMO|10.66||||10.66||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Blue Cross PPO Specialty|BCBSTX OTHER|10.66||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Blue Cross PPO Specialty|BCBSTX PPO|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 6-7 F|Blue Cross PPO Specialty|BCBSTX OTHER|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE 5 FR|Blue Cross PPO Specialty|BCBSTX PPO|1,474.50||||1,474.50||| C1760|EAP|0278|MYNX CLOSURE DEVICE|Blue Cross PPO Specialty|BCBSTX PPO|1,474.50||||1,474.50||| C1760|EAP|0278|DEVICE FEMORAL CLOSURE|Blue Cross PPO Specialty|BCBSTX PPO|10.66||||10.66||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Blue Cross HMO Specialty|BCBSTX HMO|156.00||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Blue Cross HMO Specialty|BCBSTX HMO|17,359.75||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Blue Cross HMO Specialty|BCBSTX HMO|2,893.25||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Blue Cross HMO Specialty|BCBSTX HMO|5,786.50||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Blue Cross PPO Specialty|BCBSTX PPO|2,893.25||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Blue Cross PPO Specialty|BCBSTX PPO|17,359.75||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Blue Cross PPO Specialty|BCBSTX OTHER|156.00||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Blue Cross PPO Specialty|BCBSTX PPO|115.73||||17,359.75||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Blue Cross PPO Specialty|BCBSTX PPO|5,786.50||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|156.00||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|156.00||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Aenta Medicare Advantage|AETNA MEDICARE MA|5,786.50||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Aenta Medicare Advantage|AETNA MEDICARE MA|17,359.75||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Aenta Medicare Advantage|AETNA MEDICARE MA|2,893.25||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Aenta Medicare Advantage|AETNA MEDICARE MA|180.38||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Aenta Medicare Advantage|AETNA MEDICARE MA|115.73||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Aetna|AETNA PPO|17,359.75||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Aetna|AETNA OTHER|||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Aetna|AETNA PPO|5,786.50||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|156.00||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,893.25||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,786.50||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|156.00||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|156.00||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17,359.75||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Managed Medicaid|MEDICAID SUPERIOR|2,893.25||||17,359.75||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Managed Medicaid|MEDICAID AMERIGROUP|5,786.50||||17,359.75||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5,786.50||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,786.50||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,893.25||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Humana Medicare Advantage|HUMANA MA|17,359.75||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Humana Medicare Advantage|HUMANA MA|156.00||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Humana Medicare Advantage|HUMANA MA|115.73||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Humana Medicare Advantage|HUMANA MA|2,893.25||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Humana Medicare Advantage|HUMANA MA|180.38||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Cigna|CIGNA|5,786.50||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Cigna|CIGNA|5,786.50||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Workers Compensation|TEXAS MUTUAL INSURANCE|156.00||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Workers Compensation|WORKERS COMPENSATION OTHER|156.00||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Workers Compensation|TEXAS MUTUAL INSURANCE|2,893.25||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Workers Compensation|WORKERS COMPENSATION OTHER|2,893.25||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Workers Compensation|WORKERS COMPENSATION OTHER|156.00||||17,359.75||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Workers Compensation|UT EMPLOYEE INJURY|||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Veterans Affairs|VETERANS ADMINISTRATION|5,786.50||||17,359.75||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Access Direct Platinum|HEALTHFIRST TPA UMR|156.00||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,786.50||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,786.50||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Veterans Affairs|VETERANS ADMINISTRATION|2,893.25||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,786.50||||2,893.25||| C1762|EAP|0278|GRAFT NERVE AVANCE 4-5M 7|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,786.50||||19,747.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|United Medicare Advantage|UHC MEDICARE GOLD MA|180.38||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|United Medicare Advantage|UHC MEDICARE GOLD MA|17,359.75||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|United Medicare Advantage|UHC MEDICARE GOLD MA|156.00||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17,359.75||||19,747.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|United Medicare Advantage|UHC AARP MCR HMO MA|156.00||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Workers Compensation|WORKERS COMPENSATION OTHER|156.00||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Cigna|CIGNA|115.73||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|United Medicare Advantage|UHC AARP MCR HMO MA|180.38||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|156.00||||19,747.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|United Medicare Advantage|UHC MEDICARE GOLD MA|115.73||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|United Medicare Advantage|UHC MEDICARE GOLD MA|5,786.50||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Humana Medicare Advantage|HUMANA MA|5,786.50||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|United Medicare Advantage|UHC AARP MCR HMO MA|5,786.50||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|United Medicare Advantage|UHC AARP MCR HMO MA|2,893.25||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|180.38||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|United Healthcare|UNITED HEALTHCARE OTHER|5,786.50||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Managed Medicaid|MEDICAID AMERIGROUP|5,786.50||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|United Healthcare|UNITED HEALTHCARE|5,786.50||||17,359.75||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|United Healthcare|UNITED HEALTHCARE|5,786.50||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|United Healthcare|UNITED HEALTHCARE OTHER|2,893.25||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|United Healthcare|TML GROUP BENEFITS|2,893.25||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|United Healthcare|UNITED HEALTHCARE|156.00||||17,359.75||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|United Healthcare|UNITED HEALTHCARE|5,786.50||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|United Healthcare|GEHA|5,786.50||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|United Healthcare|UNITED HEALTHCARE|2,893.25||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.38||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.73||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|UTMB|UTMB CORRECTIONAL MANAGED CARE|5,786.50||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|PHCS|GROUP AND PENSION|156.00||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Tricare|TRICARE EAST REGION|2,893.25||||17,359.75||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Tricare|TRICARE FOR LIFE|||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Aetna|AETNA PPO|17,359.75||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|NON CONTRACTED|COMMERCIAL OTHER 1|180.38||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|NON CONTRACTED|COMMERCIAL OTHER 1|5,786.50||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|NON CONTRACTED|COMMERCIAL OTHER 1|2,893.25||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|NON CONTRACTED|COMMERCIAL OTHER 2|||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Managed Medicare|HEALTHSPRING MA|5,786.50||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Managed Medicare|HEALTHSPRING MA|156.00||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Blue Cross PPO Specialty|BCBSTX PPO|180.38||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Managed Medicare|HEALTHSPRING MA|180.38||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Managed Medicare|BCBS MEDICARE PPO MA|2,893.25||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Managed Medicare|HEALTHSPRING MA|115.73||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Managed Medicare|BCBS MEDICARE PPO MA|17,359.75||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|156.00||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Blue Cross PPO Specialty|BCBSTX PPO|156.00||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Blue Cross HMO Specialty|BCBSTX HMO|180.38||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Managed Medicare|HEALTHSPRING MA|17,359.75||||5,786.50||| C1762|EAP|0278|GRAFT NERVE AVANCE 4-5M 7|Medicare|MEDICARE ACUTE|19,747.50||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Medicare|MEDICARE PART B ONLY IP|156.00||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Medicare|MEDICARE ACUTE|156.00||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Medicare|MEDICARE ACUTE|17,359.75||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G4|Medicare|MEDICARE ACUTE|5,786.50||||17,359.75||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Medicare|MEDICARE ACUTE|2,893.25||||115.73||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Medicare|MEDICARE PART B ONLY IP|5,786.50||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Medicare|MEDICARE ACUTE|20,639.50||||5,786.50||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G1|Medicare|MEDICARE ACUTE|180.38||||2,893.25||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G5|Medicare|MEDICARE ACUTE|115.73||||156.00||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G3|Medicaid|MEDICAID|115.73||||||| C1762|EAP|0278|GRAFT NERVE AVANCE 3-4MM|Medicaid|MEDICAID|23,887.50||||||| C1762|EAP|0278|GRAFT CONN TISS, HUMAN G2|Medicaid|MEDICAID|5,786.50||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Medicaid|MEDICAID|5,786.50||||||| C1763|EAP|0278|VALVE MAGNA EASE MITRAL 2|Medicaid|MEDICAID|257.68||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Medicaid|MEDICAID|2,893.25||||||| C1763|EAP|0278|IMPLANT VALVE G1|Medicaid|SMITH COUNTY INDIGENT HEALTH|12,979.25||||||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|Medicaid|MEDICAID|257.68||||||| C1763|EAP|0278|VALVE MOSAIC MITRAL 310C3|Medicare|MEDICARE ACUTE|185.64||||2,893.25||| C1763|EAP|0278|VALVE MAGNA EASE MITRAL 2|Medicare|MEDICARE ACUTE|257.68||||2,893.25||| C1763|EAP|0278|VALVE HEART THV SAPIEN 3|Medicare|MEDICARE ACUTE|1,183.00||||2,893.25||| C1763|EAP|0278|IMPLANT VALVE G1|Medicare|MEDICARE ACUTE|12,979.25||||2,893.25||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Medicare|MEDICARE PART B ONLY IP|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Medicare|MEDICARE ACUTE|5,786.50||||2,893.25||| C1763|EAP|0278|VALVE MAGNA EASE MITRAL 3|Medicare|MEDICARE ACUTE|257.68||||2,893.25||| C1763|EAP|0278|INSPRIAS RISILIA AORTIC H|Medicare|MEDICARE ACUTE|322.10||||2,893.25||| C1763|EAP|0278|VALVE HEART THV SAPIEN 3|Managed Medicare|HEALTHSPRING MA|1,183.00||||||| C1763|EAP|0278|IMPLANT VALVE G1|Managed Medicare|BCBS MEDICARE PPO MA|12,979.25||||||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|Managed Medicare|HEALTHSPRING MA|257.68||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Managed Medicare|HEALTHSPRING MA|2,893.25||||||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|NON CONTRACTED|COMMERCIAL OTHER 1|257.68||||||| C1763|EAP|0278|IMPLANT VALVE G1|Tricare|TRICARE EAST REGION|12,979.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|United Healthcare|UNITED HEALTHCARE OTHER|5,786.50||||2,893.25||| C1763|EAP|0278|VALVE HEART THV SAPIEN 3|United Healthcare|UNITED HEALTHCARE|1,183.00||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|United Healthcare|UNITED HEALTHCARE|2,893.25||||||| C1763|EAP|0278|INSPRIAS RISILIA AORTIC H|United Medicare Advantage|UHC AARP MCR HMO MA|322.10||||||| C1763|EAP|0278|INSPRIAS RISILIA AORTIC H|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|322.10||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|United Medicare Advantage|UHC AARP MCR HMO MA|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|United Medicare Advantage|UHC MEDICARE GOLD MA|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2,893.25||||||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|257.68||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Access Direct Platinum|HEALTHFIRST TPA UMR|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Access Direct Platinum|HEALTHFIRST TPA|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Veterans Affairs|VETERANS ADMINISTRATION|2,893.25||||||| C1763|EAP|0278|INSPRIAS RISILIA AORTIC H|Cigna|CIGNA|322.10||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Cigna|CIGNA|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Cigna|CIGNA OTHER|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|United Healthcare|TML GROUP BENEFITS|2,893.25||||||| C1763|EAP|0278|VALVE HEART THV SAPIEN 3|Humana Medicare Advantage|HUMANA MA|1,183.00||||||| C1763|EAP|0278|INSPRIAS RISILIA AORTIC H|Humana Medicare Advantage|HUMANA MA|322.10||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Humana Medicare Advantage|HUMANA MA|5,786.50||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Humana Medicare Advantage|HUMANA MA|2,893.25||||||| C1763|EAP|0278|VALVE HEART THV SAPIEN 3|Managed Medicare|BCBS MEDICARE PPO MA|1,183.00||||||| C1763|EAP|0278|VALVE HEART THV SAPIEN 3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,183.00||||||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|257.68||||||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|257.68||||||| C1763|EAP|0278|SHUNT STRATA II CUSTOM 27|Managed Medicaid|MEDICAID UNITED HEALTHCARE|186.84||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Medicare|MEDICARE ACUTE|2,893.25||||2,893.25||| C1763|EAP|0278|SHUNT STRATA II CUSTOM 27|Managed Medicaid|MEDICAID AMERIGROUP|186.84||||||| C1763|EAP|0278|IMPLANT VALVE G1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12,979.25||||||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|Medicare|MEDICARE ACUTE|257.68||||2,893.25||| C1763|EAP|0278|IMPLANT VALVE G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12,979.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Managed Medicaid|MEDICAID SUPERIOR|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,893.25||||||| C1763|EAP|0278|VALVE MITRAL ROTA 33MM 33|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|212.14||||||| C1763|EAP|0278|VALVE MAGNA EASE MITRAL 3|Medicaid|MEDICAID|257.68||||||| C1763|EAP|0278|INSPRIAS RISILIA AORTIC H|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|322.10||||||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|Aenta Medicare Advantage|AETNA MEDICARE MA|257.68||||||| C1763|EAP|0278|VALVE HEART THV SAPIEN 3|Aenta Medicare Advantage|AETNA MEDICARE MA|1,183.00||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Aetna|AETNA OTHER|5,786.50||||||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|Aetna|AETNA OTHER|257.68||||||| C1763|EAP|0278|VALVE HEART THV SAPIEN 3|Aetna|AETNA OTHER|1,183.00||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Aetna|AETNA PPO|2,893.25||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Aetna|AETNA OTHER|2,893.25||||||| C1763|EAP|0278|INSPRIAS RISILIA AORTIC H|Blue Cross HMO Specialty|BCBSTX HMO|322.10||||||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Blue Cross PPO Specialty|BCBSTX PPO|2,893.25||||2,893.25||| C1763|EAP|0278|VALVE HEART THV SAPIEN 3|Blue Cross PPO Specialty|BCBSTX PPO|1,183.00||||2,893.25||| C1763|EAP|0278|VALVE AORTIC MAGNA EASE 2|Blue Cross PPO Specialty|BCBSTX PPO|257.68||||2,893.25||| C1763|EAP|0278|GRAFT CONN TISS, NON-HUMA|Blue Cross PPO Specialty|BCBSTX PPO|5,786.50||||2,893.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|Blue Cross HMO Specialty|BCBSTX HMO|||||19,274.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|Blue Cross PPO Specialty|BCBSTX PPO|||||19,274.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||19,274.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||19,274.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||19,274.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|Humana Medicare Advantage|HUMANA MA|||||19,274.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|Cigna|CIGNA|||||19,274.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||19,274.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|United Medicare Advantage|UHC MEDICARE GOLD MA|19,274.25||||||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||19,274.25||| C1764|EAP|0278|REVEAL LINQ SYSTEM LINQSY|Medicare|MEDICARE ACUTE|19,274.25||||19,274.25||| C1766|EAP|0272|MOBICATH BWI D14011|United Healthcare|UNITED HEALTHCARE|||||46.18||| C1766|EAP|0272|MOBICATH BWI D14011|Managed Medicare|BCBS MEDICARE PPO MA|46.18||||46.18||| C1766|EAP|0272|MOBICATH BWI D14011|Medicare|MEDICARE ACUTE|46.18||||46.18||| C1766|EAP|0272|SHEATH INFINITY L BFR 90C|Medicare|MEDICARE ACUTE|23.81||||46.18||| C1766|EAP|0278|LARGE CURL INTRODUCER|Medicare|MEDICARE ACUTE|||||908.75||| C1766|EAP|0278|MED CURL INTRODUCER|Medicare|MEDICARE ACUTE|||||908.75||| C1766|EAP|0272|MOBICATH BWI D14011|United Medicare Advantage|UHC MEDICARE GOLD MA|||||46.18||| C1766|EAP|0272|MOBICATH BWI D14011|United Medicare Advantage|UHC AARP MCR HMO MA|||||46.18||| C1766|EAP|0272|MOBICATH BWI D14011|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.18||||||| C1766|EAP|0272|MOBICATH BWI D14011|Access Direct Platinum|HEALTHFIRST TPA UMR|||||46.18||| C1766|EAP|0272|MOBICATH BWI D14011|Humana Medicare Advantage|HUMANA MA|46.18||||46.18||| C1766|EAP|0278|MED CURL INTRODUCER|Humana Medicare Advantage|HUMANA MA|908.75||||||| C1766|EAP|0278|LARGE CURL INTRODUCER|Humana Medicare Advantage|HUMANA MA|908.75||||||| C1766|EAP|0272|MOBICATH BWI D14011|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.18||| C1766|EAP|0272|MOBICATH BWI D14011|Aenta Medicare Advantage|AETNA MEDICARE MA|||||46.18||| C1766|EAP|0272|MOBICATH BWI D14011|Aetna|AETNA PPO|46.18||||||| C1766|EAP|0272|MOBICATH BWI D14011|Blue Cross PPO Specialty|BCBSTX PPO|46.18||||46.18||| C1766|EAP|0278|MED CURL INTRODUCER|Blue Cross PPO Specialty|BCBSTX PPO|908.75||||||| C1767|EAP|0278|STIMULATOR NEURO ACTIVA S|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||32,556.25||| C1767|EAP|0278|STIMULATOR NEURO ACTIVA S|Blue Cross HMO Specialty|BCBSTX HMO|||||32,556.25||| C1767|EAP|0278|STIMULATOR NUERO INTERSTI|Blue Cross PPO Specialty|BCBSTX PPO|||||40,051.75||| C1767|EAP|0278|NEUROSTIMULATOR SYS SENZA|Blue Cross PPO Specialty|BCBSTX PPO|||||910.00||| C1767|EAP|0278|IMPL STIMULATOR BRAIN DUA|Blue Cross PPO Specialty|BCBSTX PPO|||||372.07||| C1767|EAP|0278|IMPL STIMULATOR BRAIN DUA|Aenta Medicare Advantage|AETNA MEDICARE MA|693.00||||372.07||| C1767|EAP|0278|IMPL GENERATOR PULSE SC-1|Aenta Medicare Advantage|AETNA MEDICARE MA|693.00||||693.00||| C1767|EAP|0278|STIMULATOR NUERO INTERSTI|Aenta Medicare Advantage|AETNA MEDICARE MA|693.00||||40,051.75||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|Aetna|AETNA PPO|||||500.50||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||500.50||| C1767|EAP|0278|NEUROSTIMULATOR SYS SENZA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||910.00||| C1767|EAP|0278|IMPL GENERATOR PULSE SC-1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||693.00||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||500.50||| C1767|EAP|0278|NEUROSTIMULATOR SYS SENZA|Humana Medicare Advantage|HUMANA MA|||||910.00||| C1767|EAP|0278|STIMULATOR NUERO INTERSTI|Humana Medicare Advantage|HUMANA MA|||||40,051.75||| C1767|EAP|0278|IMPL GENERATOR PULSE SC-1|Humana Medicare Advantage|HUMANA MA|||||693.00||| C1767|EAP|0278|STIMULATOR NEURO ACTIVA S|Humana Medicare Advantage|HUMANA MA|||||32,556.25||| C1767|EAP|0278|IMPL STIMULATOR BRAIN DUA|Humana Medicare Advantage|HUMANA MA|||||372.07||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|Humana Medicare Advantage|HUMANA MA|||||500.50||| C1767|EAP|0278|NEUROSTIMULATOR SYS SENZA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||910.00||| C1767|EAP|0278|IMPL IPG BATTERY KIT NIPG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||595.98||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||500.50||| C1767|EAP|0278|STIMULATOR NUERO INTERSTI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||40,051.75||| C1767|EAP|0278|NEUROSTIMULATOR SYS SENZA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||910.00||| C1767|EAP|0278|STIMULATOR NEURO ACTIVA S|United Medicare Advantage|UHC MEDICARE GOLD MA|||||32,556.25||| C1767|EAP|0278|STIMULATOR NUERO INTERSTI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||40,051.75||| C1767|EAP|0278|STIMULATOR NUERO INTERSTI|United Medicare Advantage|UHC AARP MCR HMO MA|||||40,051.75||| C1767|EAP|0278|STIMULATOR NEURO ACTIVA S|Aenta Medicare Advantage|AETNA MEDICARE MA|693.00||||32,556.25||| C1767|EAP|0278|STIMULATOR NUERO INTERSTI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.01||| C1767|EAP|0278|IMPL STIMULATOR BRAIN DUA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||372.07||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|Blue Cross PPO Specialty|BCBSTX PPO|||||500.50||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||500.50||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|United Medicare Advantage|UHC AARP MCR HMO MA|||||500.50||| C1767|EAP|0278|IMPL GENERATOR PULSE SC-1|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||693.00||| C1767|EAP|0278|STIMULATOR NEURO ACTIVA S|Medicare|MEDICARE ACUTE|910.00||||32,556.25||| C1767|EAP|0278|STIMULATOR NUERO INTERSTI|Medicare|MEDICARE ACUTE|910.00||||40,051.75||| C1767|EAP|0278|NEUROSTIMULATOR SYS SENZA|Medicare|MEDICARE PART B ONLY IP|910.00||||||| C1767|EAP|0278|NEUROSTIMULATOR SYS SENZA|Medicare|MEDICARE ACUTE|910.00||||910.00||| C1767|EAP|0278|IMPL STIMULATOR BRAIN DUA|Medicare|MEDICARE ACUTE|910.00||||372.07||| C1767|EAP|0278|IMPL GENERATOR 104|Medicare|MEDICARE ACUTE|910.00||||0.01||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|Medicare|MEDICARE ACUTE|910.00||||500.50||| C1767|EAP|0278|IMPL STIMULATOR BRAIN DUA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||372.07||| C1767|EAP|0278|IMPL GENERATOR PULSE SC-1|Managed Medicare|HEALTHSPRING MA|||||693.00||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|Managed Medicare|HEALTHSPRING MA|||||500.50||| C1767|EAP|0278|GENERATOR W/CONTROL 3660C|Tricare|TRICARE EAST REGION|||||500.50||| C1767|EAP|0278|STIMULATOR NEURO ACTIVA S|United Healthcare|UNITED HEALTHCARE OTHER|||||32,556.25||| C1767|EAP|0278|NEUROSTIMULATOR SYS SENZA|United Healthcare|UNITED HEALTHCARE|||||910.00||| C1768|EAP|0278|GRAFT, VASCULAR G1|UTMB|UTMB CORRECTIONAL MANAGED CARE|578.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G4|United Healthcare|UNITED HEALTHCARE|5,786.50||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G1|United Healthcare|UNITED HEALTHCARE|578.75||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G7|United Healthcare|UNITED HEALTHCARE|162.24||||||| C1768|EAP|0278|GRAFT, VASCULAR G5|United Healthcare|TML GROUP BENEFITS|115.73||||||| C1768|EAP|0278|GRAFT, VASCULAR G1|United Healthcare|UNITED HEALTHCARE|578.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G7|NON CONTRACTED|COMMERCIAL OTHER 1|162.24||||||| C1768|EAP|0278|GRAFT, VASCULAR G5|Tricare|TRICARE EAST REGION|115.73||||||| C1768|EAP|0278|GRAFT, VASCULAR G3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,893.25||||||| C1768|EAP|0278|GRAFT, VASCULAR G1|Managed Medicare|HEALTHSPRING MA|578.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G1|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G1|Managed Medicare|BCBS MEDICARE PPO MA|578.75||||||| C1768|EAP|0278|EXCLUDER 28.5M 14.5M 16C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|391.30||||||| C1768|EAP|0278|GRAFT, VASCULAR G5|Managed Medicare|HEALTHSPRING MA|115.73||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G6|Managed Medicare|BCBS MEDICARE PPO MA|17,359.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G6|Managed Medicare|HEALTHSPRING MA|17,359.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G7|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|162.24||||||| C1768|EAP|0278|GRAFT, VASCULAR G3|Managed Medicare|HEALTHSPRING MA|2,893.25||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G1|Managed Medicare|HEALTHSPRING MA|274.40||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G7|Managed Medicare|HEALTHSPRING MA|162.24||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5,786.50||||||| C1768|EAP|0278|GRAFT, VASCULAR G2|Managed Medicare|HEALTHSPRING MA|1,447.25||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G7|Medicare|MEDICARE PART B ONLY IP|162.24||||||| C1768|EAP|0278|GRAFT, VASCULAR G7|Medicare|MEDICARE ACUTE|162.24||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G5|Medicare|MEDICARE ACUTE|40,695.25||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G4|Medicare|MEDICARE PART B ONLY IP|5,786.50||||||| C1768|EAP|0278|GRAFT, VASCULAR G4|Medicare|MEDICARE ACUTE|391.30||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G4|Medicare|MEDICARE ACUTE|5,786.50||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G3|Medicare|MEDICARE ACUTE|2,893.25||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G3|Medicare|MEDICARE ACUTE|391.30||||2,893.25||| C1768|EAP|0278|GRAFT, VASCULAR G2|Medicare|MEDICARE ACUTE|391.30||||1,447.25||| C1768|EAP|0278|GRAFT, VASCULAR G1|Medicare|MEDICARE ACUTE|578.75||||162.24||| C1768|EAP|0278|GRAFT VEIN SAPHENOUS 70-7|Medicare|MEDICARE ACUTE|36,472.75||||162.24||| C1768|EAP|0278|GRAFT VEIN SAPENOUS 40-49|Medicare|MEDICARE ACUTE|274.40||||162.24||| C1768|EAP|0278|GRAFT ENDOVASC THORACIC T|Medicare|MEDICARE ACUTE|33,529.50||||162.24||| C1768|EAP|0278|EXCLUDER C3 35MMX14.5MMX1|Medicare|MEDICARE ACUTE|387.84||||162.24||| C1768|EAP|0278|EXCLUDER C3 31MMX14.5MMX1|Medicare|MEDICARE ACUTE|387.84||||162.24||| C1768|EAP|0278|EXCLUDER 35M 18C RLT35141|Medicare|MEDICARE ACUTE|387.84||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G1|Medicare|MEDICARE ACUTE|40,695.25||||578.75||| C1768|EAP|0278|GRAFT FEMORAL VEIN 10-30+|Medicare|MEDICARE ACUTE|252.98||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G7|Medicare|MEDICARE ACUTE|39,748.75||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G5|Medicare|MEDICARE ACUTE|115.73||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G4|Medicaid|MEDICAID|578.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G1|Medicaid|CRIME VICTIMS COMPENSATION|578.75||||||| C1768|EAP|0278|GRAFT VEIN SAPHENOUS 70-7|Medicaid|SMITH COUNTY JAIL|36,472.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G4|United Medicare Advantage|UHC MEDICARE GOLD MA|578.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G6|United Medicare Advantage|UHC MEDICARE GOLD MA|2,893.25||||17,359.75||| C1768|EAP|0278|GRAFT, VASCULAR G7|United Medicare Advantage|UHC AARP MCR HMO MA|162.24||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,786.50||||||| C1768|EAP|0278|GRAFT, VASCULAR G6|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17,359.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G4|United Medicare Advantage|UHC AARP MCR HMO MA|5,786.50||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G6|United Medicare Advantage|UHC AARP MCR HMO MA|17,359.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G4|United Medicare Advantage|UHC AARP MCR HMO MA|387.84||||5,786.50||| C1768|EAP|0278|GRAFT VEIN SAPENOUS 40-49|United Medicare Advantage|UHC AARP MCR HMO MA|274.40||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G5|United Medicare Advantage|UHC MEDICARE GOLD MA|115.73||||17,359.75||| C1768|EAP|0278|GRAFT, VASCULAR G1|United Medicare Advantage|UHC AARP MCR HMO MA|40,695.25||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G1|United Medicare Advantage|UHC AARP MCR HMO MA|578.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|115.73||||||| C1768|EAP|0278|GRAFT, VASCULAR G2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,447.25||||||| C1768|EAP|0278|BONE GRAFT VITOSS 2102-22|Workers Compensation|WORKERS COMPENSATION OTHER|578.75||||20,537.50||| C1768|EAP|0278|GRAFT, VASCULAR G1|Workers Compensation|BROOKSHIRES WORKERS COMP|578.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G1|Workers Compensation|WORKERS COMPENSATION OTHER|578.75||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G7|Veterans Affairs|VETERANS ADMINISTRATION|162.24||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G5|Veterans Affairs|VETERANS ADMINISTRATION|115.73||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|578.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G5|Veterans Affairs|VETERANS ADMINISTRATION|5,786.50||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G4|Veterans Affairs|VETERANS ADMINISTRATION|578.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G7|Access Direct Platinum|HEALTHFIRST TPA UMR|5,786.50||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|578.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G1|Cigna|CIGNA OTHER|578.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G3|Cigna|CIGNA|2,893.25||||||| C1768|EAP|0278|GRAFT, VASCULAR G2|Cigna|CIGNA|1,447.25||||||| C1768|EAP|0278|GRAFT, VASCULAR G1|Cigna|CIGNA|578.75||||||| C1768|EAP|0278|GRAFT VEIN SAPHENOUS 70-7|United Medicare Advantage|UHC AARP MCR HMO MA|36,472.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G5|United Medicare Advantage|UHC AARP MCR HMO MA|115.73||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G5|Humana Medicare Advantage|HUMANA MA|578.75||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G6|Humana Medicare Advantage|HUMANA MA|17,359.75||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G7|Humana Medicare Advantage|HUMANA MA|162.24||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G4|Humana Medicare Advantage|HUMANA MA|5,786.50||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G3|Medicaid|SMITH COUNTY INDIGENT HEALTH|2,893.25||||||| C1768|EAP|0278|GRAFT, VASCULAR G7|Humana Medicare Advantage|HUMANA MA|1,447.25||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G5|Humana Medicare Advantage|HUMANA MA|115.73||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G4|Humana Medicare Advantage|HUMANA MA|387.84||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G3|Humana Medicare Advantage|HUMANA MA|391.30||||2,893.25||| C1768|EAP|0278|GRAFT, VASCULAR G3|Humana Medicare Advantage|HUMANA MA|2,893.25||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G1|Humana Medicare Advantage|HUMANA MA|20,537.50||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G7|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|162.24||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G6|Managed Medicaid|MEDICAID SUPERIOR|17,359.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|115.73||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,447.25||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5,786.50||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,786.50||||115.73||| C1768|EAP|0278|EXCLUDER AAA ENDO RLT2814|Medicare|MEDICARE ACUTE|376.25||||162.24||| C1768|EAP|0278|GRAFT FEMORAL VEIN 10-30+|Medicare|MEDICARE ACUTE|20,537.50||||252.98||| C1768|EAP|0278|GRAFT, VASCULAR G2|Medicare|MEDICARE ACUTE|1,447.25||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|578.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|578.75||||1,447.25||| C1768|EAP|0278|GRAFT, VASCULAR G1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36,472.75||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36,472.75||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,893.25||||115.73||| C1768|EAP|0278|GRAFT VEIN SAPHENOUS 70-7|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36,472.75||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|387.84||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G7|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|162.24||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G6|Medicare|MEDICARE ACUTE|17,359.75||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|391.30||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.73||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,786.50||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,447.25||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G7|Managed Medicare|BCBS MEDICARE PPO MA|162.24||||||| C1768|EAP|0278|GRAFT, VASCULAR G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|578.75||||115.73||| C1768|EAP|0278|GRAFT VEIN SAPHENOUS 60-6|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34,489.50||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|391.30||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G7|Aenta Medicare Advantage|AETNA MEDICARE MA|162.24||||2,893.25||| C1768|EAP|0278|GRAFT, VASCULAR G2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,447.25||||||| C1768|EAP|0278|GRAFT, VASCULAR G6|Aenta Medicare Advantage|AETNA MEDICARE MA|17,359.75||||2,893.25||| C1768|EAP|0278|GRAFT, VASCULAR G4|Aenta Medicare Advantage|AETNA MEDICARE MA|5,786.50||||2,893.25||| C1768|EAP|0278|GRAFT, VASCULAR G4|Aetna|AETNA PPO|5,786.50||||||| C1768|EAP|0278|GRAFT, VASCULAR G3|Aetna|AETNA QHP HMO|2,893.25||||||| C1768|EAP|0278|GRAFT, VASCULAR G4|Managed Medicare|HEALTHSPRING MA|36,472.75||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G3|Aenta Medicare Advantage|AETNA MEDICARE MA|2,893.25||||2,893.25||| C1768|EAP|0278|GRAFT, VASCULAR G4|Aetna|AETNA OTHER|||||5,786.50||| C1768|EAP|0278|GRAFT, VASCULAR G6|Aetna|AETNA QHP HMO|17,359.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G1|Aetna|AETNA PPO|578.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G1|Tricare|TRICARE EAST REGION|578.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G3|Aenta Medicare Advantage|AETNA MEDICARE MA|1,447.25||||2,893.25||| C1768|EAP|0278|GRAFT, VASCULAR G1|Aenta Medicare Advantage|AETNA MEDICARE MA|578.75||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G2|Blue Cross HMO Specialty|BCBSTX HMO|1,447.25||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G6|Blue Cross HMO Specialty|BCBSTX HMO|17,359.75||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G1|United Healthcare|UNITED HEALTHCARE OTHER|578.75||||||| C1768|EAP|0278|GRAFT, VASCULAR G7|Blue Cross HMO Specialty|BCBSTX HMO|36,472.75||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G5|Blue Cross HMO Specialty|BCBSTX HMO|115.73||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G1|Blue Cross HMO Specialty|BCBSTX HMO|578.75||||162.24||| C1768|EAP|0278|GRAFT, VASCULAR G4|Blue Cross PPO Specialty|BCBSTX PPO|5,786.50||||17,359.75||| C1768|EAP|0278|GRAFT, VASCULAR G7|Blue Cross PPO Specialty|BCBSTX PPO|162.24||||17,359.75||| C1768|EAP|0278|GRAFT, VASCULAR G6|Blue Cross PPO Specialty|BCBSTX PPO|578.75||||17,359.75||| C1768|EAP|0278|GRAFT, VASCULAR G5|Blue Cross PPO Specialty|BCBSTX PPO|36,472.75||||115.73||| C1768|EAP|0278|GRAFT, VASCULAR G5|Blue Cross PPO Specialty|BCBSTX PPO|115.73||||17,359.75||| C1768|EAP|0278|GRAFT, VASCULAR G3|Blue Cross PPO Specialty|BCBSTX PPO|40,695.25||||2,893.25||| C1768|EAP|0278|GRAFT, VASCULAR G2|Blue Cross PPO Specialty|BCBSTX PPO|1,447.25||||17,359.75||| C1768|EAP|0278|GRAFT, VASCULAR G1|Blue Cross PPO Specialty|BCBSTX PPO|20,537.50||||578.75||| C1768|EAP|0278|GRAFT, VASCULAR G7|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|162.24||||||| C1768|EAP|0278|GRAFT, VASCULAR G3|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2,893.25||||||| C1768|EAP|0278|GRAFT ENDOVASC THORACIC T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|33,529.50||||||| C1768|EAP|0278|EXCLUDER 28.5M 14.5M 16C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|391.30||||||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|United Medicare Advantage|UHC MEDICARE GOLD MA|106.75||||528.50||| C1769|EAP|0272|FATHOM GUIDEWIRE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|550.25||||2,273.25||| C1769|EAP|0272|WIRE SUPER STIFF J-TIP 1.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||365.50||| C1769|EAP|0272|GUIDE WIRE G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,391.50||||278.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|United Medicare Advantage|UHC MEDICARE GOLD MA|935.50||||253.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|550.25||||550.25||| C1769|EAP|0272|FATHOM GUIDEWIRE|United Medicare Advantage|UHC MEDICARE GOLD MA|2,864.25||||2,273.25||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|United Medicare Advantage|UHC AARP MCR HMO MA|253.25||||389.75||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|United Medicare Advantage|UHC AARP MCR HMO MA|550.25||||528.50||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,864.25||||408.75||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|975.25||||416.25||| C1769|EAP|0272|GUIDANT WHISPER WIRE|United Medicare Advantage|UHC AARP WELLMED HMO MA|168.50||||1,015.50||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|United Medicare Advantage|UHC AARP MCR HMO MA|278.75||||2,864.25||| C1769|EAP|0272|WHOLEY .035|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||975.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||550.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|United Medicare Advantage|UHC MEDICARE GOLD MA|184.25||||550.25||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|United Medicare Advantage|UHC MEDICARE GOLD MA|975.25||||627.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|United Medicare Advantage|UHC MEDICARE GOLD MA|550.25||||331.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Medicaid|MEDICAID HMO|278.75||||253.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Medicaid|LAW ENFORCEMENT OTHER|550.25||||||| C1769|EAP|0272|FATHOM GUIDEWIRE|Medicaid|MEDICAID|2,864.25||||2,273.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Medicaid|MEDICAID|253.25||||118.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Medicaid|SMITH COUNTY INDIGENT HEALTH|331.25||||||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Medicaid|MEDICAID|142.25||||331.25||| C1769|EAP|0272|GUIDEWIRE .025 3MM J 150C|Medicaid|COUNTY INDIGENT HEALTH OTHER|550.25||||106.75||| C1769|EAP|0272|GUIDE WIRE G2|Medicaid|COUNTY INDIGENT HEALTH OTHER|550.25||||1,391.50||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Medicaid|MOLINA HEALTHCARE OF TEXAS|278.75||||168.50||| C1769|EAP|0272|FATHOM GUIDEWIRE|Medicaid|CRIME VICTIMS COMPENSATION|2,273.25||||||| C1769|EAP|0272|BENTSON 260CM GUIDEWIRE 4|Medicaid|MEDICAID|433.50||||184.25||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Medicaid|SMITH COUNTY INDIGENT HEALTH|38.64||||||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Medicaid|MEDICAID|389.75||||253.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Medicaid|SMITH COUNTY INDIGENT HEALTH|253.25||||||| C1769|EAP|0272|GUIDE WIRE G1|Medicaid|COUNTY INDIGENT HEALTH OTHER|550.25||||278.75||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Medicaid|MEDICAID|1,015.50||||389.75||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Medicaid|COUNTY INDIGENT HEALTH OTHER|550.25||||550.25||| C1769|EAP|0272|SPARTA CORE 14 5CM TIP 19|Medicaid|MEDICAID|278.75||||660.75||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Medicaid|MEDICAID|557.50||||118.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Medicaid|MEDICAID|550.25||||118.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Medicaid|CRIME VICTIMS COMPENSATION|253.25||||||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Medicaid|LAW ENFORCEMENT OTHER|389.75||||||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|Medicaid|COUNTY INDIGENT HEALTH OTHER|550.25||||408.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Medicaid|MEDICAID|331.25||||118.75||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Medicaid|MEDICAID|2,047.50||||118.75||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Medicaid|MEDICAID|168.50||||118.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Medicaid|MEDICAID|1,391.50||||550.25||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Medicaid|COUNTY INDIGENT HEALTH OTHER|550.25||||5.95||| C1769|EAP|0272|CATH QUICK CROSS .014X150|Medicare|MEDICARE ACUTE|550.25||||11.04||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Medicare|MEDICARE ACUTE|184.25||||550.25||| C1769|EAP|0272|BENTSON 260CM GUIDEWIRE 4|Medicare|MEDICARE ACUTE|917.25||||184.25||| C1769|EAP|0272|ALLSTAR GUIDEWIRE 300CM 1|Medicare|MEDICARE ACUTE|550.25||||550.25||| C1769|EAP|0272|ACCESS GUIDE WIRE|Medicare|MEDICARE ACUTE|7.81||||7.81||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Medicare|UTSW MC KIDNEY PROGRAM|||||5.95||| C1769|EAP|0272|GLIDEWIRE TAPERED 65CM CG|Medicare|MEDICARE ACUTE|528.50||||480.75||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Medicare|MEDICARE ACUTE|38.65||||550.25||| C1769|EAP|0272|GUIDEWIRE 150CM.035 STRAI|Medicare|MEDICARE ACUTE|364.75||||106.75||| C1769|EAP|0272|WHOLEY .035|Medicare|MEDICARE ACUTE|660.75||||975.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Medicare|MEDICARE PART B ONLY IP|2,864.25||||||| C1769|EAP|0272|GUIDE WIRE|Medicare|MEDICARE ACUTE|106.75||||142.25||| C1769|EAP|0272|BMW UNIVERSAL 11 300CM 5/|Medicare|MEDICARE ACUTE|550.25||||550.25||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|Medicare|MEDICARE ACUTE|142.25||||408.75||| C1769|EAP|0272|GUIDEWIRE NITINOL|Medicare|MEDICARE ACUTE|1.16||||4.45||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|Medicare|MEDICARE ACUTE|184.25||||557.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Medicare|MEDICARE ACUTE|118.75||||550.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 STRA|Medicare|MEDICARE ACUTE|253.25||||154.50||| C1769|EAP|0272|SNARE WIRE CATH 4MM SK400|Medicare|MEDICARE ACUTE|550.25||||4,221.25||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Medicare|MEDICARE ACUTE|917.25||||38.64||| C1769|EAP|0272|GUIDEWIRE AMPLATZ 180CM 4|Medicare|MEDICARE ACUTE|248.25||||408.75||| C1769|EAP|0272|GUIDEWIRE ADVANTAGE .035|Medicare|MEDICARE ACUTE|416.25||||1,428.50||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|Medicare|MEDICARE ACUTE|1,128.25||||528.50||| C1769|EAP|0272|GUIDEWIRE ROADRUNNER|Medicare|MEDICARE PART B ONLY IP|201.75||||||| C1769|EAP|0272|CATH QUICK CROSS EXTREME|Medicare|MEDICARE ACUTE|893.45||||1,279.50||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Medicare|MEDICARE ACUTE|2,105.25||||331.25||| C1769|EAP|0272|GUIDEWIRE FW EZ 190 20100|Medicare|MEDICARE ACUTE|201.75||||9,385.50||| C1769|EAP|0272|GUIDEWIRE GLIDE EXCHANGE|Medicare|MEDICARE ACUTE|416.25||||999.25||| C1769|EAP|0272|GUIDEWIRE EXCHANGE/GLIDE|Medicare|MEDICARE ACUTE|4.45||||248.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Medicare|MEDICARE ACUTE|5.95||||118.75||| C1769|EAP|0272|VIPERWIRE ADVANCE CORONAR|Medicare|MEDICARE ACUTE|557.50||||1,128.25||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Medicare|MEDICARE PART B ONLY IP|416.25||||||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Medicare|MEDICARE ACUTE|999.25||||253.25||| C1769|EAP|0272|ASAHI MIRACLEBROS 3 WIRE|Medicare|MEDICARE ACUTE|917.25||||917.25||| C1769|EAP|0272|JAG GUIDEWIRE|Medicare|MEDICARE ACUTE|550.25||||935.50||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Medicare|MEDICARE PART B ONLY IP|5.95||||||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Medicare|MEDICARE ACUTE|408.75||||168.50||| C1769|EAP|0272|GUIDEWIRE .025 3MM J 150C|Medicare|UTSW MC KIDNEY PROGRAM|||||106.75||| C1769|EAP|0272|GUIDEWIRE ROADRUNNER|Medicare|MEDICARE ACUTE|935.50||||201.75||| C1769|EAP|0272|GUIDE WIRE G2|Medicare|MEDICARE ACUTE|168.50||||1,391.50||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Medicare|MEDICARE ACUTE|5.95||||5.95||| C1769|EAP|0272|WIRE SUPER STIFF J-TIP 1.|Medicare|MEDICARE ACUTE|5.95||||365.50||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Medicare|MEDICARE ACUTE|5.95||||4,221.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Medicare|MEDICARE PART B ONLY IP|118.75||||||| C1769|EAP|0272|WIRE CONFIANZA 300C 14943|Medicare|MEDICARE ACUTE|5.95||||917.25||| C1769|EAP|0272|WIRE ASAHI ASTATO XS20 30|Medicare|MEDICARE ACUTE|5.95||||63.32||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 0|Medicare|MEDICARE ACUTE|4,221.25||||550.25||| C1769|EAP|0272|GUIDE WIRE|Medicare|MEDICARE PART B ONLY IP|142.25||||||| C1769|EAP|0272|GUIDEWIRE SYNCHRO 300CM|Medicare|MEDICARE ACUTE|550.25||||2,105.25||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 180C G|Medicare|MEDICARE ACUTE|38.64||||416.25||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|Medicare|MEDICARE PART B ONLY IP|627.75||||||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Medicare|MEDICARE PART B ONLY IP|331.25||||||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Medicare|MEDICARE ACUTE|1,732.75||||2,047.50||| C1769|EAP|0272|GUIDEWIRE ANGLED COR 503-|Medicare|MEDICARE ACUTE|331.25||||408.75||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Medicare|MEDICARE ACUTE|348.75||||416.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Medicare|MEDICARE PART B ONLY IP|253.25||||||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Medicare|MEDICARE PART B ONLY IP|168.50||||||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|Medicare|MEDICARE PART B ONLY IP|134.25||||||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Medicare|MEDICARE PART B ONLY IP|550.25||||||| C1769|EAP|0272|CATH QUICK CROSS .018X150|Medicare|MEDICARE ACUTE|433.50||||893.45||| C1769|EAP|0272|CATH QUICK CROSS .41X150|Medicare|MEDICARE ACUTE|11.04||||893.45||| C1769|EAP|0272|GUIDE WIRE G1|Medicare|MEDICARE PART B ONLY IP|278.75||||||| C1769|EAP|0272|GUIDE WIRE G1|Medicare|MEDICARE ACUTE|106.75||||278.75||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|Medicare|MEDICARE ACUTE|134.25||||528.50||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|Medicare|MEDICARE PART B ONLY IP|408.75||||||| C1769|EAP|0272|GLIDEWIRE ADVANTAGE 260CM|Medicare|MEDICARE ACUTE|389.75||||15.91||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Medicare|MEDICARE ACUTE|1,015.50||||2,864.25||| C1769|EAP|0272|GLIDECATH 4F 65CM ANGL CG|Medicare|MEDICARE ACUTE|408.75||||480.75||| C1769|EAP|0272|GLIDECATH 4F 100CM ANGL C|Medicare|MEDICARE ACUTE|2,864.25||||480.75||| C1769|EAP|0272|FATHOM GUIDEWIRE|Medicare|MEDICARE ACUTE|408.75||||2,273.25||| C1769|EAP|0272|CATHETER TRAILBLAZER SUPP|Medicare|MEDICARE ACUTE|2,273.25||||11.04||| C1769|EAP|0272|GUIDE WIRE G2|Managed Medicare|HEALTHSPRING MA|248.25||||1,391.50||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 180C G|Managed Medicare|HEALTHSPRING MA|660.75||||416.25||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2,047.50||| C1769|EAP|0272|GUIDE WIRE G1|Managed Medicare|BCBS MEDICARE PPO MA|389.75||||278.75||| C1769|EAP|0272|GUIDEWIRE ROADRUNNER|Managed Medicare|HEALTHSPRING MA|4,221.25||||201.75||| C1769|EAP|0272|WIRE PRIME 300CM .014 791|Managed Medicare|HEALTHSPRING MA|5.95||||38.65||| C1769|EAP|0272|WIRE SUPRACOR 5/BX 100270|Managed Medicare|HEALTHSPRING MA|5.95||||660.75||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|Managed Medicare|BCBS MEDICARE PPO MA|184.25||||1.16||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|Managed Medicare|HEALTHSPRING MA|1,391.50||||408.75||| C1769|EAP|0272|GUIDE WIRE G2|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1,391.50||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||168.50||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Managed Medicare|BCBS MEDICARE PPO MA|550.25||||2,864.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Managed Medicare|BCBS MEDICARE PPO MA|201.75||||550.25||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|Managed Medicare|BCBS MEDICARE PPO MA|253.25||||627.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ 180CM 4|Managed Medicare|HEALTHSPRING MA|935.50||||408.75||| C1769|EAP|0272|GUIDE WIRE G2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,047.50||||1,391.50||| C1769|EAP|0272|GUIDANT WHISPER WIRE|Managed Medicare|BCBS MEDICARE PPO MA|433.50||||1,015.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Managed Medicare|HEALTHSPRING MA|5.95||||550.25||| C1769|EAP|0272|GLIDECATH 4F 65CM ANGL CG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|433.50||||480.75||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|Managed Medicare|HEALTHSPRING MA|331.25||||557.50||| C1769|EAP|0272|WHOLEY .035|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||975.25||| C1769|EAP|0272|ASAHI MIRACLEBROS 3 WIRE|Managed Medicare|HEALTHSPRING MA|184.25||||917.25||| C1769|EAP|0272|VIPERWIRE ADVANCE CORONAR|Managed Medicare|HEALTHSPRING MA|5.95||||1,128.25||| C1769|EAP|0272|BMW UNIVERSAL 11 300CM 5/|Managed Medicare|HEALTHSPRING MA|550.25||||550.25||| C1769|EAP|0272|ASAHI MIRACLEBROS 3 14937|Managed Medicare|HEALTHSPRING MA|917.25||||917.25||| C1769|EAP|0272|GUIDE WIRE G2|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1,391.50||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Managed Medicare|WELLCARE CHOICE MA|||||2,047.50||| C1769|EAP|0272|FATHOM GUIDEWIRE|Managed Medicare|HEALTHSPRING MA|2,864.25||||2,273.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Managed Medicare|BCBS MEDICARE PPO MA|168.50||||253.25||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|557.50||||331.25||| C1769|EAP|0272|JAG GUIDEWIRE|Managed Medicare|HEALTHSPRING MA|5.95||||935.50||| C1769|EAP|0272|WHOLEY .035|Managed Medicare|BCBS MEDICARE PPO MA|38.64||||975.25||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||557.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Managed Medicare|HEALTHSPRING MA|5.95||||550.25||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||2,047.50||| C1769|EAP|0272|WIRE SUPER STIFF J-TIP 1.|Managed Medicare|BCBS MEDICARE PPO MA|557.50||||365.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|935.50||||253.25||| C1769|EAP|0272|ACCESS GUIDE WIRE|Managed Medicare|HEALTHSPRING MA|917.25||||7.81||| C1769|EAP|0272|GUIDE WIRE|Managed Medicare|BCBS MEDICARE PPO MA|1,015.50||||142.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||550.25||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Managed Medicare|HEALTHSPRING MA|118.75||||331.25||| C1769|EAP|0272|WIRE CONFIANZA 300C 14943|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||917.25||| C1769|EAP|0272|WHOLEY .035|Managed Medicare|HEALTHSPRING MA|5.95||||975.25||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Managed Medicare|HEALTHSPRING MA|5.95||||4,221.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||118.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ SS 46-5|Managed Medicare|HEALTHSPRING MA|550.25||||408.75||| C1769|EAP|0272|WIRE ASAHI ASTATO XS20 30|Managed Medicare|HEALTHSPRING MA|5.95||||63.32||| C1769|EAP|0272|GUIDE WIRE G1|Managed Medicare|HEALTHSPRING MA|416.25||||278.75||| C1769|EAP|0272|VIPERWIRE ADVANCE CORONAR|Managed Medicare|BCBS MEDICARE PPO MA|331.25||||1,128.25||| C1769|EAP|0272|CATH ANGIOSCALE COR 532-5|Managed Medicare|HEALTHSPRING MA|408.75||||433.50||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||4,221.25||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Managed Medicare|BCBS MEDICARE PPO MA|1,128.50||||416.25||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Managed Medicare|HEALTHSPRING MA|557.50||||2,047.50||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|348.75||||134.25||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Managed Medicare|HEALTHSPRING MA|5.95||||557.50||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||4,221.25||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|Managed Medicare|HEALTHSPRING MA|408.75||||408.75||| C1769|EAP|0272|SPARTA CORE 14 5CM TIP 19|Managed Medicare|HEALTHSPRING MA|5.95||||660.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Managed Medicare|BCBS MEDICARE PPO MA|1.16||||550.25||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||528.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||550.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Managed Medicare|HEALTHSPRING MA|348.75||||168.50||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|975.25||||416.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||253.25||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Managed Medicare|BCBS MEDICARE PPO MA|2,273.25||||389.75||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Managed Medicare|BCBS MEDICARE PPO MA|550.25||||557.50||| C1769|EAP|0272|GUIDEWIRE ANGLED COR 503-|Managed Medicare|HEALTHSPRING MA|550.25||||408.75||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Managed Medicare|OTHER INSTITUTIONS|||||2,047.50||| C1769|EAP|0272|JAG GUIDEWIRE|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||935.50||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Managed Medicare|BCBS MEDICARE PPO MA|142.25||||168.50||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Managed Medicare|HEALTHSPRING MA|142.25||||2,864.25||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,391.50||||389.75||| C1769|EAP|0272|GLIDEWIRE ADVANTAGE 260CM|Managed Medicare|HEALTHSPRING MA|278.75||||15.91||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Managed Medicare|HEALTHSPRING MA|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Managed Medicare|HEALTHSPRING MA|38.64||||253.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|550.25||||550.25||| C1769|EAP|0272|GLIDEWIRE TAPERED 65CM CG|Managed Medicare|HEALTHSPRING MA|168.50||||480.75||| C1769|EAP|0272|CATH QUICK CROSS EXTREME|Managed Medicare|HEALTHSPRING MA|480.75||||1,279.50||| C1769|EAP|0272|ASAHI MIRACLEBROS 3 WIRE|Managed Medicare|BCBS MEDICARE PPO MA|184.25||||917.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Managed Medicare|BCBS MEDICARE PPO MA|975.25||||118.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ SS 46-5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|38.64||||408.75||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||2,047.50||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|Managed Medicare|BCBS MEDICARE PPO MA|278.75||||557.50||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Managed Medicare|HEALTHSPRING MA|5.95||||5.95||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||38.64||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Managed Medicare|HEALTHSPRING MA|5.95||||550.25||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|Managed Medicare|HEALTHSPRING MA|2,047.50||||134.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|331.25||||168.50||| C1769|EAP|0272|GUIDE WIRE G1|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||278.75||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 0|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||550.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Managed Medicare|OTHER INSTITUTIONS|||||253.25||| C1769|EAP|0272|CATH SUPPORT .035 150C 51|Medicare|MEDICARE ACUTE|893.45||||11.04||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Managed Medicare|HEALTHSPRING MA|550.25||||416.25||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|Managed Medicare|HEALTHSPRING MA|38.65||||627.75||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|278.75||||408.75||| C1769|EAP|0272|GUIDE WIRE|Managed Medicare|HEALTHSPRING MA|364.75||||142.25||| C1769|EAP|0272|TRACER GUIDE WIRE|Managed Medicare|HEALTHSPRING MA|5.95||||7.23||| C1769|EAP|0272|GLIDECATH 4F 65CM ANGL CG|Managed Medicare|HEALTHSPRING MA|389.75||||480.75||| C1769|EAP|0272|GUIDANT WHISPER WIRE|Medicare|MEDICARE ACUTE|278.75||||1,015.50||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Managed Medicare|HEALTHSPRING MA|1,128.50||||389.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||253.25||| C1769|EAP|0272|GUIDE WIRE G2|Medicare|MEDICARE PART B ONLY IP|1,391.50||||||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|Managed Medicare|HEALTHSPRING MA|5.95||||528.50||| C1769|EAP|0272|GUIDE WIRE G1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|253.25||||278.75||| C1769|EAP|0272|GUIDANT WHISPER WIRE|Managed Medicare|HEALTHSPRING MA|154.50||||1,015.50||| C1769|EAP|0272|GUIDEWIRE HI-TORQUE SPART|Managed Medicare|HEALTHSPRING MA|550.25||||457.50||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|Medicare|MEDICARE ACUTE|557.50||||134.25||| C1769|EAP|0272|GUIDE WIRE G1|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||278.75||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|168.50||||528.50||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|Managed Medicare|HEALTHSPRING MA|253.25||||528.50||| C1769|EAP|0272|WIRE SUPRACOR 5/BX 100270|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||660.75||| C1769|EAP|0272|BENTSON 260CM GUIDEWIRE 4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|184.25||||184.25||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Rusk State Hospital|RUSK STATE HOSP|||||38.64||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Rusk State Hospital|RUSK STATE HOSP|||||253.25||| C1769|EAP|0272|FATHOM GUIDEWIRE|Rusk State Hospital|RUSK STATE HOSP|||||2,273.25||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|Medicare|MEDICARE ACUTE|527.50||||627.75||| C1769|EAP|0272|GUIDE WIRE G2|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1,391.50||| C1769|EAP|0272|WIRE VERSACORE STAND .035|PHCS|HUMANA INSURANCE|5.95||||||| C1769|EAP|0272|SNARE WIRE CATH 700 SK700|Medicare|MEDICARE ACUTE|975.25||||4,449.50||| C1769|EAP|0272|WIRE VERSACORE STAND .035|PHCS|HUMANA|5.95||||557.50||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|PHCS|HUMANA|557.50||||557.50||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Medicare|MEDICARE ACUTE|5.95||||557.50||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|PHCS|HUMANA|416.25||||557.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|PHCS|GROUP AND PENSION|253.25||||||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|PHCS|HUMANA INSURANCE|168.50||||||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|PHCS|GROUP AND PENSION|168.50||||||| C1769|EAP|0272|GUIDE WIRE G2|PHCS|HUMANA|134.25||||1,391.50||| C1769|EAP|0272|GUIDE WIRE G2|PHCS|GROUP AND PENSION|1,391.50||||||| C1769|EAP|0272|GUIDE WIRE G1|PHCS|HUMANA INSURANCE|278.75||||||| C1769|EAP|0272|GUIDE WIRE G1|PHCS|GROUP AND PENSION|278.75||||||| C1769|EAP|0272|GUIDE WIRE G1|Tricare|TRICARE EAST REGION|1,391.50||||278.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Tricare|TRICARE EAST REGION|1,391.50||||253.25||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Tricare|TRICARE EAST REGION|1,391.50||||389.75||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Tricare|TRICARE EAST REGION|1,391.50||||557.50||| C1769|EAP|0272|GUIDEWIRE .025 3MM J 150C|Medicare|MEDICARE ACUTE|1,128.50||||106.75||| C1769|EAP|0272|WIRE PRIME 300CM .014 791|Medicare|MEDICARE ACUTE|5.95||||38.65||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|Tricare|TRICARE EAST REGION|1,391.50||||557.50||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Tricare|TRICARE EAST REGION|1,391.50||||550.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ SS 46-5|Medicare|MEDICARE ACUTE|2,047.50||||408.75||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|Tricare|TRICARE FOR LIFE|557.50||||||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Tricare|TRICARE EAST REGION|1,391.50||||168.50||| C1769|EAP|0272|GUIDE WIRE G2|Tricare|TRICARE EAST REGION|1,391.50||||1,391.50||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Tricare|TRICARE EAST REGION|1,391.50||||2,864.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Tricare|TRICARE EAST REGION|278.75||||550.25||| C1769|EAP|0272|ALLSTAR GUIDEWIRE 300CM 1|Tricare|TRICARE EAST REGION|389.75||||550.25||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|Medicare|MEDICARE ACUTE|550.25||||1.16||| C1769|EAP|0272|ALLSTAR 190CM GUIDEWIR 10|Tricare|TRICARE EAST REGION|2,864.25||||550.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Multiplan|WEB TPA|||||253.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|NON CONTRACTED|COMMERCIAL OTHER 1|2,864.25||||2,864.25||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|NON CONTRACTED|COMMERCIAL OTHER 1|1,391.50||||389.75||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Medicare|MEDICARE ACUTE|1,391.50||||389.75||| C1769|EAP|0272|WIRE VERSACORE STAND .035|NON CONTRACTED|COMMERCIAL OTHER 1|5.95||||118.75||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|NON CONTRACTED|COMMERCIAL OTHER 1|557.50||||118.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||331.25||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|NON CONTRACTED|COMMERCIAL OTHER 1|550.25||||416.25||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|Medicare|MEDICARE ACUTE|480.75||||408.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|NON CONTRACTED|COMMERCIAL OTHER 1|38.64||||253.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|NON CONTRACTED|COMMERCIAL OTHER 1|331.25||||168.50||| C1769|EAP|0272|GUIDE WIRE G2|NON CONTRACTED|COMMERCIAL OTHER 2|1,391.50||||||| C1769|EAP|0272|GUIDE WIRE G2|NON CONTRACTED|COMMERCIAL OTHER 1|106.75||||1,391.50||| C1769|EAP|0272|GUIDE WIRE G1|NON CONTRACTED|COMMERCIAL OTHER 1|106.75||||278.75||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|NON CONTRACTED|COMMERCIAL OTHER 1|278.75||||408.75||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|NON CONTRACTED|COMMERCIAL OTHER 1|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE .025 3MM J 150C|NON CONTRACTED|COMMERCIAL OTHER 1|253.25||||106.75||| C1769|EAP|0272|GUIDE WIRE SV-8 .018 300|Medicare|MEDICARE ACUTE|154.50||||726.50||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Medicare|MEDICARE ACUTE|408.75||||550.25||| C1769|EAP|0272|WHOLEY .035|United Healthcare|UNITED HEALTHCARE OTHER|550.25||||975.25||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|United Healthcare|UNITED HEALTHCARE|5.95||||331.25||| C1769|EAP|0272|JAG GUIDEWIRE|United Healthcare|UNITED HEALTHCARE|38.64||||935.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|United Healthcare|UNITED HEALTHCARE|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|United Healthcare|UNITED HEALTHCARE OTHER|550.25||||528.50||| C1769|EAP|0272|GLIDECATH 4F 100CM ANGL C|United Healthcare|UNITED HEALTHCARE OTHER|2,864.25||||480.75||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|United Healthcare|UNITED HEALTHCARE OTHER|2,273.25||||408.75||| C1769|EAP|0272|GUIDANT WHISPER WIRE|United Healthcare|UNITED HEALTHCARE OTHER|168.50||||1,015.50||| C1769|EAP|0272|WIRE STORQ 180 .035 STR 5|Medicare|MEDICARE ACUTE|5.95||||408.75||| C1769|EAP|0272|CATH ANGIOSCALE COR 532-5|United Healthcare|UNITED HEALTHCARE OTHER|550.25||||433.50||| C1769|EAP|0272|GUIDE WIRE G2|United Healthcare|UNITED HEALTHCARE|168.50||||1,391.50||| C1769|EAP|0272|SPARTA CORE 14 5CM TIP 19|United Healthcare|UNITED HEALTHCARE|5.95||||660.75||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|United Healthcare|UNITED HEALTHCARE|1,128.50||||134.25||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Medicaid|MEDICAID|38.64||||118.75||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|United Healthcare|UNITED HEALTHCARE OTHER|38.64||||557.50||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|United Healthcare|UNITED HEALTHCARE|550.25||||168.50||| C1769|EAP|0272|FATHOM GUIDEWIRE|United Healthcare|TML GROUP BENEFITS|2,273.25||||1,391.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|United Healthcare|UNITED HEALTHCARE|999.25||||253.25||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|Medicaid|COUNTY INDIGENT HEALTH OTHER|550.25||||627.75||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Medicaid|COUNTY INDIGENT HEALTH OTHER|550.25||||168.50||| C1769|EAP|0272|GLIDECATH 4F 65CM ANGL CG|United Healthcare|UNITED HEALTHCARE|2,864.25||||480.75||| C1769|EAP|0272|GUIDE WIRE|United Healthcare|TML GROUP BENEFITS|142.25||||1,391.50||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|United Healthcare|UNITED HEALTHCARE OTHER|253.25||||528.50||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|United Healthcare|UNITED HEALTHCARE OTHER|557.50||||389.75||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|United Healthcare|UNITED HEALTHCARE OTHER|118.75||||660.75||| C1769|EAP|0272|GUIDANT WHISPER WIRE|United Healthcare|UNITED HEALTHCARE|389.75||||1,015.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|United Healthcare|TML GROUP BENEFITS|253.25||||1,391.50||| C1769|EAP|0272|WIRE SUPRACOR 5/BX 100270|United Healthcare|UNITED HEALTHCARE OTHER|975.25||||660.75||| C1769|EAP|0272|JAG GUIDEWIRE|Medicaid|MEDICAID|935.50||||118.75||| C1769|EAP|0272|WIRE STORQ 180 .035 STR 5|United Healthcare|UNITED HEALTHCARE|5.95||||408.75||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|United Healthcare|UNITED HEALTHCARE OTHER|917.25||||550.25||| C1769|EAP|0272|GUIDE WIRE G2|United Healthcare|TML GROUP BENEFITS|550.25||||1,391.50||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|United Healthcare|UNITED HEALTHCARE|1,732.75||||1.16||| C1769|EAP|0272|WHOLEY .035|Medicaid|MEDICAID|106.75||||975.25||| C1769|EAP|0272|GUIDE WIRE G2|United Healthcare|TML GROUP BENEFITS|1,391.50||||1,391.50||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|United Healthcare|UNITED HEALTHCARE|5.95||||1.16||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|United Healthcare|UNITED HEALTHCARE|550.25||||2,864.25||| C1769|EAP|0272|GUIDE WIRE G1|United Healthcare|UNITED HEALTHCARE|1,391.50||||278.75||| C1769|EAP|0272|GUIDE WIRE G1|Medicaid|SUPERIOR HEALTHPLAN CHIP|278.75||||278.75||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|United Healthcare|UNITED HEALTHCARE OTHER|4,221.25||||660.75||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|United Healthcare|UNITED HEALTHCARE|550.25||||118.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|United Healthcare|UNITED HEALTHCARE|5.95||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|United Healthcare|UNITED HEALTHCARE|550.25||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|United Healthcare|UNITED HEALTHCARE|5.95||||550.25||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|United Healthcare|UNITED HEALTHCARE|201.75||||627.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|United Healthcare|UNITED HEALTHCARE|4.45||||331.25||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|United Healthcare|UNITED HEALTHCARE|38.64||||416.25||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Medicaid|MEDICAID|134.25||||557.50||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.45||||557.50||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|United Healthcare|UNITED HEALTHCARE OTHER|331.25||||168.50||| C1769|EAP|0272|GUIDEWIRE 150CM.035 STRAI|United Healthcare|UNITED HEALTHCARE|253.25||||106.75||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|United Healthcare|UNITED HEALTHCARE|331.25||||134.25||| C1769|EAP|0272|GUIDE WIRE G1|United Healthcare|UNITED HEALTHCARE OTHER|2,047.50||||278.75||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|United Medicare Advantage|UHC AARP MCR HMO MA|1,391.50||||408.75||| C1769|EAP|0272|GUIDE WIRE G1|United Healthcare|UNITED HEALTHCARE|278.75||||278.75||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|United Healthcare|UNITED HEALTHCARE|278.75||||389.75||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|United Healthcare|UNITED HEALTHCARE|2,864.25||||408.75||| C1769|EAP|0272|GLIDEWIRE ADVANTAGE 260CM|United Healthcare|UNITED HEALTHCARE OTHER|142.25||||15.91||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|United Healthcare|UNITED HEALTHCARE OTHER|389.75||||2,864.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|United Healthcare|GOLDEN RULE|2,864.25||||||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|United Medicare Advantage|UHC AARP MCR HMO MA|331.25||||134.25||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|United Healthcare|UNITED HEALTHCARE|184.25||||408.75||| C1769|EAP|0272|CATH QUICK CROSS EXTREME|United Healthcare|UNITED HEALTHCARE OTHER|550.25||||1,279.50||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|United Healthcare|UNITED HEALTHCARE|331.25||||2,047.50||| C1769|EAP|0272|WHOLEY .035|United Healthcare|UNITED HEALTHCARE|550.25||||975.25||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|United Healthcare|UNITED HEALTHCARE OTHER|278.75||||408.75||| C1769|EAP|0272|GUIDE WIRE G2|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,391.50||||253.25||| C1769|EAP|0272|GLIDEWIRE TAPERED 65CM CG|United Medicare Advantage|UHC AARP MCR HMO MA|168.50||||480.75||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|331.25||||168.50||| C1769|EAP|0272|GUIDE WIRE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,864.25||||142.25||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.64||||253.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|550.25||||253.25||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|557.50||||253.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|UTMB|UTMB CORRECTIONAL MANAGED CARE|550.25||||253.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|UTMB|UTMB CORRECTIONAL MANAGED CARE|253.25||||253.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|UTMB|UTMB CORRECTIONAL MANAGED CARE|168.50||||253.25||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|UTMB|UTMB CORRECTIONAL MANAGED CARE|331.25||||253.25||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,047.50||||253.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|UTMB|UTMB CORRECTIONAL MANAGED CARE|389.75||||253.25||| C1769|EAP|0272|GUIDE WIRE G1|UTMB|UTMB CORRECTIONAL MANAGED CARE|278.75||||253.25||| C1769|EAP|0272|GUIDE WIRE G1|Workers Compensation|WORKERS COMPENSATION OTHER|38.64||||278.75||| C1769|EAP|0272|GLIDEWIRE TAPERED 65CM CG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|408.75||||480.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Blue Cross PPO Specialty|BCBSTX OTHER|550.25||||2,105.25||| C1769|EAP|0272|GUIDE WIRE G2|Blue Cross PPO Specialty|BCBSTX PPO|168.50||||1,391.50||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118.75||||416.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|106.75||||253.25||| C1769|EAP|0272|GUIDE WIRE G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|168.50||||278.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|253.25||||253.25||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Blue Cross PPO Specialty|BCBSTX PPO|557.50||||557.50||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|Aenta Medicare Advantage|AETNA MEDICARE MA|550.25||||1.16||| C1769|EAP|0272|GUIDEWIRE EXCHANGE/GLIDE|Blue Cross PPO Specialty|BCBSTX OTHER|248.25||||2,105.25||| C1769|EAP|0272|GUIDE WIRE G1|Access Direct Platinum|HEALTHFIRST TPA UMR|1,279.50||||278.75||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|Aetna|AETNA PPO|1.16||||528.50||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.64||||557.50||| C1769|EAP|0272|GUIDE WIRE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,391.50||||142.25||| C1769|EAP|0272|JAG GUIDEWIRE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.95||||935.50||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|550.25||||550.25||| C1769|EAP|0272|JAG GUIDEWIRE|United Medicare Advantage|UHC MEDICARE GOLD MA|118.75||||935.50||| C1769|EAP|0272|GUIDE WIRE|Humana Medicare Advantage|HUMANA MA|106.75||||142.25||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Veterans Affairs|VETERANS ADMINISTRATION|253.25||||331.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||253.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Humana Medicare Advantage|HUMANA MA|278.75||||2,864.25||| C1769|EAP|0272|WIRE STORQ 180 .035 STR 5|Blue Cross PPO Specialty|BCBSTX PPO|5.95||||408.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Blue Cross PPO Specialty|BCBSTX PPO|2,047.50||||331.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Blue Cross HMO Specialty|BCBSTX HMO|408.75||||253.25||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|Blue Cross PPO Specialty|BCBSTX PPO|1.16||||1.16||| C1769|EAP|0272|GUIDE WIRE SV-8 .018 300|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|364.75||||726.50||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Managed Medicaid|MEDICAID SUPERIOR|142.25||||550.25||| C1769|EAP|0272|GUIDE WIRE SV-8 .018 300|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|416.25||||726.50||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Aetna|AETNA PPO|1,391.50||||2,864.25||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|Managed Medicaid|MEDICAID UNITED HEALTHCARE|331.25||||528.50||| C1769|EAP|0272|FATHOM GUIDEWIRE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,015.50||||2,273.25||| C1769|EAP|0272|GUIDEWIRE MEIER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|253.25||||348.75||| C1769|EAP|0272|GUIDE WIRE G1|Cigna|CIGNA|278.75||||278.75||| C1769|EAP|0272|GUIDEWIRE SYNCHRO 300CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||2,105.25||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|550.25||||627.75||| C1769|EAP|0272|GUIDEWIRE SYNCHRO 200CM|Aetna|AETNA OTHER|1,732.75||||38.65||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Managed Medicaid|MEDICAID SUPERIOR|1,391.50||||168.50||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Aetna|AETNA PPO|331.25||||331.25||| C1769|EAP|0272|GUIDANT WHISPER WIRE|Veterans Affairs|VETERANS ADMINISTRATION|2,864.25||||1,015.50||| C1769|EAP|0272|GUIDE WIRE G2|Aetna|AETNA PPO|2,047.50||||1,391.50||| C1769|EAP|0272|GUIDE WIRE G1|Blue Cross HMO Specialty|BCBSTX HMO|1,391.50||||278.75||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||4,221.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Blue Cross PPO Specialty|BCBSTX PPO|416.25||||253.25||| C1769|EAP|0272|WIRE VERSACORE STAND .035|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||5.95||| C1769|EAP|0272|GUIDE WIRE G2|Veterans Affairs|VETERANS ADMINISTRATION|106.75||||1,391.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 0|Humana Medicare Advantage|HUMANA MA|5.95||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Humana Medicare Advantage|HUMANA MA|5.95||||550.25||| C1769|EAP|0272|WIRE SUPRACOR 5/BX 100270|Humana Medicare Advantage|HUMANA MA|5.95||||660.75||| C1769|EAP|0272|GUIDANT WHISPER WIRE|Blue Cross PPO Specialty|BCBSTX PPO|142.25||||1,015.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ 180CM 4|Blue Cross PPO Specialty|BCBSTX OTHER|408.75||||2,105.25||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|Aenta Medicare Advantage|AETNA MEDICARE MA|550.25||||528.50||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Veterans Affairs|VETERANS ADMINISTRATION|118.75||||5.95||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|550.25||||550.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|550.25||||550.25||| C1769|EAP|0272|CATH QUICK CROSS .014X150|Humana Medicare Advantage|HUMANA MA|2,864.25||||11.04||| C1769|EAP|0272|GUIDE WIRE G1|Access Direct Platinum|HEALTHFIRST TPA|1,391.50||||278.75||| C1769|EAP|0272|GLIDECATH 4F 65CM ANGL CG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|142.25||||480.75||| C1769|EAP|0272|GUIDANT WHISPER WIRE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|278.75||||1,015.50||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Aetna|AETNA PPO|168.50||||389.75||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|278.75||||2,864.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Managed Medicaid|MEDICAID UNITED HEALTHCARE|168.50||||168.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|557.50||||253.25||| C1769|EAP|0272|GUIDE WIRE G1|Aetna|AETNA OTHER|184.25||||278.75||| C1769|EAP|0272|JAG GUIDEWIRE|Managed Medicaid|MEDICAID SUPERIOR|935.50||||935.50||| C1769|EAP|0272|WHOLEY .035|United Medicare Advantage|UHC AARP WELLMED HMO MA|118.75||||975.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Access Direct Platinum|HEALTHFIRST TPA|168.50||||168.50||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Access Direct Platinum|HEALTHFIRST TPA UMR|331.25||||550.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.95||||118.75||| C1769|EAP|0272|WIRE STORQ 180 .035 STR 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.95||||408.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|550.25||||331.25||| C1769|EAP|0272|BMW UNIVERSAL 11 300CM 5/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|184.25||||550.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ SS 46-5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|550.25||||408.75||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|253.25||||4,221.25||| C1769|EAP|0272|GLIDEWIRE TAPERED 65CM CG|United Medicare Advantage|UHC MEDICARE GOLD MA|142.25||||480.75||| C1769|EAP|0272|BENTSON 260CM GUIDEWIRE 4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.81||||184.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|253.25||||168.50||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Managed Medicaid|MEDICAID SUPERIOR|168.50||||2,047.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Access Direct Platinum|HEALTHFIRST TPA UMR|142.25||||550.25||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|550.25||||4,221.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|389.75||||2,864.25||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Veterans Affairs|VETERANS ADMINISTRATION|1,015.50||||389.75||| C1769|EAP|0272|WIRE SUPER STIFF J-TIP 1.|Access Direct Platinum|HEALTHFIRST TPA|168.50||||365.50||| C1769|EAP|0272|WIRE SUPER STIFF J-TIP 1.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.95||||365.50||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Cigna|CIGNA|||||2,864.25||| C1769|EAP|0272|ASAHI MIRACLEBROS 3 WIRE|Aenta Medicare Advantage|AETNA MEDICARE MA|184.25||||917.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Aenta Medicare Advantage|AETNA MEDICARE MA|550.25||||550.25||| C1769|EAP|0272|FATHOM GUIDEWIRE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|389.75||||2,273.25||| C1769|EAP|0272|VIPERWIRE ADVANCE CORONAR|Blue Cross PPO Specialty|BCBSTX PPO|38.64||||1,128.25||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|Cigna|CIGNA|550.25||||408.75||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Blue Cross PPO Specialty|BCBSTX PPO|118.75||||118.75||| C1769|EAP|0272|BMW UNIVERSAL 11 300CM 5/|Humana Medicare Advantage|HUMANA MA|2,273.25||||550.25||| C1769|EAP|0272|GLIDEWIRE TAPERED 65CM CG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|408.75||||480.75||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|United Medicare Advantage|UHC MEDICARE GOLD MA|557.50||||1.16||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Aenta Medicare Advantage|AETNA MEDICARE MA|154.50||||168.50||| C1769|EAP|0272|GUIDE WIRE G1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|550.25||||278.75||| C1769|EAP|0272|GUIDE WIRE G2|Humana Medicare Advantage|HUMANA MA|1,128.50||||1,391.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ 180CM 4|Aenta Medicare Advantage|AETNA MEDICARE MA|1,128.50||||408.75||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|Blue Cross PPO Specialty|BCBSTX PPO|2,105.25||||528.50||| C1769|EAP|0272|GUIDEWIRE 150CM.035 STRAI|Humana Medicare Advantage|HUMANA MA|253.25||||106.75||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|Humana Medicare Advantage|HUMANA MA|975.25||||528.50||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Humana Medicare Advantage|HUMANA MA|134.25||||389.75||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|Blue Cross PPO Specialty|BCBSTX PPO|106.75||||528.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|United Medicare Advantage|UHC AARP MCR HMO MA|550.25||||253.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Veterans Affairs|VETERANS ADMINISTRATION|550.25||||5.95||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Blue Cross HMO Specialty|BCBSTX HMO|2,047.50||||416.25||| C1769|EAP|0272|GUIDEWIRE EXCHANGE/GLIDE|Blue Cross PPO Specialty|BCBSTX OTHER|278.75||||248.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Cigna|CIGNA|331.25||||118.75||| C1769|EAP|0272|GUIDEWIRE FW EZ 190 20100|Aenta Medicare Advantage|AETNA MEDICARE MA|38.64||||9,385.50||| C1769|EAP|0272|GUIDE WIRE|Blue Cross PPO Specialty|BCBSTX PPO|1,391.50||||142.25||| C1769|EAP|0272|GUIDE WIRE G2|United Medicare Advantage|UHC AARP MCR HMO MA|2,047.50||||1,391.50||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Blue Cross PPO Specialty|BCBSTX PPO|2,864.25||||2,864.25||| C1769|EAP|0272|WIRE ASAHI ASTATO XS20 30|Humana Medicare Advantage|HUMANA MA|5.95||||63.32||| C1769|EAP|0272|JAG GUIDEWIRE|Workers Compensation|WORKERS COMPENSATION OTHER|38.64||||935.50||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Humana Medicare Advantage|HUMANA MA|550.25||||331.25||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|United Medicare Advantage|UHC MEDICARE GOLD MA|408.75||||408.75||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Humana Medicare Advantage|HUMANA MA|5.95||||557.50||| C1769|EAP|0272|WIRE ASAHI ASTATO XS20 30|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||63.32||| C1769|EAP|0272|CATHETER TRAILBLAZER SUPP|Humana Medicare Advantage|HUMANA MA|389.75||||11.04||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.64||||118.75||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|Aenta Medicare Advantage|AETNA MEDICARE MA|168.50||||134.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,273.25||||2,864.25||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Managed Medicaid|MEDICAID UNITED HEALTHCARE|389.75||||389.75||| C1769|EAP|0272|GUIDE WIRE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|550.25||||142.25||| C1769|EAP|0272|GUIDEWIRE FW EZ 190 20100|Humana Medicare Advantage|HUMANA MA|935.50||||9,385.50||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Aenta Medicare Advantage|AETNA MEDICARE MA|5.95||||557.50||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|389.75||||134.25||| C1769|EAP|0272|GUIDE WIRE G1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|389.75||||278.75||| C1769|EAP|0272|WIRE CONFIANZA 180CM 5/BX|Aetna|AETNA PPO|550.25||||917.25||| C1769|EAP|0272|GUIDEWIRE 150CM.035 STRAI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,047.50||||106.75||| C1769|EAP|0272|WIRE SUPER STIFF J-TIP 1.|Aetna|AETNA PPO|557.50||||365.50||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|168.50||||416.25||| C1769|EAP|0272|WHOLEY .035|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.95||||975.25||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.95||||118.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Aetna|AETNA PPO|38.64||||550.25||| C1769|EAP|0272|CATHETER TRAILBLAZER SUPP|Aetna|AETNA PPO|2,864.25||||11.04||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Access Direct Platinum|HEALTHFIRST TPA UMR|408.75||||168.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Access Direct Platinum|HEALTHFIRST TPA UMR|550.25||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Access Direct Platinum|HEALTHFIRST TPA UMR|278.75||||550.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,391.50||||168.50||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||557.50||| C1769|EAP|0272|GUIDE WIRE G1|Managed Medicaid|MEDICAID AMERIGROUP|1,391.50||||278.75||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.95||||557.50||| C1769|EAP|0272|GUIDEWIRE STRAIGHT 503-35|Access Direct Platinum|HEALTHFIRST TPA UMR|528.50||||550.25||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Managed Medicaid|MEDICAID UNITED HEALTHCARE|557.50||||5.95||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Managed Medicaid|MEDICAID UNITED HEALTHCARE|550.25||||118.75||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.75||||5.95||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Access Direct Platinum|HEALTHFIRST TPA|168.50||||331.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ SS 46-5|United Medicare Advantage|UHC MEDICARE GOLD MA|38.64||||408.75||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,864.25||||389.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|253.25||||550.25||| C1769|EAP|0272|GUIDEWIRE 150CM.035 STRAI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|364.75||||106.75||| C1769|EAP|0272|GUIDE WIRE G1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|253.25||||278.75||| C1769|EAP|0272|BMW UNIVERSAL 11 300CM 5/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|550.25||||550.25||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.95||||5.95||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|United Medicare Advantage|UHC AARP MCR HMO MA|416.25||||528.50||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|Access Direct Platinum|HEALTHFIRST TPA UMR|557.50||||550.25||| C1769|EAP|0272|CATH QUICK CROSS .41X150|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2,864.25||||893.45||| C1769|EAP|0272|WIRE VERSACORE STAND .035|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||5.95||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Aetna|AETNA PPO|557.50||||5.95||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|278.75||||168.50||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|550.25||||118.75||| C1769|EAP|0272|WIRE PRIME 300CM .014 791|Aetna|AETNA OTHER|2,864.25||||38.65||| C1769|EAP|0272|BENTSON 260CM GUIDEWIRE 4|Veterans Affairs|VETERANS ADMINISTRATION|550.25||||184.25||| C1769|EAP|0272|WIRE PRIME 300CM .014 791|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.65||||5.95||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||408.75||| C1769|EAP|0272|GUIDE WIRE G2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,128.50||||1,391.50||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.64||||168.50||| C1769|EAP|0272|JAG GUIDEWIRE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|253.25||||935.50||| C1769|EAP|0272|JAG GUIDEWIRE|Managed Medicaid|MEDICAID SUPERIOR|253.25||||935.50||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|550.25||||38.64||| C1769|EAP|0272|GUIDEWIRE NITINOL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|550.25||||4.45||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|United Medicare Advantage|UHC AARP MCR HMO MA|550.25||||416.25||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||4,221.25||| C1769|EAP|0272|GUIDE WIRE G2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|168.50||||1,391.50||| C1769|EAP|0272|GUIDE WIRE G1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2,864.25||||278.75||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.64||||2,047.50||| C1769|EAP|0272|GUIDEWIRE SYNCHRO 300CM|Aetna|AETNA QHP HMO|2,105.25||||118.75||| C1769|EAP|0272|GUIDEWIRE SYNCHRO 200CM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,732.75||||118.75||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|Managed Medicaid|MEDICAID UNITED HEALTHCARE|550.25||||408.75||| C1769|EAP|0272|GUIDEWIRE ANGLED COR 503-|United Medicare Advantage|UHC MEDICARE GOLD MA|550.25||||408.75||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Blue Cross PPO Specialty|BCBSTX PPO|5.95||||4,221.25||| C1769|EAP|0272|GUIDE WIRE G1|Veterans Affairs|VETERANS ADMINISTRATION|1,391.50||||278.75||| C1769|EAP|0272|GUIDE WIRE G1|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||278.75||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Blue Cross PPO Specialty|BCBSTX PPO|5.95||||5.95||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|United Medicare Advantage|UHC MEDICARE GOLD MA|331.25||||557.50||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Cigna|CIGNA|253.25||||168.50||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||118.75||| C1769|EAP|0272|GUIDE WIRE G2|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,391.50||||253.25||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Veterans Affairs|VETERANS ADMINISTRATION|557.50||||5.95||| C1769|EAP|0272|WIRE PRIME 300CM .014 791|Blue Cross PPO Specialty|BCBSTX PPO|5.95||||38.65||| C1769|EAP|0272|GUIDE WIRE|United Medicare Advantage|UHC MEDICARE GOLD MA|106.75||||142.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|United Medicare Advantage|UHC AARP MCR HMO MA|38.64||||168.50||| C1769|EAP|0272|WHOLEY .035|Humana Medicare Advantage|HUMANA MA|5.95||||975.25||| C1769|EAP|0272|GUIDEWIRE .035|Aenta Medicare Advantage|AETNA MEDICARE MA|134.25||||259.25||| C1769|EAP|0272|GUIDEWIRE .025 3MM J 150C|Humana Medicare Advantage|HUMANA MA|364.75||||106.75||| C1769|EAP|0272|GUIDE WIRE G2|Cigna|CIGNA|168.50||||1,391.50||| C1769|EAP|0272|GUIDE WIRE G1|Workers Compensation|BROOKSHIRES WORKERS COMP|278.75||||||| C1769|EAP|0272|CATH ANGIOSCALE COR 532-5|Humana Medicare Advantage|HUMANA MA|480.75||||433.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Humana Medicare Advantage|HUMANA MA|5.95||||550.25||| C1769|EAP|0272|VIPERWIRE ADVANCE CORONAR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||1,128.25||| C1769|EAP|0272|WIRE CONFIANZA 300C 14943|Humana Medicare Advantage|HUMANA MA|5.95||||917.25||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|Humana Medicare Advantage|HUMANA MA|550.25||||627.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|278.75||||253.25||| C1769|EAP|0272|ALLSTAR GUIDEWIRE 300CM 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|550.25||||550.25||| C1769|EAP|0272|WIRE PRIME 300CM .014 791|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||38.65||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Blue Cross PPO Specialty|BCBSTX OTHER|11.04||||168.50||| C1769|EAP|0272|GUIDE WIRE G1|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||278.75||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Blue Cross HMO Specialty|BCBSTX HMO|38.64||||38.64||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||408.75||| C1769|EAP|0272|ASAHI MIRACLEBROS 3 WIRE|Humana Medicare Advantage|HUMANA MA|550.25||||917.25||| C1769|EAP|0272|BENTSON 260CM GUIDEWIRE 4|Humana Medicare Advantage|HUMANA MA|433.50||||184.25||| C1769|EAP|0272|GUIDE WIRE G2|Blue Cross HMO Specialty|BCBSTX HMO|168.50||||1,391.50||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Veterans Affairs|VETERANS ADMINISTRATION|331.25||||4,221.25||| C1769|EAP|0272|GLIDECATH 4F 100CM ANGL C|Humana Medicare Advantage|HUMANA MA|528.50||||480.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Blue Cross PPO Specialty|BCBSTX OTHER|253.25||||2,105.25||| C1769|EAP|0272|ALLSTAR 190CM GUIDEWIR 10|Blue Cross HMO Specialty|BCBSTX HMO|550.25||||550.25||| C1769|EAP|0272|WHOLEY .035|Veterans Affairs|VETERANS ADMINISTRATION|2,047.50||||975.25||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Blue Cross PPO Specialty|BCBSTX OTHER|331.25||||2,105.25||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|Aenta Medicare Advantage|AETNA MEDICARE MA|2,864.25||||408.75||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Blue Cross PPO Specialty|BCBSTX PPO|527.50||||38.64||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Aenta Medicare Advantage|AETNA MEDICARE MA|253.25||||416.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Blue Cross PPO Specialty|BCBSTX OTHER|550.25||||2,105.25||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||38.64||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Access Direct Platinum|HEALTHFIRST TPA UMR|550.25||||389.75||| C1769|EAP|0272|BMW UNIVERSAL 11 300CM 5/|Blue Cross PPO Specialty|BCBSTX PPO|550.25||||550.25||| C1769|EAP|0272|ALLSTAR 190CM GUIDEWIR 10|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|550.25||||550.25||| C1769|EAP|0272|GUIDE WIRE G1|United Medicare Advantage|UHC AARP MCR HMO MA|999.25||||278.75||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Aenta Medicare Advantage|AETNA MEDICARE MA|893.45||||2,864.25||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||408.75||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|Humana Medicare Advantage|HUMANA MA|168.50||||528.50||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Blue Cross HMO Specialty|BCBSTX HMO|253.25||||168.50||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2,273.25||||550.25||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|Humana Medicare Advantage|HUMANA MA|142.25||||408.75||| C1769|EAP|0272|ALLSTAR 190CM GUIDEWIR 10|Humana Medicare Advantage|HUMANA MA|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE ROADRUNNER|Humana Medicare Advantage|HUMANA MA|550.25||||201.75||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Veterans Affairs|VETERANS ADMINISTRATION|416.25||||550.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Access Direct Platinum|HEALTHFIRST TPA|278.75||||2,864.25||| C1769|EAP|0272|GUIDE WIRE G1|Aenta Medicare Advantage|AETNA MEDICARE MA|278.75||||278.75||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|893.45||||2,864.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|ChampVA|CHAMPVA CENTER|253.25||||||| C1769|EAP|0272|GUIDEWIRE HI-TORQUE SPART|Humana Medicare Advantage|HUMANA MA|1,128.25||||457.50||| C1769|EAP|0272|GUIDANT WHISPER WIRE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,015.50||||1,015.50||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|184.25||||550.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||118.75||| C1769|EAP|0272|WHOLEY .035|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||975.25||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|Veterans Affairs|VETERANS ADMINISTRATION|278.75||||528.50||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|528.50||||2,864.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Cigna|CIGNA OTHER|168.50||||550.25||| C1769|EAP|0272|GUIDE WIRE G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|168.50||||278.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||550.25||| C1769|EAP|0272|GLIDECATH 4F 100CM ANGL C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|433.50||||480.75||| C1769|EAP|0272|CATH QUICK CROSS .41X150|United Medicare Advantage|UHC AARP MCR HMO MA|2,273.25||||893.45||| C1769|EAP|0272|GUIDE WIRE G2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,391.50||||1,391.50||| C1769|EAP|0272|GUIDE WIRE|Veterans Affairs|VETERANS ADMINISTRATION|389.75||||142.25||| C1769|EAP|0272|CATH QUICK CROSS .014X150|United Medicare Advantage|UHC MEDICARE GOLD MA|550.25||||11.04||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,864.25||||408.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Aetna|AETNA QHP HMO|331.25||||118.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Aenta Medicare Advantage|AETNA MEDICARE MA|5.95||||550.25||| C1769|EAP|0272|GUIDE WIRE G2|Access Direct Platinum|HEALTHFIRST TPA UMR|2,864.25||||1,391.50||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Aetna|AETNA OTHER|331.25||||38.65||| C1769|EAP|0272|GUIDEWIRE 150CM.035 STRAI|Access Direct Platinum|HEALTHFIRST TPA|168.50||||106.75||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|United Medicare Advantage|UHC AARP MCR HMO MA|118.75||||550.25||| C1769|EAP|0272|GUIDE WIRE G1|Cigna|CIGNA|||||278.75||| C1769|EAP|0272|WIRE PRIME 300CM .014 791|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||38.65||| C1769|EAP|0272|GUIDE WIRE G2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|253.25||||1,391.50||| C1769|EAP|0272|WIRE SUPRACORE 190 100270|Aetna|AETNA PPO|557.50||||513.75||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|550.25||||168.50||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|253.25||||118.75||| C1769|EAP|0272|GUIDE WIRE SV-8 .018 300|Managed Medicaid|MEDICAID AMERIGROUP|331.25||||726.50||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Aetna|AETNA QHP HMO|248.25||||118.75||| C1769|EAP|0272|GUIDANT WHISPER WIRE|United Medicare Advantage|UHC MEDICARE GOLD MA|278.75||||1,015.50||| C1769|EAP|0272|GUIDEWIRE 5FR 7CM MICRO E|Aetna|BOON CHAPMAN|364.75||||||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||550.25||| C1769|EAP|0272|WIRE VERSACORE STAND .035|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||5.95||| C1769|EAP|0272|JAG GUIDEWIRE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.45||||935.50||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Aetna|AETNA OTHER|168.50||||38.65||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Access Direct Platinum|HEALTHFIRST TPA UMR|168.50||||550.25||| C1769|EAP|0272|"GUIDEWIRE 30"" 260CM"|Aetna|AETNA OTHER|1,128.50||||38.65||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|557.50||||134.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Aetna|AETNA PPO|557.50||||118.75||| C1769|EAP|0272|BMW UNIVERSAL 11 300CM 5/|Veterans Affairs|VETERANS ADMINISTRATION|917.25||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.95||||550.25||| C1769|EAP|0272|SPARTA CORE 14 5CM TIP 19|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,105.25||||660.75||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,221.25||||627.75||| C1769|EAP|0272|GUIDEWIRE HI-TORQUE SPART|United Medicare Advantage|UHC MEDICARE GOLD MA|550.25||||457.50||| C1769|EAP|0272|GLIDECATH 4F 100CM ANGL C|United Medicare Advantage|UHC AARP MCR HMO MA|142.25||||480.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,047.50||||253.25||| C1769|EAP|0272|GUIDEWIRE 150CM.035 STRAI|United Medicare Advantage|UHC AARP MCR HMO MA|935.50||||106.75||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Aetna|AETNA PPO|557.50||||4,221.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||118.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|935.50||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|557.50||||550.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|United Medicare Advantage|UHC MEDICARE GOLD MA|416.25||||168.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|168.50||||253.25||| C1769|EAP|0272|WHOLEY .035|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||975.25||| C1769|EAP|0272|CATH QUICK CROSS .41X150|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,864.25||||893.45||| C1769|EAP|0272|GUIDE WIRE G1|United Medicare Advantage|UHC MEDICARE GOLD MA|168.50||||278.75||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|975.25||||38.64||| C1769|EAP|0272|GUIDEWIRE AMPLATZ SS 46-5|Access Direct Platinum|HEALTHFIRST TPA|168.50||||408.75||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|331.25||||416.25||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Access Direct Platinum|HEALTHFIRST TPA UMR|2,047.50||||550.25||| C1769|EAP|0272|CATH QUICK CROSS EXTREME|United Medicare Advantage|UHC AARP MCR HMO MA|2,864.25||||1,279.50||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.95||||118.75||| C1769|EAP|0272|GUIDANT WHISPER WIRE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|528.50||||1,015.50||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|142.25||||408.75||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Managed Medicaid|MEDICAID SUPERIOR|2,047.50||||935.50||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|557.50||||331.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Access Direct Platinum|HEALTHFIRST TPA UMR|550.25||||2,864.25||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,128.25||||331.25||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|United Medicare Advantage|UHC MEDICARE GOLD MA|4,221.25||||38.64||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|278.75||||389.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|253.25||||331.25||| C1769|EAP|0272|GUIDEWIRE ADVANTAGE .035|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.16||||1,428.50||| C1769|EAP|0272|GUIDEWIRE STR SV8 COR 503|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|253.25||||627.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|331.25||||118.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.95||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.75||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Access Direct Platinum|HEALTHFIRST TPA UMR|1,391.50||||550.25||| C1769|EAP|0272|WIRE SUPRACOR 5/BX 100270|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||660.75||| C1769|EAP|0272|GUIDEWIRE SYNCHRO 300CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|550.25||||2,105.25||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|134.25||||528.50||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.95||||557.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|550.25||||253.25||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|557.50||||2,047.50||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|United Medicare Advantage|UHC MEDICARE GOLD MA|253.25||||134.25||| C1769|EAP|0272|GUIDE WIRE G1|Aetna|AETNA PPO|253.25||||278.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ SUPERST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|253.25||||184.25||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|416.25||||134.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.95||||550.25||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,697.50||||118.75||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.64||||253.25||| C1769|EAP|0272|WIRE CONFIANZA 180CM 5/BX|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||917.25||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.95||||4,221.25||| C1769|EAP|0272|VIPERWIRE ADVANCE CORONAR|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||1,128.25||| C1769|EAP|0272|GUIDANT WHISPER WIRE|United Medicare Advantage|UHC AARP MCR HMO MA|557.50||||1,015.50||| C1769|EAP|0272|WHOLEY .035|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.95||||975.25||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Managed Medicaid|MEDICAID UNITED HEALTHCARE|348.75||||2,047.50||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|550.25||||2,864.25||| C1769|EAP|0272|GUIDE WIRE G1|Aetna|BOON CHAPMAN|278.75||||||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Aetna|AETNA QHP HMO|253.25||||168.50||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|Access Direct Platinum|HEALTHFIRST TPA UMR|389.75||||1.16||| C1769|EAP|0272|GUIDE WIRE G2|Managed Medicaid|MEDICAID AMERIGROUP|2,047.50||||1,391.50||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Aetna|AETNA OTHER|38.64||||38.65||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Managed Medicaid|MEDICAID AMERIGROUP|38.64||||168.50||| C1769|EAP|0272|GUIDE WIRE G2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2,047.50||||1,391.50||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Aetna|BOON CHAPMAN|2,047.50||||||| C1769|EAP|0272|FATHOM GUIDEWIRE|Veterans Affairs|VETERANS ADMINISTRATION|184.25||||2,273.25||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||389.75||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Aetna|AETNA QHP HMO|38.64||||118.75||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|550.25||||1.16||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,047.50||||550.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Cigna|CIGNA|2,864.25||||2,864.25||| C1769|EAP|0272|GUIDEWIRE 150CM.035 STRAI|United Medicare Advantage|UHC MEDICARE GOLD MA|408.75||||106.75||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Managed Medicaid|MEDICAID AMERIGROUP|278.75||||2,864.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,128.50||||253.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,864.25||||550.25||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,047.50||||416.25||| C1769|EAP|0272|GUIDE WIRE G1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|278.75||||278.75||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|2,864.25||||||| C1769|EAP|0272|GUIDE WIRE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|142.25||||142.25||| C1769|EAP|0272|GUIDEWIRE .025 3MM J 150C|United Medicare Advantage|UHC MEDICARE GOLD MA|364.75||||106.75||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,391.50||||389.75||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 0|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||550.25||| C1769|EAP|0272|GUIDE WIRE G1|Managed Medicaid|MEDICAID SUPERIOR|278.75||||278.75||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Aenta Medicare Advantage|AETNA MEDICARE MA|557.50||||550.25||| C1769|EAP|0272|WHOLEY .035|Aenta Medicare Advantage|AETNA MEDICARE MA|5.95||||975.25||| C1769|EAP|0272|WIRE PRIME 300CM .014 791|Cigna|CIGNA|557.50||||38.65||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|United Medicare Advantage|UHC MEDICARE GOLD MA|1,015.50||||2,864.25||| C1769|EAP|0272|FATHOM GUIDEWIRE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||2,273.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Blue Cross PPO Specialty|BCBSTX PPO|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|Humana Medicare Advantage|HUMANA MA|557.50||||1.16||| C1769|EAP|0272|ALLSTAR 190CM GUIDEWIR 10|Access Direct Platinum|HEALTHFIRST TPA|550.25||||550.25||| C1769|EAP|0272|GLIDE WIRE EXCH 260CM 5/B|Aenta Medicare Advantage|AETNA MEDICARE MA|550.25||||408.75||| C1769|EAP|0272|JAG GUIDEWIRE|Humana Medicare Advantage|HUMANA MA|118.75||||935.50||| C1769|EAP|0272|GUIDE WIRE G2|Aenta Medicare Advantage|AETNA MEDICARE MA|1,391.50||||1,391.50||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Humana Medicare Advantage|HUMANA MA|5.95||||550.25||| C1769|EAP|0272|WIRE SUPER STIFF J-TIP 1.|Blue Cross PPO Specialty|BCBSTX PPO|5.95||||365.50||| C1769|EAP|0272|GLIDECATH 4F 100CM ANGL C|Blue Cross PPO Specialty|BCBSTX PPO|2,273.25||||480.75||| C1769|EAP|0272|GUIDE WIRE G1|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|278.75||||||| C1769|EAP|0272|GUIDEWIRE MIRAGE|Aetna|AETNA OTHER|2,697.50||||38.65||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Humana Medicare Advantage|HUMANA MA|2,047.50||||253.25||| C1769|EAP|0272|GUIDANT WHISPER WIRE|Humana Medicare Advantage|HUMANA MA|106.75||||1,015.50||| C1769|EAP|0272|ALLSTAR GUIDEWIRE 300CM 1|United Medicare Advantage|UHC AARP MCR HMO MA|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE NITINOL|ChampVA|CHAMPVA CENTER|4.45||||||| C1769|EAP|0272|GUIDE WIRE 13C 503-356Y 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|278.75||||528.50||| C1769|EAP|0272|GUIDEWIRE AMPLATZ 180CM 4|Humana Medicare Advantage|HUMANA MA|408.75||||408.75||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|550.25||||253.25||| C1769|EAP|0272|VIPERWIRE ADVANCE CORONAR|Humana Medicare Advantage|HUMANA MA|38.65||||1,128.25||| C1769|EAP|0272|FATHOM GUIDEWIRE|United Medicare Advantage|UHC AARP MCR HMO MA|408.75||||2,273.25||| C1769|EAP|0272|GUIDEWIRE ANGLED COR 503-|Humana Medicare Advantage|HUMANA MA|1.16||||408.75||| C1769|EAP|0272|ACCESS GUIDE WIRE|Humana Medicare Advantage|HUMANA MA|550.25||||7.81||| C1769|EAP|0272|ALLSTAR GUIDEWIRE 300CM 1|Humana Medicare Advantage|HUMANA MA|184.25||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Blue Cross PPO Specialty|BCBSTX PPO|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Blue Cross PPO Specialty|BCBSTX OTHER|389.75||||253.25||| C1769|EAP|0272|GUIDEWIRE TFE COATED STRT|United Medicare Advantage|UHC AARP MCR HMO MA|557.50||||1.16||| C1769|EAP|0272|GUIDE WIRE|Blue Cross HMO Specialty|BCBSTX HMO|278.75||||142.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Veterans Affairs|VETERANS ADMINISTRATION|168.50||||168.50||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|Humana Medicare Advantage|HUMANA MA|416.25||||557.50||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|Blue Cross PPO Specialty|BCBSTX PPO|550.25||||550.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Blue Cross HMO Specialty|BCBSTX HMO|550.25||||550.25||| C1769|EAP|0272|SPARTA CORE 14 5CM TIP 19|Humana Medicare Advantage|HUMANA MA|4,221.25||||660.75||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Blue Cross HMO Specialty|BCBSTX HMO|557.50||||557.50||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Humana Medicare Advantage|HUMANA MA|893.45||||550.25||| C1769|EAP|0272|CATH QUICK CROSS EXTREME|Humana Medicare Advantage|HUMANA MA|1,015.50||||1,279.50||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Humana Medicare Advantage|HUMANA MA|2,105.25||||416.25||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|Humana Medicare Advantage|HUMANA MA|408.75||||134.25||| C1769|EAP|0272|JAG GUIDEWIRE|Blue Cross PPO Specialty|BCBSTX OTHER|935.50||||2,105.25||| C1769|EAP|0272|JAG GUIDEWIRE|Blue Cross PPO Specialty|BCBSTX PPO|935.50||||935.50||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Veterans Affairs|VETERANS ADMINISTRATION|5.95||||5.95||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Aenta Medicare Advantage|AETNA MEDICARE MA|389.75||||389.75||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Blue Cross HMO Specialty|BCBSTX HMO|5.95||||118.75||| C1769|EAP|0272|ASAHI MIRACLEBROS 3 14937|Humana Medicare Advantage|HUMANA MA|550.25||||917.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Blue Cross HMO Specialty|BCBSTX HMO|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE SYNCHRO 300CM|Blue Cross PPO Specialty|BCBSTX OTHER|168.50||||2,105.25||| C1769|EAP|0272|SYNCHRO GUIDEWIRE 300CM|Veterans Affairs|VETERANS ADMINISTRATION|38.64||||5.95||| C1769|EAP|0272|CATH QUICK CROSS .41X150|Humana Medicare Advantage|HUMANA MA|408.75||||893.45||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|United Medicare Advantage|UHC AARP MCR HMO MA|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Humana Medicare Advantage|HUMANA MA|184.25||||168.50||| C1769|EAP|0272|GUIDEWIRE SYNCHRO 200CM|Blue Cross HMO Specialty|BCBSTX HMO|935.50||||1,732.75||| C1769|EAP|0272|WIRE GUIDE HD THSCF-35-18|Humana Medicare Advantage|HUMANA MA|5.95||||118.75||| C1769|EAP|0272|GUIDE WIRE G2|United Medicare Advantage|UHC MEDICARE GOLD MA|154.50||||1,391.50||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Workers Compensation|BROOKSHIRES WORKERS COMP|2,047.50||||||| C1769|EAP|0272|GUIDEWIRE 260CM .035 3M J|Blue Cross PPO Specialty|BCBSTX PPO|1,128.50||||168.50||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Veterans Affairs|VETERANS ADMINISTRATION|4,221.25||||5.95||| C1769|EAP|0272|GLIDEWIRE ANGLED EXCH 5/B|Humana Medicare Advantage|HUMANA MA|1,391.50||||408.75||| C1769|EAP|0272|GUIDE WIRE|Aenta Medicare Advantage|AETNA MEDICARE MA|142.25||||142.25||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Humana Medicare Advantage|HUMANA MA|550.25||||2,047.50||| C1769|EAP|0272|WIRE SUPRACOR 5/BX 100270|Blue Cross PPO Specialty|BCBSTX PPO|5.95||||660.75||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|Blue Cross PPO Specialty|BCBSTX OTHER|557.50||||2,105.25||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Aenta Medicare Advantage|AETNA MEDICARE MA|5.95||||5.95||| C1769|EAP|0272|ALLSTAR GUIDEWIRE 300CM 1|United Medicare Advantage|UHC MEDICARE GOLD MA|917.25||||550.25||| C1769|EAP|0272|BENTSON 260CM GUIDEWIRE 4|Blue Cross PPO Specialty|BCBSTX PPO|917.25||||184.25||| C1769|EAP|0272|GUIDEWIRE NITINOL|Blue Cross PPO Specialty|BCBSTX PPO|331.25||||4.45||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|United Medicare Advantage|UHC MEDICARE GOLD MA|5.95||||4,221.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ SUPERST|Humana Medicare Advantage|HUMANA MA|331.25||||184.25||| C1769|EAP|0272|WHISPER GUIDEWIRE 190CM 1|Blue Cross HMO Specialty|BCBSTX HMO|550.25||||550.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Veterans Affairs|VETERANS ADMINISTRATION|557.50||||253.25||| C1769|EAP|0272|GUIDEWIRE 150CM .035(BENT|Blue Cross PPO Specialty|BCBSTX PPO|154.50||||134.25||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Veterans Affairs|VETERANS ADMINISTRATION|935.50||||5.95||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|United Medicare Advantage|UHC MEDICARE GOLD MA|1,391.50||||389.75||| C1769|EAP|0272|GUIDEWIRE 300 CM J 12155-|Blue Cross PPO Specialty|BCBSTX PPO|253.25||||557.50||| C1769|EAP|0272|GUIDEWIRE FW EZ 300 20100|Humana Medicare Advantage|HUMANA MA|38.64||||9,385.50||| C1769|EAP|0272|FATHOM GUIDEWIRE|Blue Cross PPO Specialty|BCBSTX PPO|550.25||||2,273.25||| C1769|EAP|0272|GUIDEWIRE ANGLED 180CM GR|Blue Cross PPO Specialty|BCBSTX PPO|248.25||||416.25||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Blue Cross HMO Specialty|BCBSTX HMO|2,864.25||||2,864.25||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.95||||557.50||| C1769|EAP|0272|GUIDEWIRE JAGTOME RX44|Blue Cross PPO Specialty|BCBSTX OTHER|2,047.50||||2,105.25||| C1769|EAP|0272|GUIDEWIRE ROADRUNNER|Blue Cross PPO Specialty|BCBSTX PPO|4.45||||201.75||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Blue Cross PPO Specialty|BCBSTX OTHER|550.25||||550.25||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Blue Cross PPO Specialty|BCBSTX PPO|278.75||||389.75||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Blue Cross HMO Specialty|BCBSTX HMO|331.25||||331.25||| C1769|EAP|0272|WHISPER GUIDEWIRE X SUPPO|Veterans Affairs|VETERANS ADMINISTRATION|248.25||||550.25||| C1769|EAP|0272|GUIDEWIRE .025 3MM J 150C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|253.25||||106.75||| C1769|EAP|0272|GUIDE CATH 6F LA6EBU375|Blue Cross HMO Specialty|BCBSTX HMO|389.75||||389.75||| C1769|EAP|0272|WIRE PRIME 185CM .014 790|Humana Medicare Advantage|HUMANA MA|5.95||||4,221.25||| C1769|EAP|0272|GUIDE WIRE|Workers Compensation|WORKERS COMPENSATION OTHER|331.25||||142.25||| C1769|EAP|0272|GUIDEWIRE AMPLATZ GLIDE|Aenta Medicare Advantage|AETNA MEDICARE MA|364.75||||253.25||| C1769|EAP|0272|WIRE PRIME 300CM .014 791|Humana Medicare Advantage|HUMANA MA|5.95||||38.65||| C1769|EAP|0272|WHOLEY .035|Blue Cross PPO Specialty|BCBSTX PPO|975.25||||975.25||| C1769|EAP|0272|GUIDE WIRE G1|Humana Medicare Advantage|HUMANA MA|154.50||||278.75||| C1769|EAP|0272|WIRE VERSACORE STAND .035|Humana Medicare Advantage|HUMANA MA|5.95||||5.95||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Cigna|CIGNA|917.25||||550.25||| C1769|EAP|0272|GUIDE WIRE G1|Blue Cross PPO Specialty|BCBSTX PPO|134.25||||278.75||| C1769|EAP|0272|GUIDEWIRE NITINOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|118.75||||4.45||| C1769|EAP|0272|GUIDEWIRE 260CM .035 STRA|United Medicare Advantage|UHC MEDICARE GOLD MA|2,047.50||||154.50||| C1769|EAP|0272|GUIDEWIRE NAVIGUIDE .038-|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|331.25||||253.25||| C1769|EAP|0272|CATH QUICK CROSS .41X150|United Medicare Advantage|UHC MEDICARE GOLD MA|893.45||||893.45||| C1769|EAP|0272|WHISPER GUIDEWIRE 300CM 1|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||550.25||| C1769|EAP|0272|BMW UNIVERSAL 11 190CM 5/|Blue Cross PPO Specialty|BCBSTX PPO|184.25||||550.25||| C1769|EAP|0272|WIRE STORQ 180 .035 STR 5|United Medicare Advantage|UHC AARP MCR HMO MA|5.95||||408.75||| C1769|EAP|0272|GLIDEWIRE 180CM/300CM|Veterans Affairs|VETERANS ADMINISTRATION|550.25||||2,864.25||| C1769|EAP|0272|WIRE CHOICE PT XTRA 185CM|Blue Cross PPO Specialty|BCBSTX OTHER|557.50||||2,105.25||| C1769|EAP|0272|BENTSON 260CM GUIDEWIRE 4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,273.25||||184.25||| C1771|EAP|0278|IMPLANT SLING G1|Humana Medicare Advantage|HUMANA MA|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|United Healthcare|UNITED HEALTHCARE OTHER|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|NON CONTRACTED|COMMERCIAL OTHER 1|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||162.24||| C1771|EAP|0278|IMPLANT SLING G1|Cigna|CIGNA|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|United Medicare Advantage|UHC AARP MCR HMO MA|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|Aetna|AETNA OTHER|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G2|United Medicare Advantage|UHC MEDICARE GOLD MA|||||162.24||| C1771|EAP|0278|IMPLANT SLING G1|Blue Cross HMO Specialty|BCBSTX HMO|8,679.75||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|ChampVA|CHAMPVA CENTER|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|Blue Cross PPO Specialty|BCBSTX PPO|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|United Healthcare|UNITED HEALTHCARE|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G2|United Medicare Advantage|UHC AARP MCR HMO MA|||||162.24||| C1771|EAP|0278|IMPLANT SLING G1|Blue Cross PPO Specialty|BCBSTX OTHER|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|Medicare|MEDICARE ACUTE|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G2|Medicare|MEDICARE ACUTE|||||162.24||| C1771|EAP|0278|IMPLANT SLING G1|Managed Medicare|HEALTHSPRING MA|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|Aetna|AETNA PPO|||||8,679.75||| C1771|EAP|0278|IMPLANT SLING G1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8,679.75||| C1771|EAP|0278|IMPL SLING MALE ADV XP|Managed Medicare|HEALTHSPRING MA|||||203.85||| C1771|EAP|0278|IMPLANT SLING G2|Humana Medicare Advantage|HUMANA MA|||||162.24||| C1771|EAP|0278|IMPL SLING MALE ADV XP|Medicare|MEDICARE ACUTE|||||203.85||| C1773|EAP|0278|TREVO PRO KIT RETRIEVAL D|Managed Medicare|BCBS MEDICARE PPO MA|45,426.50||||||| C1773|EAP|0278|TREVO PRO KIT RETRIEVAL D|Medicare|MEDICARE ACUTE|45,426.50||||22.73||| C1773|EAP|0278|SNARE FILTER RETRIEVAL KI|Medicare|MEDICARE ACUTE|2,089.25||||22.73||| C1773|EAP|0278|RET DEV, INSERTABLE G2|Medicare|MEDICARE ACUTE|156.00||||156.00||| C1773|EAP|0278|SNARE RETRIEVAL|Managed Medicare|HEALTHSPRING MA|45,426.50||||2,089.25||| C1773|EAP|0278|TREVO PRO KIT RETRIEVAL D|United Healthcare|UNITED HEALTHCARE OTHER|45,426.50||||||| C1773|EAP|0278|TREVO PRO KIT RETRIEVAL D|Veterans Affairs|VETERANS ADMINISTRATION|45,426.50||||||| C1773|EAP|0278|SNARE FILTER RETRIEVAL KI|Workers Compensation|WORKERS COMPENSATION OTHER|||||22.73||| C1773|EAP|0278|SNARE FILTER RETRIEVAL KI|Humana Medicare Advantage|HUMANA MA|45,426.50||||22.73||| C1773|EAP|0278|SNARE FILTER RETRIEVAL KI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||22.73||| C1773|EAP|0278|SNARE FILTER RETRIEVAL KI|Blue Cross PPO Specialty|BCBSTX PPO|22.73||||||| C1773|EAP|0278|SNARE FILTER RETRIEVAL KI|Blue Cross HMO Specialty|BCBSTX HMO|45,426.50||||22.73||| C1773|EAP|0278|TREVO PRO KIT RETRIEVAL D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45,426.50||||||| C1773|EAP|0278|TREVO PRO KIT RETRIEVAL D|Blue Cross PPO Specialty|BCBSTX PPO|45,426.50||||||| C1773|EAP|0278|SNARE RETRIEVAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,089.25||| C1773|EAP|0278|TREVO PRO KIT RETRIEVAL D|United Medicare Advantage|UHC AARP MCR HMO MA|45,426.50||||||| C1773|EAP|0278|TREVO PRO KIT RETRIEVAL D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|45,426.50||||||| C1773|EAP|0278|SNARE FILTER RETRIEVAL KI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||22.73||| C1773|EAP|0278|TREVO PRO KIT RETRIEVAL D|Medicaid|MEDICAID|45,426.50||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|NON CONTRACTED|COMMERCIAL OTHER 1|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Tricare|TRICARE EAST REGION|5,786.50||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|PHCS|HUMANA|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|PHCS|HUMANA|115.73||||||| C1776|EAP|0278|IMPL COMP KNEE 5512-F-302|PHCS|HUMANA|24,571.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Tricare|TRICARE EAST REGION|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Tricare|TRICARE EAST REGION|12,979.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Multiplan|WEB TPA|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|PHCS|GROUP AND PENSION|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|NON CONTRACTED|COMMERCIAL OTHER 1|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|NON CONTRACTED|COMMERCIAL OTHER 1|5,786.50||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Tricare|TRICARE EAST REGION|17,359.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|NON CONTRACTED|COMMERCIAL OTHER 2|||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|NON CONTRACTED|COMMERCIAL OTHER 1|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|United Healthcare|UNITED HEALTHCARE|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|PHCS|GROUP AND PENSION|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|United Healthcare|UNITED HEALTHCARE|12,979.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|United Healthcare|UNITED HEALTHCARE|17,359.75||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|United Healthcare|UNITED HEALTHCARE|115.73||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|United Healthcare|UNITED HEALTHCARE|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|United Healthcare|UNITED HEALTHCARE|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|United Healthcare|GEHA|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|UTMB|UTMB CORRECTIONAL MANAGED CARE|5,786.50||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|United Healthcare|GEHA|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|United Healthcare|UNITED HEALTHCARE|5,786.50||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|United Healthcare|UNITED HEALTHCARE OTHER|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Managed Medicare|BCBS MEDICARE PPO MA|115.73||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29,959.25||||2,893.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|United Healthcare|UNITED HEALTHCARE OTHER|5,786.50||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,893.25||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Managed Medicare|HEALTHSPRING MA|208.98||||2,893.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Managed Medicare|BCBS MEDICARE PPO MA|5,786.50||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Managed Medicare|HEALTHSPRING MA|12,979.25||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|115.73||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Managed Medicare|BCBS MEDICARE PPO MA|17,359.75||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5,786.50||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Medicare|MEDICARE PART B ONLY IP|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Medicare|MEDICARE ACUTE|5,786.50||||162.24||| C1776|EAP|0278|MULTIHOLE ACETABULAR SHEL|Medicare|MEDICARE ACUTE|225.58||||162.24||| C1776|EAP|0278|IMPL TOTAL STABILIZER FEM|Medicare|MEDICARE ACUTE|259.98||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Medicare|MEDICARE ACUTE|208.98||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Medicare|MEDICARE PART B ONLY IP|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Medicare|MEDICARE ACUTE|208.98||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Medicare|MEDICARE ACUTE|115.73||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Medicare|MEDICARE ACUTE|29,959.25||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Medicare|MEDICARE ACUTE|22,536.75||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Medicare|MEDICARE PART B ONLY IP|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Medicare|MEDICARE PART B ONLY IP|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Medicare|MEDICARE ACUTE|24,526.25||||2,893.25||| C1776|EAP|0278|IMPL TRIATHLON TOTAL STAB|Medicare|MEDICARE ACUTE|25,507.25||||162.24||| C1776|EAP|0278|IMPL STEM HUMERAL 12X108M|Medicare|MEDICARE ACUTE|20,342.70||||162.24||| C1776|EAP|0278|IMPL STEM HUM REV 14M 108|Medicare|MEDICARE ACUTE|20,569.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G1|Medicare|MEDICARE ACUTE|181.20||||1,447.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Medicare|MEDICARE PART B ONLY IP|5,786.50||||||| C1776|EAP|0278|IMPL GMRS DISTAL FEMORAL|Medicare|MEDICARE ACUTE|30,231.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Medicare|MEDICARE ACUTE|162.24||||162.24||| C1776|EAP|0278|IMPL FEMORAL CEMENTED SIZ|Medicare|MEDICARE ACUTE|175.66||||207.67||| C1776|EAP|0278|IMPLANT JOINT DEVICE G1|Medicare|MEDICARE ACUTE|1,447.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|United Medicare Advantage|UHC MEDICARE GOLD MA|162.24||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|United Medicare Advantage|UHC AARP MCR HMO MA|17,359.75||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Medicaid|MEDICAID|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Medicaid|MOLINA HEALTHCARE OF TEXAS|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Medicaid|MOLINA HEALTHCARE OF TEXAS|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Medicaid|MOLINA HEALTHCARE OF TEXAS|5,786.50||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,786.50||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Managed Medicare|HEALTHSPRING MA|115.73||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|United Medicare Advantage|UHC MEDICARE GOLD MA|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|United Medicare Advantage|UHC AARP MCR HMO MA|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Medicare|MEDICARE ACUTE|17,359.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Managed Medicare|HEALTHSPRING MA|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17,359.75||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|United Medicare Advantage|UHC AARP MCR HMO MA|115.73||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|United Medicare Advantage|UHC AARP MCR HMO MA|5,786.50||||2,893.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12,979.25||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|United Medicare Advantage|UHC MEDICARE GOLD MA|115.73||||2,893.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|United Medicare Advantage|UHC AARP MCR HMO MA|12,979.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|United Healthcare|UNITED HEALTHCARE|5,786.50||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|United Medicare Advantage|UHC MEDICARE GOLD MA|17,359.75||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|115.73||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Access Direct Platinum|HEALTHFIRST TPA UMR|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12,979.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Cigna|CIGNA|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17,359.75||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Access Direct Platinum|HEALTHFIRST TPA UMR|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,786.50||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Medicare|MEDICARE ACUTE|207.67||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Access Direct Platinum|HEALTHFIRST TPA UMR|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Workers Compensation|WORKERS COMPENSATION OTHER|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Cigna|CIGNA|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Access Direct Platinum|HEALTHFIRST TPA UMR|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Veterans Affairs|VETERANS ADMINISTRATION|115.73||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Veterans Affairs|VETERANS ADMINISTRATION|24,526.25||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Veterans Affairs|VETERANS ADMINISTRATION|5,786.50||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Veterans Affairs|VETERANS ADMINISTRATION|208.98||||115.73||| C1776|EAP|0278|IMPL TRIATHLON TOTAL STAB|Veterans Affairs|VETERANS ADMINISTRATION|25,507.25||||162.24||| C1776|EAP|0278|IMPL TOTAL STABILIZER FEM|Veterans Affairs|VETERANS ADMINISTRATION|259.98||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Veterans Affairs|VETERANS ADMINISTRATION|12,979.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Veterans Affairs|VETERANS ADMINISTRATION|17,359.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Veterans Affairs|VETERANS ADMINISTRATION|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Cigna|CIGNA|17,359.75||||115.73||| C1776|EAP|0278|IMPL NUCLEUS SIZE 3 DWG40|Veterans Affairs|VETERANS ADMINISTRATION|28,073.50||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Cigna|CIGNA|162.24||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Workers Compensation|WORKERS COMPENSATION OTHER|5,786.50||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Managed Medicare|HEALTHSPRING MA|5,786.50||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Cigna|CIGNA|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Cigna|CIGNA OTHER|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Cigna|CIGNA OTHER|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|234.24||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Cigna|CIGNA OTHER|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Access Direct Platinum|HEALTHFIRST TPA UMR|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Cigna|CIGNA|12,979.25||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Cigna|CIGNA OTHER|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Cigna|CIGNA|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Cigna|CIGNA|115.73||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|115.73||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Cigna|CIGNA|5,786.50||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Cigna|CIGNA|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Veterans Affairs|VETERANS ADMINISTRATION|21,647.50||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Humana Medicare Advantage|HUMANA MA|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Humana Medicare Advantage|HUMANA MA|2,893.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Cigna|CIGNA OTHER|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Humana Medicare Advantage|HUMANA MA|5,786.50||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|United Healthcare|GEHA|12,979.25||||||| C1776|EAP|0278|IMPL STEM HUMERAL 12X108M|United Medicare Advantage|UHC MEDICARE GOLD MA|5,786.50||||20,342.70||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|162.24||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|United Medicare Advantage|UHC MEDICARE GOLD MA|12,979.25||||17,359.75||| C1776|EAP|0278|IMPL TRIATHLON TS FEMORAL|Medicare|MEDICARE ACUTE|24,571.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Humana Medicare Advantage|HUMANA MA|24,571.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Managed Medicare|BCBS MEDICARE PPO MA|12,979.25||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Managed Medicare|HEALTHSPRING MA|17,359.75||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|United Healthcare|UNITED HEALTHCARE|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12,979.25||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Humana Medicare Advantage|HUMANA MA|24,571.75||||12,979.25||| C1776|EAP|0278|MULTIHOLE ACETABULAR SHEL|Humana Medicare Advantage|HUMANA MA|225.58||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Humana Medicare Advantage|HUMANA MA|12,979.25||||162.24||| C1776|EAP|0278|IMPL GLENOSPHERE LAT REV|Medicaid|MOLINA HEALTHCARE OF TEXAS|208.98||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Medicaid|MOLINA HEALTHCARE OF TEXAS|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Humana Medicare Advantage|HUMANA MA|208.98||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Humana Medicare Advantage|HUMANA MA|29,959.25||||5,786.50||| C1776|EAP|0278|TOTAL STABILIZER FEMORAL|Medicare|MEDICARE ACUTE|286.83||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12,979.25||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Humana Medicare Advantage|HUMANA MA|17,359.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G1|Humana Medicare Advantage|HUMANA MA|1,447.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Medicare|MEDICARE PART B ONLY IP|17,359.75||||||| C1776|EAP|0278|IMPL HUMERAL STEM REVERSE|Medicare|MEDICARE ACUTE|41,139.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17,359.75||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Medicare|MEDICARE ACUTE|12,979.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Medicare|MEDICARE ACUTE|2,893.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|115.73||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G1|Humana Medicare Advantage|HUMANA MA|175.66||||1,447.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Managed Medicaid|MEDICAID UNITED HEALTHCARE|162.24||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,893.25||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,786.50||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Humana Medicare Advantage|HUMANA MA|115.73||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Humana Medicare Advantage|HUMANA MA|18,821.07||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Aetna|AETNA OTHER|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Aetna|AETNA QHP HMO|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Aetna|AETNA PPO|5,786.50||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Aetna|AETNA PPO|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Aetna|AETNA QHP HMO|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Aetna|AETNA PPO|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Aetna|AETNA OTHER|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,447.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Workers Compensation|WORKERS COMPENSATION OTHER|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Aetna|AETNA OTHER|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Humana Medicare Advantage|HUMANA MA|26,535.25||||2,893.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Aetna|AETNA PPO|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17,359.75||||12,979.25||| C1776|EAP|0278|IMPL GLENOSPHERE STANDARD|Aetna|AETNA PPO|208.98||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Aetna|AETNA PPO|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Aetna|AETNA QHP HMO|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Aenta Medicare Advantage|AETNA MEDICARE MA|162.24||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Aenta Medicare Advantage|AETNA MEDICARE MA|17,359.75||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Aenta Medicare Advantage|AETNA MEDICARE MA|12,979.25||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Aenta Medicare Advantage|AETNA MEDICARE MA|115.73||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Aenta Medicare Advantage|AETNA MEDICARE MA|2,893.25||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17,359.75||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,893.25||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Aetna Value Network|AETNA VALUE NETWORK|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.73||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|United Healthcare|UNITED HEALTHCARE OTHER|115.73||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,786.50||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Aetna Value Network|AETNA VALUE NETWORK|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12,979.25||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|162.24||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|United Healthcare|UNITED HEALTHCARE OTHER|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|NON CONTRACTED|COMMERCIAL OTHER 1|2,893.25||||||| C1776|EAP|0278|IMPL STEM HUMERAL 12X108M|Aenta Medicare Advantage|AETNA MEDICARE MA|208.98||||20,342.70||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2,893.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Aenta Medicare Advantage|AETNA MEDICARE MA|5,786.50||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Aetna Value Network|AETNA VALUE NETWORK|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Brinson Benefits|THE HEALTH PLAN SMITH CO|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|United Healthcare|UNITED HEALTHCARE OTHER|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Brinson Benefits|THE HEALTH PLAN SMITH CO|2,893.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Blue Cross HMO Specialty|BCBSTX HMO|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Blue Cross HMO Specialty|BCBSTX HMO|5,786.50||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Blue Cross HMO Specialty|BCBSTX HMO|2,893.25||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Blue Cross HMO Specialty|BCBSTX HMO|20,569.75||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Blue Cross HMO Specialty|BCBSTX HMO|17,359.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Blue Cross PPO Specialty|BCBSTX PPO|162.24||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Tricare|TRICARE EAST REGION|115.73||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|NON CONTRACTED|COMMERCIAL OTHER 1|162.24||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Blue Cross HMO Specialty|BCBSTX HMO|12,979.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Blue Cross HMO Specialty|BCBSTX HMO|24,571.75||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Blue Cross PPO Specialty|BCBSTX PPO|208.98||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Blue Cross PPO Specialty|BCBSTX PPO|200.20||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Blue Cross PPO Specialty|BCBSTX OTHER|115.73||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G7|Blue Cross PPO Specialty|BCBSTX PPO|2,893.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Blue Cross PPO Specialty|BCBSTX PPO|5,786.50||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Blue Cross PPO Specialty|BCBSTX PPO|12,979.25||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G2|Blue Cross PPO Specialty|BCBSTX PPO|175.66||||2,893.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Blue Cross PPO Specialty|BCBSTX OTHER|115.73||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|PHCS|GROUP AND PENSION|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G3|Blue Cross PPO Specialty|BCBSTX OTHER|115.73||||5,786.50||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Blue Cross PPO Specialty|BCBSTX PPO|1,447.25||||12,979.25||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Blue Cross PPO Specialty|BCBSTX PPO|17,359.75||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Blue Cross PPO Specialty|BCBSTX PPO|115.73||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Blue Cross PPO Specialty|BCBSTX PPO|41,139.25||||115.73||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Blue Cross PPO Specialty|BCBSTX OTHER|115.73||||17,359.75||| C1776|EAP|0278|IMPLANT JOINT DEVICE G5|Brinson Benefits|THE HEALTH PLAN SMITH CO|17,359.75||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G6|Brinson Benefits|THE HEALTH PLAN SMITH CO|12,979.25||||||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Blue Cross HMO Specialty|BCBSTX HMO|115.73||||162.24||| C1776|EAP|0278|IMPLANT JOINT DEVICE G4|Brinson Benefits|THE HEALTH PLAN SMITH CO|115.73||||||| C1777|EAP|0278|SMART COIL STAND/SOFT/EX|Humana Medicare Advantage|HUMANA MA|10,358.50||||333.00||| C1777|EAP|0278|SMART COIL STAND/SOFT/EX|United Medicare Advantage|UHC MEDICARE GOLD MA|10,358.50||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Cigna|CIGNA|||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Blue Cross PPO Specialty|BCBSTX PPO|6,886.50||||333.00||| C1777|EAP|0278|SMART COIL HELICAL|Humana Medicare Advantage|HUMANA MA|6,886.50||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|333.00||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|333.00||||333.00||| C1777|EAP|0278|SMART COIL STAND/SOFT/EX|Aetna|AETNA PPO|10,358.50||||||| C1777|EAP|0278|SMART COIL STAND/SOFT/EX|Blue Cross PPO Specialty|BCBSTX PPO|10,358.50||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Veterans Affairs|VETERANS ADMINISTRATION|333.00||||||| C1777|EAP|0278|SMART COIL STAND/SOFT/EX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10,358.50||||333.00||| C1777|EAP|0278|SMART COIL HELICAL|Aetna|AETNA PPO|6,886.50||||||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Humana Medicare Advantage|HUMANA MA|333.00||||333.00||| C1777|EAP|0278|SMART COIL HELICAL|Workers Compensation|WORKERS COMPENSATION OTHER|6,886.50||||||| C1777|EAP|0278|SMART COIL STAND/SOFT/EX|Workers Compensation|WORKERS COMPENSATION OTHER|10,358.50||||||| C1777|EAP|0278|ICD LEAD SINGLE COIL|United Medicare Advantage|UHC MEDICARE GOLD MA|333.00||||333.00||| C1777|EAP|0278|SMART COIL HELICAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,886.50||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Managed Medicaid|MEDICAID AMERIGROUP|||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Aenta Medicare Advantage|AETNA MEDICARE MA|333.00||||||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|333.00||||||| C1777|EAP|0278|ICD LEAD SINGLE COIL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|333.00||||333.00||| C1777|EAP|0278|SMART COIL STAND/SOFT/EX|United Medicare Advantage|UHC AARP MCR HMO MA|10,358.50||||333.00||| C1777|EAP|0278|SMART COIL HELICAL|United Medicare Advantage|UHC MEDICARE GOLD MA|6,886.50||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Medicaid|MEDICAID|333.00||||||| C1777|EAP|0278|ICD LEAD SINGLE COIL|United Medicare Advantage|UHC AARP MCR HMO MA|6,886.50||||333.00||| C1777|EAP|0278|SMART COIL HELICAL|Medicare|MEDICARE ACUTE|6,886.50||||333.00||| C1777|EAP|0278|SMART COIL HELICAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6,886.50||||||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Managed Medicare|BCBS MEDICARE PPO MA|||||333.00||| C1777|EAP|0278|SMART COIL STAND/SOFT/EX|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|10,358.50||||||| C1777|EAP|0278|ICD LEAD SINGLE COIL|United Healthcare|UNITED HEALTHCARE|333.00||||||| C1777|EAP|0278|SMART COIL STAND/SOFT/EX|Medicare|MEDICARE ACUTE|10,358.50||||333.00||| C1777|EAP|0278|ICD LEAD SINGLE COIL|NON CONTRACTED|COMMERCIAL OTHER 1|333.00||||||| C1777|EAP|0278|ICD LEAD SINGLE COIL|Medicare|MEDICARE ACUTE|333.00||||333.00||| C1778|EAP|0278|STIMULATOR LEAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||14,072.25||| C1778|EAP|0278|IMPLANT LEAD NEURO G2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||107.00||| C1778|EAP|0278|STIMULATOR LEAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||14,072.25||| C1778|EAP|0278|STIMULATOR LEAD|Blue Cross HMO Specialty|BCBSTX HMO|175.00||||14,072.25||| C1778|EAP|0278|STIMULATOR LEAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14,072.25||| C1778|EAP|0278|LEAD KIT 70CM 4X8 SC-8352|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||175.00||| C1778|EAP|0278|STIMULATOR LEAD|United Medicare Advantage|UHC MEDICARE GOLD MA|175.00||||14,072.25||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|Veterans Affairs|VETERANS ADMINISTRATION|175.00||||||| C1778|EAP|0278|STIMULATOR LEAD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||14,072.25||| C1778|EAP|0278|STIMULATOR LEAD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||14,072.25||| C1778|EAP|0278|STIMULATOR LEAD|United Medicare Advantage|UHC AARP MCR HMO MA|||||14,072.25||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|Medicare|MEDICARE ACUTE|175.00||||175.00||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|Medicare|MEDICARE PART B ONLY IP|175.00||||||| C1778|EAP|0278|STIMULATOR LEAD|Humana Medicare Advantage|HUMANA MA|||||14,072.25||| C1778|EAP|0278|STIMULATOR LEAD|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||14,072.25||| C1778|EAP|0278|NEUROSTIMULATOR|Medicare|MEDICARE ACUTE|175.00||||9,032.50||| C1778|EAP|0278|STIMULATOR LEAD|Managed Medicare|BCBS MEDICARE PPO MA|||||14,072.25||| C1778|EAP|0278|STIMULATOR LEAD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||14,072.25||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|Managed Medicare|HEALTHSPRING MA|||||175.00||| C1778|EAP|0278|STIMULATOR LEAD|Aenta Medicare Advantage|AETNA MEDICARE MA|175.00||||14,072.25||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|United Healthcare|UNITED HEALTHCARE|||||175.00||| C1778|EAP|0278|STIMULATOR LEAD|Tricare|TRICARE EAST REGION|||||14,072.25||| C1778|EAP|0278|IMPLANT LEAD NEURO G3|Blue Cross HMO Specialty|BCBSTX HMO|175.00||||53.50||| C1778|EAP|0278|STIMULATOR LEAD|Blue Cross PPO Specialty|BCBSTX PPO|175.00||||14,072.25||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|Tricare|TRICARE EAST REGION|||||175.00||| C1778|EAP|0278|STIMULATOR LEAD|United Healthcare|UNITED HEALTHCARE OTHER|||||14,072.25||| C1778|EAP|0278|IMPLANT LEAD NEURO G3|Blue Cross PPO Specialty|BCBSTX PPO|175.00||||53.50||| C1778|EAP|0278|STIMULATOR LEAD|Managed Medicare|HEALTHSPRING MA|||||14,072.25||| C1778|EAP|0278|STIMULATOR LEAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||14,072.25||| C1778|EAP|0278|STIMULATOR LEAD|Medicare|MEDICARE ACUTE|175.00||||14,072.25||| C1778|EAP|0278|LEAD KIT 70CM 4X8 SC-8352|Medicare|MEDICARE ACUTE|175.00||||175.00||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||175.00||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|United Medicare Advantage|UHC AARP MCR HMO MA|||||175.00||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|Humana Medicare Advantage|HUMANA MA|||||175.00||| C1778|EAP|0278|STIMULATOR LEAD|Managed Medicaid|MEDICAID AMERIGROUP|||||14,072.25||| C1778|EAP|0278|LEAD KIT 70CM 4X8 SC-8352|Aenta Medicare Advantage|AETNA MEDICARE MA|175.00||||175.00||| C1778|EAP|0278|IMPLANT LEAD NEURO G1|Blue Cross PPO Specialty|BCBSTX PPO|175.00||||175.00||| C1781|EAP|0278|IMPLANT MESH G1|Blue Cross HMO Specialty|BCBSTX HMO|26.75||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G3|Cigna|CIGNA|||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.75||||26.75||| C1781|EAP|0278|IMPLANT MESH G3|Managed Medicaid|MEDICAID SUPERIOR|5,786.50||||||| C1781|EAP|0278|IMPLANT MESH G6|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|145.00||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Aetna|AETNA QHP HMO|||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Aetna|BOON CHAPMAN|||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G3|Aetna Value Network|AETNA VALUE NETWORK|||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G6|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|145.00||||145.00||| C1781|EAP|0278|IMPLANT MESH G4|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||115.73||| C1781|EAP|0278|IMPLANT MESH G4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|145.00||||115.73||| C1781|EAP|0278|IMPLANT MESH G2|Blue Cross PPO Specialty|BCBSTX PPO|145.00||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||26.75||| C1781|EAP|0278|IMPLANT MESH G5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|145.00||||133.75||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|Blue Cross PPO Specialty|BCBSTX PPO|254.10||||53.23||| C1781|EAP|0278|IMPLANT MESH G2|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||26.75||| C1781|EAP|0278|IMPLANT MESH G3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.73||||5,786.50||| C1781|EAP|0278|GRAFT XEN MATRIX AB 20X20|ChampVA|CHAMPVA CENTER|331.10||||||| C1781|EAP|0278|IMPLANT MESH G1|Blue Cross PPO Specialty|BCBSTX PPO|5,786.50||||1,157.25||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|53.23||||53.23||| C1781|EAP|0278|IMPL PHASIX ST MESH 8X10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|254.10||||290.50||| C1781|EAP|0278|IMPLANT MESH G2|Aetna|AETNA PPO|||||26.75||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|Humana Medicare Advantage|HUMANA MA|53.23||||53.23||| C1781|EAP|0278|IMPLANT MESH G4|Humana Medicare Advantage|HUMANA MA|1,157.25||||115.73||| C1781|EAP|0278|IMPLANT MESH G2|Humana Medicare Advantage|HUMANA MA|55,045.38||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Humana Medicare Advantage|HUMANA MA|26.75||||115.73||| C1781|EAP|0278|IMPLANT MESH G3|Humana Medicare Advantage|HUMANA MA|290.50||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G4|Veterans Affairs|VETERANS ADMINISTRATION|||||115.73||| C1781|EAP|0278|IMPLANT MESH G2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,157.25||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Veterans Affairs|VETERANS ADMINISTRATION|||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Veterans Affairs|VETERANS ADMINISTRATION|||||1,157.25||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|Veterans Affairs|VETERANS ADMINISTRATION|||||53.23||| C1781|EAP|0278|IMPLANT MESH G4|Access Direct Platinum|HEALTHFIRST TPA UMR|||||115.73||| C1781|EAP|0278|IMPLANT MESH G2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26.75||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Access Direct Platinum|HEALTHFIRST TPA|5,786.50||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|254.10||||1,157.25||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|United Medicare Advantage|UHC AARP MCR HMO MA|||||53.23||| C1781|EAP|0278|IMPLANT MESH G3|United Medicare Advantage|UHC MEDICARE GOLD MA|26.75||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.23||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G1|United Medicare Advantage|UHC MEDICARE GOLD MA|1,157.25||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.23||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|United Medicare Advantage|UHC MEDICARE GOLD MA|26.75||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Medicaid|MEDICAID|1,157.25||||||| C1781|EAP|0278|IMPLANT MESH G1|Medicaid|COUNTY INDIGENT HEALTH OTHER|115.73||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G3|Medicare|MEDICARE PART B ONLY IP|5,786.50||||||| C1781|EAP|0278|IMPLANT MESH G2|Medicare|MEDICARE ACUTE|26.75||||115.73||| C1781|EAP|0278|IMPLANT MESH G4|Medicare|MEDICARE PART B ONLY IP|115.73||||||| C1781|EAP|0278|IMPLANT MESH G3|Medicare|MEDICARE ACUTE|190.40||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G4|Medicare|MEDICARE ACUTE|115.73||||115.73||| C1781|EAP|0278|IMPLANT MESH G1|Medicare|MEDICARE ACUTE|1,157.25||||115.73||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|Medicare|MEDICARE ACUTE|53.23||||53.23||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|115.73||||53.23||| C1781|EAP|0278|IMPLANT MESH G2|Managed Medicare|BCBS MEDICARE PPO MA|26.75||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|115.73||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Managed Medicare|HEALTHSPRING MA|254.10||||1,157.25||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|Managed Medicare|HEALTHSPRING MA|53.23||||53.23||| C1781|EAP|0278|PERICARDIAL PATCH 4X5 CM|Medicare|MEDICARE ACUTE|1,337.50||||115.73||| C1781|EAP|0278|IMPLANT MESH G1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|115.73||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G1|United Healthcare|UNITED HEALTHCARE|145.00||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|United Healthcare|UNITED HEALTHCARE OTHER|||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|United Healthcare|TML GROUP BENEFITS|||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|United Healthcare|UNITED HEALTHCARE OTHER|||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|United Healthcare|UNITED HEALTHCARE|145.00||||26.75||| C1781|EAP|0278|IMPLANT MESH G3|NON CONTRACTED|COMMERCIAL OTHER 1|53.23||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G2|NON CONTRACTED|COMMERCIAL OTHER 1|53.23||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Texas Workforce Commission|DIS DETER SERV (DDS)|||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Tricare|TRICARE EAST REGION|||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|Rusk State Hospital|RUSK STATE HOSP|26.75||||||| C1781|EAP|0278|IMPLANT MESH G3|United Healthcare|UNITED HEALTHCARE OTHER|||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G1|NON CONTRACTED|COMMERCIAL OTHER 1|53.23||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|Medicare|MEDICARE ACUTE|55,045.38||||26.75||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|United Medicare Advantage|UHC MEDICARE GOLD MA|53.23||||53.23||| C1781|EAP|0278|IMPLANT MESH G3|United Healthcare|UNITED HEALTHCARE|145.00||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G3|United Healthcare|UNITED HEALTHCARE|26.75||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G1|United Healthcare|UNITED HEALTHCARE|53.23||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|Managed Medicare|HEALTHSPRING MA|26.75||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Humana Medicare Advantage|HUMANA MA|254.10||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|Managed Medicare|BCBS MEDICARE PPO MA|53.23||||26.75||| C1781|EAP|0278|IMPLANT MESH G3|Managed Medicare|HEALTHSPRING MA|5,786.50||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G5|Humana Medicare Advantage|HUMANA MA|133.75||||115.73||| C1781|EAP|0278|IMPLANT MESH G2|Cigna|CIGNA|||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Medicare|MEDICARE ACUTE|254.10||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G3|Medicare|MEDICARE ACUTE|5,786.50||||115.73||| C1781|EAP|0278|IMPLANT MESH G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|53.23||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,786.50||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Cigna|CIGNA|||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|United Healthcare|UNITED HEALTHCARE|26.75||||26.75||| C1781|EAP|0278|IMPLANT MESH G6|Medicare|MEDICARE ACUTE|145.00||||115.73||| C1781|EAP|0278|IMPLANT MESH G2|Aenta Medicare Advantage|AETNA MEDICARE MA|1,157.25||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|Aetna|AETNA PPO|||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G5|Medicare|MEDICARE ACUTE|133.75||||115.73||| C1781|EAP|0278|IMPLANT MESH G4|Medicare|MEDICARE ACUTE|290.50||||115.73||| C1781|EAP|0278|IMPLANT MESH G3|Medicaid|COUNTY INDIGENT HEALTH OTHER|115.73||||5,786.50||| C1781|EAP|0278|ENVELOPE ABSORB TYRX CMRM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.23||||53.23||| C1781|EAP|0278|IMPLANT MESH G3|Blue Cross PPO Specialty|BCBSTX PPO|145.00||||5,786.50||| C1781|EAP|0278|IMPLANT MESH G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,157.25||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|115.73||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.75||||26.75||| C1781|EAP|0278|IMPLANT MESH G2|Blue Cross HMO Specialty|BCBSTX HMO|5,786.50||||26.75||| C1781|EAP|0278|IMPLANT MESH G1|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,157.25||||26.75||| C1781|EAP|0278|IMPLANT MESH G6|Managed Medicaid|MEDICAID AMERIGROUP|||||145.00||| C1781|EAP|0278|IMPLANT MESH G1|Access Direct Platinum|HEALTHFIRST TPA|5,786.50||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G2|Access Direct Platinum|HEALTHFIRST TPA UMR|||||26.75||| C1781|EAP|0278|IMPLANT MESH G6|Humana Medicare Advantage|HUMANA MA|145.00||||115.73||| C1781|EAP|0278|IMPLANT MESH G1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G4|Humana Medicare Advantage|HUMANA MA|115.73||||115.73||| C1781|EAP|0278|IMPLANT MESH G1|Medicaid|LAW ENFORCEMENT OTHER|||||1,157.25||| C1781|EAP|0278|IMPLANT MESH G1|Aenta Medicare Advantage|AETNA MEDICARE MA|1,157.25||||1,157.25||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|189.00||||||| C1785|EAP|0275|AZURE S DR MRI DEVICE|United Healthcare|UNITED HEALTHCARE OTHER|182.00||||||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|Medicare|MEDICARE ACUTE|19,645.20||||19,645.20||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Managed Medicare|BCBS MEDICARE PPO MA|182.00||||189.00||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|Managed Medicare|HEALTHSPRING MA|||||19,645.20||| C1785|EAP|0275|IMPL ACCOLADE SR-MRI GENE|Aenta Medicare Advantage|AETNA MEDICARE MA|182.00||||157.50||| C1785|EAP|0275|PMKR ADAPTA DR|Medicare|MEDICARE ACUTE|189.00||||36,895.25||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Medicare|MEDICARE PART B ONLY IP|189.00||||||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Medicare|MEDICARE ACUTE|222.25||||189.00||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|Medicare|MEDICARE ACUTE|20,597.50||||20,597.50||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Medicaid|MEDICAID|182.00||||||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|United Medicare Advantage|UHC MEDICARE GOLD MA|189.00||||189.00||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|189.00||||||| C1785|EAP|0275|PMKR ACCENT DR RF PM 2210|Medicare|MEDICARE ACUTE|189.00||||31,846.25||| C1785|EAP|0275|AZURE S DR MRI DEVICE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|182.00||||||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19,645.20||||||| C1785|EAP|0275|AZURE S DR MRI DEVICE|United Medicare Advantage|UHC MEDICARE GOLD MA|182.00||||182.00||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|189.00||||189.00||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|182.00||||||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|United Medicare Advantage|UHC AARP MCR HMO MA|||||19,645.20||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Veterans Affairs|VETERANS ADMINISTRATION|||||189.00||| C1785|EAP|0275|IMPL ACCOLADE DR-MRI GENE|Humana Medicare Advantage|HUMANA MA|189.00||||178.50||| C1785|EAP|0275|IMPL ACCOLADE SR-MRI GENE|Humana Medicare Advantage|HUMANA MA|189.00||||157.50||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Humana Medicare Advantage|HUMANA MA|189.00||||189.00||| C1785|EAP|0275|AZURE S DR MRI SYS|Humana Medicare Advantage|HUMANA MA|189.00||||222.25||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|Humana Medicare Advantage|HUMANA MA|19,645.20||||19,645.20||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|United Medicare Advantage|UHC MEDICARE GOLD MA|19,645.20||||||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|Humana Medicare Advantage|HUMANA MA|182.00||||20,597.50||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||182.00||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Cigna|CIGNA|189.00||||||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Blue Cross PPO Specialty|BCBSTX PPO|189.00||||189.00||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|189.00||||182.00||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|189.00||||182.00||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20,597.50||||||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Aenta Medicare Advantage|AETNA MEDICARE MA|182.00||||189.00||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Blue Cross HMO Specialty|BCBSTX HMO|189.00||||189.00||| C1785|EAP|0278|IMPL ASSURITY MRI PACEMAK|Blue Cross PPO Specialty|BCBSTX PPO|||||19,645.20||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Managed Medicare|BCBS MEDICARE PPO MA|182.00||||182.00||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|United Healthcare|UNITED HEALTHCARE|||||189.00||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|United Medicare Advantage|UHC AARP MCR HMO MA|189.00||||189.00||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Medicare|MEDICARE PART B ONLY IP|182.00||||||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Medicare|MEDICARE ACUTE|182.00||||182.00||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Managed Medicare|HEALTHSPRING MA|189.00||||189.00||| C1785|EAP|0275|IMPL ACCOLADE DR-MRI GENE|Medicare|MEDICARE ACUTE|189.00||||178.50||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Blue Cross PPO Specialty|BCBSTX OTHER|182.00||||||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|189.00||||189.00||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Humana Medicare Advantage|HUMANA MA|182.00||||182.00||| C1785|EAP|0275|AZURE XT DR MRI DEVICE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|189.00||||189.00||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Aetna|AETNA PPO|||||182.00||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Blue Cross PPO Specialty|BCBSTX PPO|189.00||||182.00||| C1785|EAP|0275|AZURE S DR MRI DEVICE|Managed Medicare|HEALTHSPRING MA|189.00||||182.00||| C1786|EAP|0275|AZURE XT SR MRI SYS|United Medicare Advantage|UHC AARP MCR HMO MA|||||192.50||| C1786|EAP|0275|AZURE S SR MRI DEVICE|United Medicare Advantage|UHC MEDICARE GOLD MA|154.00||||154.00||| C1786|EAP|0275|AZURE S SR MRI DEVICE|Medicare|MEDICARE ACUTE|154.00||||154.00||| C1786|EAP|0278|MICRA DEVICE M957651A001|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|388.50||||||| C1786|EAP|0278|IMPL ASSURITY MRI PACEMAK|Medicare|MEDICARE ACUTE|388.50||||202.23||| C1786|EAP|0275|AZURE S SR MRI DEVICE|Managed Medicare|HEALTHSPRING MA|154.00||||||| C1786|EAP|0278|MICRA DEVICE M957651A001|United Medicare Advantage|UHC AARP MCR HMO MA|388.50||||||| C1786|EAP|0278|MICRA DEVICE M957651A001|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|388.50||||388.50||| C1786|EAP|0275|AZURE S SR MRI DEVICE|Humana Medicare Advantage|HUMANA MA|||||154.00||| C1786|EAP|0278|MICRA AV PACEMAKER SINGLE|Medicare|MEDICARE ACUTE|428.75||||428.75||| C1786|EAP|0278|MICRA DEVICE M957651A001|Humana Medicare Advantage|HUMANA MA|388.50||||||| C1786|EAP|0278|MOMENTUM EL ICD DR|Medicare|MEDICARE ACUTE|428.75||||535.00||| C1787|EAP|0278|PATIENT PROGR, NEUROSTIM|Blue Cross HMO Specialty|BCBSTX HMO|55.64||||55.64||| C1787|EAP|0278|PATIENT PROGR, NEUROSTIM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||55.64||| C1787|EAP|0278|PATIENT PROGR, NEUROSTIM|Blue Cross PPO Specialty|BCBSTX PPO|||||55.64||| C1787|EAP|0278|PATIENT PROGR, NEUROSTIM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||55.64||| C1787|EAP|0278|PATIENT PROGR, NEUROSTIM|Medicare|MEDICARE ACUTE|55.64||||55.64||| C1787|EAP|0278|PATIENT PROGR, NEUROSTIM|Humana Medicare Advantage|HUMANA MA|55.64||||55.64||| C1787|EAP|0278|PATIENT PROGR, NEUROSTIM|Aetna|AETNA QHP HMO|||||55.64||| C1787|EAP|0278|PATIENT PROGR, NEUROSTIM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||55.64||| C1787|EAP|0278|PATIENT PROGR, NEUROSTIM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||55.64||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|United Healthcare|UNITED HEALTHCARE OTHER|||||19.15||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Humana Medicare Advantage|HUMANA MA|||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Humana Medicare Advantage|HUMANA MA|||||27.82||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||19.15||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||19.15||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Managed Medicaid|MEDICAID AMERIGROUP|||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||27.82||| C1788|EAP|0272|CATH HOHN POWER LINE BARD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,815.50||||||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Blue Cross PPO Specialty|BCBSTX PPO|19.15||||27.82||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Blue Cross PPO Specialty|BCBSTX PPO|19.15||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Blue Cross HMO Specialty|BCBSTX HMO|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|27.82||||||| C1788|EAP|0272|CATH HOHN POWER LINE BARD|Veterans Affairs|VETERANS ADMINISTRATION|1,815.50||||||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Veterans Affairs|VETERANS ADMINISTRATION|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|19.15||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||27.82||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Aetna|AETNA PPO|||||19.15||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Blue Cross HMO Specialty|BCBSTX HMO|||||19.15||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Veterans Affairs|VETERANS ADMINISTRATION|||||19.15||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||27.82||| C1788|EAP|0272|CATH HOHN POWER LINE BARD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,815.50||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Managed Medicaid|MEDICAID AMERIGROUP|||||27.82||| C1788|EAP|0272|CATH HOHN POWER LINE BARD|United Medicare Advantage|UHC MEDICARE GOLD MA|1,815.50||||||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|United Medicare Advantage|UHC MEDICARE GOLD MA|||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|United Medicare Advantage|UHC AARP MCR HMO MA|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Managed Medicaid|MEDICAID SUPERIOR|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||27.82||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||19.15||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|United Medicare Advantage|UHC AARP MCR HMO MA|||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.82||| C1788|EAP|0272|CATH HOHN POWER LINE BARD|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,815.50||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|PHCS|GROUP AND PENSION|||||27.82||| C1788|EAP|0272|CATH HOHN POWER LINE BARD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,815.50||||||| C1788|EAP|0272|CATH HOHN POWER LINE BARD|Humana Medicare Advantage|HUMANA MA|1,815.50||||||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Tricare|TRICARE EAST REGION|||||19.15||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|NON CONTRACTED|COMMERCIAL OTHER 1|||||19.15||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|United Healthcare|UNITED HEALTHCARE|||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|United Healthcare|UNITED HEALTHCARE OTHER|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|United Healthcare|UNITED HEALTHCARE|||||27.82||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Managed Medicare|HEALTHSPRING MA|||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Managed Medicare|BCBS MEDICARE PPO MA|27.82||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Managed Medicare|HEALTHSPRING MA|||||27.82||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Cigna|CIGNA|||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Medicaid|MEDICAID|27.82||||27.82||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Medicaid|MEDICAID HMO|27.82||||||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Medicaid|MEDICAID|19.15||||19.15||| C1788|EAP|0272|CATH HOHN POWER LINE BARD|Medicare|MEDICARE ACUTE|1,815.50||||1,815.50||| C1788|EAP|0278|POWERPORT CLEARVUE 8F|Medicare|MEDICARE ACUTE|27.82||||19.15||| C1788|EAP|0278|PORT, INDWELLING, IMP G1|Medicare|MEDICARE ACUTE|27.82||||27.82||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Medicare|MEDICARE ACUTE|115.73||||115.73||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Medicare|MEDICARE ACUTE|115.73||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Managed Medicare|HEALTHSPRING MA|||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Tricare|TRICARE EAST REGION|||||115.73||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Tricare|TRICARE EAST REGION|||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|United Medicare Advantage|UHC MEDICARE GOLD MA|115.73||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|115.73||||||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Blue Cross HMO Specialty|BCBSTX HMO|||||115.73||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Blue Cross PPO Specialty|BCBSTX PPO|115.73||||115.73||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Blue Cross PPO Specialty|BCBSTX PPO|115.73||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Aetna|AETNA PPO|||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|115.73||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Humana Medicare Advantage|HUMANA MA|115.73||||115.73||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|PHCS|GROUP AND PENSION|||||115.73||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Medicare|MEDICARE PART B ONLY IP|115.73||||||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Humana Medicare Advantage|HUMANA MA|115.73||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||115.73||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|115.73||||2,893.25||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|115.73||||2,893.25||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.73||||115.73||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.73||||5,786.50||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Blue Cross PPO Specialty|BCBSTX PPO|115.73||||2,893.25||| C1789|EAP|0278|IMPLANT PROSTHESIS BREAST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||115.73||| C1813|EAP|0278|IMPL PUMP PENILE ES8820|Humana Medicare Advantage|HUMANA MA|||||30,152.50||| C1813|EAP|0278|IMPL PUMP PENILE 72404236|Humana Medicare Advantage|HUMANA MA|||||301.91||| C1813|EAP|0278|IMPL PUMP PENILE 18CM 12M|Humana Medicare Advantage|HUMANA MA|||||300.03||| C1813|EAP|0278|IMPL PUMP PENILE ES2918|Humana Medicare Advantage|HUMANA MA|||||262.50||| C1813|EAP|0278|IMPL PUMP PENILE ES8818|Access Direct Platinum|HEALTHFIRST TPA UMR|||||317.80||| C1813|EAP|0278|IMPLANT PROSTHESIS PENILE|United Medicare Advantage|UHC AARP MCR HMO MA|||||162.24||| C1813|EAP|0278|IMPLANT PROSTHESIS PENILE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||162.24||| C1813|EAP|0278|IMPL PUMP PENILE 18C 7240|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||263.91||| C1813|EAP|0278|IMPL PUMP PENILE 15C 7240|United Medicare Advantage|UHC AARP MCR HMO MA|||||29,615.25||| C1813|EAP|0278|IMPL PUMP PENILE 72404257|United Medicare Advantage|UHC MEDICARE GOLD MA|||||28,251.25||| C1813|EAP|0278|IMPLANT PROSTHESIS PENILE|United Healthcare|UNITED HEALTHCARE OTHER|||||162.24||| C1813|EAP|0278|IMPL PUMP PENILE ES8820|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||30,152.50||| C1813|EAP|0278|IMPL PUMP PENILE ES8818|United Healthcare|UNITED HEALTHCARE OTHER|||||317.80||| C1813|EAP|0278|IMPL PUMP PENILE 18CM 12M|United Healthcare|UNITED HEALTHCARE|||||300.03||| C1813|EAP|0278|IMPL PUMP PENILE ES2918|United Healthcare|UNITED HEALTHCARE|||||262.50||| C1813|EAP|0278|IMPL PUMP PENILE 72404257|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||28,251.25||| C1813|EAP|0278|IMPLANT PROSTHESIS PENILE|United Healthcare|UNITED HEALTHCARE|||||162.24||| C1813|EAP|0278|IMPL PUMP PENILE 15C 7240|Managed Medicare|HEALTHSPRING MA|||||29,615.25||| C1813|EAP|0278|IMPL PUMP PENILE ES8822|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||252.00||| C1813|EAP|0278|IMPL PUMP PENILE ES8820|Managed Medicare|HEALTHSPRING MA|||||30,152.50||| C1813|EAP|0278|IMPLANT PROSTHESIS PENILE|Managed Medicare|HEALTHSPRING MA|||||162.24||| C1813|EAP|0278|INFRAPUBIC BIOFLEX CYL SE|Humana Medicare Advantage|HUMANA MA|||||311.43||| C1813|EAP|0278|IMPLANT PROSTHESIS PENILE|Medicare|MEDICARE ACUTE|317.80||||162.24||| C1813|EAP|0278|IMPLANT PROSTHESIS PENILE|Humana Medicare Advantage|HUMANA MA|||||162.24||| C1813|EAP|0278|IMPL PUMP PENILE 72404257|Medicare|MEDICARE ACUTE|317.80||||28,251.25||| C1813|EAP|0278|IMPL PUMP PENILE ES8820|Medicare|MEDICARE ACUTE|317.80||||30,152.50||| C1813|EAP|0278|IMPL PUMP PENILE ES8818|Medicare|MEDICARE ACUTE|317.80||||317.80||| C1813|EAP|0278|IMPL PUMP PENILE 18CM 12M|Medicare|MEDICARE ACUTE|317.80||||300.03||| C1813|EAP|0278|IMPLANT PROSTHESIS PENILE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||162.24||| C1813|EAP|0278|IMPL PUMP PENILE 15C 7240|Medicare|MEDICARE ACUTE|317.80||||29,615.25||| C1813|EAP|0278|IMPL PENILE PUMP 21C 7240|Medicare|MEDICARE ACUTE|262.50||||29,615.25||| C1815|EAP|0278|IMPL URINARY SPHINCTER CO|Medicare|MEDICARE ACUTE|||||237.18||| C1815|EAP|0278|IMPL URINARY SPHINCTER CO|Blue Cross PPO Specialty|BCBSTX PPO|||||237.18||| C1815|EAP|0278|IMPL URINARY SPHINCTER CO|Humana Medicare Advantage|HUMANA MA|||||237.18||| C1817|EAP|0278|OCCLUDER PFO 025|Access Direct Platinum|HEALTHFIRST TPA|||||349.82||| C1817|EAP|0278|OCCLUDER PFO 025|Managed Medicare|BCBS MEDICARE PPO MA|||||349.82||| C1817|EAP|0278|OCCLUDER PFO 025|Medicare|MEDICARE ACUTE|||||349.82||| C1817|EAP|0278|OCCLUDER PFO 025|Blue Cross PPO Specialty|BCBSTX PPO|||||349.82||| C1817|EAP|0278|OCCLUDER PFO 025|Aetna|AETNA PPO|||||349.82||| C1817|EAP|0278|OCCLUDER|Medicare|MEDICARE ACUTE|||||32,495.75||| C1817|EAP|0278|OCCLUDER PFO 025|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||349.82||| C1820|EAP|0278|STIMULATOR NEURO ACTIVA R|Medicare|MEDICARE ACUTE|||||56,675.75||| C1820|EAP|0278|GENERATOR ELITE 7 IPG 366|Medicare|MEDICARE ACUTE|||||489.58||| C1820|EAP|0278|GENERATOR ELITE 7 IPG 366|Managed Medicare|HEALTHSPRING MA|||||489.58||| C1820|EAP|0278|GENERATOR ELITE 7 IPG 366|Humana Medicare Advantage|HUMANA MA|||||489.58||| C1820|EAP|0278|STIMULATOR NEURO ACTIVA R|Blue Cross PPO Specialty|BCBSTX PPO|||||56,675.75||| C1820|EAP|0278|IMPL GENERATOR PRODIGY IP|Blue Cross PPO Specialty|BCBSTX PPO|||||53,182.50||| C1820|EAP|0278|STIMULATOR NEURO ACTIVA R|Aetna|AETNA QHP HMO|||||56,675.75||| C1820|EAP|0278|GENERATOR ELITE 7 IPG 366|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||489.58||| C1820|EAP|0278|IMPL GENERATOR PRODIGY IP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||53,182.50||| C1821|EAP|0278|IMPL CONNECTOR 5.5M 200M|United Medicare Advantage|UHC MEDICARE GOLD MA|262.50||||262.50||| C1821|EAP|0278|IMPL CONNECTOR 5.5M 200M|Veterans Affairs|VETERANS ADMINISTRATION|||||262.50||| C1821|EAP|0278|IMPL COFLEX SZ 8 UQI00008|Veterans Affairs|VETERANS ADMINISTRATION|||||232.96||| C1821|EAP|0278|IMPL COFLEX SZ 8 UQI00008|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||232.96||| C1821|EAP|0278|IMPL CONNECTOR 5.5M 200M|Blue Cross PPO Specialty|BCBSTX PPO|262.50||||||| C1821|EAP|0278|IMPL CONNECTOR 5.5M 200M|Humana Medicare Advantage|HUMANA MA|262.50||||||| C1821|EAP|0278|IMPL CONNECTOR 5.5M 200M|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||262.50||| C1821|EAP|0278|IMPL COFLEX 10M UQI00010|Managed Medicare|HEALTHSPRING MA|||||232.96||| C1821|EAP|0278|IMPL CONNECTOR 5.5M 200M|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||262.50||| C1821|EAP|0278|IMPL CONNECTOR 5.5M 200M|Medicare|MEDICARE ACUTE|262.50||||232.96||| C1821|EAP|0278|IMPL COFLEX SZ 8 UQI00008|Medicare|MEDICARE ACUTE|232.96||||232.96||| C1822|EAP|0278|IMPL NEUROSTIMULATOR|Medicare|MEDICARE ACUTE|803.25||||803.25||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,673.75||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,673.75||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Cigna|CIGNA|43.40||||43.40||| C1830|EAP|0272|ONCONTROL COAXIAL BIOP TR|Humana Medicare Advantage|HUMANA MA|12,519.50||||12,519.50||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Humana Medicare Advantage|HUMANA MA|12,519.50||||43.40||| C1830|EAP|0272|ONCONTROL COAXIAL BIOP TR|Aenta Medicare Advantage|AETNA MEDICARE MA|43.40||||12,519.50||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Aenta Medicare Advantage|AETNA MEDICARE MA|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|ChampVA|CHAMPVA CENTER|43.40||||||| C1830|EAP|0272|BIOPSY SYS COMPREHENS TRA|Blue Cross PPO Specialty|BCBSTX PPO|43.40||||4,673.75||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Blue Cross HMO Specialty|BCBSTX HMO|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Veterans Affairs|VETERANS ADMINISTRATION|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Blue Cross PPO Specialty|BCBSTX PPO|12,519.50||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||43.40||| C1830|EAP|0272|BIOPSY SYS COMPREHENS TRA|Humana Medicare Advantage|HUMANA MA|43.40||||4,673.75||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|United Medicare Advantage|UHC AARP MCR HMO MA|12,519.50||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|NON CONTRACTED|COMMERCIAL OTHER 1|||||43.40||| C1830|EAP|0272|ONCONTROL COAXIAL BIOP TR|Cigna|CIGNA|43.40||||12,519.50||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|PHCS|HUMANA INSURANCE|43.40||||||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Tricare|TRICARE EAST REGION|43.40||||||| C1830|EAP|0272|ONCONTROL COAXIAL BIOP TR|UTMB|UTMB CORRECTIONAL MANAGED CARE|12,519.50||||||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|United Healthcare|UNITED HEALTHCARE OTHER|43.40||||||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|United Healthcare|UNITED HEALTHCARE|||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|43.40||||43.40||| C1830|EAP|0272|ONCONTROL COAXIAL BIOP TR|Blue Cross PPO Specialty|BCBSTX PPO|12,519.50||||12,519.50||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Managed Medicare|HEALTHSPRING MA|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Medicaid|MEDICAID|43.40||||43.40||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Medicaid|COUNTY INDIGENT HEALTH OTHER|43.40||||||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Medicare|UTSW MC KIDNEY PROGRAM|||||43.40||| C1830|EAP|0272|ONCONTROL COAXIAL BIOP TR|Medicare|MEDICARE ACUTE|12,519.50||||12,519.50||| C1830|EAP|0272|ONCONTROL BIOPSY SYSTM TR|Medicare|MEDICARE ACUTE|43.40||||43.40||| C1830|EAP|0272|BIOPSY SYS COMPREHENS TRA|Medicare|MEDICARE ACUTE|4,673.75||||4,673.75||| C1830|EAP|0272|ONCONTROL COAXIAL BIOP TR|Medicaid|MEDICAID|12,519.50||||43.40||| C1874|EAP|0278|XIENCE XPED DES 4.00MM X|Medicare|MEDICARE ACUTE|640.15||||9,272.50||| C1874|EAP|0278|XIENCE XPED SV DES 2.25MM|Medicare|MEDICARE ACUTE|9,272.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 3.00 X 28|Medicare|MEDICARE ACUTE|3,587.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED LL DES 3.50MM|Medicare|MEDICARE ACUTE|9,272.50||||9,578.75||| C1874|EAP|0278|XIENCE XPED LL DES 3.25MM|Medicare|MEDICARE ACUTE|9,272.50||||9,578.75||| C1874|EAP|0278|XIENCE XPED DES 4.00MM X|Medicare|MEDICARE ACUTE|9,272.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 3.50MM X|Medicare|MEDICARE ACUTE|10,358.25||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 3.00 X 15|Medicare|MEDICARE ACUTE|33,596.50||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Medicare|MEDICARE ACUTE|2,893.25||||3,587.50||| C1874|EAP|0278|IMPLT STNT, COAT/COV W/DE|Medicare|MEDICARE ACUTE|38,566.50||||162.24||| C1874|EAP|0278|EXCLUDER C3 23X14.5X14C|Medicare|MEDICARE ACUTE|376.25||||376.25||| C1874|EAP|0278|EXCLUDER 26X12M 12CM|Medicare|MEDICARE ACUTE|78.75||||376.25||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Medicaid|MEDICAID|2,893.25||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Medicaid|MEDICAID|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Medicaid|LAW ENFORCEMENT OTHER|3,587.50||||||| C1874|EAP|0278|XIENCE XPED LL DES 3.00 X|Medicare|MEDICARE ACUTE|9,272.50||||9,578.75||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Managed Medicare|HEALTHSPRING MA|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3,587.50||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 3.50MM X|Managed Medicare|HEALTHSPRING MA|3,587.50||||9,272.50||| C1874|EAP|0278|STENT COBRA PZF (MULTIPLE|Managed Medicare|BCBS MEDICARE PPO MA|3,587.50||||42.80||| C1874|EAP|0278|IMPLT STNT, COAT/COV W/DE|Managed Medicare|HEALTHSPRING MA|12,026.25||||162.24||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|United Healthcare|GOLDEN RULE|3,587.50||||||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|United Healthcare|TML GROUP BENEFITS|3,587.50||||||| C1874|EAP|0278|IMPL STENT G3|United Healthcare|UNITED HEALTHCARE|376.25||||2,893.25||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Medicare|MEDICARE PART B ONLY IP|3,587.50||||||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|United Healthcare|UNITED HEALTHCARE|3,587.50||||||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|United Healthcare|UNITED HEALTHCARE OTHER|3,587.50||||3,587.50||| C1874|EAP|0278|IMPL STENT G3|Medicare|MEDICARE ACUTE|376.25||||2,893.25||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|United Healthcare|UNITED HEALTHCARE|3,587.50||||3,587.50||| C1874|EAP|0278|EXCLUDER 26M 12 C RLT2614|United Healthcare|UNITED HEALTHCARE|376.25||||||| C1874|EAP|0278|XIENCE XPED DES 3.50MM X|United Healthcare|UNITED HEALTHCARE|3,587.50||||9,272.50||| C1874|EAP|0278|EXCLUDER 26X12M 12CM|United Healthcare|TML GROUP BENEFITS|376.25||||||| C1874|EAP|0278|IMPLT STNT, COAT/COV W/DE|United Healthcare|UNITED HEALTHCARE|162.24||||||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,587.50||||||| C1874|EAP|0278|EXCLUDER C3 23X14.5X14C|PHCS|GROUP AND PENSION|376.25||||||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Tricare|TRICARE FOR LIFE|3,587.50||||||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Tricare|TRICARE EAST REGION|172.55||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|NON CONTRACTED|COMMERCIAL OTHER 1|3,587.50||||3,587.50||| C1874|EAP|0278|EXCLUDER 26X12M 12CM|NON CONTRACTED|COMMERCIAL OTHER 1|162.24||||376.25||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|United Medicare Advantage|UHC AARP MCR HMO MA|3,587.50||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 3.25MM X|United Medicare Advantage|UHC AARP MCR HMO MA|145.64||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 3.25MM X|United Medicare Advantage|UHC MEDICARE GOLD MA|9,272.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 2.50MM X|United Medicare Advantage|UHC MEDICARE GOLD MA|9,272.50||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,893.25||||3,587.50||| C1874|EAP|0278|XIENCE XPED LL DES 3.50MM|United Medicare Advantage|UHC AARP MCR HMO MA|145.64||||9,578.75||| C1874|EAP|0278|IMPL STENT G3|United Medicare Advantage|UHC AARP MCR HMO MA|376.25||||2,893.25||| C1874|EAP|0278|XIENCE XPED DES 3.25MM X|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,587.50||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|United Medicare Advantage|UHC MEDICARE GOLD MA|162.24||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 3.00MM X|United Medicare Advantage|UHC MEDICARE GOLD MA|3,587.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED SV DES 2.25MM|Veterans Affairs|VETERANS ADMINISTRATION|9,272.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 3.25MM X|Veterans Affairs|VETERANS ADMINISTRATION|9,272.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 2.75MM X|Veterans Affairs|VETERANS ADMINISTRATION|3,587.50||||9,272.50||| C1874|EAP|0278|STENT PROTEGE EV3|Veterans Affairs|VETERANS ADMINISTRATION|145.64||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Veterans Affairs|VETERANS ADMINISTRATION|42.80||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Access Direct Platinum|HEALTHFIRST TPA|3,587.50||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 4.00MM X|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9,272.50||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2,893.25||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 3.00 X 23|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9,272.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Access Direct Platinum|HEALTHFIRST TPA UMR|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|3,587.50||||||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3,587.50||||3,587.50||| C1874|EAP|0278|EXCLUDER C3 23X14.5X14C|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3,587.50||||376.25||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Tricare|TRICARE EAST REGION|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|PHCS|HUMANA|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Blue Cross HMO Specialty|BCBSTX HMO|3,587.50||||3,587.50||| C1874|EAP|0278|XIENCE XPED SV DES 2.25MM|Blue Cross PPO Specialty|BCBSTX PPO|9,578.75||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 3.50MM X|Blue Cross PPO Specialty|BCBSTX PPO|145.64||||9,272.50||| C1874|EAP|0278|IMPL STENT G3|Blue Cross PPO Specialty|BCBSTX PPO|2,893.25||||2,893.25||| C1874|EAP|0278|EXCLUDER C3 23X14.5X14C|Blue Cross PPO Specialty|BCBSTX PPO|376.25||||376.25||| C1874|EAP|0278|STENT COBRA PZF (MULTIPLE|United Healthcare|UNITED HEALTHCARE|2,893.25||||42.80||| C1874|EAP|0278|XIENCE XPED DES 3.25MM X|Blue Cross PPO Specialty|BCBSTX PPO|3,587.50||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3,587.50||||||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Blue Cross PPO Specialty|BCBSTX OTHER|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Aetna|AETNA PPO|3,587.50||||3,587.50||| C1874|EAP|0278|XIENCE XPED LL DES 3.50MM|Aetna|AETNA PPO|9,578.75||||3,587.50||| C1874|EAP|0278|IMPL STENT G3|United Healthcare|UNITED HEALTHCARE OTHER|3,587.50||||2,893.25||| C1874|EAP|0278|XIENCE XPED DES 2.75MM X|Medicare|MEDICARE ACUTE|42.80||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Managed Medicare|BCBS MEDICARE PPO MA|9,272.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Aetna|AETNA PPO|162.24||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 3.00 X 12|Blue Cross HMO Specialty|BCBSTX HMO|9,578.75||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Aetna|AETNA OTHER|3,587.50||||||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Blue Cross PPO Specialty|BCBSTX PPO|42.80||||3,587.50||| C1874|EAP|0278|XIENCE XPED LL DES 3.50MM|Aenta Medicare Advantage|AETNA MEDICARE MA|9,578.75||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 4.00MM X|Aenta Medicare Advantage|AETNA MEDICARE MA|9,272.50||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 4.00MM X|Managed Medicare|HEALTHSPRING MA|3,587.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 3.25MM X|Medicare|MEDICARE ACUTE|145.64||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Medicaid|COUNTY INDIGENT HEALTH OTHER|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Aenta Medicare Advantage|AETNA MEDICARE MA|3,587.50||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 2.75MM X|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,587.50||||9,272.50||| C1874|EAP|0278|STENT COBRA PZF (MULTIPLE|Medicare|MEDICARE ACUTE|12,026.25||||42.80||| C1874|EAP|0278|XIENCE XPED LL DES 3.25MM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9,578.75||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|162.24||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 3.50MM X|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9,272.50||||9,272.50||| C1874|EAP|0278|EXCLUDER C3 23X14.5X14C|Humana Medicare Advantage|HUMANA MA|78.75||||376.25||| C1874|EAP|0278|STENT COBRA PZF (MULTIPLE|Humana Medicare Advantage|HUMANA MA|42.80||||42.80||| C1874|EAP|0278|XIENCE XPED DES 2.50MM X|Medicare|MEDICARE ACUTE|162.24||||9,272.50||| C1874|EAP|0278|IMPLT STNT, COAT/COV W/DE|Humana Medicare Advantage|HUMANA MA|162.24||||162.24||| C1874|EAP|0278|XIENCE XPED DES 3.25MM X|Humana Medicare Advantage|HUMANA MA|9,272.50||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Humana Medicare Advantage|HUMANA MA|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Cigna|CIGNA|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Cigna|CIGNA OTHER|||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Cigna|CIGNA|||||3,587.50||| C1874|EAP|0278|EXCLUDER ENDO 14.5X12-13.|Humana Medicare Advantage|HUMANA MA|2,893.25||||376.25||| C1874|EAP|0278|XIENCE XPED SV DES 2.25MM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,587.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 2.50MM X|Humana Medicare Advantage|HUMANA MA|145.64||||9,272.50||| C1874|EAP|0278|XIENCE XPED LL DES 3.25MM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,587.50||||9,578.75||| C1874|EAP|0278|XIENCE XPED LL DES 3.00 X|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,587.50||||9,578.75||| C1874|EAP|0278|XIENCE XPED LL DES 2.75MM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,587.50||||9,578.75||| C1874|EAP|0278|XIENCE XPED DES 3.00 X 15|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|162.24||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 3.00 X 18|Humana Medicare Advantage|HUMANA MA|9,272.50||||9,272.50||| C1874|EAP|0278|XIENCE XPED DES 3.00 X 12|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|376.25||||9,272.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|376.25||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,587.50||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|376.25||||3,587.50||| C1874|EAP|0278|STENT ONYX DRUG ELUDING A|Managed Medicaid|MEDICAID AMERIGROUP|||||3,587.50||| C1874|EAP|0278|XIENCE XPED DES 2.75MM X|Humana Medicare Advantage|HUMANA MA|9,272.50||||9,272.50||| C1876|EAP|0278|AMSTERDAM STENT|Managed Medicaid|MEDICAID SUPERIOR|756.25||||756.25||| C1876|EAP|0278|AMSTERDAM STENT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|756.25||||756.25||| C1876|EAP|0278|STENT INTEGRITY 3.00X18 I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|53.26||||8,679.75||| C1876|EAP|0278|STENT GRAFT AORTC 34M TV-|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|34,940.25||||8,679.75||| C1876|EAP|0278|STENT COBALT ASSURANT 8X6|Managed Medicaid|MEDICAID UNITED HEALTHCARE|756.25||||7,013.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8,679.75||||7,013.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17,359.75||||8,679.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8,679.75||||8,679.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.90||||8,679.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Managed Medicaid|MEDICAID AMERIGROUP|8,679.75||||8,679.75||| C1876|EAP|0278|STENT INTEGRITY 3.50X18 I|Humana Medicare Advantage|HUMANA MA|7,395.50||||53.26||| C1876|EAP|0278|STENT INTEGRITY 3.00X15 I|Humana Medicare Advantage|HUMANA MA|53.26||||53.26||| C1876|EAP|0278|STENT COBALT ASSURANT 7X2|Humana Medicare Advantage|HUMANA MA|7,013.75||||7,013.75||| C1876|EAP|0278|STENT COMPLETE 8X40X130 S|Humana Medicare Advantage|HUMANA MA|33,596.50||||7,144.75||| C1876|EAP|0278|RACER 7X12 80 CM STENT XD|Cigna|CIGNA|7,794.25||||||| C1876|EAP|0278|STENT COBALT ASSURANT 6X3|Humana Medicare Advantage|HUMANA MA|8,679.75||||7,013.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Humana Medicare Advantage|HUMANA MA|383.78||||8,679.75||| C1876|EAP|0278|AMSTERDAM STENT|Humana Medicare Advantage|HUMANA MA|756.25||||756.25||| C1876|EAP|0278|STENT VISI PRO ALL SIZES|Humana Medicare Advantage|HUMANA MA|9,652.75||||53.50||| C1876|EAP|0278|STENT INTEGRITY 2.50X22 I|Humana Medicare Advantage|HUMANA MA|53.26||||53.26||| C1876|EAP|0278|RACER 6X12 80CM STENT XD6|Humana Medicare Advantage|HUMANA MA|8,653.50||||7,794.25||| C1876|EAP|0278|STENT INTEGRITY 3.50X12 I|Humana Medicare Advantage|HUMANA MA|202.55||||53.26||| C1876|EAP|0278|IMPL STEM, SHELL HUMERAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19,778.50||||7,013.75||| C1876|EAP|0278|STENT INTEGRITY 4.00X22 I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|202.55||||53.26||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,679.75||||17,359.75||| C1876|EAP|0278|STENT COMPLETE SE 8.0X40|Humana Medicare Advantage|HUMANA MA|53.26||||7,144.75||| C1876|EAP|0278|RACER 6X12 80CM STENT XD6|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17,359.75||||7,794.25||| C1876|EAP|0278|IMPL STENT PRECISE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|756.25||||8,653.50||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Aetna|AETNA PPO|756.25||||17,359.75||| C1876|EAP|0278|STENT COBALT ASSURANT 6X6|Humana Medicare Advantage|HUMANA MA|17,359.75||||7,013.75||| C1876|EAP|0278|STENT COBALT ASSURANT 8X2|Aetna|AETNA PPO|8,679.75||||7,013.75||| C1876|EAP|0278|STENT NEUROFORM|Aetna|AETNA PPO|202.55||||7,013.75||| C1876|EAP|0278|STENT COMP BIL6X 100X130|Aenta Medicare Advantage|AETNA MEDICARE MA|8,679.75||||10,067.50||| C1876|EAP|0278|STENT COBALT ASSURANT 8X2|Aenta Medicare Advantage|AETNA MEDICARE MA|8,679.75||||7,013.75||| C1876|EAP|0278|WALL STENT|Blue Cross HMO Specialty|BCBSTX HMO|8,679.75||||7,395.50||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Blue Cross PPO Specialty|BCBSTX PPO|19,778.50||||8,679.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Blue Cross HMO Specialty|BCBSTX HMO|7.90||||17,359.75||| C1876|EAP|0278|IMPL STEM, SHELL HUMERAL|Blue Cross HMO Specialty|BCBSTX HMO|756.25||||19,778.50||| C1876|EAP|0278|STENT INTEGRITY 4.00X22 I|Blue Cross PPO Specialty|BCBSTX PPO|53.26||||7,144.75||| C1876|EAP|0278|STENT INTEGRITY 2.50X26 I|Blue Cross PPO Specialty|BCBSTX PPO|53.26||||7,144.75||| C1876|EAP|0278|STENT COMPLETE SE 8.0X40|Blue Cross PPO Specialty|BCBSTX PPO|8,679.75||||7,144.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Blue Cross PPO Specialty|BCBSTX PPO|8,653.50||||17,359.75||| C1876|EAP|0278|IMPL STENT PRECISE|Blue Cross PPO Specialty|BCBSTX PPO|756.25||||8,653.50||| C1876|EAP|0278|WALL STENT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,653.50||||7,395.50||| C1876|EAP|0278|STENT NEUROFORM|Blue Cross HMO Specialty|BCBSTX HMO|202.55||||7,395.50||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Access Direct Platinum|HEALTHFIRST TPA UMR|756.25||||17,359.75||| C1876|EAP|0278|IMPL STENT PRECISE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8,653.50||| C1876|EAP|0278|GEENAN PANCREATIC STENT|Access Direct Platinum|HEALTHFIRST TPA UMR|756.25||||7.90||| C1876|EAP|0278|AMSTERDAM STENT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|8,653.50||||756.25||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Veterans Affairs|VETERANS ADMINISTRATION|53.26||||17,359.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Veterans Affairs|VETERANS ADMINISTRATION|756.25||||8,679.75||| C1876|EAP|0278|STENT INTEGRITY 2.25X12 I|United Medicare Advantage|UHC MEDICARE GOLD MA|53.26||||53.26||| C1876|EAP|0278|WALL STENT|Blue Cross HMO Specialty|BCBSTX HMO|7,395.50||||7,395.50||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Aenta Medicare Advantage|AETNA MEDICARE MA|8,679.75||||8,679.75||| C1876|EAP|0278|COMPLETE SE STENT 7X100X1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8,679.75||||10,067.50||| C1876|EAP|0278|STENT INTEGRITY 3.00X22 I|United Medicare Advantage|UHC AARP MCR HMO MA|53.26||||53.50||| C1876|EAP|0278|STENT COMP BIL6X 150X130|United Medicare Advantage|UHC MEDICARE GOLD MA|53.26||||10,716.75||| C1876|EAP|0278|STENT COBALT ASSURANT 9X3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.26||||7,013.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|United Medicare Advantage|UHC MEDICARE GOLD MA|53.26||||17,359.75||| C1876|EAP|0278|IMPL STEM HUMERAL 10X108M|United Medicare Advantage|UHC MEDICARE GOLD MA|8,679.75||||19,778.50||| C1876|EAP|0278|AMSTERDAM STENT|United Medicare Advantage|UHC MEDICARE GOLD MA|756.25||||756.25||| C1876|EAP|0278|STENT COMPLETE SE 8.0X40|United Medicare Advantage|UHC MEDICARE GOLD MA|53.26||||7,144.75||| C1876|EAP|0278|STENT SE COMPLETE 8X150X1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.26||||10,715.50||| C1876|EAP|0278|STENT INTEGRITY 3.00X30 I|United Medicare Advantage|UHC MEDICARE GOLD MA|53.26||||53.26||| C1876|EAP|0278|STENT COMP BIL5X 150X130|United Medicare Advantage|UHC MEDICARE GOLD MA|53.26||||7,144.75||| C1876|EAP|0278|STENT COMPLETE SE 7X80X30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.26||||7,144.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|United Medicare Advantage|UHC MEDICARE GOLD MA|17,359.75||||8,679.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|United Medicare Advantage|UHC AARP MCR HMO MA|8,679.75||||17,359.75||| C1876|EAP|0278|STENT VISI PRO ALL SIZES|United Medicare Advantage|UHC AARP MCR HMO MA|53.26||||53.50||| C1876|EAP|0278|STENT INTEGRITY 3.00X09 I|United Medicare Advantage|UHC MEDICARE GOLD MA|53.26||||53.26||| C1876|EAP|0278|STENT COBALT ASSURANT 8X3|Aenta Medicare Advantage|AETNA MEDICARE MA|8,679.75||||7,013.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|United Medicare Advantage|UHC AARP MCR HMO MA|19,778.50||||8,679.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17,359.75||||17,359.75||| C1876|EAP|0278|STENT COMPLETE SE 8.0X40|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|53.26||||7,144.75||| C1876|EAP|0278|STENT COBALT ASSURANT 8X2|United Medicare Advantage|UHC MEDICARE GOLD MA|53.26||||7,013.75||| C1876|EAP|0278|STENT COBALT ASSURANT 8X3|United Medicare Advantage|UHC AARP MCR HMO MA|17,359.75||||7,013.75||| C1876|EAP|0278|STENT GRAFT AORTIC 26M TV|NON CONTRACTED|COMMERCIAL OTHER 1|33,596.50||||||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Texas Workforce Commission|DIS DETER SERV (DDS)|||||17,359.75||| C1876|EAP|0278|STENT GENESIS 6X24 PG2460|UTMB|UTMB CORRECTIONAL MANAGED CARE|53.26||||||| C1876|EAP|0278|STENT INTEGRITY 3.00X30 I|UTMB|UTMB CORRECTIONAL MANAGED CARE|53.26||||||| C1876|EAP|0278|STENT INTEGRITY 2.50X12 I|UTMB|UTMB CORRECTIONAL MANAGED CARE|53.26||||||| C1876|EAP|0278|STENT ULTRA RX 4.5X28 100|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4,871.25||| C1876|EAP|0278|IMPL STENT PRECISE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||8,653.50||| C1876|EAP|0278|IMPL STENT PRECISE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|756.25||||8,653.50||| C1876|EAP|0278|STENT NEUROFORM|Blue Cross PPO Specialty|BCBSTX PPO|202.55||||7,144.75||| C1876|EAP|0278|AMSTERDAM STENT|Blue Cross PPO Specialty|BCBSTX OTHER|756.25||||||| C1876|EAP|0278|STENT INTEGRITY 3.00X15 I|UTMB|UTMB CORRECTIONAL MANAGED CARE|53.26||||||| C1876|EAP|0278|STENT INTEGRITY 2.50X18 I|UTMB|UTMB CORRECTIONAL MANAGED CARE|53.26||||||| C1876|EAP|0278|STENT INTEGRITY 2.25X26 I|UTMB|UTMB CORRECTIONAL MANAGED CARE|53.26||||||| C1876|EAP|0278|AMSTERDAM STENT|United Healthcare|UNITED HEALTHCARE|17,359.75||||756.25||| C1876|EAP|0278|STENT INTEGRITY 2.25X26 I|Blue Cross PPO Specialty|BCBSTX PPO|53.26||||7,144.75||| C1876|EAP|0278|WALL STENT|United Healthcare|UNITED HEALTHCARE|17,359.75||||7,395.50||| C1876|EAP|0278|RACER 5X12 80CM STENT XD5|United Healthcare|UNITED HEALTHCARE|202.55||||7,794.25||| C1876|EAP|0278|IMPL STENT PRECISE|United Healthcare|UNITED HEALTHCARE|17,359.75||||8,653.50||| C1876|EAP|0278|STENT COBALT ASSURANT 6X2|United Healthcare|UNITED HEALTHCARE|202.55||||7,013.75||| C1876|EAP|0278|STENT COMP BIL5X 150X130|Managed Medicare|HEALTHSPRING MA|53.26||||7,144.75||| C1876|EAP|0278|STENT BILIARY PROTEGE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9,368.50||||7,144.75||| C1876|EAP|0278|STENT COMPLETE SE 8.0X40|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4,481.50||||7,144.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Managed Medicare|HEALTHSPRING MA|53.26||||17,359.75||| C1876|EAP|0278|STENT COMP BIL6X 150X130|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17,359.75||||10,716.75||| C1876|EAP|0278|STENT COBALT ASSURANT 7X4|Managed Medicare|HEALTHSPRING MA|53.26||||7,013.75||| C1876|EAP|0278|COMPLETE STENT SE 6X80X12|Managed Medicare|HEALTHSPRING MA|7.90||||7,144.75||| C1876|EAP|0278|GEENAN PANCREATIC STENT|Managed Medicare|HEALTHSPRING MA|19,778.50||||7.90||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Managed Medicare|HEALTHSPRING MA|8,679.75||||8,679.75||| C1876|EAP|0278|STENT ULTRA MULTILINK RX|Managed Medicare|HEALTHSPRING MA|53.26||||6,332.75||| C1876|EAP|0278|STENT COMPLETE SE 8.0X40|Aenta Medicare Advantage|AETNA MEDICARE MA|8,679.75||||7,144.75||| C1876|EAP|0278|AMSTERDAM STENT|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||756.25||| C1876|EAP|0278|STENT VISI PRO ALL SIZES|Managed Medicare|HEALTHSPRING MA|53.26||||53.50||| C1876|EAP|0278|COMPLETE STENT SE 6X80X12|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|756.25||||7,144.75||| C1876|EAP|0278|STENT BILIARY PROTEGE|Medicaid|MEDICAID|9,368.50||||||| C1876|EAP|0278|WALLSTENT ENTERAL UNISTEP|Medicaid|MEDICAID|9,652.75||||||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19,778.50||||8,679.75||| C1876|EAP|0278|STENT COMPLETE SE 7X60X13|Humana Medicare Advantage|HUMANA MA|53.26||||7,144.75||| C1876|EAP|0278|STENT INTEGRITY 3.00X15 I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9,368.50||||53.26||| C1876|EAP|0278|STENT INTEGRITY 4.00X22 I|Medicaid|SMITH COUNTY INDIGENT HEALTH|53.26||||||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Humana Medicare Advantage|HUMANA MA|19,778.50||||17,359.75||| C1876|EAP|0278|AMSTERDAM STENT|Managed Medicare|HEALTHSPRING MA|756.25||||756.25||| C1876|EAP|0278|STENT COMP BIL6X 150X130|Medicaid|MEDICAID|10,716.75||||||| C1876|EAP|0278|STENT COMP BIL5X 150X130|Humana Medicare Advantage|HUMANA MA|7,013.75||||7,144.75||| C1876|EAP|0278|STENT COMP BIL6X 150X130|Managed Medicare|HEALTHSPRING MA|53.26||||10,716.75||| C1876|EAP|0278|AMSTERDAM STENT|Medicaid|MEDICAID|756.25||||||| C1876|EAP|0278|STENT INTEGRITY 3.50X22 I|Medicare|MEDICARE ACUTE|53.26||||7,395.50||| C1876|EAP|0278|GEENAN PANCREATIC STENT|Medicare|MEDICARE ACUTE|200.93||||7.90||| C1876|EAP|0278|STENT COBALT ASSURANT 6X3|United Healthcare|UNITED HEALTHCARE|202.55||||7,013.75||| C1876|EAP|0278|WALL STENT|Medicare|MEDICARE ACUTE|53.26||||7,395.50||| C1876|EAP|0278|STENT COBALT ASSURANT 7X4|Medicare|MEDICARE ACUTE|8,653.50||||7,013.75||| C1876|EAP|0278|WALLSTENT ENTERAL UNISTEP|Medicare|MEDICARE ACUTE|9,652.75||||7,395.50||| C1876|EAP|0278|STENT INTEGRITY 2.50X12 I|Medicare|MEDICARE ACUTE|53.26||||53.26||| C1876|EAP|0278|STENT INTEGRITY 3.00X12 I|Medicare|MEDICARE ACUTE|53.26||||53.26||| C1876|EAP|0278|STENT INTEGRITY 3.00X22 I|Medicare|MEDICARE ACUTE|53.26||||7,395.50||| C1876|EAP|0278|STENT INTEGRITY 3.00X15 I|Medicare|MEDICARE ACUTE|53.26||||53.26||| C1876|EAP|0278|STENT INTEGRITY 4.00X22 I|Medicare|MEDICARE ACUTE|53.26||||7,395.50||| C1876|EAP|0278|STENT INTEGRITY 3.50X15 I|Medicare|MEDICARE PART B ONLY IP|53.26||||||| C1876|EAP|0278|STENT INTEGRITY 3.00X15 I|Medicare|MEDICARE ACUTE|53.26||||7,395.50||| C1876|EAP|0278|STENT INTEGRITY 3.00X12W|Medicare|MEDICARE ACUTE|53.26||||53.26||| C1876|EAP|0278|STENT INTEGRITY 2.75X18 I|Medicare|MEDICARE ACUTE|33,596.50||||53.26||| C1876|EAP|0278|STENT INTEGRITY 3.50X09 I|Medicare|MEDICARE ACUTE|53.26||||53.26||| C1876|EAP|0278|STENT INTEGRITY 2.25X26 I|Medicare|MEDICARE PART B ONLY IP|53.26||||||| C1876|EAP|0278|STENT COMP SE SC620L|Medicare|MEDICARE ACUTE|6,332.75||||7,144.75||| C1876|EAP|0278|STENT COBALT ASSURANT 8X2|Managed Medicaid|MEDICAID AMERIGROUP|8,679.75||||7,013.75||| C1876|EAP|0278|STENT COMP BIL6X 40X130 S|Medicare|MEDICARE ACUTE|17,359.75||||7,144.75||| C1876|EAP|0278|WALL STENT|Medicare|MEDICARE ACUTE|7,395.50||||7,395.50||| C1876|EAP|0278|STENT INTEGRITY 3.50X12W|Medicare|MEDICARE ACUTE|53.26||||53.26||| C1876|EAP|0278|STENT COMP BIL6X 150X130|Medicare|MEDICARE ACUTE|8,679.75||||10,716.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Medicare|MEDICARE PART B ONLY IP|8,679.75||||||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Medicare|MEDICARE ACUTE|19,778.50||||17,359.75||| C1876|EAP|0278|IMPLT STNT NO-COA/NO-COV|Medicare|MEDICARE ACUTE|19,778.50||||8,679.75||| C1876|EAP|0278|STENT BILIARY PROTEGE|Managed Medicare|OTHER INSTITUTIONS|||||9,368.50||| C1876|EAP|0278|COMPLETE STENT 6X60X130 S|Medicare|MEDICARE ACUTE|34,912.50||||7,144.75||| C1876|EAP|0278|COMPLETE SE STENT 7X150X1|Medicare|MEDICARE ACUTE|7.90||||10,716.75||| C1876|EAP|0278|WALLSTENT ENTERAL UNISTEP|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||9,652.75||| C1876|EAP|0278|AMSTERDAM STENT|Medicare|MEDICARE ACUTE|756.25||||756.25||| C1876|EAP|0278|STENT INTEGRITY 4.00X30 I|Medicare|MEDICARE ACUTE|53.26||||53.26||| C1876|EAP|0278|STENT NEUROFORM|Medicare|MEDICARE ACUTE|202.55||||7,395.50||| C1876|EAP|0278|STENT COMPLETE SE 7X60X13|Medicare|MEDICARE ACUTE|9,368.50||||7,144.75||| C1877|EAP|0278|IMPLT STNT NO-COAT/COV W/|Medicare|MEDICARE ACUTE|||||5,786.50||| C1877|EAP|0278|IMPLT STNT NO-COAT/COV W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,786.50||||||| C1877|EAP|0278|IMPLT STNT NO-COAT/COV W/|Humana Medicare Advantage|HUMANA MA|5,786.50||||5,786.50||| C1877|EAP|0278|IMPLT STNT NO-COAT/COV W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5,786.50||| C1880|EAP|0278|FILTER VENA CAVA TRAPEASE|Blue Cross PPO Specialty|BCBSTX PPO|6,049.50||||||| C1880|EAP|0278|FILTER IVC BARD|Aenta Medicare Advantage|AETNA MEDICARE MA|7,137.50||||||| C1880|EAP|0278|IMPLANT VENA CAVA FILTER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,786.50||||||| C1880|EAP|0278|FILTER IVC BARD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7,137.50||||||| C1880|EAP|0278|FILTER IVC BARD|Humana Medicare Advantage|HUMANA MA|7,137.50||||||| C1880|EAP|0278|IMPLANT VENA CAVA FILTER|Access Direct Platinum|HEALTHFIRST TPA|5,786.50||||||| C1880|EAP|0278|IMPLANT VENA CAVA FILTER|United Medicare Advantage|UHC AARP MCR HMO MA|5,786.50||||||| C1880|EAP|0278|FILTER IVC BARD|United Healthcare|UNITED HEALTHCARE OTHER|7,137.50||||||| C1880|EAP|0278|IMPLANT VENA CAVA FILTER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5,786.50||||||| C1880|EAP|0278|VENA CAVA FILTER KIT/TRAP|Managed Medicare|HEALTHSPRING MA|||||76.11||| C1880|EAP|0278|IMPLANT VENA CAVA FILTER|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||5,786.50||| C1880|EAP|0278|FILTER VENA CAVA TRAPEASE|Managed Medicare|HEALTHSPRING MA|||||6,049.50||| C1880|EAP|0278|IMPLANT VENA CAVA FILTER|Medicaid|MEDICAID|5,786.50||||||| C1880|EAP|0278|IMPLANT VENA CAVA FILTER|Medicare|MEDICARE PART B ONLY IP|5,786.50||||||| C1880|EAP|0278|IMPLANT VENA CAVA FILTER|Medicare|MEDICARE ACUTE|5,786.50||||5,786.50||| C1880|EAP|0278||Medicare|MEDICARE ACUTE|5,786.50||||5,862.75||| C1882|EAP|0278|UNIFY ASSURA NXT GEN CRT-|Medicare|MEDICARE ACUTE|568.75||||51,473.75||| C1882|EAP|0278|UNIFY ASSURA NXT GEN CRT-|Medicare|MEDICARE ACUTE|568.75||||50,303.75||| C1882|EAP|0278|QUADRA ASSURA (3369-40Q)|Medicare|MEDICARE ACUTE|568.75||||568.75||| C1882|EAP|0278|AMPLIA MRI QUAD CRTD DEVI|Medicare|MEDICARE ACUTE|162.24||||603.58||| C1882|EAP|0278|UNIFY ASSURA NXT GEN CRT-|Medicare|MEDICARE ACUTE|568.75||||54,983.50||| C1882|EAP|0278|AMPLIA MRI QUAD CRTD DEVI|Medicaid|MEDICAID|603.58||||||| C1882|EAP|0278|AMPLIA MRI CRTD DEVICE DT|Medicare|MEDICARE ACUTE|603.58||||603.58||| C1882|EAP|0275|ANPLIA MRI QUAD SYSTEM|Managed Medicare|BCBS MEDICARE PPO MA|||||108,344.50||| C1882|EAP|0275|ANPLIA MRI QUAD SYSTEM|Managed Medicare|HEALTHSPRING MA|||||108,344.50||| C1882|EAP|0278|AMPLIA MRI QUAD CRTD DEVI|Managed Medicare|HEALTHSPRING MA|||||603.58||| C1882|EAP|0278|QUADRA ASSURA (3369-40Q)|Managed Medicare|HEALTHSPRING MA|||||568.75||| C1882|EAP|0278|AMPLIA MRI CRTD DEVICE DT|Managed Medicare|HEALTHSPRING MA|||||603.58||| C1882|EAP|0278|AMPLIA MRI QUAD CRTD DEVI|United Healthcare|UNITED HEALTHCARE|||||603.58||| C1882|EAP|0278|UNIFY ASSURA NXT GEN CRT-|United Medicare Advantage|UHC MEDICARE GOLD MA|603.58||||50,303.75||| C1882|EAP|0278|MOMENTUM CRT-D (G125)|Managed Medicare|BCBS MEDICARE PPO MA|568.75||||673.75||| C1882|EAP|0278|QUADRA ASSURA NXT GEN CRT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|603.58||||60,832.75||| C1882|EAP|0278|DYNAGEN X4 CRTD|United Medicare Advantage|UHC AARP MCR HMO MA|162.24||||665.00||| C1882|EAP|0278|QUADRA ASSURA NXT GEN CRT|Medicare|MEDICARE ACUTE|568.75||||60,832.75||| C1882|EAP|0278|AMPLIA MRI QUAD CRTD DEVI|United Medicare Advantage|UHC AARP MCR HMO MA|162.24||||603.58||| C1882|EAP|0278|AMPLIA MRI CRTD DEVICE DT|Veterans Affairs|VETERANS ADMINISTRATION|603.58||||603.58||| C1882|EAP|0278|MOMENTUM CRT-D (G125)|Medicare|MEDICARE ACUTE|568.75||||673.75||| C1882|EAP|0275|ANPLIA MRI QUAD SYSTEM|Humana Medicare Advantage|HUMANA MA|108,344.50||||108,344.50||| C1882|EAP|0278|MOMENTUM CRT-D (G125)|Humana Medicare Advantage|HUMANA MA|568.75||||673.75||| C1882|EAP|0278|DYNAGEN X4 CRTD|Humana Medicare Advantage|HUMANA MA|603.58||||665.00||| C1882|EAP|0278|AMPLIA MRI CRTD DEVICE DT|Humana Medicare Advantage|HUMANA MA|603.58||||603.58||| C1882|EAP|0275|ANPLIA MRI QUAD SYSTEM|Medicare|MEDICARE ACUTE|||||108,344.50||| C1882|EAP|0278|INOGEN G141|Humana Medicare Advantage|HUMANA MA|87,202.50||||709.62||| C1882|EAP|0278|UNIFY ASSURA NXT GEN CRT-|Humana Medicare Advantage|HUMANA MA|568.75||||51,473.75||| C1882|EAP|0278|QUADRA ASSURA (3369-40Q)|Humana Medicare Advantage|HUMANA MA|568.75||||568.75||| C1882|EAP|0278|AMPLIA MRI QUAD CRTD DEVI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|603.58||||||| C1882|EAP|0278|QUADRA ASSURA NXT GEN CRT|Veterans Affairs|VETERANS ADMINISTRATION|700.00||||60,832.75||| C1882|EAP|0278|UNIFY ASSURA NXT GEN CRT-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|51,473.75||||||| C1882|EAP|0278|AMPLIA MRI QUAD CRTD DEVI|Veterans Affairs|VETERANS ADMINISTRATION|700.00||||603.58||| C1882|EAP|0278|AMPLIA MRI CRTD DEVICE DT|Blue Cross PPO Specialty|BCBSTX PPO|603.58||||||| C1883|EAP|0278|IMPLANT LEAD G1|Blue Cross HMO Specialty|BCBSTX HMO|||||5,786.50||| C1883|EAP|0278|IMPLANT LEAD G1|Blue Cross PPO Specialty|BCBSTX PPO|||||5,786.50||| C1883|EAP|0278|IMPLANT LEAD G2|Aetna|AETNA PPO|||||162.24||| C1883|EAP|0278|IMPLANT LEAD G2|Aenta Medicare Advantage|AETNA MEDICARE MA|||||162.24||| C1883|EAP|0278|IMPLANT LEAD G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,786.50||| C1883|EAP|0278|IMPLANT LEAD G2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||162.24||| C1883|EAP|0278|IMPLANT LEAD G2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||162.24||| C1883|EAP|0278|IMPLANT LEAD G2|Humana Medicare Advantage|HUMANA MA|5,786.50||||162.24||| C1883|EAP|0278|IMPLANT LEAD G1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5,786.50||| C1883|EAP|0278|IMPLANT LEAD G1|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5,786.50||| C1883|EAP|0278|IMPLANT LEAD G1|Aetna|AETNA QHP HMO|||||5,786.50||| C1883|EAP|0278|IMPLANT LEAD G2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||162.24||| C1883|EAP|0278|IMPLANT LEAD G2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||162.24||| C1883|EAP|0278|IMPLANT LEAD G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5,786.50||| C1883|EAP|0278|IMPLANT LEAD G1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5,786.50||| C1883|EAP|0278|IMPLANT LEAD G2|United Medicare Advantage|UHC AARP MCR HMO MA|5,786.50||||162.24||| C1883|EAP|0278|IMPLANT LEAD G2|Blue Cross PPO Specialty|BCBSTX PPO|||||162.24||| C1883|EAP|0278|IMPLANT LEAD G2|Managed Medicare|HEALTHSPRING MA|||||162.24||| C1883|EAP|0278|IMPLANT LEAD G2|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||162.24||| C1883|EAP|0278|IMPLANT LEAD G1|Medicare|MEDICARE ACUTE|5,786.50||||5,786.50||| C1883|EAP|0278|IMPLANT LEAD G2|Medicare|MEDICARE ACUTE|5,786.50||||162.24||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11,691.25||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Veterans Affairs|VETERANS ADMINISTRATION|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|United Medicare Advantage|UHC AARP MCR HMO MA|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Medicaid|MEDICAID|362.50||||||| C1884|EAP|0278|PROTECTION SYSTEM EMBOLIC|Medicaid|MEDICAID|84.15||||||| C1884|EAP|0278|PROTECTION SYSTEM EMBOLIC|Medicare|MEDICARE ACUTE|84.15||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|PHCS|GROUP AND PENSION|362.50||||||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|NON CONTRACTED|COMMERCIAL OTHER 1|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|UTMB|UTMB CORRECTIONAL MANAGED CARE|362.50||||||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|United Healthcare|UNITED HEALTHCARE|362.50||||362.50||| C1884|EAP|0278|PROTECTION SYSTEM EMBOLIC|United Healthcare|UNITED HEALTHCARE OTHER|362.50||||84.15||| C1884|EAP|0272|CATH SPIDERFX 6.0 SPSD-US|Medicare|MEDICARE ACUTE|||||8,866.25||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Medicare|MEDICARE PART B ONLY IP|362.50||||||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Medicare|MEDICARE ACUTE|448.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Medicare|MEDICARE ACUTE|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Medicaid|SMITH COUNTY JAIL|362.50||||||| C1884|EAP|0278|COIL TARGET 360 ULTRA|Medicaid|MEDICAID|11,691.25||||||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||362.50||| C1884|EAP|0272|CATH SPIDERFX7.0SPSD-US-7|Managed Medicare|HEALTHSPRING MA|8,866.25||||||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Managed Medicare|HEALTHSPRING MA|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|448.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Managed Medicare|BCBS MEDICARE PPO MA|||||362.50||| C1884|EAP|0272|CATH SPIDERFX 6.0 SPSD-US|United Medicare Advantage|UHC AARP MCR HMO MA|||||8,866.25||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|362.50||||362.50||| C1884|EAP|0278|PROTECTION SYSTEM EMBOLIC|United Medicare Advantage|UHC AARP MCR HMO MA|84.15||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|United Medicare Advantage|UHC MEDICARE GOLD MA|362.50||||||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|United Medicare Advantage|UHC AARP MCR HMO MA|11,691.25||||362.50||| C1884|EAP|0278|COIL TARGET 360 ULTRA|Workers Compensation|WORKERS COMPENSATION OTHER|11,691.25||||||| C1884|EAP|0278|PROTECTION SYSTEM EMBOLIC|Veterans Affairs|VETERANS ADMINISTRATION|84.15||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Veterans Affairs|VETERANS ADMINISTRATION|11,691.25||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||362.50||| C1884|EAP|0278|COILS-NESTER|Medicare|MEDICARE ACUTE|11,691.25||||448.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Access Direct Platinum|HEALTHFIRST TPA|||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Cigna|CIGNA|362.50||||362.50||| C1884|EAP|0272|CATH SPIDERFX7.0 SPD2-US-|Humana Medicare Advantage|HUMANA MA|8,866.25||||||| C1884|EAP|0278|PROTECTION SYSTEM EMBOLIC|Humana Medicare Advantage|HUMANA MA|84.15||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Humana Medicare Advantage|HUMANA MA|11,691.25||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Humana Medicare Advantage|HUMANA MA|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Managed Medicaid|MEDICAID SUPERIOR|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|362.50||||||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Managed Medicaid|MEDICAID AMERIGROUP|||||362.50||| C1884|EAP|0272|CATH SPIDERFX7.0SPSD-US-7|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8,866.25||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|362.50||||362.50||| C1884|EAP|0272|CATH SPIDERFX 6.0 SPSD-US|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8,866.25||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Blue Cross HMO Specialty|BCBSTX HMO|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Blue Cross HMO Specialty|BCBSTX HMO|11,691.25||||362.50||| C1884|EAP|0278|PROTECTION SYSTEM EMBOLIC|Blue Cross PPO Specialty|BCBSTX PPO|84.15||||84.15||| C1884|EAP|0278|PROTECTION SYSTEM EMBOLIC|Blue Cross PPO Specialty|BCBSTX PPO|448.50||||84.15||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Aenta Medicare Advantage|AETNA MEDICARE MA|362.50||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Blue Cross PPO Specialty|BCBSTX PPO|11,691.25||||362.50||| C1884|EAP|0278|EMBOLIZATION PROTECT SYST|Blue Cross PPO Specialty|BCBSTX PPO|362.50||||84.15||| C1886|EAP|0272|CATH ABL 4MM 7FR 5031TH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5,406.25||| C1886|EAP|0272|CATH ABL 4MM 7FR 5031TH|Blue Cross PPO Specialty|BCBSTX PPO|||||5,406.25||| C1886|EAP|0272|CATHETER ABLATION HALO 90|Humana Medicare Advantage|HUMANA MA|||||4,413.50||| C1886|EAP|0272|CATH ABL 4MM 7FR 5031TH|Medicare|MEDICARE ACUTE|||||5,406.25||| C1887|EAP|0272|GUIDECATH 5F 100C STR 5/B|Medicare|MEDICARE ACUTE|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 7F RCB LA6RCB|Medicare|MEDICARE ACUTE|389.75||||144.25||| C1887|EAP|0272|CATHETER REPERFUSION PENU|Medicaid|MEDICAID|6,807.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35 LA6JR3|Managed Medicare|BCBS MEDICARE PPO MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6FR LA6LAR12|PHCS|HUMANA|381.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|UTMB|UTMB CORRECTIONAL MANAGED CARE|389.75||||||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|United Healthcare|UNITED HEALTHCARE|||||389.75||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|United Healthcare|UNITED HEALTHCARE OTHER|14,953.25||||5,791.50||| C1887|EAP|0272|PERIPH GUIDE 6F IMA 55 LA|United Healthcare|UNITED HEALTHCARE|||||389.75||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|United Healthcare|UNITED HEALTHCARE|10,673.25||||5,791.50||| C1887|EAP|0272|CATH GUIDE 4F 65CM STRA C|United Healthcare|UNITED HEALTHCARE OTHER|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 6F LA6EBU35SH|United Healthcare|UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|United Healthcare|UNITED HEALTHCARE|||||389.75||| C1887|EAP|0272|GUIDECATH 5F 100C STR 5/B|United Healthcare|UNITED HEALTHCARE OTHER|389.75||||480.75||| C1887|EAP|0272|CATHETER, GUIDING G1|United Healthcare|TML GROUP BENEFITS|389.75||||362.50||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|United Healthcare|UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|United Healthcare|UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|United Healthcare|UNITED HEALTHCARE OTHER|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|United Healthcare|GOLDEN RULE|389.75||||||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|United Healthcare|UNITED HEALTHCARE OTHER|389.75||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|United Healthcare|UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|United Healthcare|UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|UTMB|UTMB CORRECTIONAL MANAGED CARE|389.75||||||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|NON CONTRACTED|COMMERCIAL OTHER 1|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|NON CONTRACTED|COMMERCIAL OTHER 1|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|NON CONTRACTED|COMMERCIAL OTHER 1|14,953.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|NON CONTRACTED|COMMERCIAL OTHER 1|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LA6EBU375SH|PHCS|HUMANA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|PHCS|HUMANA|389.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Tricare|TRICARE EAST REGION|||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Tricare|TRICARE EAST REGION|||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Tricare|TRICARE FOR LIFE|389.75||||||| C1887|EAP|0272|GUIDE CATH 6F AL1 LA6AL10|Tricare|TRICARE EAST REGION|||||389.75||| C1887|EAP|0270|CATH LYSUS INFUSION SYSTE|Managed Medicare|HEALTHSPRING MA|13,858.50||||||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Managed Medicare|BCBS MEDICARE PPO MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F IM LA6IMA|Managed Medicare|BCBS MEDICARE PPO MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LA6EBU375SH|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AR1 LA6AR10|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|14,953.25||||5,791.50||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|Managed Medicare|HEALTHSPRING MA|778.94||||5,791.50||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|Managed Medicare|BCBS MEDICARE PPO MA|5,791.50||||5,791.50||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|CATH ANGLED 100CM 5/BX CG|Managed Medicare|HEALTHSPRING MA|2,565.75||||480.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Managed Medicare|BCBS MEDICARE PPO MA|14,953.25||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F AL1 LA6AL10|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Managed Medicare|HEALTHSPRING MA|389.75||||2,565.75||| C1887|EAP|0272|CATH ANGIOGR 5FR 451-546S|Managed Medicare|HEALTHSPRING MA|14,953.25||||106.50||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|389.75||||389.75||| C1887|EAP|0272|PERIPH GUIDE 6F IMA 55 LA|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Managed Medicare|BCBS MEDICARE PPO MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35 LA6JR3|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LA6EBU35SH|Managed Medicare|HEALTHSPRING MA|381.75||||389.75||| C1887|EAP|0272|PERIPH GUIDE 7F SCR LA7SC|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL2 LA6AL20|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|PERIPH GUIDE 6F RDC 55 LA|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|CATH GUIDE 4F 100 STRA CG|Managed Medicare|HEALTHSPRING MA|6,807.25||||480.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Medicaid|MEDICAID|389.75||||389.75||| C1887|EAP|0272|PERIPH GUIDE 6F RDC 55 LA|Medicaid|MEDICAID|14,953.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Medicaid|MEDICAID|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Medicaid|MEDICAID|778.94||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Medicaid|MEDICAID|389.75||||389.75||| C1887|EAP|0270|CATH LYSUS INFUSION SYSTE|Medicaid|SMITH COUNTY INDIGENT HEALTH|13,858.50||||||| C1887|EAP|0270|CATH LYSUS INFUSION SYSTE|Medicare|MEDICARE ACUTE|13,858.50||||||| C1887|EAP|0272|GUIDE CATH 6FJL5 LA6JL50|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|6FR. TD SWAN|Medicare|MEDICARE ACUTE|10,673.25||||778.94||| C1887|EAP|0272|GUIDE CATH EBU35 LA7EBU35|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6FR LA6JL60|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F MP1SH LA6MB|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6FR JL3.0 LA6J|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35SH LA6J|Medicare|MEDICARE PART B ONLY IP|389.75||||||| C1887|EAP|0272|GUIDE CATH 6F HS1 LA6HS1|Medicare|MEDICARE ACUTE|389.75||||3.90||| C1887|EAP|0272|GUIDE CATH 6F AL1SH LA6AL|Medicare|MEDICARE ACUTE|2,565.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F EBU 3.75 LA|Medicare|MEDICARE ACUTE|389.75||||144.25||| C1887|EAP|0272|GUIDE CATH EBU35 LA7EBU35|Medicare|MEDICARE ACUTE|389.75||||144.25||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Medicare|MEDICARE PART B ONLY IP|389.75||||||| C1887|EAP|0272|GUIDECATH 65CM CG505|Medicare|MEDICARE ACUTE|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 7F RCB LA6RCB|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LCB LA6LCB|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL45 LA6JL4|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35SH LA6J|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|CATH GUIDE 4F 65CM STRA C|Medicare|MEDICARE ACUTE|5,791.50||||480.75||| C1887|EAP|0272|GUIDE CATH 6F AL2 LA6AL20|Medicare|MEDICARE ACUTE|6,807.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL75SH LA6A|Medicare|MEDICARE ACUTE|362.50||||389.75||| C1887|EAP|0272|CATH ANGLED 100CM 5/BX CG|Medicare|MEDICARE ACUTE|56.17||||480.75||| C1887|EAP|0272|CATHETER, GUIDING G1|Medicare|MEDICARE ACUTE|9.30||||362.50||| C1887|EAP|0272|GUIDE CATH 6F RBU3.5 LA6R|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Access Direct Platinum|HEALTHFIRST TPA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|Access Direct Platinum|HEALTHFIRST TPA UMR|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|389.75||||||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6,169.75||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F LCB LA6LCB|Veterans Affairs|VETERANS ADMINISTRATION|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Veterans Affairs|VETERANS ADMINISTRATION|6,807.25||||389.75||| C1887|EAP|0272|CATHETER, GUIDING G1|Veterans Affairs|VETERANS ADMINISTRATION|2,565.75||||362.50||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|Veterans Affairs|VETERANS ADMINISTRATION|5,791.50||||5,791.50||| C1887|EAP|0272|GUIDE CATH 6FR JL3.0 LA6J|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F RCB LA6RCB|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F RBU40 LA6RB|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|United Medicare Advantage|UHC MEDICARE GOLD MA|6,807.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|United Medicare Advantage|UHC MEDICARE GOLD MA|2,565.75||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||389.75||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|United Medicare Advantage|UHC MEDICARE GOLD MA|5,791.50||||5,791.50||| C1887|EAP|0272|GUIDECATH 5F 100C STR 5/B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 6F LA6RBU35SH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||389.75||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|United Medicare Advantage|UHC AARP MCR HMO MA|14,953.25||||5,791.50||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35SH LA6J|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL1 LA6AL10|United Medicare Advantage|UHC AARP MCR HMO MA|6,807.25||||389.75||| C1887|EAP|0272|GUIDECATH 65CM CG505|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 8FR JR4|United Medicare Advantage|UHC MEDICARE GOLD MA|353.50||||480.75||| C1887|EAP|0272|GUIDE CATH 6F LA6EBU35SH|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||389.75||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,791.50||||5,791.50||| C1887|EAP|0272|GUIDE CATH 7F EBU 3.75 LA|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL2 LA6AL20|United Medicare Advantage|UHC AARP MCR HMO MA|362.50||||389.75||| C1887|EAP|0272|GUIDE CATH 6FR LA6LAR12|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||381.75||| C1887|EAP|0272|GUIDE CATH 6F MP1SH LA6MB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LA6RBU35SH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Managed Medicaid|MEDICAID AMERIGROUP|6,807.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35SH LA6J|Managed Medicaid|MEDICAID SUPERIOR|||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|United Medicare Advantage|UHC AARP MCR HMO MA|2,565.75||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Managed Medicaid|MEDICAID SUPERIOR|||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AR1 LA6AR10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL75SH LA6A|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL1 LA6AL10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL1SH LA6AL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|389.75||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6FR JL3.0 LA6J|Cigna|CIGNA OTHER|||||389.75||| C1887|EAP|0272|PERIPH GUIDE 6F IMA 55 LA|Cigna|CIGNA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|Cigna|CIGNA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Cigna|CIGNA|||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Cigna|CIGNA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35SH LA6J|Cigna|CIGNA OTHER|||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR5 LA6JR50|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Humana Medicare Advantage|HUMANA MA|2,565.75||||2,565.75||| C1887|EAP|0272|GUIDE CATH 7F JL4 LA7JL40|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LCB LA6LCB|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F RCB LA6RCB|Humana Medicare Advantage|HUMANA MA|381.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F MB1 LA7MB1|Humana Medicare Advantage|HUMANA MA|381.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F EBU 3.75 LA|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35SH LA6J|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AR10SH LA6A|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35 LA6JR3|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AR1 LA6AR10|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F IM LA6IMA|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL1SH LA6AL|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|CATHETER, GUIDING G1|Humana Medicare Advantage|HUMANA MA|6,807.25||||362.50||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|Humana Medicare Advantage|HUMANA MA|14,953.25||||5,791.50||| C1887|EAP|0272|GUIDE CATH 7F RCB LA6RCB|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|PERIPH GUIDE 6F IMA 55 LA|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL1 LA6AL10|Humana Medicare Advantage|HUMANA MA|362.50||||389.75||| C1887|EAP|0272|GUIDE CATH EBU35 LA7EBU35|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Humana Medicare Advantage|HUMANA MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|Cigna|CIGNA|389.75||||389.75||| C1887|EAP|0272|6FR. TD SWAN|Humana Medicare Advantage|HUMANA MA|5,791.50||||778.94||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Aenta Medicare Advantage|AETNA MEDICARE MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Cigna|CIGNA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F MP1SH LA6MB|Aenta Medicare Advantage|AETNA MEDICARE MA|389.75||||389.75||| C1887|EAP|0272|PERIPH GUIDE 7F SCR LA7SC|Cigna|CIGNA|389.75||||389.75||| C1887|EAP|0272|GUIDECATH 65CM CG505|Aenta Medicare Advantage|AETNA MEDICARE MA|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Aenta Medicare Advantage|AETNA MEDICARE MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Cigna|CIGNA|14,953.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|Aenta Medicare Advantage|AETNA MEDICARE MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Aenta Medicare Advantage|AETNA MEDICARE MA|389.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Aenta Medicare Advantage|AETNA MEDICARE MA|362.50||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F AL1SH LA6AL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|CATH ANGLED 100CM 5/BX CG|Aenta Medicare Advantage|AETNA MEDICARE MA|14,953.25||||480.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Aetna|AETNA OTHER|389.75||||||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Aetna|AETNA PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Aetna|AETNA PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Managed Medicaid|MEDICAID AMERIGROUP|14,953.25||||389.75||| C1887|EAP|0272|CATH PHENOM 27|Aetna|AETNA QHP HMO|69.55||||||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Aetna|AETNA PPO|389.75||||389.75||| C1887|EAP|0272|APOLLO MICRO CATHETER 509|Aetna|AETNA OTHER|10,673.25||||||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Aetna|AETNA OTHER|389.75||||||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,791.50||||5,791.50||| C1887|EAP|0272|GUIDE CATH 6F IM LA6IMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|CATH GUIDE 4F 65CM STRA C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14,953.25||||480.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,807.25||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Managed Medicaid|MEDICAID UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|CATHETER, GUIDING G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|389.75||||362.50||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14,953.25||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F IM LA6IMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LCB LA6LCB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|480.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6FR JL3.0 LA6J|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|PERIPH GUIDE 6F RDC 55 LA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|480.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6FR JL3.0 LA6J|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|480.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6FR LA6LAR12|Medicare|MEDICARE ACUTE|389.75||||381.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14,953.25||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F RCB LA6RCB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LCB LA6LCB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2,565.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35 LA6JR3|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F JL4 LA7JL40|Blue Cross HMO Specialty|BCBSTX HMO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6FJL5 LA6JL50|Blue Cross HMO Specialty|BCBSTX HMO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL1SH LA6AL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Blue Cross HMO Specialty|BCBSTX HMO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Blue Cross HMO Specialty|BCBSTX HMO|6,807.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F RBU3.5 LA6R|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|Medicaid|COUNTY INDIGENT HEALTH OTHER|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|Blue Cross HMO Specialty|BCBSTX HMO|2,565.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Blue Cross HMO Specialty|BCBSTX HMO|14,953.25||||2,565.75||| C1887|EAP|0272|GUIDE CATH EBU35 LA7EBU35|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F EBU3.5 SH L|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F EBU 3.75 LA|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6FR JL3.0 LA6J|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LCB LA6LCB|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LCB LA6LCB|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL1 LA6AL10|Managed Medicare|BCBS MEDICARE PPO MA|6,807.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F RBU40 LA6RB|Managed Medicare|HEALTHSPRING MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Blue Cross PPO Specialty|BCBSTX OTHER|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|CATHETER, GUIDING G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,807.25||||362.50||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Blue Cross PPO Specialty|BCBSTX OTHER|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35SH LA6J|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|Blue Cross PPO Specialty|BCBSTX OTHER|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AR10SH LA6A|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35SH LA6J|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|381.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|Blue Cross PPO Specialty|BCBSTX PPO|362.50||||389.75||| C1887|EAP|0272|PERIPH GUIDE 6F MPH 55 LA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Blue Cross PPO Specialty|BCBSTX OTHER|389.75||||389.75||| C1887|EAP|0272|CATH ANGLED 100CM 5/BX CG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 6F AL1SH LA6AL|Blue Cross PPO Specialty|BCBSTX PPO|2,565.75||||389.75||| C1887|EAP|0272|GUIDECATH 5F 100C STR 5/B|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 6F AL1 LA6AL10|Blue Cross PPO Specialty|BCBSTX PPO|6,169.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F EBU 3.75 LA|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Blue Cross PPO Specialty|BCBSTX PPO|14,953.25||||2,565.75||| C1887|EAP|0272|6FR. TD SWAN|Blue Cross PPO Specialty|BCBSTX PPO|5,791.50||||778.94||| C1887|EAP|0272|CATH DISTAL DELIVERY 5 MA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|389.75||||14,953.25||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Blue Cross PPO Specialty|BCBSTX PPO|6,807.25||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LA6RBU35SH|United Medicare Advantage|UHC MEDICARE GOLD MA|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Veterans Affairs|VETERANS ADMINISTRATION|14,953.25||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|Blue Cross PPO Specialty|BCBSTX PPO|389.75||||389.75||| C1887|EAP|0272|6FR. TD SWAN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|480.75||||778.94||| C1887|EAP|0272|GUIDECATH 65CM CG505|United Medicare Advantage|UHC AARP MCR HMO MA|389.75||||480.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Veterans Affairs|VETERANS ADMINISTRATION|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Veterans Affairs|VETERANS ADMINISTRATION|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|69.55||||389.75||| C1887|EAP|0272|GUIDE CATH 6FR JL3.0 LA6J|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|NON CONTRACTED|COMMERCIAL OTHER 1|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Access Direct Platinum|HEALTHFIRST TPA UMR|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU35 LA6EB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|10,673.25||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|United Healthcare|UNITED HEALTHCARE|||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Access Direct Platinum|HEALTHFIRST TPA UMR|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LCB LA6LCB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F RBU40 LA6RB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL75SH LA6A|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|389.75||||389.75||| C1887|EAP|0272|PERIPH GUIDE 6F IMA 55 LA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F IM LA6IMA|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F EBU40 LA6EB|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F FR35 LA6JR3|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|United Healthcare|UNITED HEALTHCARE OTHER|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F LA6EBU35SH|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JR40 LA6JR4|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AR1 LA6AR10|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL4 LA6JL40|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|BI-V DELIVERY SYSTEM|Medicare|MEDICARE ACUTE|79.45||||5,791.50||| C1887|EAP|0272|CATH ANGLED 100CM 5/BX CG|United Healthcare|UNITED HEALTHCARE OTHER|6,807.25||||480.75||| C1887|EAP|0272|CATH GUIDE 7FR RBU40 LA7R|Medicare|MEDICARE ACUTE|480.75||||389.75||| C1887|EAP|0272|CATHETER GUIDE LINER 6FR|Medicare|MEDICARE ACUTE|14,953.25||||2,565.75||| C1887|EAP|0272|GUIDE CATH 6F AL1 LA6AL10|Medicare|MEDICARE ACUTE|69.55||||389.75||| C1887|EAP|0272|I.V. ANGIOCATH G3|Medicare|MEDICARE ACUTE|381.75||||144.25||| C1887|EAP|0272|GUIDE CATH 6F FR4SH LA6JR|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F JL35 LA 6JL|Medicare|MEDICARE PART B ONLY IP|389.75||||||| C1887|EAP|0272|GUIDE CATH 6F LCBSH LA6LC|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F RBU40 LA6RB|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 7F EBU 3.75 LA|Medicare|MEDICARE ACUTE|389.75||||389.75||| C1887|EAP|0272|GUIDE CATH 6F AL1 LA6AL10|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2,565.75||||389.75||| C1889|EAP|0278|IMPLANT/INSERT DEVICE, NO|Managed Medicare|BCBS MEDICARE PPO MA|||||208.46||| C1889|EAP|0278|IMPLANT/INSERT DEVICE, NO|Medicare|MEDICARE ACUTE|||||8,685.83||| C1891|EAP|0278|IMPL PUMP SYNCHROMED 8637|Workers Compensation|WORKERS COMPENSATION OTHER|||||38,794.75||| C1892|EAP|0278|INTRO/SHEATH,FIXED,PEEL-A|Medicare|MEDICARE ACUTE|||||55.64||| C1892|EAP|0278|INTRO/SHEATH,FIXED,PEEL-A|United Medicare Advantage|UHC AARP MCR HMO MA|55.64||||||| C1892|EAP|0278|INTRO/SHEATH,FIXED,PEEL-A|Humana Medicare Advantage|HUMANA MA|||||55.64||| C1892|EAP|0278|INTRO/SHEATH,FIXED,PEEL-A|Blue Cross PPO Specialty|BCBSTX PPO|||||55.64||| C1892|EAP|0278|INTRO/SHEATH,FIXED,PEEL-A|United Healthcare|UNITED HEALTHCARE|||||55.64||| C1893|EAP|0278|PREFACE 301805M|United Medicare Advantage|UHC AARP MCR HMO MA|||||9.57||| C1893|EAP|0278|PREFACE 301805M|Humana Medicare Advantage|HUMANA MA|9.57||||9.57||| C1893|EAP|0278|PREFACE 301805M|Managed Medicare|HEALTHSPRING MA|||||9.57||| C1893|EAP|0278|PREFACE 301805M|United Healthcare|UNITED HEALTHCARE OTHER|||||9.57||| C1893|EAP|0278|PREFACE 301805M|Medicare|MEDICARE ACUTE|9.57||||9.57||| C1893|EAP|0278|PREFACE 301805M|Managed Medicare|BCBS MEDICARE PPO MA|9.57||||||| C1893|EAP|0278|PREFACE 301805M|Blue Cross PPO Specialty|BCBSTX PPO|9.57||||9.57||| C1893|EAP|0278|PREFACE 301805M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.57||| C1893|EAP|0278|PREFACE 301805M|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.57||| C1893|EAP|0278|PREFACE 301805M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.57||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|641.84||||2.59||| C1894|EAP|0278|SHEATH URETHRAL 12X35 G19|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|641.84||||2.59||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,151.15||||1,011.75||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|737.23||||2.59||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|807.85||||2.59||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|556.50||||556.50||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Managed Medicaid|MEDICAID SUPERIOR|||||641.84||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.99||||641.84||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Managed Medicaid|MEDICAID AMERIGROUP|737.23||||641.84||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.59||||807.85||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.59||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,151.15||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Managed Medicaid|MEDICAID AMERIGROUP|737.23||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,011.75||||641.84||| C1894|EAP|0278|SHEATH PINNACLE 5FR 10CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,332.60||||90.50||| C1894|EAP|0278|SHEATH FAST CATH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|737.23||||3.99||| C1894|EAP|0278|SHEATH FAST CATH|Managed Medicaid|MEDICAID AMERIGROUP|737.23||||3.99||| C1894|EAP|0278|SHEATH 6FR. 55CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.99||||417.45||| C1894|EAP|0278|SET MICRO PUNCTURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|201.75||||201.75||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|423.50||||556.50||| C1894|EAP|0278|CATH SPIDERFX 4.0 SPSD-US|Managed Medicaid|MEDICAID UNITED HEALTHCARE|556.50||||8,866.25||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Cigna|CIGNA|||||556.50||| C1894|EAP|0278|SHEATH PINNACLE 6FR 90CM|Humana Medicare Advantage|HUMANA MA|850.65||||850.65||| C1894|EAP|0278|SHEATH FAST CATH|Humana Medicare Advantage|HUMANA MA|3,151.15||||3.99||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Humana Medicare Advantage|HUMANA MA|423.50||||423.50||| C1894|EAP|0278|SHEATH DRY SEAL FLEX 16FR|Humana Medicare Advantage|HUMANA MA|2,332.60||||2,332.60||| C1894|EAP|0278|SHEATH VASCULAR 90CM|Humana Medicare Advantage|HUMANA MA|2.59||||2.59||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Humana Medicare Advantage|HUMANA MA|737.23||||737.23||| C1894|EAP|0278|SHEATH URETHRAL 12X55 FUS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|641.84||||641.84||| C1894|EAP|0278|SHEATH 6FR. 55CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|201.75||||417.45||| C1894|EAP|0278|SHEATH 6FR. 55CM|United Medicare Advantage|UHC AARP MCR HMO MA|423.50||||417.45||| C1894|EAP|0278|SHEATH PINNACLE 5FR 10CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|737.23||||90.50||| C1894|EAP|0278|SHEATH FAST CATH|United Medicare Advantage|UHC AARP MCR HMO MA|2,332.60||||3.99||| C1894|EAP|0278|SHEATH URETHRAL 14X35 G30|United Medicare Advantage|UHC MEDICARE GOLD MA|641.84||||641.84||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|United Medicare Advantage|UHC AARP MCR HMO MA|2,332.60||||1,011.75||| C1894|EAP|0278|SET MICRO PUNCTURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|423.50||||201.75||| C1894|EAP|0278|SHEATH FAST CATH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.99||||3.99||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|641.84||||1,011.75||| C1894|EAP|0278|SHEATH 6FR. 55CM|United Medicare Advantage|UHC MEDICARE GOLD MA|823.90||||417.45||| C1894|EAP|0278|SET MICRO PUNCTURE|Veterans Affairs|VETERANS ADMINISTRATION|90.50||||201.75||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Access Direct Platinum|HEALTHFIRST TPA UMR|556.50||||556.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||556.50||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||423.50||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|423.50||||641.84||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,011.75||| C1894|EAP|0278|SHEATH FAST CATH|Access Direct Platinum|HEALTHFIRST TPA UMR|1,182.25||||3.99||| C1894|EAP|0278|SHEATH FAST CATH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.99||||641.84||| C1894|EAP|0278|SHEATH FAST CATH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|556.50||||3.99||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||737.23||| C1894|EAP|0278|SHEATH FAST CATH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.99||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|737.23||||641.84||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||641.84||| C1894|EAP|0278|SHEATH FAST CATH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3.99||| C1894|EAP|0371||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||240.35||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Access Direct Platinum|HEALTHFIRST TPA|201.75||||641.84||| C1894|EAP|0278|SHEATH FAST CATH|Access Direct Platinum|HEALTHFIRST TPA|556.50||||3.99||| C1894|EAP|0278|SHEATH CROSSCUT 6FR 65 RS|Access Direct Platinum|HEALTHFIRST TPA UMR|1,182.25||||823.90||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Veterans Affairs|VETERANS ADMINISTRATION|3.99||||423.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Veterans Affairs|VETERANS ADMINISTRATION|3,151.15||||556.50||| C1894|EAP|0278|SHEATH FAST CATH|Veterans Affairs|VETERANS ADMINISTRATION|90.50||||3.99||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Veterans Affairs|VETERANS ADMINISTRATION|90.50||||1,011.75||| C1894|EAP|0278|CATH SPIDERFX3.0 SPSD-US-|Veterans Affairs|VETERANS ADMINISTRATION|556.50||||8,866.25||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Veterans Affairs|VETERANS ADMINISTRATION|90.50||||737.23||| C1894|EAP|0278|SHEATH VASCULAR 90CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|641.84||||2.59||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|641.84||||641.84||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|United Medicare Advantage|UHC MEDICARE GOLD MA|423.50||||423.50||| C1894|EAP|0278|SHEATH FAST CATH|United Medicare Advantage|UHC MEDICARE GOLD MA|3.99||||3.99||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|United Medicare Advantage|UHC AARP MCR HMO MA|3.99||||641.84||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|641.84||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|United Medicare Advantage|UHC MEDICARE GOLD MA|737.23||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6FR 90CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|641.84||||850.65||| C1894|EAP|0278|SHEATH VASCULAR 90CM|United Medicare Advantage|UHC MEDICARE GOLD MA|641.84||||2.59||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|641.84||||1,182.25||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|United Medicare Advantage|UHC MEDICARE GOLD MA|807.85||||641.84||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|United Medicare Advantage|UHC MEDICARE GOLD MA|90.50||||1,011.75||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|United Medicare Advantage|UHC AARP MCR HMO MA|3,151.15||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|United Medicare Advantage|UHC AARP MCR HMO MA|737.23||||641.84||| C1894|EAP|0278|SHEATH FAST CATH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,332.60||||3.99||| C1894|EAP|0278|SET MICRO PUNCTURE|United Medicare Advantage|UHC MEDICARE GOLD MA|201.75||||201.75||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|556.50||||556.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|United Medicare Advantage|UHC MEDICARE GOLD MA|556.50||||556.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|United Medicare Advantage|UHC AARP MCR HMO MA|556.50||||556.50||| C1894|EAP|0371||United Medicare Advantage|UHC AARP MCR HMO MA|||||240.35||| C1894|EAP|0371||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||240.35||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.59||||1,011.75||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM C|Humana Medicare Advantage|HUMANA MA|807.85||||807.85||| C1894|EAP|0278|SHEATH URETHRAL 14X35 G30|Humana Medicare Advantage|HUMANA MA|2.59||||641.84||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Humana Medicare Advantage|HUMANA MA|556.50||||556.50||| C1894|EAP|0278|CATH SPIDERFX 5.0 SPD2-US|Humana Medicare Advantage|HUMANA MA|8,866.25||||8,866.25||| C1894|EAP|0278|SHEATH VASCULAR 90CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.59||||641.84||| C1894|EAP|0278|CATH SPIDERFX 4.0 SPSD-US|Humana Medicare Advantage|HUMANA MA|8,866.25||||8,866.25||| C1894|EAP|0278|SHEATH 6FR. 55CM|Humana Medicare Advantage|HUMANA MA|1,685.25||||417.45||| C1894|EAP|0278|SHEATH CROSSCUT 6FR 65 RS|Humana Medicare Advantage|HUMANA MA|11.04||||823.90||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.99||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 5FR 10CM|Humana Medicare Advantage|HUMANA MA|3.99||||90.50||| C1894|EAP|0278|SHEATH DRY SEAL FLEX 12FR|Humana Medicare Advantage|HUMANA MA|2,332.60||||2,332.60||| C1894|EAP|0278|SET MICRO PUNCTURE|Humana Medicare Advantage|HUMANA MA|201.75||||201.75||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Humana Medicare Advantage|HUMANA MA|1,011.75||||1,011.75||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|90.50||||641.84||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Humana Medicare Advantage|HUMANA MA|641.84||||641.84||| C1894|EAP|0371||Humana Medicare Advantage|HUMANA MA|||||240.35||| C1894|EAP|0278|SHEATH FAST CATH|Cigna|CIGNA|||||3.99||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Managed Medicaid|MEDICAID AMERIGROUP|556.50||||556.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|556.50||||556.50||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|423.50||||423.50||| C1894|EAP|0278|SET MICRO PUNCTURE|Managed Medicaid|MEDICAID AMERIGROUP|737.23||||201.75||| C1894|EAP|0278|SET MICRO PUNCTURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|201.75||||201.75||| C1894|EAP|0371||United Medicare Advantage|UHC MEDICARE GOLD MA|||||240.35||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Texas Workforce Commission|DIS DETER SERV (DDS)|||||556.50||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|PHCS|HUMANA|||||737.23||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|PHCS|GROUP AND PENSION|423.50||||||| C1894|EAP|0278|SHEATH URETHRAL 14X35 G30|Tricare|TRICARE EAST REGION|556.50||||641.84||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Tricare|TRICARE EAST REGION|556.50||||641.84||| C1894|EAP|0371||Medicare|MEDICARE ACUTE|240.35||||240.35||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|NON CONTRACTED|COMMERCIAL OTHER 1|2.59||||641.84||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|NON CONTRACTED|COMMERCIAL OTHER 1|2.59||||737.23||| C1894|EAP|0278|SET MICRO PUNCTURE|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||201.75||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|NON CONTRACTED|COMMERCIAL OTHER 1|3.99||||423.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|NON CONTRACTED|COMMERCIAL OTHER 1|556.50||||556.50||| C1894|EAP|0371||Tricare|TRICARE EAST REGION|||||240.35||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|UTMB|UTMB CORRECTIONAL MANAGED CARE|641.84||||||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|UTMB|UTMB CORRECTIONAL MANAGED CARE|556.50||||||| C1894|EAP|0278|SHEATH 6FR. 55CM|United Healthcare|UNITED HEALTHCARE OTHER|3.99||||417.45||| C1894|EAP|0278|SET MICRO PUNCTURE|United Healthcare|UNITED HEALTHCARE OTHER|556.50||||201.75||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|United Healthcare|UNITED HEALTHCARE OTHER|3.99||||1,011.75||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|United Healthcare|TML GROUP BENEFITS|737.23||||556.50||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM C|United Healthcare|UNITED HEALTHCARE|807.85||||3.99||| C1894|EAP|0278|SHEATH FAST CATH|United Healthcare|UNITED HEALTHCARE|344.85||||3.99||| C1894|EAP|0278|SHEATH FAST CATH|United Healthcare|UNITED HEALTHCARE OTHER|3.99||||3.99||| C1894|EAP|0278|SHEATH FAST CATH|United Healthcare|UNITED HEALTHCARE|2,332.60||||3.99||| C1894|EAP|0278|SHEATH DRY SEAL FLEX 16FR|United Healthcare|UNITED HEALTHCARE|2,332.60||||3.99||| C1894|EAP|0278|SHEATH 6FR. 55CM|United Healthcare|UNITED HEALTHCARE|556.50||||417.45||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|United Healthcare|UNITED HEALTHCARE|423.50||||3.99||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|United Healthcare|UNITED HEALTHCARE|556.50||||556.50||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||641.84||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Medicaid|MEDICAID|641.84||||201.75||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Medicaid|MEDICAID|423.50||||201.75||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Medicaid|SMITH COUNTY JAIL|556.50||||||| C1894|EAP|0278|SHEATH URETHRAL 12X55 FUS|Medicare|MEDICARE ACUTE|2,332.60||||641.84||| C1894|EAP|0278|CATH SPIDERFX3.0 SPSD-US-|Medicare|MEDICARE ACUTE|8,866.25||||8,866.25||| C1894|EAP|0278|SHEATH URETHRAL 12X35 G19|Medicare|MEDICARE ACUTE|2,332.60||||641.84||| C1894|EAP|0278|SHEATH VASCULAR 90CM|Medicare|MEDICARE ACUTE|24.61||||2.59||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Medicare|MEDICARE ACUTE|3,151.15||||641.84||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM G|Medicare|MEDICARE ACUTE|1,182.25||||2.59||| C1894|EAP|0278|SHEATH FAST CATH|Medicare|MEDICARE PART B ONLY IP|3.99||||||| C1894|EAP|0278|SHEATH URETHRAL 12X35 G19|Medicare|MEDICARE ACUTE|641.84||||2.59||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Medicare|MEDICARE PART B ONLY IP|737.23||||||| C1894|EAP|0278|SHEATH VASCULAR 90CM|Medicare|MEDICARE ACUTE|2.59||||2.59||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Medicare|MEDICARE ACUTE|641.84||||2.59||| C1894|EAP|0278|SHEATH URETHRAL 12X55 FUS|Medicare|MEDICARE ACUTE|641.84||||2.59||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM C|Medicare|MEDICARE ACUTE|807.85||||2.59||| C1894|EAP|0278|SHEATH PINNACLE 7F 45 RSR|Medicare|MEDICARE ACUTE|1,011.75||||2.59||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Medicare|MEDICARE ACUTE|823.90||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Medicare|MEDICARE ACUTE|737.23||||2.59||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Medicare|MEDICARE ACUTE|1,011.75||||2.59||| C1894|EAP|0278|SHEATH PINNACLE 5FR 10CM|Medicare|MEDICARE ACUTE|90.50||||2.59||| C1894|EAP|0278|SHEATH FAST CATH|Medicare|MEDICARE ACUTE|11.04||||3.99||| C1894|EAP|0278|SHEATH 6FR. 55CM|Medicare|MEDICARE ACUTE|423.50||||417.45||| C1894|EAP|0278|SET MICRO PUNCTURE|Medicare|MEDICARE ACUTE|344.85||||201.75||| C1894|EAP|0278|INTRODUCER 16F 35M RCFW16|Medicare|MEDICARE ACUTE|556.50||||679.45||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Medicare|MEDICARE ACUTE|8,866.25||||556.50||| C1894|EAP|0278|CATH SPIDERFX 5.0 SPD2-US|Medicare|MEDICARE ACUTE|8,866.25||||8,866.25||| C1894|EAP|0278|CATH SPIDERFX 4.0 SPSD-US|Medicare|MEDICARE ACUTE|8,866.25||||8,866.25||| C1894|EAP|0371||Managed Medicare|HEALTHSPRING MA|||||240.35||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3,151.15||||737.23||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|807.85||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 7F 45 RSR|Managed Medicare|HEALTHSPRING MA|2.59||||1,011.75||| C1894|EAP|0278|SHEATH URETHRAL 12X55 FUS|Managed Medicare|BCBS MEDICARE PPO MA|3,151.15||||641.84||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Managed Medicare|HEALTHSPRING MA|2.59||||641.84||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM G|Managed Medicare|HEALTHSPRING MA|2.59||||1,182.25||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Medicare|MEDICARE ACUTE|434.25||||423.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Medicare|MEDICARE PART B ONLY IP|556.50||||||| C1894|EAP|0278|SHEATH URETHRAL 12X55 FUS|Managed Medicare|HEALTHSPRING MA|2.59||||641.84||| C1894|EAP|0278|SHEATH SHUTTLE 7FR 90CM G|Managed Medicare|HEALTHSPRING MA|2.59||||796.75||| C1894|EAP|0278|SHEATH 6FR. 55CM|Managed Medicare|HEALTHSPRING MA|3.99||||417.45||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Managed Medicare|BCBS MEDICARE PPO MA|3.99||||641.84||| C1894|EAP|0278|SHEATH 7F 45CM 401745M 2/|Medicare|MEDICARE ACUTE|201.75||||346.75||| C1894|EAP|0278|SHEATH VASCULAR 90CM|Managed Medicare|OTHER INSTITUTIONS|||||2.59||| C1894|EAP|0278|SHEATH PINNACLE 5FR 10CM|Managed Medicare|HEALTHSPRING MA|2.59||||90.50||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|737.23||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Managed Medicare|HEALTHSPRING MA|2.59||||1,011.75||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Managed Medicare|HEALTHSPRING MA|2.59||||737.23||| C1894|EAP|0278|SHEATH FAST CATH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.99||||737.23||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM C|Medicare|MEDICARE ACUTE|31.51||||807.85||| C1894|EAP|0278|SHEATH FAST CATH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,332.60||||3.99||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,332.60||||1,011.75||| C1894|EAP|0278|CATH SPIDERFX3.0 SPSD-US-|Managed Medicare|HEALTHSPRING MA|423.50||||8,866.25||| C1894|EAP|0278|SHEATH FAST CATH|Managed Medicare|BCBS MEDICARE PPO MA|2,332.60||||3.99||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Medicare|MEDICARE ACUTE|417.45||||1,011.75||| C1894|EAP|0278|SHEATH FAST CATH|Medicare|MEDICARE ACUTE|3.99||||2.59||| C1894|EAP|0278|CATH SPIDERFX 4.0 SPSD-US|Managed Medicare|HEALTHSPRING MA|556.50||||8,866.25||| C1894|EAP|0278|SHEATH FAST CATH|Managed Medicare|HEALTHSPRING MA|737.23||||3.99||| C1894|EAP|0278|SHEATH 6FR. 55CM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|201.75||||417.45||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||423.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||556.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Managed Medicare|HEALTHSPRING MA|201.75||||556.50||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Managed Medicare|HEALTHSPRING MA|11.04||||423.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||556.50||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Medicaid|MEDICAID|737.23||||201.75||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|556.50||||556.50||| C1894|EAP|0371||Blue Cross PPO Specialty|BCBSTX PPO|||||240.35||| C1894|EAP|0278|SHEATH DRY SEAL FLEX 12FR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2,332.60||||||| C1894|EAP|0278|SHEATH 20FR DSL2028|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,658.50||||||| C1894|EAP|0278|SET MICRO PUNCTURE|Medicaid|MEDICAID|556.50||||201.75||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|556.50||||||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Blue Cross HMO Specialty|BCBSTX HMO|641.84||||641.84||| C1894|EAP|0278|SHEATH FAST CATH|Blue Cross HMO Specialty|BCBSTX HMO|641.84||||3.99||| C1894|EAP|0278|SHEATH 7F 90CM TERUMO RSC|Blue Cross HMO Specialty|BCBSTX HMO|641.84||||850.65||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|United Healthcare|TML GROUP BENEFITS|556.50||||556.50||| C1894|EAP|0278|SHEATH 6F 90C TERUM0 RSC0|Blue Cross HMO Specialty|BCBSTX HMO|423.50||||11.04||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Blue Cross HMO Specialty|BCBSTX HMO|556.50||||556.50||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Blue Cross PPO Specialty|BCBSTX OTHER|1,011.75||||2.59||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Blue Cross PPO Specialty|BCBSTX PPO|8,866.25||||556.50||| C1894|EAP|0278|SHEATH FAST CATH|United Healthcare|UNITED HEALTHCARE|3.99||||3.99||| C1894|EAP|0278|SET MICRO PUNCTURE|Blue Cross PPO Specialty|BCBSTX PPO|344.85||||201.75||| C1894|EAP|0278|SHEATH VASCULAR 90CM|Blue Cross PPO Specialty|BCBSTX OTHER|423.50||||2.59||| C1894|EAP|0278|SHEATH URETHRAL 14FR 28C|Blue Cross PPO Specialty|BCBSTX PPO|737.23||||641.84||| C1894|EAP|0278|SHEATH URETHRAL 12X55 FUS|Blue Cross PPO Specialty|BCBSTX PPO|737.23||||641.84||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|UTMB|UTMB CORRECTIONAL MANAGED CARE|737.23||||||| C1894|EAP|0278|SHEATH SHUTTLE 7FR 90CM G|Blue Cross PPO Specialty|BCBSTX PPO|737.23||||796.75||| C1894|EAP|0278|SHEATH SHUTTLE 6FR 90CM G|Blue Cross PPO Specialty|BCBSTX PPO|3.99||||1,182.25||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Blue Cross PPO Specialty|BCBSTX PPO|3,151.15||||737.23||| C1894|EAP|0278|SHEATH PINNACLE 5FR 10CM|Blue Cross PPO Specialty|BCBSTX OTHER|90.50||||2.59||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|NON CONTRACTED|COMMERCIAL OTHER 2|556.50||||||| C1894|EAP|0278|SHEATH FAST CATH|Blue Cross PPO Specialty|BCBSTX PPO|2,332.60||||3.99||| C1894|EAP|0278|SHEATH 6F 90C TERUM0 RSC0|Blue Cross PPO Specialty|BCBSTX PPO|423.50||||11.04||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Blue Cross PPO Specialty|BCBSTX PPO|556.50||||423.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Aetna|AETNA PPO|556.50||||556.50||| C1894|EAP|0278|SHEATH FAST CATH|Aetna|AETNA PPO|3.99||||3.99||| C1894|EAP|0278|SHEATH FAST CATH|Aetna|AETNA OTHER|||||3.99||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|PHCS|HUMANA|||||556.50||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 RSR|Aetna|AETNA PPO|3.99||||1,011.75||| C1894|EAP|0278|SHEATH VASCULAR 90CM|Aenta Medicare Advantage|AETNA MEDICARE MA|2.59||||2.59||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Tricare|TRICARE EAST REGION|556.50||||556.50||| C1894|EAP|0278|IMPLANT SHEATH, NON-LASER|Aenta Medicare Advantage|AETNA MEDICARE MA|556.50||||556.50||| C1894|EAP|0278|SHEATH 6FR. 55CM|Aenta Medicare Advantage|AETNA MEDICARE MA|2,332.60||||417.45||| C1894|EAP|0278|SHEATH FAST CATH|Aenta Medicare Advantage|AETNA MEDICARE MA|1,011.75||||3.99||| C1894|EAP|0278|SET MICRO PUNCTURE|Aenta Medicare Advantage|AETNA MEDICARE MA|423.50||||201.75||| C1894|EAP|0278|SHEATH PINNACLE 6F 45 TER|Aenta Medicare Advantage|AETNA MEDICARE MA|737.23||||737.23||| C1894|EAP|0371||Aenta Medicare Advantage|AETNA MEDICARE MA|240.35||||||| C1894|EAP|0278|SHEATH VASCULAR 90CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,011.75||||2.59||| C1894|EAP|0278|SHEATH FAST CATH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,332.60||||3.99||| C1894|EAP|0278|PRELUDE SNAP 8F|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|201.75||||4.24||| C1894|EAP|0278|MINISTICK ENVI (4 COMPONE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|423.50||||423.50||| C1894|EAP|0278|SET MICRO PUNCTURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,332.60||||201.75||| C1894|EAP|0278|SHEATH VASCULAR 90CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.59||||2.59||| C1895|EAP|0275|ICD LEAD DUAL COIL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|Veterans Affairs|VETERANS ADMINISTRATION|35,392.25||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|United Medicare Advantage|UHC MEDICARE GOLD MA|35,392.25||||||| C1895|EAP|0275|ICD LEAD DUAL COIL|United Medicare Advantage|UHC AARP MCR HMO MA|35,392.25||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|Humana Medicare Advantage|HUMANA MA|35,392.25||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35,392.25||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35,392.25||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|Blue Cross PPO Specialty|BCBSTX PPO|35,392.25||||||| C1895|EAP|0275|ICD LEAD DUAL COIL|Blue Cross PPO Specialty|BCBSTX OTHER|35,392.25||||||| C1895|EAP|0275|ICD LEAD DUAL COIL|Managed Medicare|HEALTHSPRING MA|||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|Managed Medicare|BCBS MEDICARE PPO MA|35,392.25||||||| C1895|EAP|0275|ICD LEAD DUAL COIL|Medicare|MEDICARE ACUTE|35,392.25||||35,392.25||| C1895|EAP|0275|ICD DF4 SJ4 PASS/TBP DUAL|Medicare|MEDICARE ACUTE|35,392.25||||14,601.50||| C1895|EAP|0275|ICD LEAD DUAL COIL|Medicaid|MEDICAID|||||35,392.25||| C1895|EAP|0275|ICD LEAD DUAL COIL|United Healthcare|UNITED HEALTHCARE|||||35,392.25||| C1896|EAP|0275|ELECTRODE Q-GUIDE INSERT|Medicare|MEDICARE ACUTE|||||5,786.50||| C1896|EAP|0275|ELECTRODE Q-GUIDE INSERT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,786.50||| C1896|EAP|0275|ELECTRODE Q-GUIDE INSERT|Humana Medicare Advantage|HUMANA MA|||||5,786.50||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|United Medicare Advantage|UHC AARP MCR HMO MA|6,796.75||||6,796.75||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|United Medicare Advantage|UHC MEDICARE GOLD MA|6,796.75||||6,796.75||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|United Medicare Advantage|UHC AARP MCR HMO MA|||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|United Medicare Advantage|UHC MEDICARE GOLD MA|28.89||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.89||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|United Medicare Advantage|UHC MEDICARE GOLD MA|28.89||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|United Medicare Advantage|UHC AARP MCR HMO MA|||||28.89||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Veterans Affairs|VETERANS ADMINISTRATION|6,796.75||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Veterans Affairs|VETERANS ADMINISTRATION|28.89||||28.89||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6,796.75||||6,796.75||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,796.75||||6,796.75||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6,796.75||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.89||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.89||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Managed Medicaid|MEDICAID AMERIGROUP|||||28.89||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Cigna|CIGNA|6,796.75||||||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Humana Medicare Advantage|HUMANA MA|6,796.75||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|Humana Medicare Advantage|HUMANA MA|28.89||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Humana Medicare Advantage|HUMANA MA|28.89||||28.89||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Blue Cross HMO Specialty|BCBSTX HMO|||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|Blue Cross HMO Specialty|BCBSTX HMO|28.89||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Blue Cross HMO Specialty|BCBSTX HMO|28.89||||28.89||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Blue Cross PPO Specialty|BCBSTX PPO|6,796.75||||6,796.75||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Blue Cross PPO Specialty|BCBSTX OTHER|6,796.75||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|Blue Cross PPO Specialty|BCBSTX PPO|||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Blue Cross PPO Specialty|BCBSTX PPO|||||28.89||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Aenta Medicare Advantage|AETNA MEDICARE MA|6,796.75||||6,796.75||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Aetna|AETNA PPO|||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.89||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|Aenta Medicare Advantage|AETNA MEDICARE MA|28.89||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Aenta Medicare Advantage|AETNA MEDICARE MA|28.89||||||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6,796.75||||6,796.75||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,796.75||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.89||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.89||||28.89||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|United Healthcare|UNITED HEALTHCARE|||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|United Healthcare|UNITED HEALTHCARE OTHER|28.89||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|United Healthcare|UNITED HEALTHCARE|28.89||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.89||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|United Healthcare|UNITED HEALTHCARE|||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|United Healthcare|UNITED HEALTHCARE|28.89||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|United Healthcare|UNITED HEALTHCARE|||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|United Healthcare|UNITED HEALTHCARE OTHER|28.89||||||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,796.75||||||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Managed Medicare|HEALTHSPRING MA|6,796.75||||6,796.75||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Managed Medicare|BCBS MEDICARE PPO MA|6,796.75||||6,796.75||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6,796.75||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|Managed Medicare|HEALTHSPRING MA|28.89||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Managed Medicare|HEALTHSPRING MA|28.89||||28.89||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Medicaid|MEDICAID|6,796.75||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Medicaid|MEDICAID|28.89||||||| C1898|EAP|0275|PACEMAKER LEAD ATRIAL/VEN|Medicare|MEDICARE ACUTE|6,796.75||||6,796.75||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|Medicare|MEDICARE ACUTE|28.89||||28.89||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 58|Medicare|MEDICARE PART B ONLY IP|28.89||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Medicare|MEDICARE PART B ONLY IP|28.89||||||| C1898|EAP|0278|IMPL TENDRIL MRI LEAD, 46|Medicare|MEDICARE ACUTE|28.89||||28.89||| C1900|EAP|0275|LV LEAD|Medicare|MEDICARE ACUTE|14,624.50||||14,624.50||| C1900|EAP|0275|LV LEAD|Medicaid|MEDICAID|14,624.50||||||| C1900|EAP|0275|LV LEAD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||14,624.50||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|Managed Medicare|BCBS MEDICARE PPO MA|33,769.25||||||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|United Healthcare|UNITED HEALTHCARE OTHER|||||33,769.25||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|United Healthcare|UNITED HEALTHCARE|||||33,769.25||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|Managed Medicare|HEALTHSPRING MA|||||33,769.25||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14,624.50||||33,769.25||| C1900|EAP|0275|LV LEAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14,624.50||||14,624.50||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|Blue Cross PPO Specialty|BCBSTX PPO|33,769.25||||||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|Humana Medicare Advantage|HUMANA MA|33,769.25||||33,769.25||| C1900|EAP|0275|LV LEAD|Humana Medicare Advantage|HUMANA MA|14,624.50||||14,624.50||| C1900|EAP|0275|LV LEAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||14,624.50||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|Veterans Affairs|VETERANS ADMINISTRATION|14,624.50||||33,769.25||| C1900|EAP|0275|LV LEAD|Veterans Affairs|VETERANS ADMINISTRATION|14,624.50||||14,624.50||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|Medicare|MEDICARE ACUTE|33,769.25||||33,769.25||| C1900|EAP|0275|LV LEAD|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||14,624.50||| C1900|EAP|0275|LV LEAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14,624.50||||14,624.50||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|United Medicare Advantage|UHC AARP MCR HMO MA|||||33,769.25||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33,769.25||||14,624.50||| C1900|EAP|0275|LV LEAD|United Medicare Advantage|UHC AARP MCR HMO MA|||||14,624.50||| C1900|EAP|0275|LV LEAD|United Medicare Advantage|UHC MEDICARE GOLD MA|14,624.50||||14,624.50||| C1900|EAP|0275|LV LEAD QUARTET 1458Q|United Medicare Advantage|UHC MEDICARE GOLD MA|14,624.50||||33,769.25||| C2613|EAP|0621|LUNG BX PLUG W/DEL SYS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||10.50||| C2613|EAP|0621|LUNG BX PLUG W/DEL SYS|Veterans Affairs|VETERANS ADMINISTRATION|10.50||||||| C2613|EAP|0621|LUNG BX PLUG W/DEL SYS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||10.50||| C2613|EAP|0621|LUNG BX PLUG W/DEL SYS|Humana Medicare Advantage|HUMANA MA|10.50||||10.50||| C2613|EAP|0621|LUNG BX PLUG W/DEL SYS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||10.50||| C2613|EAP|0621|LUNG BX PLUG W/DEL SYS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10.50||| C2613|EAP|0621|LUNG BX PLUG W/DEL SYS|Medicare|MEDICARE ACUTE|10.50||||10.50||| C2613|EAP|0621|LUNG BX PLUG W/DEL SYS|United Healthcare|UNITED HEALTHCARE|||||10.50||| C2613|EAP|0621|LUNG BX PLUG W/DEL SYS|Managed Medicare|HEALTHSPRING MA|10.50||||10.50||| C2616|EAP|0278|BRACHYTX, NON-STR, YTTRIU|Medicare|MEDICARE ACUTE|||||577.50||| C2616|EAP|0278|BRACHYTX, NON-STR, YTTRIU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||577.50||| C2616|EAP|0278|BRACHYTX, NON-STR, YTTRIU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||577.50||| C2616|EAP|0278|BRACHYTX, NON-STR, YTTRIU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||577.50||| C2616|EAP|0278|BRACHYTX, NON-STR, YTTRIU|United Medicare Advantage|UHC AARP MCR HMO MA|||||577.50||| C2616|EAP|0278|BRACHYTX, NON-STR, YTTRIU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||577.50||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|United Medicare Advantage|UHC AARP MCR HMO MA|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|United Medicare Advantage|UHC MEDICARE GOLD MA|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Cigna|CIGNA|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Humana Medicare Advantage|HUMANA MA|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Managed Medicaid|MEDICAID SUPERIOR|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Managed Medicaid|MEDICAID AMERIGROUP|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Blue Cross HMO Specialty|BCBSTX HMO|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Blue Cross PPO Specialty|BCBSTX PPO|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Aetna|AETNA PPO|||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Aetna|AETNA OTHER|||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Aetna|BOON CHAPMAN|9.82||||||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Aenta Medicare Advantage|AETNA MEDICARE MA|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Access Direct Platinum|HEALTHFIRST TPA|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.82||||||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|United Healthcare|UNITED HEALTHCARE OTHER|||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|United Healthcare|UNITED HEALTHCARE|||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|PHCS|HUMANA INSURANCE|9.82||||||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|PHCS|GROUP AND PENSION|9.82||||||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Tricare|TRICARE EAST REGION|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|NON CONTRACTED|COMMERCIAL OTHER 1|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Managed Medicare|BCBS MEDICARE PPO MA|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Managed Medicare|HEALTHSPRING MA|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Medicaid|MEDICAID HMO|9.82||||||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Medicaid|MEDICAID|9.82||||||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Medicaid|MOLINA HEALTHCARE OF TEXAS|9.82||||||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Medicare|MEDICARE ACUTE|9.82||||9.82||| C2617|EAP|0278|IMPLT STNT, NO-COR, TEMP|Medicare|MEDICARE PART B ONLY IP|9.82||||||| C2621|EAP|0278|VISIONIST X4 CRT-P (U228)|Medicare|MEDICARE ACUTE|402.50||||229.25||| C2621|EAP|0278|SERENA MRI CRT DEVICE W1T|Medicare|MEDICARE ACUTE|402.50||||402.50||| C2621|EAP|0278|PM3210 ANTHEM CRT-P|Medicare|MEDICARE ACUTE|402.50||||252.00||| C2621|EAP|0278|SERENA MRI QUAD CRT-P DEV|Medicare|MEDICARE ACUTE|402.50||||402.50||| C2621|EAP|0278|SERENA MRI CRT DEVICE W1T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||402.50||| C2621|EAP|0278|QUADRA ALLURE MP(PM3562)|United Healthcare|UNITED HEALTHCARE OTHER|||||175.00||| C2621|EAP|0278|SERENA MRI QUAD CRT-P DEV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||402.50||| C2621|EAP|0278|SERENA MRI QUAD CRT-P DEV|United Medicare Advantage|UHC AARP MCR HMO MA|||||402.50||| C2621|EAP|0278|SERENA MRI QUAD CRT-P DEV|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||402.50||| C2621|EAP|0278|SERENA MRI QUAD CRT-P DEV|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|402.50||||402.50||| C2623|EAP|0272|BALL INVATEC ADM 8X40X80|Access Direct Platinum|HEALTHFIRST TPA UMR|1,052.50||||||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Access Direct Platinum|HEALTHFIRST TPA UMR|103.87||||||| C2623|EAP|0272|BALL ADMIRAL INPACT DCB 4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 7X200X13|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||14.13||| C2623|EAP|0272|BALL INVATEC ADM 6X250X13|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,743.75||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.87||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|United Medicare Advantage|UHC AARP MCR HMO MA|||||103.87||| C2623|EAP|0278|BALLOON CATH DRUG-COAT G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||104.32||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.87||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.87||| C2623|EAP|0272|BALL INVATEC ADM 8X40X80|Humana Medicare Advantage|HUMANA MA|||||1,052.50||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Humana Medicare Advantage|HUMANA MA|104.32||||103.87||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Blue Cross PPO Specialty|BCBSTX PPO|||||103.87||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Aetna|AETNA PPO|||||103.87||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||103.87||| C2623|EAP|0272|BALL INVATEC ADM 7X20X80|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,052.50||||1,052.50||| C2623|EAP|0272|BALL ADMIRAL INPACT DCB 4|Aetna|AETNA PPO|||||1,052.50||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.87||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.87||| C2623|EAP|0272|BALL INVATEC ADM 7X60X130|United Healthcare|UNITED HEALTHCARE OTHER|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 8X40X130|United Healthcare|UNITED HEALTHCARE OTHER|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 8X40X80|United Healthcare|UNITED HEALTHCARE|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 8X40X80|United Healthcare|UNITED HEALTHCARE OTHER|||||1,052.50||| C2623|EAP|0272|BALL ADMIRAL INPACT DCB 4|United Healthcare|UNITED HEALTHCARE OTHER|||||1,052.50||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|United Healthcare|UNITED HEALTHCARE OTHER|||||103.87||| C2623|EAP|0272|BALL INVATEC ADM 7X60X130|Humana Medicare Advantage|HUMANA MA|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 8X40X80|Managed Medicare|HEALTHSPRING MA|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 8X40X130|Managed Medicare|HEALTHSPRING MA|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 7X40X130|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 6X250X13|Managed Medicare|HEALTHSPRING MA|||||1,743.75||| C2623|EAP|0272|BALL ADMIRAL INPACT DCB 4|Managed Medicare|HEALTHSPRING MA|||||1,052.50||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Veterans Affairs|VETERANS ADMINISTRATION|||||103.87||| C2623|EAP|0278|BALLOON CATH DRUG-COAT G1|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||104.32||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|104.32||||103.87||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Managed Medicare|HEALTHSPRING MA|103.87||||103.87||| C2623|EAP|0272|BALL INVATEC AHU 3X14X150|Medicare|MEDICARE ACUTE|||||1,954.25||| C2623|EAP|0272|BALL INVATEC ADM 8X40X130|Medicare|MEDICARE ACUTE|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 8X20X130|Medicare|MEDICARE ACUTE|||||1,052.50||| C2623|EAP|0272|BALL INVATEC ADM 7X200X13|Medicare|MEDICARE ACUTE|||||14.13||| C2623|EAP|0272|BALL INVATEC ADM 8X40X80|Medicare|MEDICARE ACUTE|||||1,052.50||| C2623|EAP|0272|BALL INVATEC AMP 2X80X150|Medicare|MEDICARE ACUTE|||||1,954.25||| C2623|EAP|0272|BALL ADMIRAL INPACT DCB 4|Medicare|MEDICARE ACUTE|||||1,052.50||| C2623|EAP|0278|BALL IN.PACT ADMIRAL DRUG|Medicare|MEDICARE ACUTE|103.87||||103.87||| C2623|EAP|0278|BALLOON CATH DRUG-COAT G1|Medicare|MEDICARE ACUTE|104.32||||103.87||| C2625|EAP|0278|IMPLT STNT NO-COR TEMP W/|Medicare|MEDICARE ACUTE|21,036.50||||5,786.50||| C2625|EAP|0278|STENT URETERAL|Managed Medicare|HEALTHSPRING MA|||||872.50||| C2625|EAP|0278|STENT URETERAL|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||872.50||| C2625|EAP|0278|IMPLT STNT NO-COR TEMP W/|United Healthcare|UNITED HEALTHCARE OTHER|||||5,786.50||| C2625|EAP|0278|STENT URETERAL|Medicare|MEDICARE ACUTE|872.50||||872.50||| C2625|EAP|0278|IMPLT STNT NO-COR TEMP W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,786.50||| C2625|EAP|0278|IMPLT STNT NO-COR TEMP W/|Blue Cross PPO Specialty|BCBSTX PPO|||||5,786.50||| C2625|EAP|0278|STENT URETERAL|Humana Medicare Advantage|HUMANA MA|21,036.50||||872.50||| C2625|EAP|0278|STENT COVERED ENDOPROSTHE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21,036.50||||||| C2625|EAP|0278|IMPLT STNT NO-COR TEMP W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5,786.50||| C2625|EAP|0278|IMPLT STNT NO-COR TEMP W/|United Medicare Advantage|UHC AARP MCR HMO MA|||||5,786.50||| C2625|EAP|0278|STENT URETERAL|United Medicare Advantage|UHC MEDICARE GOLD MA|872.50||||||| C2625|EAP|0278|IMPLT STNT NO-COR TEMP W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5,786.50||||||| C2625|EAP|0278|STENT URETERAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||872.50||| C2625|EAP|0278|STENT URETERAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|872.50||||||| C2625|EAP|0278|IMPLT STNT NO-COR TEMP W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5,786.50||| C2625|EAP|0278|STENT URETERAL|Veterans Affairs|VETERANS ADMINISTRATION|||||872.50||| C2628|EAP|0371||United Medicare Advantage|UHC MEDICARE GOLD MA|||||517.50||| C2628|EAP|0371||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||517.50||| C2628|EAP|0371||United Medicare Advantage|UHC AARP MCR HMO MA|||||517.50||| C2628|EAP|0272|CATH TREK RX 3.25MMX20MM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,104.25||| C2628|EAP|0272|CATH NEURO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||16.77||| C2628|EAP|0272|CATH TREK RX 2.25MMX12MM|United Medicare Advantage|UHC MEDICARE GOLD MA|39.99||||1,104.25||| C2628|EAP|0272|CATH NEURO|United Medicare Advantage|UHC MEDICARE GOLD MA|16.77||||16.77||| C2628|EAP|0272|CATH TREK RX 3.75MMX12MM|United Medicare Advantage|UHC MEDICARE GOLD MA|1,104.25||||1,104.25||| C2628|EAP|0272|CATH NEURO|United Medicare Advantage|UHC AARP MCR HMO MA|39.99||||16.77||| C2628|EAP|0272|CATH TREK RX 3.25MMX15MM|United Medicare Advantage|UHC MEDICARE GOLD MA|1,104.25||||1,104.25||| C2628|EAP|0272|CATH NEURO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.77||||||| C2628|EAP|0272|CATH TREK RX 4.0MMX12MM|Humana Medicare Advantage|HUMANA MA|1,104.25||||||| C2628|EAP|0272|CATH NEURO BALLN|Humana Medicare Advantage|HUMANA MA|39.99||||||| C2628|EAP|0371||Blue Cross PPO Specialty|BCBSTX PPO|||||517.50||| C2628|EAP|0272|CATH TREK RX 4.0MMX8MM|Blue Cross PPO Specialty|BCBSTX PPO|1,104.25||||1,104.25||| C2628|EAP|0272|CATH TREK RX 3.25MMX8MM|Blue Cross PPO Specialty|BCBSTX PPO|1,104.25||||1,104.25||| C2628|EAP|0272|CATH TREK RX 3.25MMX12MM|Blue Cross PPO Specialty|BCBSTX PPO|1,104.25||||1,104.25||| C2628|EAP|0272|CATH NEURO|Blue Cross PPO Specialty|BCBSTX PPO|39.99||||16.77||| C2628|EAP|0278|PENUMBRA OCCULSION DEVICE|Blue Cross PPO Specialty|BCBSTX PPO|115.16||||||| C2628|EAP|0272|CATH TREK RX 2.75MMX12MM|Aetna|AETNA OTHER|1,104.25||||||| C2628|EAP|0371||Humana Medicare Advantage|HUMANA MA|||||517.50||| C2628|EAP|0272|CATH TREK RX 3.25MMX15MM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.77||||1,104.25||| C2628|EAP|0272|CATH TREK RX 3.75MMX8MM|United Medicare Advantage|UHC AARP MCR HMO MA|1,104.25||||16.77||| C2628|EAP|0371||Aenta Medicare Advantage|AETNA MEDICARE MA|517.50||||||| C2628|EAP|0272|CATH TREK RX 4.0MMX12MM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,104.25||| C2628|EAP|0272|CATH TREK RX 2.75MMX12MM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,104.25||| C2628|EAP|0272|CATH NEURO|Rusk State Hospital|RUSK STATE HOSP|||||16.77||| C2628|EAP|0371||Medicare|MEDICARE ACUTE|517.50||||517.50||| C2628|EAP|0371||Tricare|TRICARE EAST REGION|||||517.50||| C2628|EAP|0371||Managed Medicare|HEALTHSPRING MA|||||517.50||| C2628|EAP|0371||Managed Medicare|BCBS MEDICARE PPO MA|||||517.50||| C2628|EAP|0371||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||517.50||| C2628|EAP|0278|PENUMBRA OCCULSION DEVICE|Managed Medicare|HEALTHSPRING MA|115.16||||||| C2628|EAP|0272|CATH TREK RX 2.25MMX12MM|Medicare|MEDICARE ACUTE|39.99||||1,104.25||| C2628|EAP|0272|CATH TREK RX 3.25MMX8MM|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C2628|EAP|0272|CATH NEURO|Medicare|MEDICARE ACUTE|16.77||||16.77||| C2628|EAP|0272|CATH TREK RX 2.75MMX12MM|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C2628|EAP|0272|CATH TREK RX 4.0MMX12MM|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C2628|EAP|0272|CATH TREK RX 4.0MMX8MM|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C2628|EAP|0272|CATH TREK RX 3.25MMX15MM|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C2628|EAP|0272|CATH TREK RX 3.25MMX12MM|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C2628|EAP|0272|CATH TREK RX 2.75MMX8MM|Medicare|MEDICARE ACUTE|1,104.25||||1,104.25||| C2628|EAP|0278|PENUMBRA OCCULSION DEVICE|Medicare|MEDICARE ACUTE|115.16||||115.16||| C2629|EAP|0278|IMPL SHEATH LASER G1|Medicare|MEDICARE ACUTE|17,359.75||||17,359.75||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||92.71||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||177.77||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Aetna|AETNA PPO|177.77||||155.15||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Aenta Medicare Advantage|AETNA MEDICARE MA|||||177.77||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Blue Cross HMO Specialty|BCBSTX HMO|||||155.15||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Blue Cross PPO Specialty|BCBSTX PPO|155.15||||155.15||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Blue Cross PPO Specialty|BCBSTX PPO|177.77||||177.77||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Cigna|CIGNA|||||155.15||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Humana Medicare Advantage|HUMANA MA|177.77||||155.15||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Humana Medicare Advantage|HUMANA MA|177.77||||177.77||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||155.15||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||177.77||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|177.77||||177.77||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|United Medicare Advantage|UHC AARP MCR HMO MA|||||92.71||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|United Medicare Advantage|UHC MEDICARE GOLD MA|92.71||||||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|92.71||||92.71||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|United Medicare Advantage|UHC AARP MCR HMO MA|155.15||||155.15||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||155.15||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|155.15||||177.77||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|United Medicare Advantage|UHC AARP MCR HMO MA|177.77||||177.77||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||177.77||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|177.77||||177.77||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|Veterans Affairs|VETERANS ADMINISTRATION|||||92.71||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|Humana Medicare Advantage|HUMANA MA|92.71||||92.71||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Veterans Affairs|VETERANS ADMINISTRATION|155.15||||177.77||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||155.15||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Access Direct Platinum|HEALTHFIRST TPA UMR|||||155.15||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||155.15||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|Blue Cross PPO Specialty|BCBSTX PPO|92.71||||||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||177.77||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||177.77||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|United Healthcare|UNITED HEALTHCARE|||||177.77||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|United Healthcare|UNITED HEALTHCARE|177.77||||177.77||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|United Healthcare|UNITED HEALTHCARE|||||155.15||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|United Healthcare|UNITED HEALTHCARE OTHER|177.77||||155.15||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|United Healthcare|UNITED HEALTHCARE|177.77||||155.15||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|United Healthcare|UNITED HEALTHCARE OTHER|177.77||||177.77||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||92.71||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|Managed Medicare|HEALTHSPRING MA|92.71||||92.71||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||155.15||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Managed Medicare|BCBS MEDICARE PPO MA|177.77||||177.77||| C2630|EAP|0272|CATH NON NAV SF BD135FJRT|Medicare|MEDICARE ACUTE|92.71||||92.71||| C2630|EAP|0278|CATH THERMOCOOL SMARTTOUC|Medicare|MEDICARE ACUTE|177.77||||177.77||| C2630|EAP|0278|TACTICATH IRR CONT FRC AB|Medicare|MEDICARE ACUTE|155.15||||155.15||| C5271|EAP|0761|APP LC SKIN SUB T/A/L <10|Managed Medicare|HEALTHSPRING MA|||||12.96||| C5271|EAP|0761|APP LC SKIN SUB T/A/L <10|Medicare|MEDICARE ACUTE|||||12.96||| C5271|EAP|0761|APP LC SKIN SUB T/A/L <10|Veterans Affairs|VETERANS ADMINISTRATION|||||12.96||| C5271|EAP|0761|APP LC SKIN SUB T/A/L <10|Humana Medicare Advantage|HUMANA MA|||||12.96||| C5272|EAP|0761|APP LC SKIN SUB T/A/L <10|Humana Medicare Advantage|HUMANA MA|||||21.00||| C5272|EAP|0761|APP LC SKIN SUB T/A/L <10|Veterans Affairs|VETERANS ADMINISTRATION|||||21.00||| C5272|EAP|0761|APP LC SKIN SUB T/A/L <10|Medicare|MEDICARE ACUTE|||||21.00||| C5275|EAP|0761|APP LC SKIN SUB F/H/F <10|Managed Medicare|HEALTHSPRING MA|||||972.90||| C5276|EAP|0761|APP LC SKIN SUB F/H/F <10|Managed Medicare|HEALTHSPRING MA|||||17.79||| C8900|EAP|0610|MRI ANGIO ABDOM W DYE|Medicare|MEDICARE ACUTE|||||7,580.10||| C8901|EAP|0610||Medicare|MEDICARE ACUTE|||||57.91||| C8902|EAP|0610||United Medicare Advantage|UHC AARP MCR HMO MA|||||57.91||| C8902|EAP|0610||Humana Medicare Advantage|HUMANA MA|||||6,370.10||| C8902|EAP|0610||Medicare|MEDICARE ACUTE|||||6,370.10||| C8908|EAP|0610||Managed Medicare|BCBS MEDICARE PPO MA|||||7,903.50||| C8908|EAP|0610||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||71.85||| C8908|EAP|0610||Managed Medicare|HEALTHSPRING MA|||||7,903.50||| C8908|EAP|0610||Medicare|MEDICARE ACUTE|||||7,903.50||| C8908|EAP|0610||Aenta Medicare Advantage|AETNA MEDICARE MA|||||71.85||| C8908|EAP|0610||Humana Medicare Advantage|HUMANA MA|||||7,903.50||| C8908|EAP|0610||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,903.50||| C8908|EAP|0610||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||71.85||| C8908|EAP|0610||Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||71.85||| C8908|EAP|0610||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7,544.25||| C8908|EAP|0610||Access Direct Platinum|HEALTHFIRST TPA|||||71.85||| C8908|EAP|0610||United Medicare Advantage|UHC MEDICARE GOLD MA|||||7,903.50||| C8908|EAP|0610||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7,903.50||| C8908|EAP|0610||United Medicare Advantage|UHC AARP MCR HMO MA|||||7,903.50||| C8911|EAP|0610|MRA CHEST W WO CONT|Medicare|MEDICARE ACUTE|||||8,617.40||| C8924|EAP|0483||United Medicare Advantage|UHC AARP MCR HMO MA|||||1,472.28||| C8924|EAP|0483||Medicare|MEDICARE ACUTE|||||13.78||| C8928|EAP|0483||Medicare|MEDICARE ACUTE|||||2,957.39||| C8928|EAP|0483||Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,957.39||| C8929|EAP|0483||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||27.68||| C8929|EAP|0483||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||27.68||| C8929|EAP|0483||Access Direct Platinum|HEALTHFIRST TPA|||||27.68||| C8929|EAP|0483||United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.68||| C8929|EAP|0483||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.68||||||| C8929|EAP|0483||Humana Medicare Advantage|HUMANA MA|||||27.68||| C8929|EAP|0483||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||27.68||| C8929|EAP|0483||Medicare|MEDICARE ACUTE|27.68||||2,957.39||| C8930|EAP|0483||Medicare|MEDICARE ACUTE|||||27.68||| C8930|EAP|0483||Managed Medicare|OTHER INSTITUTIONS|||||27.68||| C8930|EAP|0483||Managed Medicare|HEALTHSPRING MA|||||27.68||| C8930|EAP|0483||Humana Medicare Advantage|HUMANA MA|||||27.68||| C8930|EAP|0483||United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.68||| C8930|EAP|0483||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,957.39||| C8930|EAP|0483||United Medicare Advantage|UHC AARP MCR HMO MA|||||2,957.39||| C8934|EAP|0610|MR ANGIO UPR EXTR W/DYE L|NON CONTRACTED|COMMERCIAL OTHER 1|||||4,463.80||| C9041|ERX|0636|FACTOR XA,INACTIVE-ZHZO 2|United Medicare Advantage|UHC AARP MCR HMO MA|8.75||||||| C9041|ERX|0636|FACTOR XA,INACTIVE-ZHZO 2|Aenta Medicare Advantage|AETNA MEDICARE MA|8.75||||||| C9041|ERX|0636|FACTOR XA,INACTIVE-ZHZO 2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.75||||||| C9041|ERX|0636|FACTOR XA,INACTIVE-ZHZO 2|Humana Medicare Advantage|HUMANA MA|8.75||||||| C9041|ERX|0636|FACTOR XA,INACTIVE-ZHZO 2|Medicare|MEDICARE ACUTE|8.75||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Managed Medicare|BCBS MEDICARE PPO MA|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Medicare|MEDICARE ACUTE|5.83||||5.83||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Humana Medicare Advantage|HUMANA MA|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Blue Cross PPO Specialty|BCBSTX PPO|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Blue Cross HMO Specialty|BCBSTX HMO|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Aenta Medicare Advantage|AETNA MEDICARE MA|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|Workers Compensation|BROOKSHIRES WORKERS COMP|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|United Medicare Advantage|UHC MEDICARE GOLD MA|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.83||||||| C9132|ERX|0636|KCENTRA 500, 1 UNIT CHG|United Medicare Advantage|UHC AARP MCR HMO MA|5.83||||||| C9352|EAP|0278|IMPLANT NERVE G1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||115.73||| C9352|EAP|0278|IMPLANT NERVE G1|Workers Compensation|TEXAS MUTUAL INSURANCE|||||115.73||| C9352|EAP|0278|IMPLANT NERVE G1|Workers Compensation|WORKERS COMPENSATION OTHER|||||115.73||| C9352|EAP|0278|IMPLANT NERVE G1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||115.73||| C9352|EAP|0278|IMPLANT NERVE G1|Blue Cross PPO Specialty|BCBSTX PPO|||||115.73||| C9352|EAP|0278|IMPLANT NERVE G1|Managed Medicaid|MEDICAID AMERIGROUP|||||115.73||| C9352|EAP|0278|IMPLANT NERVE G1|Humana Medicare Advantage|HUMANA MA|115.73||||||| C9352|EAP|0278|IMPLANT NERVE G1|United Healthcare|UNITED HEALTHCARE|115.73||||||| C9352|EAP|0278|IMPLANT NERVE G1|PHCS|HUMANA|115.73||||||| C9352|EAP|0278|IMPLANT NERVE G1|Tricare|TRICARE FOR LIFE|||||115.73||| C9352|EAP|0278|IMPLANT NERVE G1|Tricare|TRICARE EAST REGION|115.73||||||| C9352|EAP|0278|IMPLANT NERVE G1|Medicaid|MEDICAID|115.73||||||| C9352|EAP|0278|IMPLANT NERVE G1|Medicare|MEDICARE ACUTE|115.73||||115.73||| C9352|EAP|0278|IMPLANT NERVE G1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||115.73||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicare|HEALTHSPRING MA|1,447.25||||2,893.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicare|HEALTHSPRING MA|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicare|BCBS MEDICARE PPO MA|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Medicare|MEDICARE PART B ONLY IP|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Medicare|MEDICARE ACUTE|156.00||||111.28||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Medicare|MEDICARE ACUTE|2,893.25||||2,893.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Medicare|MEDICARE ACUTE|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Medicare|MEDICARE ACUTE|55.64||||55.64||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Medicare|MEDICARE PART B ONLY IP|111.28||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Medicaid|MOLINA HEALTHCARE OF TEXAS|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|NON CONTRACTED|COMMERCIAL OTHER 1|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|PHCS|HUMANA|1,447.25||||111.28||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Tricare|TRICARE EAST REGION|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|United Healthcare|UNITED HEALTHCARE|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|United Healthcare|GEHA|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|United Healthcare|UNITED HEALTHCARE OTHER|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|United Healthcare|UNITED HEALTHCARE|2,893.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Cigna|CIGNA|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Cigna|CIGNA OTHER|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Cigna|CIGNA|55.64||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Humana Medicare Advantage|HUMANA MA|1,447.25||||111.28||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Cigna|CIGNA|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Humana Medicare Advantage|HUMANA MA|1,447.25||||55.64||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Humana Medicare Advantage|HUMANA MA|1,447.25||||2,893.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Humana Medicare Advantage|HUMANA MA|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|United Healthcare|UNITED HEALTHCARE|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55.64||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Tricare|TRICARE EAST REGION|2,893.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicaid|MEDICAID AMERIGROUP|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Blue Cross HMO Specialty|BCBSTX HMO|111.28||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Blue Cross HMO Specialty|BCBSTX HMO|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Blue Cross PPO Specialty|BCBSTX PPO|111.28||||111.28||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Blue Cross PPO Specialty|BCBSTX PPO|55.64||||55.64||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Blue Cross PPO Specialty|BCBSTX OTHER|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Medicare|MEDICARE ACUTE|111.28||||111.28||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Blue Cross PPO Specialty|BCBSTX PPO|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Aetna|AETNA PPO|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Aetna|AETNA QHP HMO|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Aetna|AETNA OTHER|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Aenta Medicare Advantage|AETNA MEDICARE MA|111.28||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Aenta Medicare Advantage|AETNA MEDICARE MA|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,447.25||||55.64||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,447.25||||111.28||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Access Direct Platinum|HEALTHFIRST TPA UMR|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Workers Compensation|WORKERS COMPENSATION OTHER|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|Veterans Affairs|VETERANS ADMINISTRATION|1,447.25||||||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|United Medicare Advantage|UHC AARP MCR HMO MA|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|United Medicare Advantage|UHC MEDICARE GOLD MA|111.28||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|United Medicare Advantage|UHC MEDICARE GOLD MA|1,447.25||||1,447.25||| C9359|EAP|0278|IMPLT BON FILL-PUT PER .5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,447.25||||1,447.25||| C9361|EAP|0278|IMPL NEURO MEND 2.5CM X 4|Blue Cross PPO Specialty|BCBSTX PPO|||||11.75||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|UTMB|UTMB CORRECTIONAL MANAGED CARE|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|United Healthcare|UNITED HEALTHCARE|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Tricare|TRICARE EAST REGION|1,447.25||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|NON CONTRACTED|COMMERCIAL OTHER 1|115.73||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Medicaid|MEDICAID|115.73||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Medicare|MEDICARE PART B ONLY IP|2,893.25||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Medicare|MEDICARE PART B ONLY IP|1,447.25||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Medicare|MEDICARE ACUTE|5,786.50||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Medicare|MEDICARE ACUTE|115.73||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Medicare|MEDICARE ACUTE|2,893.25||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicare|HEALTHSPRING MA|115.73||||5,786.50||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicare|BCBS MEDICARE PPO MA|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicare|BCBS MEDICARE PPO MA|5,786.50||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|United Medicare Advantage|UHC MEDICARE GOLD MA|5,786.50||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|United Medicare Advantage|UHC AARP MCR HMO MA|||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|115.73||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,786.50||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|United Medicare Advantage|UHC AARP MCR HMO MA|||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Workers Compensation|WORKERS COMP PHYSICIAN|||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|United Medicare Advantage|UHC MEDICARE GOLD MA|115.73||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Veterans Affairs|VETERANS ADMINISTRATION|115.73||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|115.73||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5,786.50||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicare|HEALTHSPRING MA|5,786.50||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicaid|MEDICAID SUPERIOR|||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicaid|MEDICAID SUPERIOR|||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,447.25||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Managed Medicaid|MEDICAID AMERIGROUP|115.73||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Medicare|MEDICARE ACUTE|1,447.25||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Humana Medicare Advantage|HUMANA MA|115.73||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Humana Medicare Advantage|HUMANA MA|2,893.25||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Humana Medicare Advantage|HUMANA MA|1,447.25||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Cigna|CIGNA|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,893.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Aetna|AETNA QHP HMO|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Aetna|AETNA PPO|||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Aenta Medicare Advantage|AETNA MEDICARE MA|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Blue Cross HMO Specialty|BCBSTX HMO|115.73||||||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Blue Cross PPO Specialty|BCBSTX PPO|1,447.25||||1,447.25||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Blue Cross PPO Specialty|BCBSTX PPO|115.73||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Blue Cross PPO Specialty|BCBSTX PPO|5,786.50||||115.73||| C9362|EAP|0278|IMPLT BON FILL-PUT MLDABL|Blue Cross PPO Specialty|BCBSTX PPO|2,893.25||||2,893.25||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Blue Cross PPO Specialty|BCBSTX PPO|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Aenta Medicare Advantage|AETNA MEDICARE MA|214.34||||22,505.70||| C9600|EAP|0481||Aenta Medicare Advantage|AETNA MEDICARE MA|22,505.70||||21,969.85||| C9600|EAP|0481||Aetna|AETNA PPO|||||214.34||| C9600|EAP|0481||Cigna|CIGNA|||||21,969.85||| C9600|EAP|0481||Cigna|CIGNA|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Humana Medicare Advantage|HUMANA MA|214.34||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Humana Medicare Advantage|HUMANA MA|214.34||||214.34||| C9600|EAP|0481||Humana Medicare Advantage|HUMANA MA|214.34||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|214.34||||21,969.85||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Access Direct Platinum|HEALTHFIRST TPA UMR|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Access Direct Platinum|HEALTHFIRST TPA|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||22,505.70||| C9600|EAP|0481||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|214.34||||22,505.70||| C9600|EAP|0481||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||21,969.85||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Veterans Affairs|VETERANS ADMINISTRATION|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Veterans Affairs|VETERANS ADMINISTRATION|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21,969.85||| C9600|EAP|0481||United Medicare Advantage|UHC MEDICARE GOLD MA|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|United Medicare Advantage|UHC MEDICARE GOLD MA|||||21,969.85||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|United Medicare Advantage|UHC AARP MCR HMO MA|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21,969.85||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|United Medicare Advantage|UHC AARP MCR HMO MA|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|United Medicare Advantage|UHC MEDICARE GOLD MA|||||22,505.70||| C9600|EAP|0481||Access Direct Platinum|HEALTHFIRST TPA UMR|||||22,505.70||| C9600|EAP|0481||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22,505.70||| C9600|EAP|0481||United Medicare Advantage|UHC AARP MCR HMO MA|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|214.34||||21,969.85||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Managed Medicare|HEALTHSPRING MA|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Managed Medicare|BCBS MEDICARE PPO MA|||||21,969.85||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Managed Medicare|HEALTHSPRING MA|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Managed Medicare|BCBS MEDICARE PPO MA|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Humana Medicare Advantage|HUMANA MA|214.34||||22,505.70||| C9600|EAP|0481||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||214.34||| C9600|EAP|0481||Managed Medicare|HEALTHSPRING MA|||||22,505.70||| C9600|EAP|0481||Managed Medicare|BCBS MEDICARE PPO MA|||||22,505.70||| C9600|EAP|0481||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Cigna|CIGNA|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Medicare|MEDICARE ACUTE|21,969.85||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Medicare|MEDICARE ACUTE|22,505.70||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Medicare|MEDICARE ACUTE|21,969.85||||22,505.70||| C9600|EAP|0481||Medicare|MEDICARE ACUTE|214.34||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Aenta Medicare Advantage|AETNA MEDICARE MA|214.34||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|PHCS|HUMANA|||||214.34||| C9600|EAP|0481||NON CONTRACTED|COMMERCIAL OTHER 1|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|United Healthcare|UNITED HEALTHCARE OTHER|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|United Healthcare|UNITED HEALTHCARE|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|United Healthcare|UNITED HEALTHCARE OTHER|||||214.34||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|United Healthcare|UNITED HEALTHCARE|||||22,505.70||| C9600|EAP|0481||United Healthcare|UNITED HEALTHCARE OTHER|||||214.34||| C9600|EAP|0481||United Healthcare|UNITED HEALTHCARE|||||22,505.70||| C9600|EAP|0481|STENT SINGLE VESSEL DES R|Tricare|TRICARE EAST REGION|||||21,969.85||| C9600|EAP|0481|STENT SINGLE VESSEL DES L|Tricare|TRICARE EAST REGION|||||21,969.85||| C9600|EAP|0481||Tricare|TRICARE EAST REGION|||||22,505.70||| C9601|EAP|0481|STENT ADDL VESSEL DES RC|Medicare|MEDICARE ACUTE|107.17||||107.17||| C9601|EAP|0481||Medicare|MEDICARE ACUTE|107.17||||11,252.85||| C9601|EAP|0481|STENT ADDL VESSEL DES RC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||107.17||| C9601|EAP|0481||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||107.17||| C9601|EAP|0481||United Medicare Advantage|UHC MEDICARE GOLD MA|||||107.17||| C9601|EAP|0481||United Medicare Advantage|UHC AARP MCR HMO MA|||||11,252.85||| C9601|EAP|0481|STENT ADDL VESSEL DES RC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11,252.85||| C9601|EAP|0481|STENT ADDL VESSEL DES RC|Veterans Affairs|VETERANS ADMINISTRATION|||||11,252.85||| C9601|EAP|0481|STENT ADDL VESSEL DES RC|Humana Medicare Advantage|HUMANA MA|||||10,984.93||| C9601|EAP|0481||Humana Medicare Advantage|HUMANA MA|||||11,252.85||| C9601|EAP|0481||Humana Medicare Advantage|HUMANA MA|||||107.17||| C9602|EAP|0481|PTCA/STENT/ATH DES RC|Humana Medicare Advantage|HUMANA MA|||||22,505.70||| C9602|EAP|0481|PTCA/STENT/ATH DES LD|Humana Medicare Advantage|HUMANA MA|||||21,969.85||| C9602|EAP|0481|PTCA/STENT/ATH DES RC|Medicare|MEDICARE ACUTE|||||22,505.70||| C9602|EAP|0481|PTCA/STENT/ATH DES LD|Medicare|MEDICARE ACUTE|||||22,505.70||| C9603|EAP|0481||United Medicare Advantage|UHC AARP MCR HMO MA|||||11,252.85||| C9604|EAP|0481||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||214.34||| C9604|EAP|0481||Managed Medicare|HEALTHSPRING MA|||||21,969.85||| C9604|EAP|0481|PTCA/STENT/ATH SVG DES LM|Medicare|MEDICARE ACUTE|214.34||||22,505.70||| C9604|EAP|0481|PTCA/STENT/ATH SVG DES LD|Medicare|MEDICARE ACUTE|214.34||||21,969.85||| C9604|EAP|0481||Medicare|MEDICARE ACUTE|214.34||||22,505.70||| C9604|EAP|0481||Aenta Medicare Advantage|AETNA MEDICARE MA|||||214.34||| C9604|EAP|0481|PTCA/STENT/ATH SVG DES LD|Humana Medicare Advantage|HUMANA MA|||||214.34||| C9604|EAP|0481||Humana Medicare Advantage|HUMANA MA|||||21,969.85||| C9604|EAP|0481||Humana Medicare Advantage|HUMANA MA|||||214.34||| C9604|EAP|0481||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||214.34||| C9604|EAP|0481||United Medicare Advantage|UHC MEDICARE GOLD MA|||||214.34||| C9604|EAP|0481||United Medicare Advantage|UHC AARP MCR HMO MA|||||22,505.70||| C9604|EAP|0481|PTCA/STENT/ATH SVG DES LD|United Medicare Advantage|UHC MEDICARE GOLD MA|||||22,505.70||| C9605|EAP|0481|PTCA/STENT/ATH SVG ADDL D|Medicare|MEDICARE ACUTE|||||11,252.85||| C9606|EAP|0481||Humana Medicare Advantage|HUMANA MA|22,505.70||||||| C9606|EAP|0481|PTCA/STENT/ATH/ACUTE DES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||214.34||| C9606|EAP|0481||Managed Medicare|HEALTHSPRING MA|214.34||||||| C9606|EAP|0481||Medicare|MEDICARE ACUTE|||||22,505.70||| C9607|EAP|0481||Medicare|MEDICARE ACUTE|22,505.70||||22,505.70||| C9607|EAP|0481||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22,505.70||| C9739|EAP|0510|CYSTOSCOPY PROSTATIC IMP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4,496.25||| C9739|EAP|0510|CYSTOSCOPY PROSTATIC IMP|Blue Cross PPO Specialty|BCBSTX PPO|||||4,496.25||| C9739|EAP|0510|CYSTOSCOPY PROSTATIC IMP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,496.25||| C9739|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||107.91||| C9739|EAP|0510|CYSTOSCOPY PROSTATIC IMP|Managed Medicare|BCBS MEDICARE PPO MA|||||107.91||| C9739|EAP|0510|CYSTOSCOPY PROSTATIC IMP|Medicare|MEDICARE ACUTE|||||4,496.25||| C9740|EAP|0510|CYSTO IMPL 4 OR MORE|Medicare|MEDICARE ACUTE|||||8,555.42||| C9740|EAP|0361||Managed Medicare|BCBS MEDICARE PPO MA|||||205.33||| C9740|EAP|0510|CYSTO IMPL 4 OR MORE|Managed Medicare|BCBS MEDICARE PPO MA|||||205.33||| C9740|EAP|0510|CYSTO IMPL 4 OR MORE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8,555.42||| C9740|EAP|0510|CYSTO IMPL 4 OR MORE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8,555.42||| C9740|EAP|0510|CYSTO IMPL 4 OR MORE|Blue Cross PPO Specialty|BCBSTX PPO|||||8,555.42||| D7140|EAP|0981|EXTRACT ERUPT/EXP TOOTH/R|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||199.75||| D7210|EAP|0981|CROWN RESIN-BASED INDIREC|Medicaid|SMITH COUNTY JAIL|||||7.92||| D7210|EAP|0981|REMOVAL ERUPTED TOOTH #9|Medicare|MEDICARE ACUTE|||||6.60||| D7210|EAP|0981|REMOVAL ERUPTED TOOTH #7|Medicare|MEDICARE ACUTE|||||6.60||| D7210|EAP|0981|CROWN RESIN-BASED INDIREC|Medicare|MEDICARE ACUTE|||||7.92||| D7210|EAP|0981|CROWN RESIN-BASED INDIREC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.92||| D7210|EAP|0981|REM IMP TOOTH W MUCOPER F|ChampVA|CHAMPVA CENTER|||||27.56||| D7210|EAP|0981|CROWN RESIN-BASED INDIREC|Blue Cross PPO Specialty|BCBSTX PPO|||||7.92||| D7250|EAP|0981|SX REMOVE TOOTH ROOTS RES|Workers Compensation|WORKERS COMPENSATION OTHER|||||494.50||| D7270|EAP|0981|TOOTH REIMPLANTATION|NON CONTRACTED|COMMERCIAL OTHER 1|||||13.36||| D7270|EAP|0981|TOOTH REIMPLANTATION|Medicare|MEDICARE ACUTE|||||13.36||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Aetna|BOON CHAPMAN|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Aetna|BH AETNA|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Aetna|AETNA QHP HMO|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Aetna|AETNA OTHER|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Blue Cross HMO Specialty|BCBSTX HMO|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Blue Cross PPO Specialty|BCBSTX PPO|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Blue Cross PPO Specialty|BCBSTX OTHER|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Magellan Behavioral Health|BH MAGELLAN|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|ChampVA|CHAMPVA CENTER|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Cigna|CIGNA OTHER|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Cigna Behavioral Health|BH CIGNA|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicaid|MEDICAID SUPERIOR|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicaid|MEDICAID AMERIGROUP|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|United Medicare Advantage|UHC AARP MCR HMO MA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Access Direct Platinum|HEALTHFIRST TPA|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Access Direct Platinum|ANDREWS CENTER|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Veterans Affairs|VETERANS ADMINISTRATION|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Workers Compensation|WORKERS COMPENSATION OTHER|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Workers Compensation|TEXAS MUTUAL INSURANCE|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicare|OTHER INSTITUTIONS|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicare|HEALTHSPRING MA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Cigna|CIGNA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Managed Medicare|BCBS MEDICARE PPO MA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|MEDICAID HMO|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Humana Medicare Advantage|HUMANA MA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|SMITH COUNTY JAIL|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|MEDICAID|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|LAW ENFORCEMENT OTHER|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|CRIME VICTIMS COMPENSATION|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicaid|BH TEXAS CHILDRENS MEDICAID|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Aetna|AETNA PPO|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Tricare|TRICARE EAST REGION|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|United Healthcare|UNITED HEALTHCARE OTHER|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|United Healthcare|UNITED HEALTHCARE|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|United Healthcare|TML GROUP BENEFITS|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicare|MEDICARE PART B ONLY IP|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Medicare|MEDICARE ACUTE|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|PHCS|GROUP AND PENSION|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|NON CONTRACTED|COMMUNITY HEALTH CENTER|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|NON CONTRACTED|COMMERCIAL OTHER 1|0.70||||0.70||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Rusk State Hospital|RUSK STATE HOSP|0.70||||||| G0008|EAP|0771|ADMIN INFLUENZA VACCINE|Optum Behavioral Health|BH OPTUM UHC|0.70||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|NON CONTRACTED|COMMERCIAL OTHER 1|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Rusk State Hospital|RUSK STATE HOSP|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Medicare|MEDICARE PART B ONLY IP|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Medicare|MEDICARE ACUTE|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|United Healthcare|UNITED HEALTHCARE|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|United Healthcare|UNITED HEALTHCARE|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|United Healthcare|TML GROUP BENEFITS|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Medicaid|SMITH COUNTY JAIL|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Medicaid|MEDICAID HMO|||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Medicaid|MEDICAID|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Medicaid|LAW ENFORCEMENT OTHER|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Medicaid|CRIME VICTIMS COMPENSATION|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicare|WELLCARE CHOICE MA|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicare|OTHER INSTITUTIONS|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicare|ETMC AFFILIATE HOSPITALS|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicare|BCBS MEDICARE PPO MA|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Veterans Affairs|VETERANS ADMINISTRATION|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Workers Compensation|WORKERS COMPENSATION OTHER|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Workers Compensation|UT EMPLOYEE INJURY|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Workers Compensation|TEXAS MUTUAL INSURANCE|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Workers Compensation|GALLAGHER BASSETT|||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicare|HEALTHSPRING MA|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Access Direct Platinum|HEALTHFIRST TPA UMR|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Access Direct Platinum|HEALTHFIRST TPA|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|United Medicare Advantage|UHC MEDICARE GOLD MA|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|United Medicare Advantage|UHC AARP MCR HMO MA|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Tricare|TRICARE EAST REGION|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicaid|MEDICAID SUPERIOR|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|United Healthcare|UNITED HEALTHCARE OTHER|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Managed Medicaid|MEDICAID AMERIGROUP|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Cigna|CIGNA OTHER|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Cigna|CIGNA|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Cigna|CIGNA|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Humana Medicare Advantage|HUMANA MA|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Blue Cross PPO Specialty|BCBSTX PPO|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Blue Cross PPO Specialty|BCBSTX OTHER|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Blue Cross HMO Specialty|BCBSTX HMO|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Aetna|BOON CHAPMAN|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Aetna|BH AETNA|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Aetna|AETNA PPO|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Aetna|AETNA OTHER|0.69||||||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.69||||0.69||| G0009|EAP|0771|ADMIN PNEUMOCOCCAL VACCIN|Aenta Medicare Advantage|AETNA MEDICARE MA|0.69||||0.69||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Aetna Value Network|AETNA VALUE NETWORK|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Aetna|AETNA PPO|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Blue Cross HMO Specialty|BCBSTX HMO|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Blue Cross PPO Specialty|BCBSTX OTHER|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|ChampVA|CHAMPVA CENTER|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Cigna|CIGNA OTHER|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Cigna|CIGNA|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Managed Medicaid|MEDICAID SUPERIOR|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Managed Medicaid|MEDICAID AMERIGROUP|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Access Direct Platinum|HEALTHFIRST TPA|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Blue Cross PPO Specialty|BCBSTX PPO|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Aetna|AETNA OTHER|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Medicaid|MEDICAID HMO|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Medicaid|MEDICAID|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Tricare|TRICARE EAST REGION|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|United Healthcare|UNITED HEALTHCARE OTHER|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|United Healthcare|UNITED HEALTHCARE|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|United Healthcare|TML GROUP BENEFITS|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|Multiplan|WEB TPA|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|PHCS|HUMANA INSURANCE|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|PHCS|GROUP AND PENSION|0.69||||||| G0010|EAP|0771|ADMIN HEPATITIS B VACCINE|NON CONTRACTED|COMMERCIAL OTHER 1|0.69||||||| G0103|EAP|0301|PSA SCREEN|Medicare|MEDICARE ACUTE|1.85||||||| G0103|EAP|0301|PSA SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.85||| G0103|EAP|0301|PSA SCREEN|United Medicare Advantage|UHC MEDICARE GOLD MA|1.85||||||| G0103|EAP|0301|PSA SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.85||||||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||194.58||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Managed Medicaid|MEDICAID AMERIGROUP|||||194.58||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Humana Medicare Advantage|HUMANA MA|208.15||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Cigna|CIGNA OTHER|||||194.58||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Cigna|CIGNA|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Cigna|CIGNA|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Blue Cross PPO Specialty|BCBSTX PPO|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Blue Cross HMO Specialty|BCBSTX HMO|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Aenta Medicare Advantage|AETNA MEDICARE MA|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Aetna|AETNA QHP HMO|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Aetna|AETNA PPO|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Access Direct Platinum|HEALTHFIRST TPA UMR|||||194.58||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Access Direct Platinum|HEALTHFIRST TPA|||||194.58||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|United Medicare Advantage|UHC AARP MCR HMO MA|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Managed Medicare|HEALTHSPRING MA|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Managed Medicare|BCBS MEDICARE PPO MA|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Medicaid|MEDICAID HMO|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|United Healthcare|UNITED HEALTHCARE OTHER|||||194.58||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|United Healthcare|UNITED HEALTHCARE|||||208.15||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|United Healthcare|UNITED HEALTHCARE|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Tricare|TRICARE EAST REGION|||||194.58||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.81||| G0108|EAP|0942|DIABETES INITIAL ASSESSME|Medicare|MEDICARE ACUTE|||||1.81||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Medicare|MEDICARE ACUTE|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Medicare|MEDICARE ACUTE|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Access Direct Platinum|HEALTHFIRST TPA|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Access Direct Platinum|HEALTHFIRST TPA|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||153.73||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||153.73||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Blue Cross PPO Specialty|BCBSTX PPO|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Blue Cross PPO Specialty|BCBSTX PPO|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 2 GROU|Humana Medicare Advantage|HUMANA MA|||||1.43||| G0109|EAP|0942|DIABETES EDUCATION 1 GROU|Humana Medicare Advantage|HUMANA MA|||||1.43||| G0257|EAP|0820||Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.49||||3,046.35||| G0257|EAP|0820||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,046.35||| G0257|EAP|0820||Humana Medicare Advantage|HUMANA MA|||||3,046.35||| G0257|EAP|0820||Blue Cross PPO Specialty|BCBSTX PPO|||||3,046.35||| G0257|EAP|0820||Aetna|AETNA OTHER|||||26.49||| G0257|EAP|0820||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,046.35||| G0257|EAP|0820||United Medicare Advantage|UHC MEDICARE GOLD MA|3,046.35||||3,046.35||| G0257|EAP|0820||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,046.35||| G0257|EAP|0820||United Medicare Advantage|UHC AARP MCR HMO MA|||||26.49||| G0257|EAP|0820||Medicaid|MEDICAID|||||3,046.35||| G0257|EAP|0820||Managed Medicare|OTHER INSTITUTIONS|||||3,046.35||| G0257|EAP|0820||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||26.49||| G0257|EAP|0820||Managed Medicare|HEALTHSPRING MA|2,847.68||||3,046.35||| G0257|EAP|0820||Managed Medicare|BCBS MEDICARE PPO MA|||||26.49||| G0257|EAP|0820||Tricare|TRICARE EAST REGION|||||3,046.35||| G0257|EAP|0820||Medicare|MEDICARE ACUTE|3,046.35||||26.49||| G0260|EAP|0361||Medicare|MEDICARE ACUTE|||||14.81||| G0260|EAP|0361||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||14.81||| G0260|EAP|0361||Managed Medicare|HEALTHSPRING MA|||||1,525.43||| G0260|EAP|0361||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||14.81||| G0260|EAP|0361||Tricare|TRICARE EAST REGION|||||1,569.86||| G0260|EAP|0361||United Medicare Advantage|UHC AARP MCR HMO MA|||||1,569.86||| G0260|EAP|0361||United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,525.43||| G0260|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||14.81||| G0260|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,569.86||| G0260|EAP|0361||Access Direct Platinum|HEALTHFIRST TPA|||||14.81||| G0260|EAP|0361||Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,569.86||| G0260|EAP|0361||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14.81||| G0260|EAP|0361||Blue Cross PPO Specialty|BCBSTX PPO|||||14.81||| G0260|EAP|0361||ChampVA|CHAMPVA CENTER|||||1,569.86||| G0260|EAP|0361||Humana Medicare Advantage|HUMANA MA|||||14.81||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Managed Medicaid|MEDICAID SUPERIOR|||||1,831.80||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Cigna|CIGNA|1,959.60||||||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Cigna|CIGNA|||||1,959.60||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Blue Cross PPO Specialty|BCBSTX PPO|||||17.04||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Humana Medicare Advantage|HUMANA MA|1,959.60||||1,959.60||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Blue Cross PPO Specialty|BCBSTX OTHER|1,959.60||||1,959.60||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||17.04||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,959.60||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Access Direct Platinum|HEALTHFIRST TPA|||||17.04||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,959.60||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|United Medicare Advantage|UHC AARP MCR HMO MA|1,959.60||||1,959.60||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||17.04||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Managed Medicare|HEALTHSPRING MA|||||1,959.60||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|United Healthcare|UNITED HEALTHCARE OTHER|||||17.04||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.04||||||| G0277|EAP|0413|HBOT, FULL BODY CHAMBER 3|Medicare|MEDICARE ACUTE|1,959.60||||17.04||| G0279|EAP|0401|BC DX DIGITAL TOMOSYNTHES|Medicare|MEDICARE ACUTE|||||136.90||| G0279|EAP|0401|BC DX DIGITAL TOMOSYNTHES|Access Direct Platinum|HEALTHFIRST TPA UMR|||||130.05||| G0279|EAP|0401|BC DX DIGITAL TOMOSYNTHES|Humana Medicare Advantage|HUMANA MA|||||136.90||| G0279|EAP|0401|BC DX DIGITAL TOMOSYNTHES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||130.05||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Aetna|AETNA OTHER|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Blue Cross HMO Specialty|BCBSTX HMO|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Blue Cross PPO Specialty|BCBSTX PPO|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Cigna|CIGNA OTHER|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Cigna|CIGNA|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Cigna|CIGNA|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|ChampVA|CHAMPVA CENTER|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Humana Medicare Advantage|HUMANA MA|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|United Medicare Advantage|UHC AARP MCR HMO MA|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.87||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Managed Medicare|HEALTHSPRING MA|||||1.87||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Managed Medicare|BCBS MEDICARE PPO MA|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Tricare|TRICARE EAST REGION|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|United Healthcare|UNITED HEALTHCARE OTHER|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|United Healthcare|UNITED HEALTHCARE|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|United Healthcare|UNITED HEALTHCARE|||||1.70||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|PHCS|HUMANA|||||2.04||| G0297|EAP|0350|CT-LOW DOSE CT-LUNG SCREE|Medicare|MEDICARE ACUTE|||||2.04||| G0328|EAP|0300||Medicare|MEDICARE ACUTE|0.66||||0.66||| G0328|EAP|0300||Tricare|TRICARE EAST REGION|||||0.66||| G0328|EAP|0300||Medicaid|MEDICAID|||||0.66||| G0328|EAP|0300||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.66||||0.66||| G0328|EAP|0300||Managed Medicare|HEALTHSPRING MA|0.66||||0.66||| G0328|EAP|0300||Managed Medicare|BCBS MEDICARE PPO MA|0.66||||0.66||| G0328|EAP|0300||Veterans Affairs|VETERANS ADMINISTRATION|||||0.66||| G0328|EAP|0300||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.66||| G0328|EAP|0300||Tricare|TRICARE FOR LIFE|||||0.66||| G0328|EAP|0300||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.66||| G0328|EAP|0300||Access Direct Platinum|HEALTHFIRST TPA|||||0.66||| G0328|EAP|0300||United Medicare Advantage|UHC AARP MCR HMO MA|||||0.66||| G0328|EAP|0300||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.66||||0.66||| G0328|EAP|0300||United Medicare Advantage|UHC MEDICARE GOLD MA|0.66||||0.66||| G0328|EAP|0300||Humana Medicare Advantage|HUMANA MA|0.66||||0.66||| G0328|EAP|0300||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.66||| G0328|EAP|0300||Managed Medicaid|MEDICAID SUPERIOR|||||0.66||| G0328|EAP|0300||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.66||| G0328|EAP|0300||Managed Medicaid|MEDICAID AMERIGROUP|0.66||||0.66||| G0328|EAP|0300||Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.66||| G0365|EAP|0921||United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,930.94||| G0365|EAP|0921||Medicare|MEDICARE ACUTE|||||4,930.94||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Managed Medicare|OTHER INSTITUTIONS|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NOA|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Managed Medicare|WELLCARE CHOICE MA|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Managed Medicare|OTHER INSTITUTIONS|||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Managed Medicare|HOSPICE OF EAST TEXAS|1.27||||||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Managed Medicare|BCBS MEDICARE PPO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Medicaid|SMITH COUNTY JAIL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Medicaid|LAW ENFORCEMENT OTHER|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Medicaid|SMITH COUNTY JAIL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Medicaid|MEDICAID HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Medicaid|MEDICAID HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Medicaid|MEDICAID BCBSTX|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Medicaid|MEDICAID BCBSTX|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Medicaid|MEDICAID|1.27||||121.75||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Medicaid|SMITH COUNTY JAIL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|United Healthcare|GOLDEN RULE|1.27||||||| G0378|EAP|0762|OBSERVATION PER HR 3NO|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Tricare|TRICARE FOR LIFE|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Tricare|TRICARE FOR LIFE|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Tricare|TRICARE FOR LIFE|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|PHCS|HUMANA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|PHCS|GROUP AND PENSION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|PHCS|HUMANA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Medicare|MEDICARE PART B ONLY IP|1.27||||||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Medicare|MEDICARE PART B ONLY IP|1.27||||||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Medicare|MEDICARE PART B ONLY IP|1.27||||||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Medicare|MEDICARE PART B ONLY IP|1.27||||||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Medicare|MEDICARE PART B ONLY IP|1.27||||||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Medicare|MEDICARE PART B ONLY IP|1.27||||||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.27||||126.50||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR PSYCH|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Blue Cross PPO Specialty|BCBSTX OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Blue Cross PPO Specialty|BCBSTX OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Blue Cross PPO Specialty|BCBSTX OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Blue Cross PPO Specialty|BCBSTX OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Blue Cross PPO Specialty|BCBSTX OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Blue Cross PPO Specialty|BCBSTX OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WB|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Blue Cross PPO Specialty|BCBSTX OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Blue Cross PPO Specialty|BCBSTX OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Blue Cross HMO Specialty|BCBSTX HMO|2.17||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||126.50||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Aetna Value Network|AETNA VALUE NETWORK|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Aetna|AETNA PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Aetna|AETNA OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Aetna|AETNA PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Aetna|AETNA PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|Aetna|AETNA PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Aetna|AETNA PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Aetna|AETNA OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Aetna|AETNA PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Aetna|AETNA OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Aetna|AETNA PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WB|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR PSYCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Aenta Medicare Advantage|AETNA MEDICARE MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Aetna|AETNA PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Aetna|AETNA QHP HMO|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Blue Cross HMO Specialty|BCBSTX HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Managed Medicaid|MEDICAID SUPERIOR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Managed Medicaid|MEDICAID AMERIGROUP|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|ChampVA|CHAMPVA CENTER|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Cigna|CIGNA|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Cigna|CIGNA OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Cigna|CIGNA OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Cigna|CIGNA OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Blue Cross PPO Specialty|BCBSTX PPO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Cigna|CIGNA|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Cigna|CIGNA|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Cigna|CIGNA OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Cigna|CIGNA|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Cigna|CIGNA OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Cigna|CIGNA|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Cigna|CIGNA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NOB|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WB|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Medicare|MEDICARE ACUTE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Humana Medicare Advantage|HUMANA MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|NON CONTRACTED|COMMERCIAL OTHER 2|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|Access Direct Platinum|HEALTHFIRST TPA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|NON CONTRACTED|COMMERCIAL OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Access Direct Platinum|HEALTHFIRST TPA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Tricare|TRICARE EAST REGION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Access Direct Platinum|HEALTHFIRST TPA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|United Healthcare|GEHA|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Access Direct Platinum|HEALTHFIRST TPA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|United Healthcare|TML GROUP BENEFITS|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Access Direct Platinum|HEALTHFIRST TPA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Access Direct Platinum|HEALTHFIRST TPA UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|United Healthcare|UNITED HEALTHCARE OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||2.17||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|United Healthcare|UNITED HEALTHCARE|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Medicaid|MEDICAID|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Veterans Affairs|VETERANS ADMINISTRATION|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Workers Compensation|WORKERS COMPENSATION OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|Workers Compensation|WORKERS COMPENSATION OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|Workers Compensation|WORKERS COMPENSATION OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|Workers Compensation|WORKERS COMPENSATION OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|Workers Compensation|GALLAGHER BASSETT|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Workers Compensation|WORKERS COMPENSATION OTHER|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SP PE|Medicaid|MEDICAID HMO|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6NO|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NOB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WB|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WC|Managed Medicare|OTHER INSTITUTIONS|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 5NO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4WA|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WC|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 6SO|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WB|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|Managed Medicare|OTHER INSTITUTIONS|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3WA|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3SO|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NOA|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NO|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 3NOA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WC|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WB|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2WA|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 4NO|Managed Medicare|HEALTHSPRING MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2SO|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOB|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|United Medicare Advantage|UHC AARP WELLMED HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HR 2NOA|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|United Medicare Advantage|UHC MEDICARE GOLD MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.27||||1.27||| G0378|EAP|0762|OBSERVATION PER HOUR ERW|United Medicare Advantage|UHC AARP MCR HMO MA|1.27||||1.27||| G0379|EAP|0762|OBSERVATION DIRECT ADMIT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.32||| G0406|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|||||2.25||| G0434|EAP|0300||Blue Cross HMO Specialty|BCBSTX HMO|||||430.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Humana Medicare Advantage|HUMANA MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Humana Medicare Advantage|HUMANA MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Humana Medicare Advantage|HUMANA MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Humana Medicare Advantage|HUMANA MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Humana Medicare Advantage|HUMANA MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Humana Medicare Advantage|HUMANA MA|2.00||||1.50||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Humana Medicare Advantage|HUMANA MA|2.00||||1.75||| G0463|EAP|0510|E&M NP L3|Humana Medicare Advantage|HUMANA MA|2.00||||5.64||| G0463|EAP|0510|E&M EP L4|Humana Medicare Advantage|HUMANA MA|2.00||||711.60||| G0463|EAP|0510|E&M EP L3|Humana Medicare Advantage|HUMANA MA|2.00||||5.64||| G0463|EAP|0510|E&M EP L2|Humana Medicare Advantage|HUMANA MA|2.00||||490.80||| G0463|EAP|0510|E&M EP L1|Humana Medicare Advantage|HUMANA MA|2.00||||327.60||| G0463|EAP|0510|CLINIC OP VISIT LEVEL 1 E|Humana Medicare Advantage|HUMANA MA|2.00||||416.40||| G0463|EAP|0510||Humana Medicare Advantage|HUMANA MA|2.00||||4.09||| G0463|EAP|0510||Humana Medicare Advantage|HUMANA MA|2.00||||2.00||| G0463|EAP|0510||Humana Medicare Advantage|HUMANA MA|2.00||||1.50||| G0463|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||4.15||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Magellan Behavioral Health|BH MAGELLAN|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Cigna|CIGNA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Cigna|CIGNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Cigna|CIGNA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Cigna|CIGNA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Cigna|CIGNA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Cigna|CIGNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Cigna|CIGNA OTHER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Cigna|CIGNA OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Cigna|CIGNA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Cigna|CIGNA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Cigna|CIGNA|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Cigna|CIGNA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Cigna|CIGNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Cigna|CIGNA OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Cigna|CIGNA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Cigna|CIGNA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Cigna|CIGNA|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Cigna|CIGNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Cigna|CIGNA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Cigna|CIGNA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Cigna|CIGNA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Cigna|CIGNA OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Cigna|CIGNA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Cigna|CIGNA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Cigna|CIGNA|||||1.50||| G0463|EAP|0510||Cigna|CIGNA OTHER|||||2.00||| G0463|EAP|0510||Cigna|CIGNA|||||2.00||| G0463|EAP|0510||Cigna|CIGNA|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|ChampVA|CHAMPVA CENTER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|ChampVA|CHAMPVA CENTER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|ChampVA|CHAMPVA CENTER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|ChampVA|CHAMPVA CENTER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|ChampVA|CHAMPVA CENTER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|ChampVA|CHAMPVA CENTER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|ChampVA|CHAMPVA CENTER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|ChampVA|CHAMPVA CENTER|||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|ChampVA|CHAMPVA CENTER|||||1.75||| G0463|EAP|0510||ChampVA|CHAMPVA CENTER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID SUPERIOR|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID SUPERIOR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID SUPERIOR|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID SUPERIOR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID SUPERIOR|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID SUPERIOR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID SUPERIOR|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID SUPERIOR|||||1.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID SUPERIOR|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID SUPERIOR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|MEDICAID SUPERIOR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 80 MI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.25||| G0463|EAP|0510|OFFICE CONSULTATION 80 MI|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.25||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Managed Medicaid|MEDICAID SUPERIOR|||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.75||| G0463|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.00||| G0463|EAP|0510||Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.50||| G0463|EAP|0510||Managed Medicaid|MEDICAID SUPERIOR|||||1.50||| G0463|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||2.00||| G0463|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.75||| G0463|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.50||| G0463|EAP|0510||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.25||| G0463|EAP|0510||Managed Medicaid|MEDICAID AMERIGROUP|1.75||||2.00||| G0463|EAP|0510||Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.75||| G0463|EAP|0510|E&M EP L3|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||4.70||| G0463|EAP|0510|E&M EP L2|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||490.80||| G0463|EAP|0510||Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Aetna Value Network|AETNA VALUE NETWORK|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna Value Network|AETNA VALUE NETWORK|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna Value Network|AETNA VALUE NETWORK|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Aetna Value Network|AETNA VALUE NETWORK|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna Value Network|AETNA VALUE NETWORK|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Aetna|AETNA PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna Value Network|AETNA VALUE NETWORK|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aetna Value Network|AETNA VALUE NETWORK|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aetna Value Network|AETNA VALUE NETWORK|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Aetna|AETNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Aetna|AETNA PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Aetna|AETNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Aetna|AETNA OTHER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|BOON CHAPMAN|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|BOON CHAPMAN|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|AETNA QHP HMO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|AETNA PPO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|AETNA PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|AETNA PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|AETNA PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|AETNA OTHER|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|AETNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|AETNA OTHER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aetna|AETNA OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Aetna|BOON CHAPMAN|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Aetna|AETNA PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Aetna|AETNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna|BOON CHAPMAN|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna|AETNA PPO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna|AETNA PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna|AETNA PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Aenta Medicare Advantage|AETNA MEDICARE MA|2.00||||1.50||| G0463|EAP|0510||Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna|AETNA PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna|AETNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna|AETNA OTHER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Aetna|AETNA OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aetna|BOON CHAPMAN|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aetna|BOON CHAPMAN|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.25||| G0463|EAP|0510||Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.25||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 80 MI|Managed Medicaid|MEDICAID SUPERIOR|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aetna|BOON CHAPMAN|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| G0463|EAP|0510|OFFICE CONSULTATION 80 MI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.25||| G0463|EAP|0510|OFFICE CONSULTATION 60 MI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| G0463|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.00||| G0463|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.00||| G0463|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| G0463|EAP|0510||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aetna|AETNA PPO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aetna|AETNA PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aetna|AETNA PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aetna|AETNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID AMERIGROUP|1.75||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Aetna|AETNA OTHER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aetna|BOON CHAPMAN|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aetna|AETNA PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aetna|AETNA PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aetna|AETNA PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aetna|AETNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Aetna|AETNA OTHER|||||1.75||| G0463|EAP|0510||Aetna|AETNA PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID SUPERIOR|||||2.25||| G0463|EAP|0000||Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| G0463|EAP|0510||Aetna|AETNA PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.00||| G0463|EAP|0510||Aetna|AETNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID SUPERIOR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 60 MI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.75||| G0463|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID SUPERIOR|||||1.75||| G0463|EAP|0510||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.25||||1.75||| G0463|EAP|0510|E&M EP L2|ChampVA|CHAMPVA CENTER|||||4.09||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|ChampVA|CHAMPVA CENTER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross PPO Specialty|BCBSTX PPO|||||1.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| G0463|EAP|0510||Cigna|CIGNA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Cigna|CIGNA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Cigna|CIGNA|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Cigna|CIGNA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 80 MI|Blue Cross PPO Specialty|BCBSTX PPO|||||2.25||| G0463|EAP|0510|OFFICE CONSULTATION 60 MI|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Blue Cross PPO Specialty|BCBSTX PPO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Cigna|CIGNA OTHER|||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||1.75||| G0463|EAP|0510|E&M EP L3|Blue Cross PPO Specialty|BCBSTX PPO|||||5.64||| G0463|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| G0463|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Cigna|CIGNA|||||2.25||| G0463|EAP|0510||Blue Cross PPO Specialty|BCBSTX PPO|||||1.25||| G0463|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||2.00||| G0463|EAP|0510||Blue Cross PPO Specialty|BCBSTX OTHER|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Cigna|CIGNA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| G0463|EAP|0510||Humana Medicare Advantage|HUMANA MA|1.75||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.75||| G0463|EAP|0510||Humana Medicare Advantage|HUMANA MA|2.00||||7.10||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.75||| G0463|EAP|0510||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross HMO Specialty|BCBSTX HMO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Humana Medicare Advantage|HUMANA MA|2.00||||2.00||| G0463|EAP|0510||Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Humana Medicare Advantage|HUMANA MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross HMO Specialty|BCBSTX HMO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Humana Medicare Advantage|HUMANA MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross HMO Specialty|BCBSTX HMO|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Blue Cross HMO Specialty|BCBSTX HMO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|AARP|||||2.00||| G0463|EAP|0510|E&M EP L4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||5.93||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.25||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Workers Compensation|UT EMPLOYEE INJURY|||||1.50||| G0463|EAP|0761|BC E&M LEVEL 1|Managed Medicare|HEALTHSPRING MA|||||481.20||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Managed Medicare|HEALTHSPRING MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Medicaid|MEDICAID|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|GOLDEN RULE|||||2.00||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|UNITED HEALTHCARE OTHER|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Healthcare|UNITED HEALTHCARE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||2.00||| G0463|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| G0463|EAP|0510|E&M EP L2|Managed Medicare|HEALTHSPRING MA|2.00||||4.09||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Multiplan|WEB TPA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|BCBS MEDICARE PPO MA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|HEALTHSPRING MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|HEALTHSPRING MA|2.00||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 60 MI|United Healthcare|UNITED HEALTHCARE ERS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicare|HEALTHSPRING MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|HEALTHSPRING MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|BCBS MEDICARE PPO MA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|MEDICAID|2.00||||1.50||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicaid|MEDICAID|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Workers Compensation|UT EMPLOYEE INJURY|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|AARP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Workers Compensation|UT EMPLOYEE INJURY|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.00||| G0463|EAP|0510|E&M EP L3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.64||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|TEXAS MUTUAL INSURANCE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Tricare|TRICARE EAST REGION|||||2.00||| G0463|EAP|0510||Managed Medicare|BCBS MEDICARE PPO MA|||||1.50||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST TPA|||||2.25||| G0463|EAP|0510||Managed Medicare|HEALTHSPRING MA|2.00||||8.52||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|BCBS MEDICARE PPO MA|||||1.75||| G0463|EAP|0510|E&M EP L2|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||490.80||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicare|MEDICARE ACUTE|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicare|MEDICARE PART B ONLY IP|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|HEALTHSPRING MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|UT EMPLOYEE INJURY|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|TEXAS COMMUNITY CARE MA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicare|ADVANTRA FREEDOM MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Humana Medicare Advantage|HUMANA MA|2.00||||1.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|OTHER INSTITUTIONS|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicare|HEALTHSPRING MA|2.00||||2.00||| G0463|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|BCBS MEDICARE PPO MA|||||1.50||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.25||| G0463|EAP|0510||United Healthcare|GOLDEN RULE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE ERS|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicaid|MEDICAID|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicaid|MEDICAID|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|MEDICAID|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|TML GROUP BENEFITS|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicaid|MEDICAID|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|United Healthcare|UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Humana Medicare Advantage|HUMANA MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Access Direct Platinum|HEALTHFIRST TPA|||||2.00||| G0463|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Healthcare|TML GROUP BENEFITS|||||2.00||| G0463|EAP|0510|E&M EP L3|Workers Compensation|BROOKSHIRES WORKERS COMP|||||4.70||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|BROOKSHIRES WORKERS COMP|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Healthcare|UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Veterans Affairs|VETERANS ADMINISTRATION|2.25||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Tricare|TRICARE EAST REGION|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Tricare|TRICARE EAST REGION|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Tricare|TRICARE EAST REGION|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|UT EMPLOYEE INJURY|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|PHCS|HUMANA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Tricare|TRICARE EAST REGION|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|PHCS|HUMANA INSURANCE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Tricare|TRICARE EAST REGION|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Tricare|TRICARE FOR LIFE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Veterans Affairs|VETERANS ADMINISTRATION|2.25||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|PHCS|HUMANA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|PHCS|HUMANA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|PHCS|HUMANA INSURANCE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| G0463|EAP|0510|E&M EP L2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||490.80||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.25||| G0463|EAP|0510|E&M EP L4|Managed Medicare|BCBS MEDICARE PPO MA|||||5.93||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|HEALTHSPRING MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicare|MEDICARE ACUTE|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|HEALTHSPRING MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicare|MEDICARE ACUTE|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|HEALTHSPRING MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Multiplan|WEB TPA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|BCBS MEDICARE PPO MA|||||1.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicare|MEDICARE ACUTE|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|BCBS MEDICARE PPO MA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicare|MEDICARE ACUTE|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicare|MEDICARE ACUTE|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicare|UTSW MC KIDNEY PROGRAM|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Multiplan|NALC|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|UNIVERSAL HEALTHCARE MA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|HEALTHSPRING MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.00||| G0463|EAP|0510||Multiplan|NEW ERA LIFE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|BCBS MEDICARE PPO MA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.75||| G0463|EAP|0510||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicare|MEDICARE ACUTE|2.00||||1.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| G0463|EAP|0510||Medicaid|MEDICAID|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|HEALTHSPRING MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Humana Medicare Advantage|HUMANA MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicaid|MEDICAID|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|TML GROUP BENEFITS|||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|United Healthcare|GOLDEN RULE|||||1.75||| G0463|EAP|0510|E&M EP L2|Workers Compensation|BROOKSHIRES WORKERS COMP|||||4.09||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|AARP|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|MEDICAID|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicaid|MEDICAID HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicaid|MEDICAID|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|United Healthcare|UNITED HEALTHCARE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|MEDICAID|2.00||||2.25||| G0463|EAP|0761||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.15||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicaid|SMITH COUNTY JAIL|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|GEHA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|MEDICAID|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA|||||2.00||| G0463|EAP|0510|E&M EP L3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||5.64||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|United Healthcare|UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE ERS|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|GEHA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.00||| G0463|EAP|0510|E&M EP L2|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||490.80||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Workers Compensation|BROOKSHIRES WORKERS COMP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Workers Compensation|UT EMPLOYEE INJURY|||||2.00||| G0463|EAP|0510||Tricare|TRICARE EAST REGION|||||1.50||| G0463|EAP|0510|E&M EP L1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||327.60||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|TML GROUP BENEFITS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| G0463|EAP|0510|E&M EP L2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||490.80||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Healthcare|UNITED HEALTHCARE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Healthcare|GEHA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Healthcare|UNITED HEALTHCARE|||||1.50||| G0463|EAP|0510|E&M EP L2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||490.80||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|BROOKSHIRES WORKERS COMP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.75||| G0463|EAP|0510|E&M EP L3|Tricare|TRICARE EAST REGION|||||5.17||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|TEXAS MUTUAL INSURANCE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|TEXAS MUTUAL INSURANCE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Tricare|TRICARE EAST REGION|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Tricare|TRICARE EAST REGION|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|UT EMPLOYEE INJURY|||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 80 MI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Tricare|TRICARE FOR LIFE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Tricare|TRICARE EAST REGION|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.75||| G0463|EAP|0510||NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|ZURICH COMPANY|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Texas Workforce Commission|DIS DETER SERV (DDS)|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|PHCS|HUMANA INSURANCE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Veterans Affairs|VETERANS ADMINISTRATION|2.25||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Tricare|TRICARE FOR LIFE|||||2.00||| G0463|EAP|0510|E&M EP L3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||4.70||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Rusk State Hospital|RUSK STATE HOSP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|PHCS|HUMANA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|PHCS|GROUP AND PENSION|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|PHCS|HUMANA|||||1.50||| G0463|EAP|0510|E&M EP L2|Managed Medicare|BCBS MEDICARE PPO MA|||||4.09||| G0463|EAP|0510||Managed Medicare|HEALTHSPRING MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|PHCS|HUMANA INSURANCE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|PHCS|GROUP AND PENSION|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||2.00||| G0463|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.50||| G0463|EAP|0510|E&M EP L2|Medicare|MEDICARE ACUTE|2.25||||490.80||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| G0463|EAP|0510||Medicare|MEDICARE ACUTE|2.00||||1.50||| G0463|EAP|0510|E&M EP L3|Managed Medicare|BCBS MEDICARE PPO MA|||||4.70||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|PHCS|HUMANA|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.25||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Managed Medicare|BCBS MEDICARE PPO MA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Humana Medicare Advantage|HUMANA MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| G0463|EAP|0761||Medicare|MEDICARE ACUTE|||||289.20||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.25||| G0463|EAP|0510||Medicare|MEDICARE ACUTE|2.25||||1.75||| G0463|EAP|0510||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|BCBS MEDICARE PPO MA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Managed Medicare|HEALTHSPRING MA|2.00||||2.00||| G0463|EAP|0510|E&M EP L1|Medicare|MEDICARE ACUTE|2.00||||2.73||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|MEDICARE ADVANTAGE PHYSICIAN|||||2.00||| G0463|EAP|0761||United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.98||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Medicare|MEDICARE ACUTE|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|HEALTHSPRING MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicare|MEDICARE ACUTE|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|BCBS MEDICARE PPO MA|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicare|MEDICARE PART B ONLY IP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicare|MEDICARE PART B ONLY IP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Medicare|MEDICARE ACUTE|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|HEALTHSPRING MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|HEALTHSPRING MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicare|MEDICARE ACUTE|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Multiplan|WEB TPA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|United Healthcare|GEHA|||||1.75||| G0463|EAP|0510||Medicaid|MEDICAID HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.50||| G0463|EAP|0510|E&M NP L3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||5.64||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Medicaid|MEDICAID HMO|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|HEALTHSPRING MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicare|BCBS MEDICARE PPO MA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|OTHER INSTITUTIONS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Humana Medicare Advantage|HUMANA MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Medicaid|MEDICAID HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|OTHER INSTITUTIONS|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|OTHER INSTITUTIONS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|BCBS MEDICARE PPO MA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Managed Medicare|HEALTHSPRING MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Humana Medicare Advantage|HUMANA MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.00||| G0463|EAP|0510||Medicaid|MEDICAID|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Humana Medicare Advantage|HUMANA MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|BCBS MEDICARE PPO MA|||||1.50||| G0463|EAP|0510|E&M EP L4|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||652.30||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|MEDICAID HMO|||||1.75||| G0463|EAP|0510||United Healthcare|UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.75||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|TML GROUP BENEFITS|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|CRIME VICTIMS COMPENSATION|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicaid|MEDICAID HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|MEDICAID HMO|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|CRIME VICTIMS COMPENSATION|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|MEDICAID HMO|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicaid|MEDICAID|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|GOLDEN RULE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Humana Medicare Advantage|HUMANA MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| G0463|EAP|0510||Workers Compensation|WORKERS COMPENSATION OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|MEDICAID|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Humana Medicare Advantage|HUMANA MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA|||||1.75||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.50||| G0463|EAP|0510|E&M EP L3|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.64||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|UNITED HEALTHCARE OTHER|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|AARP|||||2.00||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|GEHA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|UNITED HEALTHCARE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|TML GROUP BENEFITS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Medicaid|MEDICAID|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|UNITED HEALTHCARE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Tricare|TRICARE FOR LIFE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|TML GROUP BENEFITS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.50||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| G0463|EAP|0510||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Humana Medicare Advantage|HUMANA MA|2.00||||1.50||| G0463|EAP|0510|E&M EP L2|Workers Compensation|WORKERS COMPENSATION OTHER|||||490.80||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|UNITED HEALTHCARE OTHER|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|United Healthcare|GEHA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Workers Compensation|BROOKSHIRES WORKERS COMP|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|GEHA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Workers Compensation|UT EMPLOYEE INJURY|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Workers Compensation|UT EMPLOYEE INJURY|||||2.00||| G0463|EAP|0510|E&M EP L1|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.73||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Healthcare|UNITED HEALTHCARE ERS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Humana Medicare Advantage|HUMANA MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Humana Medicare Advantage|HUMANA MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|UNITED HEALTHCARE|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|UNITED HEALTHCARE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|UNITED HEALTHCARE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|TML GROUP BENEFITS|||||1.75||| G0463|EAP|0510|E&M EP L2|Access Direct Platinum|HEALTHFIRST TPA|||||4.09||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Access Direct Platinum|HEALTHFIRST TPA|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Healthcare|UNITED HEALTHCARE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Workers Compensation|UT EMPLOYEE INJURY|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|BROOKSHIRES WORKERS COMP|||||1.75||| G0463|EAP|0510|E&M EP L2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.09||| G0463|EAP|0510||United Medicare Advantage|SECURE HORIZONS MA|||||1.50||| G0463|EAP|0510|E&M EP L3|Tricare|TRICARE FOR LIFE|||||5.64||| G0463|EAP|0510|E&M EP L3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.70||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Healthcare|UNITED HEALTHCARE OTHER|||||2.00||| G0463|EAP|0510|E&M EP L3|Access Direct Platinum|HEALTHFIRST TPA|||||5.17||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Healthcare|UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|United Healthcare|UNITED HEALTHCARE OTHER|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||2.00||| G0463|EAP|0510||Tricare|TRICARE FOR LIFE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.25||| G0463|EAP|0761||United Medicare Advantage|UHC AARP MCR HMO MA|||||4.98||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Healthcare|UNITED HEALTHCARE OTHER|||||1.75||| G0463|EAP|0510||Tricare|TRICARE EAST REGION|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Healthcare|UNITED HEALTHCARE ERS|||||2.00||| G0463|EAP|0510||Tricare|TRICARE EAST REGION|||||4.09||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Tricare|TRICARE EAST REGION|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|United Healthcare|UNITED HEALTHCARE ERS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|TRAVELERS INSURANCE COMPANY|||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Tricare|TRICARE EAST REGION|||||1.75||| G0463|EAP|0510|E&M EP L4|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.93||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Tricare|TRICARE EAST REGION|||||1.50||| G0463|EAP|0510|E&M EP L4|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.93||| G0463|EAP|0510||United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Tricare|TRICARE EAST REGION|||||1.75||| G0463|EAP|0510|E&M EP L4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||711.60||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Tricare|TRICARE FOR LIFE|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Tricare|TRICARE EAST REGION|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Texas Workforce Commission|DIS DETER SERV (DDS)|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|WORKERS COMP PHYSICIAN|||||1.75||| G0463|EAP|0510|E&M NP L4|Access Direct Platinum|HEALTHFIRST TPA|||||8.52||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|PHCS|HUMANA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Tricare|TRICARE FOR LIFE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Tricare|TRICARE SOUTH PHYSICIAN|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Tricare|TRICARE EAST REGION|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Tricare|TRICARE EAST REGION|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Veterans Affairs|VETERANS ADMINISTRATION|2.25||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Tricare|TRICARE EAST REGION|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|PHCS|GROUP AND PENSION|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Texas Workforce Commission|DIS DETER SERV (DDS)|||||2.00||| G0463|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Veterans Affairs|VETERANS ADMINISTRATION|2.25||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Tricare|TRICARE FOR LIFE|||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 60 MI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Tricare|TRICARE EAST REGION|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Veterans Affairs|VETERANS ADMINISTRATION|2.25||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Tricare|TRICARE EAST REGION|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 80 MI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.25||| G0463|EAP|0761||Managed Medicare|BCBS MEDICARE PPO MA|||||4.15||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|PHCS|HUMANA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST TPA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|PHCS|HUMANA INSURANCE|||||2.00||| G0463|EAP|0510||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.25||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|PHCS|MULTIPLAN PHCS|||||2.00||| G0463|EAP|0510||Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|PHCS|HUMANA INSURANCE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.00||| G0463|EAP|0510||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||8.52||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|PHCS|HUMANA|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|PHCS|HUMANA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.75||| G0463|EAP|0510||Managed Medicare|HEALTHSPRING MA|2.25||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|PHCS|MULTIPLAN PHCS|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|PHCS|HUMANA|||||2.00||| G0463|EAP|0510|E&M EP L3|Managed Medicare|HEALTHSPRING MA|2.00||||5.64||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST TPA|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|PHCS|HUMANA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|PHCS|HUMANA INSURANCE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|PHCS|HUMANA INSURANCE|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| G0463|EAP|0510||United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.00||| G0463|EAP|0510|E&M EP L2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||490.80||| G0463|EAP|0761||Medicare|MEDICARE ACUTE|||||4.15||| G0463|EAP|0510|E&M EP L1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||327.60||| G0463|EAP|0510|OFFICE CONSULTATION 60 MI|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| G0463|EAP|0510|E&M EP L4|Managed Medicare|HEALTHSPRING MA|2.00||||711.60||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|PHCS|GROUP AND PENSION|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|PHCS|HUMANA|||||2.00||| G0463|EAP|0761|BC E&M LEVEL 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.01||| G0463|EAP|0510||Medicare|MEDICARE ACUTE|2.25||||7.10||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|BCBS MEDICARE PPO MA|||||1.50||| G0463|EAP|0510|OFFICE CONSULTATION 60 MI|Managed Medicare|BCBS MEDICARE PPO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|NON CONTRACTED|COMMERCIAL OTHER 4|||||2.00||| G0463|EAP|0510||Medicare|MEDICARE ACUTE|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Managed Medicare|HEALTHSPRING MA|2.00||||2.00||| G0463|EAP|0510|E&M EP L2|Medicare|MEDICARE PART B ONLY IP|||||4.09||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA|||||1.75||| G0463|EAP|0761|BC E&M LEVEL 1|Medicare|MEDICARE ACUTE|||||481.20||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| G0463|EAP|0510|CLINIC OP VISIT LEVEL 1 E|Medicare|MEDICARE ACUTE|2.00||||416.40||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Multiplan|TRUSTMARK|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicare|MEDICARE PART B ONLY IP|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||1.75||| G0463|EAP|0510|E&M EP L3|Medicare|MEDICARE ACUTE|2.00||||5.64||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Access Direct Platinum|HEALTHFIRST TPA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC AARP WELLMED HMO MA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| G0463|EAP|0510|E&M NP L3|Medicare|MEDICARE ACUTE|2.00||||5.64||| G0463|EAP|0510|E&M EP L4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||5.93||| G0463|EAP|0510|E&M EP L4|Medicare|MEDICARE ACUTE|2.00||||711.60||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicare|MEDICARE ACUTE|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicare|MEDICARE ACUTE|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicare|MEDICARE ACUTE|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Medicare|MEDICARE ACUTE|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT CONSULT|Medicare|MEDICARE ACUTE|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Humana Medicare Advantage|HUMANA MA|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicare|MEDICARE ACUTE|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Multiplan|WEB TPA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Managed Medicare|HEALTHSPRING MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicare|MEDICARE ACUTE|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicare|MEDICARE ACUTE|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Multiplan|GILSBAR INC|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicare|MEDICARE ACUTE|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,E|Medicare|MEDICARE ACUTE|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.00||| G0463|EAP|0510|E&M EP L3|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||5.64||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Medicare|MEDICARE PART B ONLY IP|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicare|MEDICARE ACUTE|2.00||||1.25||| G0463|EAP|0510|E&M EP L3|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||5.64||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Humana Medicare Advantage|HUMANA MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicare|MEDICARE ACUTE|2.00||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Medicare|MEDICARE ACUTE|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Multiplan|WEB TPA|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,N|Medicare|MEDICARE ACUTE|2.00||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.00||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.25||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Managed Medicare|HEALTHSPRING MA|2.00||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Multiplan|PACIFICARE|||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Medicaid|MEDICAID|2.00||||1.75||| G0463|EAP|0510|E&M EP L4|United Medicare Advantage|UHC AARP MCR HMO MA|2.00||||711.60||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Access Direct Platinum|HEALTHFIRST TPA|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.00||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|United Medicare Advantage|UHC MEDICARE GOLD MA|2.00||||1.75||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Tricare|TRICARE EAST REGION|||||1.50||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT N|Tricare|TRICARE FOR LIFE|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT V|Tricare|TRICARE EAST REGION|||||2.00||| G0463|EAP|0510|OFFICE CONSULTATION 40 MI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.75||| G0463|EAP|0510|OFFICE/OUTPATIENT VISIT,|PHCS|HUMANA INSURANCE|||||1.75||| G0475|EAP|0300||Blue Cross HMO Specialty|BCBSTX HMO|||||819.95||| G0475|EAP|0300||Managed Medicare|HEALTHSPRING MA|7.13||||7.13||| G0475|EAP|0300||Medicare|UTSW MC KIDNEY PROGRAM|||||766.48||| G0475|EAP|0300||Medicare|MEDICARE ACUTE|819.95||||7.13||| G0479|EAP|0300||Medicare|MEDICARE ACUTE|4.43||||4.43||| G0479|EAP|0300||Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.43||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicare|BCBS MEDICARE PPO MA|239.80||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicare|MA PART B ONLY IP|2.18||||||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|CRIME VICTIMS COMPENSATION|2.18||||||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|MEDICAID BCBSTX|||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.18||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|239.80||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Access Direct Platinum|HEALTHFIRST TPA|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Workers Compensation|TRAVELERS INSURANCE COMPANY|2.18||||||| G0480|EAP|0300|ALCOHOL, SERUM|ChampVA|CHAMPVA CENTER|2.18||||||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.18||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicaid|MEDICAID AMERIGROUP|2.18||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Cigna|CIGNA OTHER|2.18||||239.80||| G0480|EAP|0300|ALCOHOL, SERUM|Magellan Behavioral Health|BH MAGELLAN|||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Humana Medicare Advantage|HUMANA MA|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Blue Cross PPO Specialty|BCBSTX PPO|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|239.80||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Veterans Affairs|VETERANS ADMINISTRATION|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Aenta Medicare Advantage|AETNA MEDICARE MA|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Aetna|BOON CHAPMAN|2.18||||||| G0480|EAP|0300|ALCOHOL, SERUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Aetna|AETNA PPO|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.18||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Aetna|BH AETNA|||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Workers Compensation|UT EMPLOYEE INJURY|||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Workers Compensation|WORKERS COMPENSATION OTHER|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Blue Cross HMO Specialty|BCBSTX HMO|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Cigna|CIGNA|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Aetna|AETNA OTHER|239.80||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Cigna|CIGNA|239.80||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||239.80||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicaid|MEDICAID SUPERIOR|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|239.80||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|SMITH COUNTY JAIL|||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|United Medicare Advantage|UHC AARP MCR HMO MA|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.18||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|MEDICAID HMO|2.18||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|MEDICAID|2.18||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.18||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|BH TEXAS CHILDRENS MEDICAID|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.18||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicare|WELLCARE CHOICE MA|||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.18||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Managed Medicare|HEALTHSPRING MA|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|United Healthcare|ZZZZZ UNITED HEALTHCARE|||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Access Direct Platinum|HEALTHFIRST TPA UMR|2.18||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|United Healthcare|UNITED HEALTHCARE OTHER|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|United Healthcare|UNITED HEALTHCARE|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|United Healthcare|TML GROUP BENEFITS|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Optum Behavioral Health|BH OPTUM UHC|261.60||||||| G0480|EAP|0300|ALCOHOL, SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|PHCS|HUMANA INSURANCE|||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Medicare|MEDICARE ACUTE|470.40||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|PHCS|HUMANA|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|United Healthcare|UNITED HEALTHCARE|261.60||||239.80||| G0480|EAP|0300|ALCOHOL, SERUM|Tricare|TRICARE EAST REGION|261.60||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Medicare|MEDICARE ACUTE|261.60||||2.18||| G0480|EAP|0300||Medicare|MEDICARE ACUTE|2.71||||909.50||| G0480|EAP|0300|ALCOHOL, SERUM|NON CONTRACTED|COMMERCIAL OTHER 2|261.60||||261.60||| G0480|EAP|0300|ALCOHOL, SERUM|Medicare|MEDICARE PART B ONLY IP|239.80||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|NON CONTRACTED|COMMERCIAL OTHER 4|||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|Tricare|TRICARE FOR LIFE|||||2.18||| G0480|EAP|0300|ALCOHOL, SERUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.18||||261.60||| G8978|EAP|0420|MOBIL CURR STAT 40%-59%|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.01||| G8978|EAP|0420|MOBIL CURR STAT 60%-79%|Medicare|MEDICARE ACUTE|0.01||||||| G8978|EAP|0420|MOBILITY CURRENT STAT 20%|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.01||||||| G8978|EAP|0420|MOBIL CURR STAT 80%-99%|United Medicare Advantage|UHC MEDICARE GOLD MA|0.01||||0.01||| G8978|EAP|0420|MOBIL CURR STAT 40%-59%|United Medicare Advantage|UHC MEDICARE GOLD MA|0.01||||0.01||| G8978|EAP|0420|MOBILITY CURRENT STAT 20%|Blue Cross PPO Specialty|BCBSTX OTHER|0.01||||||| G8978|EAP|0420|MOBILITY CURRENT STAT 20%|Medicare|MEDICARE ACUTE|0.01||||||| G8978|EAP|0420|MOBILITY CURRENT STATUS 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.01||| G8979|EAP|0420|MOBILITY GOAL STATUS 40%-|United Medicare Advantage|UHC MEDICARE GOLD MA|0.01||||0.01||| G8979|EAP|0420|MOBILITY GOAL STATUS 1%-1|United Medicare Advantage|UHC MEDICARE GOLD MA|0.01||||0.01||| G8979|EAP|0420|MOBILITY GOAL STATUS 1%-1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.01||||||| G8979|EAP|0420|MOBILITY GOAL STATUS 20%-|Medicare|MEDICARE ACUTE|0.01||||||| G8979|EAP|0420|MOBILITY GOAL STATUS 20%-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.01||| G8979|EAP|0420|MOBILITY GOAL STATUS 1%-1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.01||| G8979|EAP|0420|MOBILITY GOAL STATUS 1%-1|Medicare|MEDICARE ACUTE|0.01||||||| G8979|EAP|0420|MOBILITY GOAL STATUS 1%-1|Blue Cross PPO Specialty|BCBSTX OTHER|0.01||||||| G8980|EAP|0420|MOBILITY DC STAT 1%-19%|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.01||| G8987|EAP|0430|SELF-CARE, CURRENT STATUS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.01||||||| G8987|EAP|0430|SELF-CARE, CURRENT STATUS|United Medicare Advantage|UHC MEDICARE GOLD MA|0.01||||0.01||| G8988|EAP|0430|SELF-CARE, GOAL STATUS 1-|United Medicare Advantage|UHC MEDICARE GOLD MA|0.01||||0.01||| G8988|EAP|0430|SELF-CARE, GOAL STATUS 60|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.01||||||| G8989|EAP|0430|SELF-CARE, D/C STATUS 1-1|United Medicare Advantage|UHC MEDICARE GOLD MA|0.01||||0.01||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Blue Cross HMO Specialty|BCBSTX HMO|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Managed Medicaid|MEDICAID AMERIGROUP|1,315.20||||1,315.20||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Medicaid|MEDICAID|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Medicaid|MEDICAID HMO|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Medicare|MEDICARE ACUTE|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|United Healthcare|UNITED HEALTHCARE|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|United Healthcare|UNITED HEALTHCARE OTHER|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Aetna|AETNA PPO|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Humana Medicare Advantage|HUMANA MA|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Managed Medicaid|MEDICAID SUPERIOR|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|United Medicare Advantage|UHC AARP MCR HMO MA|1,315.20||||||| J0270|ERX|0250|ALPROSTADIL 40 MCG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||558.66||| J0285|ERX|0250|AMPHOTERICIN B 50MG VIAL|Medicare|MEDICARE ACUTE|251.75||||||| J0285|ERX|0250|AMPHOTERICIN B 50MG VIAL|Managed Medicare|HEALTHSPRING MA|||||251.75||| J0289|ERX|0636|AMPHOTERICIN B LIPOSOME 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|322.50||||||| J0289|ERX|0636|AMPHOTERICIN B LIPOSOME 5|Humana Medicare Advantage|HUMANA MA|||||322.50||| J0289|ERX|0636|AMPHOTERICIN B LIPOSOME 5|Managed Medicare|HEALTHSPRING MA|322.50||||||| J0289|ERX|0636|AMPHOTERICIN B LIPOSOME 5|Medicare|MEDICARE ACUTE|322.50||||322.50||| J0289|ERX|0636|AMPHOTERICIN B LIPOSOME 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||322.50||| J0289|ERX|0636|AMPHOTERICIN B LIPOSOME 5|Blue Cross PPO Specialty|BCBSTX PPO|322.50||||322.50||| J0289|ERX|0636|AMPHOTERICIN B LIPOSOME 5|Managed Medicare|BCBS MEDICARE PPO MA|322.50||||||| J0289|ERX|0636|AMPHOTERICIN B LIPOSOME 5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|322.50||||||| J0476|ERX|0636|BACLOFEN INTRATHECAL 50MC|Managed Medicare|HEALTHSPRING MA|||||439.60||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|United Healthcare|UNITED HEALTHCARE OTHER|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Managed Medicaid|MEDICAID AMERIGROUP|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Veterans Affairs|VETERANS ADMINISTRATION|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Blue Cross PPO Specialty|BCBSTX OTHER|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 2|Medicaid|MEDICAID|35.70||||||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Blue Cross HMO Specialty|BCBSTX HMO|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZ 600000|Managed Medicaid|MEDICAID AMERIGROUP|||||50.29||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Blue Cross PPO Specialty|BCBSTX PPO|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|42.79||||||| J0561|ERX|0636|PENICILLIN G BENZATHINE 2|NON CONTRACTED|COMMERCIAL OTHER 1|||||35.70||| J0561|ERX|0636|PENICILLIN G BENZATHINE 2|Blue Cross PPO Specialty|BCBSTX PPO|||||35.70||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Medicaid|MEDICAID|42.79||||||| J0561|ERX|0636|PENICILLIN G BENZ 600000|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||50.29||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Managed Medicaid|MEDICAID SUPERIOR|||||42.79||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Managed Medicare|BCBS MEDICARE PPO MA|537.50||||537.50||| J0583|ERX|0250||Medicare|MEDICARE ACUTE|||||2,006.40||| J0583|ERX|0250||Medicaid|MEDICAID|||||2,006.40||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Medicaid|MEDICAID|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Aetna|AETNA PPO|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|PHCS|HUMANA|||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Tricare|TRICARE EAST REGION|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|United Healthcare|UNITED HEALTHCARE OTHER|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|United Healthcare|UNITED HEALTHCARE|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|United Healthcare|GOLDEN RULE|537.50||||||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Aenta Medicare Advantage|AETNA MEDICARE MA|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Aetna|AETNA OTHER|537.50||||||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|United Medicare Advantage|UHC AARP MCR HMO MA|537.50||||537.50||| J0583|ERX|0250||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,006.40||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|537.50||||||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Blue Cross HMO Specialty|BCBSTX HMO|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Veterans Affairs|VETERANS ADMINISTRATION|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Blue Cross PPO Specialty|BCBSTX OTHER|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Cigna|CIGNA|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Humana Medicare Advantage|HUMANA MA|537.50||||537.50||| J0583|ERX|0250||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,006.40||| J0583|ERX|0250||Blue Cross PPO Specialty|BCBSTX PPO|||||2,006.40||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|537.50||||||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Managed Medicaid|MEDICAID AMERIGROUP|||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|537.50||||537.50||| J0583|ERX|0250||United Medicare Advantage|UHC AARP MCR HMO MA|2,006.40||||2,006.40||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|United Medicare Advantage|UHC MEDICARE GOLD MA|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Cigna|CIGNA|||||537.50||| J0583|ERX|0250||Humana Medicare Advantage|HUMANA MA|||||2,006.40||| J0583|ERX|0250||Access Direct Platinum|HEALTHFIRST TPA UMR|||||2,006.40||| J0583|ERX|0250||Managed Medicare|HEALTHSPRING MA|||||2,006.40||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Access Direct Platinum|HEALTHFIRST TPA|||||537.50||| J0583|ERX|0250||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,006.40||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|537.50||||537.50||| J0583|ERX|0250||Veterans Affairs|VETERANS ADMINISTRATION|||||2,006.40||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Medicaid|LAW ENFORCEMENT OTHER|537.50||||||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Blue Cross PPO Specialty|BCBSTX PPO|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|537.50||||||| J0583|ERX|0250||NON CONTRACTED|COMMERCIAL OTHER 1|||||2,006.40||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|NON CONTRACTED|COMMERCIAL OTHER 1|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Medicare|MEDICARE PART B ONLY IP|537.50||||||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Access Direct Platinum|HEALTHFIRST TPA UMR|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Managed Medicare|HEALTHSPRING MA|537.50||||537.50||| J0583|ERX|0636|BIVALIRUDIN 250 MG/50 ML|Medicare|MEDICARE ACUTE|537.50||||537.50||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.40||||22.84||| J0585|ERX|0636|BOTOX 200 UNIT VIAL WASTE|United Medicare Advantage|UHC AARP MCR HMO MA|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.40||| J0585|ERX|0636|BOTOX 50 UNIT VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||28.47||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||22.84||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.40||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL WASTE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||27.40||| J0585|ERX|0636|BOTOX 50 UNIT VIAL|Humana Medicare Advantage|HUMANA MA|||||28.47||| J0585|ERX|0636|BOTOX 200 UNIT VIAL WASTE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.40||||22.84||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.40||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Humana Medicare Advantage|HUMANA MA|||||22.84||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Aetna|AETNA OTHER|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|ChampVA|CHAMPVA CENTER|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Humana Medicare Advantage|HUMANA MA|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Blue Cross HMO Specialty|BCBSTX HMO|||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL WASTE|Humana Medicare Advantage|HUMANA MA|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Cigna|CIGNA OTHER|||||27.40||| J0585|ERX|0636|BOTOX 50 UNIT VIAL WASTE|Blue Cross PPO Specialty|BCBSTX OTHER|||||28.47||| J0585|ERX|0636|BOTOX 200 UNIT VIAL WASTE|Blue Cross PPO Specialty|BCBSTX PPO|27.40||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Blue Cross PPO Specialty|BCBSTX OTHER|||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL WASTE|Aetna|AETNA QHP HMO|||||22.84||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Blue Cross PPO Specialty|BCBSTX PPO|27.40||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Blue Cross PPO Specialty|BCBSTX PPO|27.40||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Aetna|AETNA QHP HMO|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Humana Medicare Advantage|HUMANA MA|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|ChampVA|CHAMPVA CENTER|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Cigna|CIGNA|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Aetna|AETNA PPO|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Aetna|AETNA PPO|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Aetna|AETNA OTHER|||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.40||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.40||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.40||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Medicare|MEDICARE ACUTE|27.40||||27.40||| J0585|ERX|0636|BOTOX 50 UNIT VIAL WASTE|Humana Medicare Advantage|HUMANA MA|||||28.47||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||27.40||| J0585|ERX|0636|BOTOX 50 UNIT VIAL WASTE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.40||||28.47||| J0585|ERX|0636|BOTOX 50 UNIT VIAL|United Healthcare|UNITED HEALTHCARE|||||28.47||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|United Healthcare|UNITED HEALTHCARE|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|PHCS|HUMANA|||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Medicare|MEDICARE ACUTE|27.40||||22.84||| J0585|ERX|0636|BOTOX 50 UNIT VIAL WASTE|Medicare|MEDICARE ACUTE|27.40||||28.47||| J0585|ERX|0636|BOTOX 200 UNIT VIAL WASTE|Managed Medicare|HEALTHSPRING MA|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Managed Medicare|BCBS MEDICARE PPO MA|||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|United Healthcare|UNITED HEALTHCARE|||||22.84||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Managed Medicare|BCBS MEDICARE PPO MA|||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL WASTE|Medicare|MEDICARE ACUTE|27.40||||22.84||| J0585|ERX|0636|BOTOX 200 UNIT VIAL|Managed Medicare|HEALTHSPRING MA|||||22.84||| J0585|ERX|0636|BOTOX 50 UNIT VIAL|Medicare|MEDICARE ACUTE|27.40||||28.47||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Managed Medicare|HEALTHSPRING MA|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|United Healthcare|UNITED HEALTHCARE|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Blue Cross PPO Specialty|BCBSTX PPO|27.40||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Medicare|MEDICARE ACUTE|27.40||||27.40||| J0585|ERX|0636|BOTOX 200 UNIT VIAL WASTE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.40||||22.84||| J0585|ERX|0636|BOTOX 50 UNIT VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||28.47||| J0585|ERX|0636|BOTOX 100 UNIT VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||27.40||| J0585|ERX|0636|BOTOX 100 UNIT VIAL WASTE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||27.40||| J0587|ERX|0636|MYBLOC 5000 UNIT VIAL|Medicare|MEDICARE ACUTE|||||44.16||| J0587|ERX|0636|MYOBLOC 2500 UNIT VIAL|Humana Medicare Advantage|HUMANA MA|||||49.97||| J0587|ERX|0636|MYBLOC 5000 UNIT VIAL WAS|Medicare|MEDICARE ACUTE|||||44.16||| J0587|ERX|0636|MYOBLOC 2500 UNIT VIAL|Medicare|MEDICARE ACUTE|||||49.97||| J0588|ERX|0636|XEOMIN 100 UNIT VIAL WAST|Medicare|MEDICARE ACUTE|||||20.73||| J0588|ERX|0636|XEOMIN 100 UNIT VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||20.73||| J0588|ERX|0636|XEOMIN 50 UNIT VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||21.76||| J0588|ERX|0636|XEOMIN 100 UNIT VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||20.73||| J0588|ERX|0636|XEOMIN 50 UNIT VIAL|Medicare|MEDICARE ACUTE|||||21.76||| J0588|ERX|0636|XEOMIN 50 UNIT VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||21.76||| J0588|ERX|0636|XEOMIN 100 UNIT VIAL WAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||20.73||| J0588|ERX|0636|XEOMIN 100 UNIT VIAL|Medicare|MEDICARE ACUTE|||||20.73||| J0588|ERX|0636|XEOMIN 50 UNIT VIAL WASTE|Medicare|MEDICARE ACUTE|||||21.76||| J0610|ERX|0250|CALCIUM GLUCONATE 1 G/50|Medicare|MEDICARE ACUTE|||||109.97||| J0610|ERX|0250|CALCIUM GLUCONATE 2 G/100|United Medicare Advantage|UHC MEDICARE GOLD MA|197.50||||||| J0630|ERX|0636|CALCITONIN,SYNTH 400 UNIT|Humana Medicare Advantage|HUMANA MA|9,490.75||||||| J0630|ERX|0636|CALCITONIN,SYNTH 400 UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|9,490.75||||||| J0630|ERX|0636|CALCITONIN,SYNTH 400 UNIT|Veterans Affairs|VETERANS ADMINISTRATION|9,490.75||||||| J0630|ERX|0636|CALCITONIN,SYNTH 400 UNIT|Medicaid|SMITH COUNTY JAIL|9,490.75||||||| J0630|ERX|0636|CALCITONIN,SYNTH 400 UNIT|Medicare|MEDICARE ACUTE|9,490.75||||||| J0637|ERX|0636|CASPOFUNGIN 50MG VIAL|Medicare|MEDICARE ACUTE|346.83||||||| J0695|ERX|0636|CEFTOLOZANE-TAZOBACTAM 1.|Medicare|MEDICARE ACUTE|27.20||||||| J0712|ERX|0636|CEFTAROLINE 600 MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.54||||||| J0712|ERX|0636|CEFTAROLINE 600 MG VIAL|Medicare|MEDICARE ACUTE|0.54||||||| J0712|ERX|0636|CEFTAROLINE 600 MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.54||||||| J0714|ERX|0636|CEFTAZIDIME-AVIBACTAM 2.5|Managed Medicare|HEALTHSPRING MA|422.71||||||| J0714|ERX|0636|CEFTAZIDIME-AVIBACTAM 2.5|Medicaid|MEDICAID|422.71||||||| J0714|ERX|0636|CEFTAZIDIME-AVIBACTAM 2.5|Medicare|MEDICARE ACUTE|422.71||||||| J0714|ERX|0636|CEFTAZIDIME-AVIBACTAM 2.5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|422.71||||||| J0714|ERX|0636|CEFTAZIDIME-AVIBACTAM 2.5|United Medicare Advantage|UHC AARP MCR HMO MA|422.71||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Aetna|AETNA PPO|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|549.97||||549.97||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Cigna|CIGNA|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Humana Medicare Advantage|HUMANA MA|549.97||||549.97||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Medicare|MEDICARE ACUTE|549.97||||549.97||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Medicaid|MEDICAID|549.97||||||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Managed Medicare|HEALTHSPRING MA|||||549.97||| J0840|ERX|0636|ANTIVENIN,CROTALIDAE 1 VI|Managed Medicaid|MEDICAID SUPERIOR|||||12,912.75||| J0840|ERX|0636|ANTIVENIN,CROTALIDAE 1 VI|Medicare|MEDICARE ACUTE|12,912.75||||12,912.75||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Aetna|AETNA OTHER|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Aetna|BOON CHAPMAN|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Humana Medicare Advantage|HUMANA MA|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Medicare|MEDICARE ACUTE|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Medicaid|MEDICAID|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Managed Medicare|HEALTHSPRING MA|3.81||||||| J0878|ERX|0636|DAPTOMYCIN 500MG VIAL|Tricare|TRICARE EAST REGION|3.81||||||| J0884|ERX|0636|ARGATROBAN 100MG/ML, 2.5|Medicare|MEDICARE ACUTE|8.66||||||| J0884|ERX|0636|ARGATROBAN 100MG/ML, 2.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.66||||||| J0884|ERX|0636|ARGATROBAN 100MG/ML, 2.5|Medicaid|MEDICAID|8.66||||||| J0884|ERX|0636|ARGATROBAN 100MG/ML, 2.5|Veterans Affairs|VETERANS ADMINISTRATION|8.66||||||| J0885|ERX|0636|EPOETIN 8,000 UNIT/0.4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|164.31||||||| J0885|ERX|0636|EPOETIN 10000 UNIT/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|134.90||||||| J0894|ERX|0636|DECITABINE 50MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|308.13||||||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Humana Medicare Advantage|HUMANA MA|||||73.35||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Blue Cross PPO Specialty|BCBSTX PPO|||||73.35||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Medicare|MEDICARE ACUTE|||||73.35||| J1110|ERX|0636|DIHYDROERGOTAMINE 1MG/ML|Medicare|MEDICARE ACUTE|642.85||||||| J1110|ERX|0636|DIHYDROERGOTAMINE 1MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|642.85||||||| J1110|ERX|0636|DIHYDROERGOTAMINE 1MG/ML|Aetna|AETNA PPO|642.85||||||| J1110|ERX|0636|DIHYDROERGOTAMINE 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|642.85||||||| J1110|ERX|0636|DIHYDROERGOTAMINE 1MG/ML|Cigna|CIGNA|642.85||||||| J1110|ERX|0636|DIHYDROERGOTAMINE 1MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|642.85||||||| J1110|ERX|0636|DIHYDROERGOTAMINE 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|642.85||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Humana Medicare Advantage|HUMANA MA|38.28||||38.28||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Cigna|CIGNA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Blue Cross HMO Specialty|BCBSTX HMO|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Blue Cross PPO Specialty|BCBSTX PPO|38.28||||38.28||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|United Medicare Advantage|UHC AARP MCR HMO MA|38.28||||38.28||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Veterans Affairs|VETERANS ADMINISTRATION|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|United Healthcare|UNITED HEALTHCARE OTHER|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|United Healthcare|UNITED HEALTHCARE|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|United Healthcare|TML GROUP BENEFITS|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|NON CONTRACTED|COMMERCIAL OTHER 1|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Medicare|MEDICARE ACUTE|38.28||||38.28||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Managed Medicare|WELLCARE CHOICE MA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|38.28||||38.28||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Managed Medicare|HEALTHSPRING MA|38.28||||38.28||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Managed Medicare|BCBS MEDICARE PPO MA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Medicaid|MEDICAID|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.28||||||| J1162|ERX|0636|DIGOXIN IMMUNE FAB 40MG V|Managed Medicare|HEALTHSPRING MA|149.10||||||| J1162|ERX|0636|DIGOXIN IMMUNE FAB 40MG V|Medicare|MEDICARE ACUTE|149.10||||||| J1212|ERX|0636|DIMETHYL SULFOX 500MG/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.45||| J1212|ERX|0636|DIMETHYL SULFOX 500MG/ML,|Blue Cross PPO Specialty|BCBSTX PPO|||||7.45||| J1212|ERX|0636|DIMETHYL SULFOX 500MG/ML,|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.45||| J1212|ERX|0636|DIMETHYL SULFOX 500MG/ML,|Medicare|MEDICARE ACUTE|||||7.45||| J1212|ERX|0636|DIMETHYL SULFOX 500MG/ML,|Managed Medicare|BCBS MEDICARE PPO MA|||||7.45||| J1364|ERX|0636|ERYTHROMYCIN 500MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|2.81||||||| J1364|ERX|0636|ERYTHROMYCIN 500MG VIAL|Medicare|MEDICARE ACUTE|2.81||||||| J1364|ERX|0636|ERYTHROMYCIN 500MG VIAL|Medicaid|MEDICAID HMO|2.81||||||| J1364|ERX|0636|ERYTHROMYCIN 500MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.81||||||| J1364|ERX|0636|ERYTHROMYCIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|2.81||||||| J1364|ERX|0636|ERYTHROMYCIN 500MG VIAL|Aetna|BOON CHAPMAN|2.81||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Humana Medicare Advantage|HUMANA MA|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Managed Medicaid|MEDICAID AMERIGROUP|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Humana Medicare Advantage|HUMANA MA|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Aenta Medicare Advantage|AETNA MEDICARE MA|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Blue Cross HMO Specialty|BCBSTX HMO|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Blue Cross PPO Specialty|BCBSTX PPO|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Blue Cross PPO Specialty|BCBSTX PPO|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Veterans Affairs|VETERANS ADMINISTRATION|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|United Healthcare|UNITED HEALTHCARE OTHER|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Tricare|TRICARE EAST REGION|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|NON CONTRACTED|COMMERCIAL OTHER 1|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|NON CONTRACTED|COMMERCIAL OTHER 1|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Medicare|MEDICARE ACUTE|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Medicare|MEDICARE ACUTE|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Managed Medicare|WELLCARE CHOICE MA|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Managed Medicare|HEALTHSPRING MA|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Managed Medicare|HEALTHSPRING MA|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 480MCG/0.8|Medicaid|MEDICAID|4.63||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.62||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Medicaid|MEDICAID|4.62||||||| J1451|ERX|0636|FOMEPIZOLE 1500 MG/1.5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|113.89||||||| J1451|ERX|0636|FOMEPIZOLE 1500 MG/1.5ML|Humana Medicare Advantage|HUMANA MA|113.89||||||| J1451|ERX|0636|FOMEPIZOLE 1500 MG/1.5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|113.89||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|301.70||||301.70||| J1568|ERX|0636|OCTAGAM 10GM VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|301.70||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|301.70||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|301.70||||||| J1568|ERX|0636|OCTAGAM (5%) 5 GM/100 ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|340.20||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Veterans Affairs|VETERANS ADMINISTRATION|301.70||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Blue Cross PPO Specialty|BCBSTX PPO|301.70||||||| J1568|ERX|0636|OCTAGAM (5%) 5 GM/100 ML|Blue Cross PPO Specialty|BCBSTX PPO|340.20||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|301.70||||301.70||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|301.70||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Aetna|AETNA PPO|301.70||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|301.70||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|301.70||||||| J1568|ERX|0636|OCTAGAM (5%) 5 GM/100 ML|Medicare|MEDICARE ACUTE|340.20||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|301.70||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Managed Medicare|HEALTHSPRING MA|301.70||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|301.70||||||| J1568|ERX|0636|OCTAGAM (5%) 5 GM/100 ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|340.20||||||| J1568|ERX|0636|OCTAGAM (5%) 5 GM/100 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|340.20||||||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Humana Medicare Advantage|HUMANA MA|301.70||||301.70||| J1568|ERX|0636|OCTAGAM 10GM VIAL|Medicare|MEDICARE ACUTE|301.70||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Medicaid|SMITH COUNTY JAIL|||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Managed Medicare|HEALTHSPRING MA|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|United Healthcare|UNITED HEALTHCARE|||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|891.50||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Medicare|MEDICARE ACUTE|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|891.50||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Cigna|CIGNA|||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Humana Medicare Advantage|HUMANA MA|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Aetna|BOON CHAPMAN|891.50||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Aetna|AETNA PPO|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Medicaid|MEDICAID|891.50||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|891.50||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|891.50||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|891.50||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Workers Compensation|BROOKSHIRES WORKERS COMP|891.50||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|891.50||||||| J1610|ERX|0636|GLUCAGON 1MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|891.50||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Access Direct Platinum|HEALTHFIRST TPA|||||891.50||| J1610|ERX|0636|GLUCAGON 1MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||891.50||| J1670|ERX|0636|TETANUS IMMUNE GLOB 250 U|Blue Cross PPO Specialty|BCBSTX PPO|||||1,167.50||| J1742|ERX|0636|IBUTILIDE 0.1MG/ML, 10ML|Medicare|MEDICARE ACUTE|3,519.25||||3,519.25||| J1742|ERX|0636|IBUTILIDE 0.1MG/ML, 10ML|Managed Medicare|HEALTHSPRING MA|3,519.25||||||| J1742|ERX|0636|IBUTILIDE 0.1MG/ML, 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,519.25||||||| J1742|ERX|0636|IBUTILIDE 0.1MG/ML, 10ML|United Medicare Advantage|UHC AARP MCR HMO MA|3,519.25||||||| J1742|ERX|0636|IBUTILIDE 0.1MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA|3,519.25||||||| J1742|ERX|0636|IBUTILIDE 0.1MG/ML, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,519.25||||||| J1742|ERX|0636|IBUTILIDE 0.1MG/ML, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|3,519.25||||3,519.25||| J1742|ERX|0636|IBUTILIDE 0.1MG/ML, 10ML|Humana Medicare Advantage|HUMANA MA|3,519.25||||3,519.25||| J1742|ERX|0636|IBUTILIDE 0.1MG/ML, 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,519.25||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|193.63||||193.63||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|193.63||||193.63||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Cigna|CIGNA|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|193.63||||193.63||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Veterans Affairs|VETERANS ADMINISTRATION|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Workers Compensation|ZURICH COMPANY|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Medicaid|MEDICAID|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|193.63||||193.63||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|193.63||||||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Medicare|MEDICARE ACUTE|193.63||||193.63||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Multiplan|NALC|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|NON CONTRACTED|COMMERCIAL OTHER 1|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|United Healthcare|UNITED HEALTHCARE OTHER|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|UTMB|UTMB CORRECTIONAL MANAGED CARE|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Medicare|MEDICARE ACUTE|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicare|HEALTHSPRING MA|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Medicaid|SMITH COUNTY JAIL|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Medicaid|MEDICAID|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|United Medicare Advantage|UHC MEDICARE GOLD MA|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|United Medicare Advantage|UHC AARP WELLMED HMO MA|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|United Medicare Advantage|UHC AARP MCR HMO MA|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicare|BCBS MEDICARE PPO MA|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Access Direct Platinum|HEALTHFIRST TPA UMR|||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Workers Compensation|ZURICH COMPANY|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID AMERIGROUP|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Medicare|MEDICARE PART B ONLY IP|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|United Healthcare|UNITED HEALTHCARE|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Aenta Medicare Advantage|AETNA MEDICARE MA|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Aetna|AETNA PPO|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Blue Cross HMO Specialty|BCBSTX HMO|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Blue Cross PPO Specialty|BCBSTX PPO|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID SUPERIOR|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Cigna|CIGNA|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Cigna|CIGNA OTHER|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Humana Medicare Advantage|HUMANA MA|635.50||||635.50||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Veterans Affairs|VETERANS ADMINISTRATION|635.50||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|635.50||||||| J1950|ERX|0636||Medicare|MEDICARE ACUTE|1,240.13||||1,009.69||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Aetna|AETNA PPO|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Aenta Medicare Advantage|AETNA MEDICARE MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Managed Medicaid|MEDICAID SUPERIOR|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Veterans Affairs|VETERANS ADMINISTRATION|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Access Direct Platinum|HEALTHFIRST TPA UMR|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Humana Medicare Advantage|HUMANA MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|United Medicare Advantage|UHC AARP MCR HMO MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Managed Medicaid|MEDICAID AMERIGROUP|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Medicaid|MEDICAID|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Blue Cross PPO Specialty|BCBSTX PPO|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Managed Medicare|HEALTHSPRING MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Access Direct Platinum|HEALTHFIRST TPA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Managed Medicare|BCBS MEDICARE PPO MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|NON CONTRACTED|COMMERCIAL OTHER 1|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Medicare|MEDICARE ACUTE|4.80||||4.80||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Rusk State Hospital|RUSK STATE HOSP|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|United Healthcare|TML GROUP BENEFITS|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|United Healthcare|UNITED HEALTHCARE|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|United Healthcare|UNITED HEALTHCARE OTHER|4.80||||4.80||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Multiplan|WEB TPA|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicare|MEDICARE ACUTE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicare|MEDICARE PART B ONLY IP|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|PHCS|HUMANA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|NON CONTRACTED|COMMERCIAL OTHER 2|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Rusk State Hospital|RUSK STATE HOSP|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|NON CONTRACTED|COMMERCIAL OTHER 1|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Tricare|TRICARE FOR LIFE|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Healthcare|GOLDEN RULE|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Tricare|TRICARE EAST REGION|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|WELLCARE CHOICE MA|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Healthcare|TML GROUP BENEFITS|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|HOSPICE OF EAST TEXAS|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|HEALTHSPRING MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|BCBS MEDICARE PPO MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|SMITH COUNTY JAIL|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|MEDICAID HMO|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Healthcare|UNITED HEALTHCARE OTHER|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|MEDICAID|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|LAW ENFORCEMENT OTHER|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|CRIME VICTIMS COMPENSATION|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Medicare Advantage|UHC AARP MCR HMO MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Healthcare|UNITED HEALTHCARE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Veterans Affairs|VETERANS ADMINISTRATION|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Workers Compensation|ZURICH COMPANY|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Workers Compensation|WORKERS COMPENSATION OTHER|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Workers Compensation|UT EMPLOYEE INJURY|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Workers Compensation|GALLAGHER BASSETT|||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Workers Compensation|BROOKSHIRES WORKERS COMP|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|ChampVA|CHAMPVA CENTER|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Cigna|CIGNA OTHER|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Cigna|CIGNA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Humana Medicare Advantage|HUMANA MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicaid|MEDICAID SUPERIOR|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Aetna|BOON CHAPMAN|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|PHCS|GROUP AND PENSION|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Blue Cross HMO Specialty|BCBSTX HMO|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Blue Cross PPO Specialty|BCBSTX PPO|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Blue Cross PPO Specialty|BCBSTX OTHER|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Aetna|AETNA QHP HMO|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicaid|MEDICAID AMERIGROUP|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Aetna|AETNA OTHER|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Aetna|AETNA PPO|0.16||||0.16||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Blue Cross PPO Specialty|BCBSTX PPO|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Blue Cross PPO Specialty|BCBSTX OTHER|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Aetna|AETNA PPO|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Aetna|AETNA OTHER|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Aenta Medicare Advantage|AETNA MEDICARE MA|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Managed Medicaid|MEDICAID SUPERIOR|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Aetna Value Network|AETNA VALUE NETWORK|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Managed Medicaid|MEDICAID AMERIGROUP|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Humana Medicare Advantage|HUMANA MA|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|ChampVA|CHAMPVA CENTER|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Cigna|CIGNA|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Cigna|CIGNA|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Veterans Affairs|VETERANS ADMINISTRATION|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Cigna|CIGNA OTHER|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Access Direct Platinum|HEALTHFIRST TPA|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Access Direct Platinum|HEALTHFIRST TPA UMR|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Blue Cross HMO Specialty|BCBSTX HMO|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|United Medicare Advantage|UHC MEDICARE GOLD MA|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|United Medicare Advantage|UHC AARP MCR HMO MA|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Medicaid|MEDICAID|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Managed Medicare|HEALTHSPRING MA|||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Managed Medicare|BCBS MEDICARE PPO MA|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Tricare|TRICARE EAST REGION|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|United Healthcare|UNITED HEALTHCARE|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|United Healthcare|UNITED HEALTHCARE OTHER|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|United Healthcare|TML GROUP BENEFITS|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|United Healthcare|GEHA|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|United Healthcare|UNITED HEALTHCARE|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|PHCS|HUMANA|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Medicare|MEDICARE PART B ONLY IP|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|Medicare|MEDICARE ACUTE|0.67||||0.67||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|NON CONTRACTED|COMMERCIAL OTHER 1|0.67||||||| J2274|ERX|0636|MORPHINE SULFATE PF 2MG/2|PHCS|GROUP AND PENSION|0.67||||||| J2405|ERX|0636||Multiplan|WEB TPA|||||16.80||| J2405|ERX|0636||Medicare|MEDICARE ACUTE|16.80||||16.80||| J2405|ERX|0636||Medicare|MEDICARE PART B ONLY IP|16.80||||||| J2405|ERX|0250||NON CONTRACTED|COMMERCIAL OTHER 2|||||16.80||| J2405|ERX|0250||NON CONTRACTED|COMMERCIAL OTHER 1|||||16.80||| J2405|ERX|0636||PHCS|MULTIPLAN PHCS|||||16.80||| J2405|ERX|0636||PHCS|HUMANA|||||16.80||| J2405|ERX|0636||PHCS|GROUP AND PENSION|||||16.80||| J2405|ERX|0636||NON CONTRACTED|COMMERCIAL OTHER 2|||||16.80||| J2405|ERX|0250||Rusk State Hospital|RUSK STATE HOSP|||||16.80||| J2405|ERX|0636||Rusk State Hospital|RUSK STATE HOSP|||||16.80||| J2405|ERX|0250||PHCS|GROUP AND PENSION|||||16.80||| J2405|ERX|0636||Texas Workforce Commission|DIS DETER SERV (DDS)|||||16.80||| J2405|ERX|0250||Tricare|TRICARE EAST REGION|||||16.80||| J2405|ERX|0250||Tricare|TRICARE SOUTH PHYSICIAN|||||16.80||| J2405|ERX|0250||United Healthcare|TML GROUP BENEFITS|16.80||||16.80||| J2405|ERX|0250||United Healthcare|UNITED HEALTHCARE|||||16.80||| J2405|ERX|0250||PHCS|HUMANA INSURANCE|||||16.80||| J2405|ERX|0636||United Healthcare|GEHA|||||16.80||| J2405|ERX|0636||United Healthcare|UNITED HEALTHCARE OTHER|16.80||||16.80||| J2405|ERX|0636||United Healthcare|UNITED HEALTHCARE|16.80||||16.80||| J2405|ERX|0636||United Healthcare|AARP|||||16.80||| J2405|ERX|0636||United Healthcare|TML GROUP BENEFITS|||||16.80||| J2405|ERX|0636||United Healthcare|GOLDEN RULE|||||16.80||| J2405|ERX|0636||Tricare|TRICARE FOR LIFE|||||16.80||| J2405|ERX|0636||Tricare|TRICARE EAST REGION|16.80||||16.80||| J2405|ERX|0250||Texas Workforce Commission|DIS DETER SERV (DDS)|||||16.80||| J2405|ERX|0250||UTMB|UTMB CORRECTIONAL MANAGED CARE|16.80||||16.80||| J2405|ERX|0636||UTMB|UTMB CORRECTIONAL MANAGED CARE|16.80||||16.80||| J2405|ERX|0250||Managed Medicare|HEALTHSPRING MA|16.80||||16.80||| J2405|ERX|0250||Managed Medicare|ETMC REHABILITATION HOSPITAL|||||16.80||| J2405|ERX|0250||Managed Medicare|BCBS MEDICARE PPO MA|||||16.80||| J2405|ERX|0636||Managed Medicare|WELLCARE CHOICE MA|||||16.80||| J2405|ERX|0636||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.80||||16.80||| J2405|ERX|0636||Managed Medicare|HEALTHSPRING MA|16.80||||16.80||| J2405|ERX|0636||Managed Medicare|ETMC SPECIALTY HOSPITAL|||||16.80||| J2405|ERX|0636||Managed Medicare|ETMC AFFILIATE HOSPITALS|||||16.80||| J2405|ERX|0250||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||16.80||| J2405|ERX|0636||Managed Medicare|BCBS MEDICARE PPO MA|16.80||||16.80||| J2405|ERX|0250||Medicare|MEDICARE ACUTE|16.80||||16.80||| J2405|ERX|0250||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||16.80||| J2405|ERX|0250||Medicaid|SMITH COUNTY INDIGENT HEALTH|||||16.80||| J2405|ERX|0250||Medicaid|MEDICAID|16.80||||16.80||| J2405|ERX|0250||Medicaid|LAW ENFORCEMENT OTHER|||||16.80||| J2405|ERX|0250||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||16.80||| J2405|ERX|0636||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||16.80||| J2405|ERX|0636||Medicaid|MEDICAID|16.80||||16.80||| J2405|ERX|0636||Medicaid|LAW ENFORCEMENT OTHER|||||16.80||| J2405|ERX|0636||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||16.80||| J2405|ERX|0250||United Medicare Advantage|UHC MEDICARE GOLD MA|16.80||||16.80||| J2405|ERX|0636||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||16.80||| J2405|ERX|0250||United Medicare Advantage|UHC AARP WELLMED HMO MA|16.80||||16.80||| J2405|ERX|0636||United Medicare Advantage|UHC MEDICARE GOLD MA|16.80||||16.80||| J2405|ERX|0250||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||16.80||| J2405|ERX|0636||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.80||||16.80||| J2405|ERX|0636||United Medicare Advantage|UHC AARP MCR HMO MA|16.80||||16.80||| J2405|ERX|0250||Access Direct Platinum|HEALTHFIRST TPA|||||16.80||| J2405|ERX|0250||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.80||||16.80||| J2405|ERX|0250||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|16.80||||16.80||| J2405|ERX|0250||Access Direct Platinum|HEALTHFIRST TPA UMR|16.80||||16.80||| J2405|ERX|0636||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.80||||16.80||| J2405|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||16.80||| J2405|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.80||||16.80||| J2405|ERX|0250||Medicare|MEDICARE PART B ONLY IP|16.80||||||| J2405|ERX|0250||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.80||| J2405|ERX|0250||Medicaid|MEDICAID HMO|||||16.80||| J2405|ERX|0250||United Medicare Advantage|UHC AARP MCR HMO MA|16.80||||16.80||| J2405|ERX|0636||Medicaid|MEDICAID HMO|||||16.80||| J2405|ERX|0250||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.80||||16.80||| J2405|ERX|0636||Medicaid|SMITH COUNTY INDIGENT HEALTH|||||16.80||| J2405|ERX|0636||Medicaid|SMITH COUNTY JAIL|||||16.80||| J2405|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|16.80||||16.80||| J2405|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA|16.80||||16.80||| J2405|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA UMR|16.80||||16.80||| J2405|ERX|0636||Veterans Affairs|VETERANS ADMINISTRATION|16.80||||16.80||| J2405|ERX|0250||Workers Compensation|WORKERS COMPENSATION OTHER|16.80||||16.80||| J2405|ERX|0250||Workers Compensation|UT EMPLOYEE INJURY|||||16.80||| J2405|ERX|0250||Workers Compensation|TRAVELERS INSURANCE COMPANY|||||16.80||| J2405|ERX|0250||Workers Compensation|TEXAS MUTUAL INSURANCE|||||16.80||| J2405|ERX|0250||Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||16.80||| J2405|ERX|0250||Workers Compensation|ZURICH COMPANY|||||16.80||| J2405|ERX|0250||Workers Compensation|WORKERS COMP PHYSICIAN|||||16.80||| J2405|ERX|0250||Workers Compensation|GALLAGHER BASSETT|||||16.80||| J2405|ERX|0250||Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||16.80||| J2405|ERX|0250||Workers Compensation|BROOKSHIRES WORKERS COMP|||||16.80||| J2405|ERX|0250||Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||16.80||| J2405|ERX|0250||Veterans Affairs|VETERANS ADMINISTRATION|16.80||||16.80||| J2405|ERX|0250||Medicaid|SMITH COUNTY JAIL|||||16.80||| J2405|ERX|0636||Managed Medicare|ETMC REHABILITATION HOSPITAL|||||16.80||| J2405|ERX|0636||Workers Compensation|ZURICH COMPANY|||||16.80||| J2405|ERX|0636||Workers Compensation|WORKERS COMPENSATION OTHER|||||16.80||| J2405|ERX|0250||Managed Medicare|WELLCARE CHOICE MA|16.80||||||| J2405|ERX|0636||Workers Compensation|UT EMPLOYEE INJURY|||||16.80||| J2405|ERX|0636||Workers Compensation|TRAVELERS INSURANCE COMPANY|||||16.80||| J2405|ERX|0636||Managed Medicare|OTHER INSTITUTIONS|||||16.80||| J2405|ERX|0636||Workers Compensation|TEXAS MUTUAL INSURANCE|||||16.80||| J2405|ERX|0636||Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||16.80||| J2405|ERX|0636||Workers Compensation|GALLAGHER BASSETT|||||16.80||| J2405|ERX|0250||Managed Medicare|ETMC SPECIALTY HOSPITAL|||||16.80||| J2405|ERX|0636||ChampVA|CHAMPVA CENTER|||||16.80||| J2405|ERX|0636||Cigna|CIGNA OTHER|||||16.80||| J2405|ERX|0636||Cigna|CIGNA|16.80||||16.80||| J2405|ERX|0636||Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||16.80||| J2405|ERX|0250||Cigna|CIGNA|||||16.80||| J2405|ERX|0636||Cigna|CIGNA|||||16.80||| J2405|ERX|0250||Cigna|CIGNA|16.80||||16.80||| J2405|ERX|0250||Cigna|CIGNA OTHER|||||16.80||| J2405|ERX|0250||Humana Medicare Advantage|HUMANA MA|16.80||||16.80||| J2405|ERX|0636||United Healthcare|UNITED HEALTHCARE ERS|||||16.80||| J2405|ERX|0250||Managed Medicaid|MEDICAID SUPERIOR|||||16.80||| J2405|ERX|0250||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||16.80||| J2405|ERX|0250||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||16.80||| J2405|ERX|0250||PHCS|HUMANA|||||16.80||| J2405|ERX|0250||United Healthcare|UNITED HEALTHCARE OTHER|||||16.80||| J2405|ERX|0250||Tricare|TRICARE FOR LIFE|||||16.80||| J2405|ERX|0250||Managed Medicaid|MEDICAID AMERIGROUP|||||16.80||| J2405|ERX|0636||Humana Medicare Advantage|HUMANA MA|16.80||||16.80||| J2405|ERX|0636||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||16.80||| J2405|ERX|0636||Managed Medicaid|MEDICAID SUPERIOR|||||16.80||| J2405|ERX|0636||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||16.80||| J2405|ERX|0636||Managed Medicaid|MEDICAID AMERIGROUP|16.80||||16.80||| J2405|ERX|0636||Aenta Medicare Advantage|AETNA MEDICARE MA|16.80||||16.80||| J2405|ERX|0250||Aetna|AETNA QHP HMO|||||16.80||| J2405|ERX|0250||Aetna|AETNA PPO|||||16.80||| J2405|ERX|0250||Aetna|AETNA OTHER|||||16.80||| J2405|ERX|0250||Aenta Medicare Advantage|AETNA MEDICARE MA|16.80||||16.80||| J2405|ERX|0636||Aetna Value Network|AETNA VALUE NETWORK|||||16.80||| J2405|ERX|0636||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.80||||16.80||| J2405|ERX|0636||NON CONTRACTED|COMMERCIAL OTHER 1|16.80||||16.80||| J2405|ERX|0636||PHCS|HUMANA INSURANCE|||||16.80||| J2405|ERX|0636||Aetna|AETNA OTHER|16.80||||16.80||| J2405|ERX|0636||Aetna|AETNA PPO|||||16.80||| J2405|ERX|0250||Aetna Value Network|AETNA VALUE NETWORK|||||16.80||| J2405|ERX|0250||NON CONTRACTED|COMMERCIAL OTHER 4|||||16.80||| J2405|ERX|0250||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.80||||16.80||| J2405|ERX|0636||Aetna|BOON CHAPMAN|||||16.80||| J2405|ERX|0636||Blue Cross HMO Specialty|BCBSTX HMO|16.80||||16.80||| J2405|ERX|0250||Blue Cross HMO Specialty|BCBSTX HMO|16.80||||16.80||| J2405|ERX|0250||Blue Cross PPO Specialty|BCBSTX PPO|16.80||||16.80||| J2405|ERX|0250||Blue Cross PPO Specialty|BCBSTX OTHER|16.80||||16.80||| J2405|ERX|0250||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|16.80||||16.80||| J2405|ERX|0636||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||16.80||| J2405|ERX|0250||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||16.80||| J2405|ERX|0636||Blue Cross PPO Specialty|BCBSTX PPO|16.80||||16.80||| J2405|ERX|0636||Blue Cross PPO Specialty|BCBSTX OTHER|||||16.80||| J2405|ERX|0636||Brinson Benefits|THE HEALTH PLAN SMITH CO|||||16.80||| J2405|ERX|0250||ChampVA|CHAMPVA CENTER|||||16.80||| J2426|ERX|0636|PALIPERIDONE ER 234MG/1.5|Blue Cross PPO Specialty|BCBSTX OTHER|42.80||||||| J2426|ERX|0636|PALIPERIDONE ER 156MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|46.47||||||| J2426|ERX|0636|PALIPERIDONE ER 156MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|46.47||||||| J2426|ERX|0636|PALIPERIDONE ER 234MG/1.5|Aenta Medicare Advantage|AETNA MEDICARE MA|42.80||||||| J2426|ERX|0636|PALIPERIDONE ER 234MG/1.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|42.80||||||| J2426|ERX|0636|PALIPERIDONE ER 234MG/1.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|42.80||||||| J2426|ERX|0636|PALIPERIDONE ER 234MG/1.5|Managed Medicaid|MEDICAID AMERIGROUP|42.80||||||| J2426|ERX|0636|PALIPERIDONE ER 156MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.47||||||| J2426|ERX|0636|PALIPERIDONE ER 156MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.47||||||| J2426|ERX|0636|PALIPERIDONE ER 156MG/1ML|Humana Medicare Advantage|HUMANA MA|46.47||||||| J2426|ERX|0636|PALIPERIDONE ER 234MG/1.5|Humana Medicare Advantage|HUMANA MA|42.80||||||| J2426|ERX|0636|PALIPERIDONE ER 234MG/1.5|Medicare|MEDICARE ACUTE|42.80||||||| J2426|ERX|0636|PALIPERIDONE ER 156MG/1ML|Medicare|MEDICARE ACUTE|46.47||||||| J2426|ERX|0636|PALIPERIDONE ER 234MG/1.5|Access Direct Platinum|ANDREWS CENTER|42.80||||||| J2426|ERX|0636|PALIPERIDONE ER 156MG/1ML|Access Direct Platinum|ANDREWS CENTER|46.47||||||| J2504|ERX|0636||Medicare|MEDICARE PART B ONLY IP|||||16.80||| J2505|ERX|0636|PEGFILGRASTIM 6MG/0.6ML|Cigna|CIGNA|19,939.39||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Medicaid|MEDICAID|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Managed Medicare|HEALTHSPRING MA|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Tricare|TRICARE EAST REGION|||||98.38||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|United Healthcare|UNITED HEALTHCARE|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Rusk State Hospital|RUSK STATE HOSP|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Medicare|MEDICARE ACUTE|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|98.38||||98.38||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Humana Medicare Advantage|HUMANA MA|98.38||||||| J2760|ERX|0636|PHENTOLAMINE 5MG VIAL|Managed Medicare|HEALTHSPRING MA|623.75||||||| J2760|ERX|0636|PHENTOLAMINE 5MG VIAL|Cigna|CIGNA|623.75||||||| J2760|ERX|0636|PHENTOLAMINE 5MG VIAL|Humana Medicare Advantage|HUMANA MA|623.75||||||| J2760|ERX|0636|PHENTOLAMINE 5MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|623.75||||||| J2760|ERX|0636|PHENTOLAMINE 5MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||623.75||| J2760|ERX|0636|PHENTOLAMINE 5MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|623.75||||||| J2760|ERX|0636|PHENTOLAMINE 5MG VIAL|Medicare|MEDICARE ACUTE|623.75||||||| J2760|ERX|0636|PHENTOLAMINE 5MG VIAL|Rusk State Hospital|RUSK STATE HOSP|623.75||||||| J2760|ERX|0636|PHENTOLAMINE 5MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||623.75||| J2783|ERX|0636|RASBURICASE 7.5MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,120.30||||||| J2783|ERX|0636|RASBURICASE 7.5MG VIAL|Medicaid|MEDICAID|1,120.30||||||| J2783|ERX|0636|RASBURICASE 7.5MG VIAL|Tricare|TRICARE EAST REGION|1,120.30||||||| J2783|ERX|0636|RASBURICASE 1.5MG VIAL|Tricare|TRICARE EAST REGION|4,636.75||||||| J2783|ERX|0636|RASBURICASE 7.5MG VIAL|Medicare|MEDICARE ACUTE|1,120.30||||||| J2783|ERX|0636|RASBURICASE 1.5MG VIAL|Medicare|MEDICARE ACUTE|4,636.75||||||| J2783|ERX|0636|RASBURICASE 1.5MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|4,636.75||||||| J2783|ERX|0636|RASBURICASE 1.5MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,636.75||||||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Blue Cross PPO Specialty|BCBSTX PPO|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Managed Medicaid|MEDICAID SUPERIOR|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Cigna|CIGNA OTHER|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Veterans Affairs|VETERANS ADMINISTRATION|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Access Direct Platinum|HEALTHFIRST TPA UMR|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|United Medicare Advantage|UHC MEDICARE GOLD MA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|United Medicare Advantage|UHC AARP MCR HMO MA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Humana Medicare Advantage|HUMANA MA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Cigna|CIGNA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Managed Medicaid|MEDICAID AMERIGROUP|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Aenta Medicare Advantage|AETNA MEDICARE MA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Aetna|AETNA PPO|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Aetna|AETNA OTHER|1,650.50||||||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Blue Cross PPO Specialty|BCBSTX OTHER|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Blue Cross HMO Specialty|BCBSTX HMO|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|NON CONTRACTED|COMMERCIAL OTHER 1|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Medicare|UTSW MC KIDNEY PROGRAM|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Medicare|MEDICARE PART B ONLY IP|1,650.50||||||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Medicare|MEDICARE ACUTE|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|United Healthcare|UNITED HEALTHCARE OTHER|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|United Healthcare|UNITED HEALTHCARE|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|United Healthcare|UNITED HEALTHCARE|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|United Healthcare|GEHA|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Tricare|TRICARE FOR LIFE|1,650.50||||||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Tricare|TRICARE EAST REGION|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Managed Medicare|OTHER INSTITUTIONS|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Access Direct Platinum|HEALTHFIRST TPA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Managed Medicare|HEALTHSPRING MA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Managed Medicare|BCBS MEDICARE PPO MA|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Medicaid|SMITH COUNTY JAIL|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Medicaid|MEDICAID|1,650.50||||1,650.50||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Medicaid|LAW ENFORCEMENT OTHER|1,650.50||||||| J2785|EAP|0636|LEXISCAN 0.4MG INJECTION|Medicaid|COUNTY INDIGENT HEALTH OTHER|1,650.50||||1,650.50||| J2792|ERX|0636|RHO(D) IMMUNEGLOB 1500 UN|NON CONTRACTED|COMMERCIAL OTHER 1|||||177.75||| J2792|ERX|0636|RHO(D) IMMUNEGLOB 1500 UN|Medicaid|MEDICAID|||||177.75||| J2792|ERX|0636|RHO(D) IMMUNEGLOB 1500 UN|Managed Medicaid|MEDICAID AMERIGROUP|||||177.75||| J2794|ERX|0636|RISPERIDONE MICROSPH 50MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|49.50||||||| J2794|ERX|0636|RISPERIDONE MICROSPH 50MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|49.50||||||| J2794|ERX|0636|RISPERIDONE MICROSPH 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||49.51||| J2796|ERX|0636|ROMIPLOSTIM 250MCG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|308.57||||||| J2796|ERX|0636|ROMIPLOSTIM 250MCG VIAL|Medicare|MEDICARE ACUTE|308.57||||||| J2796|ERX|0636|ROMIPLOSTIM 250MCG VIAL|Managed Medicare|HEALTHSPRING MA|308.57||||||| J2796|ERX|0636|ROMIPLOSTIM 250MCG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|308.57||||308.57||| J2796|ERX|0636|ROMIPLOSTIM 250MCG VIAL|Aetna|AETNA PPO|308.57||||||| J2796|ERX|0636|ROMIPLOSTIM 250MCG VIAL|Humana Medicare Advantage|HUMANA MA|308.57||||||| J2796|ERX|0636|ROMIPLOSTIM 250MCG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|308.57||||||| J2796|ERX|0636|ROMIPLOSTIM 250MCG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|308.57||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Workers Compensation|TRAVELERS INSURANCE COMPANY|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.00||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Cigna|CIGNA|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|5.00||||5.00||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Aetna|AETNA PPO|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Aetna|AETNA OTHER|||||5.00||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Tricare|TRICARE EAST REGION|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|United Healthcare|TML GROUP BENEFITS|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Medicare|MEDICARE PART B ONLY IP|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Medicare|MEDICARE ACUTE|5.00||||5.00||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|PHCS|HUMANA|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|United Healthcare|UNITED HEALTHCARE|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Managed Medicare|HEALTHSPRING MA|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Medicaid|MEDICAID|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Medicaid|CRIME VICTIMS COMPENSATION|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.00||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|5.00||||5.00||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Humana Medicare Advantage|HUMANA MA|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|5.00||||5.00||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|United Medicare Advantage|UHC AARP MCR HMO MA|||||5.00||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|5.00||||||| J2800|ERX|0636|METHOCARBAMOL 100MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.00||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Medicare|MEDICARE ACUTE|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Managed Medicare|HEALTHSPRING MA|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Medicaid|MEDICAID HMO|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Humana Medicare Advantage|HUMANA MA|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Cigna|CIGNA|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Managed Medicaid|MEDICAID SUPERIOR|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Aetna|AETNA OTHER|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Medicaid|SMITH COUNTY INDIGENT HEALTH|6.74||||||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.74||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|United Healthcare|UNITED HEALTHCARE|||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|||||6.74||| J2805|ERX|0636|SINCALIDE 5MCG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||6.74||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|329.08||||||| J2997|ERX|0636|ALTEPLASE 5MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|252.50||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|329.08||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Access Direct Platinum|HEALTHFIRST TPA|329.08||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Veterans Affairs|VETERANS ADMINISTRATION|329.08||||||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|281.61||||252.50||| J2997|ERX|0636|ALTEPLASE 5MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|252.50||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|281.61||||281.61||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|329.08||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Managed Medicaid|MEDICAID AMERIGROUP|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Humana Medicare Advantage|HUMANA MA|281.61||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|281.61||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Blue Cross PPO Specialty|BCBSTX PPO|329.08||||||| J2997|ERX|0636|ALTEPLASE 50MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|135.30||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|281.61||||||| J2997|ERX|0636|ALTEPLASE 5MG|Managed Medicare|HEALTHSPRING MA|252.50||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 50MG VIAL|Tricare|TRICARE EAST REGION|135.30||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Tricare|TRICARE EAST REGION|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|United Healthcare|UNITED HEALTHCARE|281.61||||329.08||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|United Healthcare|UNITED HEALTHCARE OTHER|329.08||||329.08||| J2997|ERX|0636|ALTEPLASE 50MG VIAL|Medicare|MEDICARE ACUTE|135.30||||252.50||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Medicare|MEDICARE ACUTE|329.08||||329.08||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|NON CONTRACTED|COMMERCIAL OTHER 1|329.08||||||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|Medicare|MEDICARE ACUTE|329.08||||252.50||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|United Healthcare|UNITED HEALTHCARE|329.08||||329.08||| J2997|ERX|0636|ALTEPLASE 5MG|United Healthcare|UNITED HEALTHCARE OTHER|252.50||||329.08||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|281.61||||329.08||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|329.08||||||| J2997|ERX|0636|ALTEPLASE 5MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|252.50||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Tricare|TRICARE EAST REGION|281.61||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Managed Medicare|BCBS MEDICARE PPO MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Managed Medicare|HEALTHSPRING MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Managed Medicare|HEALTHSPRING MA|281.61||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|281.61||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Medicaid|MEDICAID|329.08||||||| J2997|ERX|0636|ALTEPLASE 5MG|Medicaid|SMITH COUNTY INDIGENT HEALTH|252.50||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Aenta Medicare Advantage|AETNA MEDICARE MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Aetna|AETNA PPO|329.08||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Aetna|BOON CHAPMAN|329.08||||||| J2997|ERX|0636|ALTEPLASE 2MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|252.50||||||| J2997|ERX|0636|ALTEPLASE 5MG|Blue Cross PPO Specialty|BCBSTX PPO|252.50||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Blue Cross PPO Specialty|BCBSTX OTHER|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|281.61||||||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|329.08||||||| J2997|ERX|0636|ALTEPLASE 5MG|Medicare|MEDICARE ACUTE|252.50||||252.50||| J2997|ERX|0636|ALTEPLASE 50MG VIAL|Managed Medicare|HEALTHSPRING MA|135.30||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Blue Cross HMO Specialty|BCBSTX HMO|329.08||||||| J2997|ERX|0636|ALTEPLASE 5MG|Blue Cross HMO Specialty|BCBSTX HMO|252.50||||||| J2997|ERX|0636|ALTEPLASE 50MG VIAL|Humana Medicare Advantage|HUMANA MA|135.30||||||| J2997|ERX|0636|ALTEPLASE 5MG|Humana Medicare Advantage|HUMANA MA|252.50||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|ChampVA|CHAMPVA CENTER|329.08||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Humana Medicare Advantage|HUMANA MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|281.61||||||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|281.61||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|United Medicare Advantage|UHC AARP WELLMED HMO MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|329.08||||281.61||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|United Medicare Advantage|UHC MEDICARE GOLD MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|281.61||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|281.61||||||| J2997|ERX|0636|ALTEPLASE 5MG|United Medicare Advantage|UHC AARP MCR HMO MA|329.08||||252.50||| J2997|ERX|0636|ALTEPLASE 5MG|United Medicare Advantage|UHC MEDICARE GOLD MA|252.50||||||| J2997|ERX|0636|ALTEPLASE 1 MG/1 ML SYRIN|Workers Compensation|TEXAS MUTUAL INSURANCE|329.08||||||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|329.08||||252.50||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|281.61||||||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|Humana Medicare Advantage|HUMANA MA|329.08||||||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|Medicare|MEDICARE ACUTE|281.61||||329.08||| J3039|ERX|0636|BLINATUMOMAB 35 MCG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|400.58||||||| J3039|ERX|0636|BLINATUMOMAB 35 MCG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|400.58||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|Veterans Affairs|VETERANS ADMINISTRATION|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|Aetna|AETNA PPO|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|Blue Cross HMO Specialty|BCBSTX HMO|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|Blue Cross PPO Specialty|BCBSTX PPO|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|United Medicare Advantage|UHC MEDICARE GOLD MA|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|United Medicare Advantage|UHC AARP MCR HMO MA|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|Medicaid|MEDICAID|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|Medicare|MEDICARE ACUTE|431.02||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|NON CONTRACTED|COMMERCIAL OTHER 2|431.02||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|United Healthcare|UNITED HEALTHCARE|63.80||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|United Healthcare|UNITED HEALTHCARE OTHER|92.18||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|United Healthcare|UNITED HEALTHCARE OTHER|63.80||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|NON CONTRACTED|COMMERCIAL OTHER 1|63.80||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Medicare|MEDICARE ACUTE|63.80||||63.80||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Medicare|MEDICARE ACUTE|92.18||||92.18||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|63.80||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Managed Medicare|BCBS MEDICARE PPO MA|63.80||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Managed Medicare|BCBS MEDICARE PPO MA|92.18||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|63.80||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Veterans Affairs|VETERANS ADMINISTRATION|92.18||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Veterans Affairs|VETERANS ADMINISTRATION|63.80||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|United Medicare Advantage|UHC AARP MCR HMO MA|63.80||||63.80||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|92.18||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|92.18||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|United Medicare Advantage|UHC AARP MCR HMO MA|92.18||||92.18||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Cigna|CIGNA OTHER|||||92.18||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Managed Medicaid|MEDICAID UNITED HEALTHCARE|63.80||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Humana Medicare Advantage|HUMANA MA|63.80||||63.80||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|63.80||||63.80||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Humana Medicare Advantage|HUMANA MA|92.18||||92.18||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|92.18||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|63.80||||92.18||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Blue Cross HMO Specialty|BCBSTX HMO|63.80||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Blue Cross HMO Specialty|BCBSTX HMO|92.18||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|NON CONTRACTED|COMMERCIAL OTHER 1|92.18||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|92.18||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|63.80||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Blue Cross PPO Specialty|BCBSTX PPO|63.80||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Blue Cross PPO Specialty|BCBSTX OTHER|92.18||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|63.80||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Aetna|AETNA OTHER|92.18||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Aetna|AETNA PPO|92.18||||92.18||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Aenta Medicare Advantage|AETNA MEDICARE MA|92.18||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|92.18||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Aenta Medicare Advantage|AETNA MEDICARE MA|63.80||||||| J3246|ERX|0636|TIROFIBAN 12.5 MG/250 ML|Blue Cross PPO Specialty|BCBSTX PPO|92.18||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Blue Cross PPO Specialty|BCBSTX OTHER|63.80||||||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Aetna|AETNA PPO|63.80||||63.80||| J3246|ERX|0636|TIROFIBAN 3.75 MG/15 ML V|Aetna|AETNA OTHER|63.80||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Blue Cross PPO Specialty|BCBSTX PPO|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 200 MG/10 ML|Blue Cross PPO Specialty|BCBSTX PPO|21.47||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Blue Cross HMO Specialty|BCBSTX HMO|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Managed Medicaid|MEDICAID SUPERIOR|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Humana Medicare Advantage|HUMANA MA|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|United Medicare Advantage|UHC MEDICARE GOLD MA|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|United Medicare Advantage|UHC AARP MCR HMO MA|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Veterans Affairs|VETERANS ADMINISTRATION|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Workers Compensation|WORKERS COMPENSATION OTHER|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Workers Compensation|TEXAS MUTUAL INSURANCE|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Medicaid|MEDICAID|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Medicare|MEDICARE ACUTE|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|United Healthcare|UNITED HEALTHCARE|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Rusk State Hospital|RUSK STATE HOSP|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|NON CONTRACTED|COMMERCIAL OTHER 1|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|19.92||||||| J3262|ERX|0636|TOCILIZUMAB 200 MG/10 ML|Medicare|MEDICARE ACUTE|21.47||||||| J3262|ERX|0636|TOCILIZUMAB 400 MG/20 ML|Managed Medicare|HEALTHSPRING MA|19.92||||||| J3380|ERX|0636|VEDOLIZUMAB 300MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|70.17||||||| J3380|ERX|0636|VEDOLIZUMAB 300MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|70.17||||||| J3465|ERX|0636|VORICONAZOLE 200MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|524.90||||||| J3465|ERX|0636|VORICONAZOLE 200MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|524.90||||||| J3465|ERX|0636|VORICONAZOLE 200MG VIAL|Medicare|MEDICARE ACUTE|524.90||||||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|Managed Medicare|HEALTHSPRING MA|3,185.50||||||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|Medicare|MEDICARE ACUTE|3,185.50||||||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|3,185.50||||||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|3,185.50||||||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|Humana Medicare Advantage|HUMANA MA|3,185.50||||3,185.50||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,185.50||||||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|United Medicare Advantage|UHC AARP MCR HMO MA|3,185.50||||||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,185.50||||||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|3,185.50||||||| J3489|ERX|0636|ZOLEDRONIC ACID 4MG/5ML|Medicaid|SMITH COUNTY JAIL|3,185.50||||||| J7187|ERX|0636|HUMATE-P 600, 1 UNIT CHG|Medicare|MEDICARE ACUTE|7.25||||7.25||| J7187|ERX|0636|HUMATE-P 1200, 1 UNIT CHG|Medicare|MEDICARE ACUTE|7.25||||7.25||| J7187|ERX|0636|HUMATE-P 600, 1 UNIT CHG|Medicare|MEDICARE PART B ONLY IP|7.25||||||| J7187|ERX|0636|HUMATE-P 2400, 1 UNIT CHG|Medicare|MEDICARE ACUTE|7.25||||7.25||| J7189|ERX|0636|FACTOR VIIA RECOMB 1000 M|Medicare|MEDICARE ACUTE|||||10.60||| J7189|ERX|0636|FACTOR VIIA RECOMB 2000 M|Veterans Affairs|VETERANS ADMINISTRATION|10.60||||||| J7189|ERX|0636|FACTOR VIIA RECOMB 1000 M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10.60||||||| J7192|ERX|0636|HELIXATE FS 1000, 1 UNIT|Humana Medicare Advantage|HUMANA MA|||||7.70||| J7195|ERX|0636|FACTOR IX HUMAN RECOMB 10|Veterans Affairs|VETERANS ADMINISTRATION|4.30||||||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Managed Medicare|UNIVERSAL HEALTHCARE MA|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Managed Medicare|BCBS MEDICARE PPO MA|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|United Healthcare|UNITED HEALTHCARE OTHER|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|United Healthcare|UNITED HEALTHCARE|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Medicare|MEDICARE PART B ONLY IP|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Medicare|MEDICARE ACUTE|1,461.70||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Aetna|AETNA PPO|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Cigna|CIGNA|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Cigna|CIGNA OTHER|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Humana Medicare Advantage|HUMANA MA|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Blue Cross HMO Specialty|BCBSTX HMO|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Tricare|TRICARE EAST REGION|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|United Medicare Advantage|UHC AARP MCR HMO MA|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Workers Compensation|UT EMPLOYEE INJURY|||||1,461.70||| J7323|ERX|0636|EUFLEXXA, 2ML SYRINGE|Managed Medicare|HEALTHSPRING MA|||||1,461.70||| J7325|ERX|0636|HYLAN 16MG/2ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||138.89||| J7325|ERX|0636|HYLAN G-F 20, 48 MG/6ML S|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||118.17||| J7325|ERX|0636|HYLAN G-F 20, 48 MG/6ML S|United Medicare Advantage|UHC MEDICARE GOLD MA|||||118.17||| J7325|ERX|0636|HYLAN G-F 20, 48 MG/6ML S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||118.17||| J7325|ERX|0636|HYLAN 16MG/2ML SYRINGE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||138.89||| J7325|ERX|0636|HYLAN 16MG/2ML SYRINGE|Humana Medicare Advantage|HUMANA MA|||||138.89||| J7325|ERX|0636|HYLAN 16MG/2ML SYRINGE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||138.89||| J7325|ERX|0636|HYLAN 16MG/2ML SYRINGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||138.89||| J7325|ERX|0636|HYLAN G-F 20, 48 MG/6ML S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||118.17||| J7325|ERX|0636|HYLAN G-F 20, 48 MG/6ML S|Blue Cross PPO Specialty|BCBSTX PPO|||||118.17||| J7325|ERX|0636|HYLAN G-F 20, 48 MG/6ML S|Medicare|MEDICARE ACUTE|||||118.17||| J7325|ERX|0636|HYLAN 16MG/2ML SYRINGE|Medicare|MEDICARE ACUTE|||||138.89||| J7503|ERX|0636|TACROLIMUS XR 1 MG TABLET|Medicare|MEDICARE ACUTE|29.35||||29.35||| J7503|ERX|0636|TACROLIMUS XR 1 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29.35||||29.35||| J7503|ERX|0636|TACROLIMUS XR 1 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.35||||||| J7504|ERX|0636|TACROLIMUS XR 0.75 MG TAB|Medicare|MEDICARE ACUTE|26.53||||26.53||| J7507|ERX|0636|TACROLIMUS 5MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|||||244.75||| J7507|ERX|0636|TACROLIMUS 5MG CAPSULE|Medicare|MEDICARE ACUTE|244.75||||244.75||| J7508|ERX|0636|TACROLIMUS XL 1 MG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.35||| J7508|ERX|0636|TACROLIMUS XL 1 MG CAPSUL|Medicare|MEDICARE PART B ONLY IP|0.35||||||| J7508|ERX|0636|TACROLIMUS XL 1 MG CAPSUL|Medicare|MEDICARE ACUTE|19.78||||0.35||| J7508|ERX|0636|TACROLIMUS XL 1 MG CAPSUL|Medicare|MEDICARE ACUTE|0.35||||0.35||| J7508|ERX|0636|TACROLIMUS XL 1 MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.35||||||| J7508|ERX|0636|TACROLIMUS XL 0.5 MG CAPS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.78||||||| J7508|ERX|0636|TACROLIMUS XL 1 MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|0.35||||||| J7525|ERX|0636|TACROLIMUS 5MG/1ML 5MG|Blue Cross HMO Specialty|BCBSTX HMO|1,403.50||||||| J7525|ERX|0636|TACROLIMUS 5MG/1ML 5MG|Medicare|MEDICARE ACUTE|1,403.50||||||| J7682|ERX|0636|TOBRAMYCIN 300 MG/5 ML NE|Medicaid|MEDICAID|553.71||||||| J8501|ERX|0250|APREPITANT 40 MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|439.75||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|1,092.50||||1,092.50||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UMR|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|ChampVA|CHAMPVA CENTER|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Cigna|CIGNA|1,382.75||||1,092.50||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Cigna|CIGNA OTHER|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Cigna|CIGNA|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Cigna|CIGNA|1,092.50||||1,092.50||| J8501|ERX|0250|APREPITANT 40 MG CAPSULE|Humana Medicare Advantage|HUMANA MA|439.75||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Humana Medicare Advantage|HUMANA MA|1,092.50||||||| J8501|ERX|0250|APREPITANT 40 MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|439.75||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|1,092.50||||||| J8501|ERX|0250|APREPITANT 40 MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|439.75||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|1,092.50||||||| J8501|ERX|0636|APREPITANT 125MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|1,382.75||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Aetna|AETNA PPO|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,092.50||||1,092.50||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Aetna|AETNA OTHER|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|1,092.50||||1,092.50||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|1,092.50||||||| J8501|ERX|0250|APREPITANT 40 MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|439.75||||||| J8501|ERX|0250|APREPITANT 40 MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|439.75||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|United Medicare Advantage|UHC AARP MCR HMO MA|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||1,092.50||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|United Healthcare|UNITED HEALTHCARE|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Tricare|TRICARE EAST REGION|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|1,092.50||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Medicare|MEDICARE ACUTE|1,092.50||||1,092.50||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Medicare|MEDICARE ACUTE|1,382.75||||1,092.50||| J8501|ERX|0250|APREPITANT 40 MG CAPSULE|Managed Medicare|HEALTHSPRING MA|439.75||||||| J8501|ERX|0636|APREPITANT 80MG CAPSULE|Managed Medicare|HEALTHSPRING MA|1,092.50||||1,092.50||| J8501|ERX|0250|APREPITANT 40 MG CAPSULE|Medicare|MEDICARE ACUTE|439.75||||||| J9025|ERX|0636|AZACITIDINE 100MG/10ML|Medicaid|MEDICAID|47.53||||||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Blue Cross PPO Specialty|BCBSTX PPO|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Aetna|AETNA QHP HMO|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Aetna|AETNA PPO|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Humana Medicare Advantage|HUMANA MA|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|United Medicare Advantage|UHC AARP MCR HMO MA|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Medicare|MEDICARE ACUTE|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|PHCS|HUMANA INSURANCE|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Managed Medicare|HEALTHSPRING MA|||||13.50||| J9030|ERX|0636|BCG LIVE, 50 MG VIAL (INT|Managed Medicare|BCBS MEDICARE PPO MA|||||13.50||| J9035|ERX|0636|BEVACIZUMAB 400MG 16ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|564.91||||||| J9035|ERX|0636|BEVACIZUMAB 100MG 4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|564.95||||||| J9035|ERX|0636|BEVACIZUMAB 400MG 16ML|Blue Cross PPO Specialty|BCBSTX PPO|564.91||||||| J9041|ERX|0636|BORTEZOMIB 3.5MG 3.5ML|United Healthcare|UNITED HEALTHCARE OTHER|349.80||||||| J9041|ERX|0636|BORTEZOMIB 3.5MG 3.5ML|Medicare|MEDICARE ACUTE|349.80||||||| J9047|ERX|0636|ALBUMIN 25%, 25G/100ML|Medicare|MEDICARE ACUTE|1,155.63||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|Managed Medicaid|MEDICAID UNITED HEALTHCARE|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|Managed Medicaid|MEDICAID AMERIGROUP|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|Managed Medicaid|MEDICAID AMERIGROUP|52.60||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|Humana Medicare Advantage|HUMANA MA|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|Humana Medicare Advantage|HUMANA MA|52.60||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|Blue Cross HMO Specialty|BCBSTX HMO|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|Blue Cross HMO Specialty|BCBSTX HMO|52.60||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|Blue Cross PPO Specialty|BCBSTX PPO|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|52.60||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|52.60||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|Medicaid|MEDICAID|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|Medicaid|MEDICAID|52.60||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|Tricare|TRICARE EAST REGION|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|Tricare|TRICARE EAST REGION|52.60||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|United Healthcare|UNITED HEALTHCARE OTHER|52.60||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|United Healthcare|UNITED HEALTHCARE OTHER|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|NON CONTRACTED|COMMERCIAL OTHER 1|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|NON CONTRACTED|COMMERCIAL OTHER 1|52.60||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 500MG/25|Medicare|MEDICARE ACUTE|54.05||||||| J9070|ERX|0636|CYCLOPHOSPHAMIDE 1000MG 5|Medicare|MEDICARE ACUTE|52.60||||||| J9171|ERX|0636|DOCETAXEL 80MG/8ML|Medicare|MEDICARE ACUTE|180.48||||||| J9171|ERX|0636|DOCETAXEL 20MG/2ML|Medicare|MEDICARE ACUTE|180.46||||||| J9171|ERX|0636|DOCETAXEL 80MG/8ML|Medicaid|MEDICAID|180.48||||||| J9171|ERX|0636|DOCETAXEL 20MG/2ML|Medicaid|MEDICAID|180.46||||||| J9171|ERX|0636|DOCETAXEL 80MG/8ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.48||||||| J9179|ERX|0636|ERIBULIN MESYLATE 1MG/2ML|Medicare|MEDICARE ACUTE|528.88||||||| J9211|ERX|0636|IDARUBICIN 5MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|386.25||||||| J9211|ERX|0636|IDARUBICIN 5MG/5ML|Cigna|CIGNA|386.25||||||| J9211|ERX|0636|IDARUBICIN 5MG/5ML|Humana Medicare Advantage|HUMANA MA|386.25||||||| J9211|ERX|0636|IDARUBICIN 5MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|386.25||||||| J9211|ERX|0636|IDARUBICIN 5MG/5ML|Medicare|MEDICARE ACUTE|386.25||||||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Managed Medicare|HEALTHSPRING MA|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Managed Medicare|BCBS MEDICARE PPO MA|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|United Healthcare|UNITED HEALTHCARE OTHER|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|United Healthcare|UNITED HEALTHCARE|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|PHCS|HUMANA|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Medicare|MEDICARE PART B ONLY IP|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Medicare|MEDICARE ACUTE|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Aetna Value Network|AETNA VALUE NETWORK|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Aetna|AETNA PPO|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5,325.77||| J9217|ERX|0636|ELIGARD 45 MG KIT|Medicare|MEDICARE ACUTE|||||1,580.91||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|United Healthcare|UNITED HEALTHCARE|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Blue Cross PPO Specialty|BCBSTX PPO|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Blue Cross HMO Specialty|BCBSTX HMO|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Managed Medicaid|MEDICAID SUPERIOR|||||5,142.27||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Humana Medicare Advantage|HUMANA MA|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Cigna|CIGNA|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|United Medicare Advantage|UHC AARP MCR HMO MA|||||5,325.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,958.77||| J9217|ERX|0636|LUPRON DEPOT 45 MG KIT|Veterans Affairs|VETERANS ADMINISTRATION|||||4,958.77||| J9264|ERX|0636|ABRAXANE 100MG/20ML|Blue Cross PPO Specialty|BCBSTX PPO|89.62||||||| J9280|ERX|0636|MITOMYCIN 20MG/40ML|Medicare|MEDICARE ACUTE|||||893.38||| J9280|ERX|0636|MITOMYCIN 20MG/40ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|893.38||||||| J9280|ERX|0636|MITOMYCIN 20MG/40ML|Humana Medicare Advantage|HUMANA MA|||||893.38||| J9280|ERX|0636|MITOMYCIN 20MG/40ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||893.38||| J9280|ERX|0636|MITOMYCIN 20MG/40ML|Blue Cross PPO Specialty|BCBSTX PPO|||||893.38||| J9299|ERX|0636|NIVOLUMAB 240 MG/24 ML VI|Access Direct Platinum|HEALTHFIRST TPA|99.20||||||| J9299|ERX|0636|NIVOLUMAB 240 MG/24 ML VI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|99.20||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Medicaid|MEDICAID|328.83||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Medicaid|MEDICAID|357.02||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Managed Medicare|BCBS MEDICARE PPO MA|||||328.83||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Managed Medicare|HEALTHSPRING MA|357.02||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Managed Medicare|BCBS MEDICARE PPO MA|||||357.02||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Tricare|TRICARE EAST REGION|328.83||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|328.83||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|NON CONTRACTED|COMMERCIAL OTHER 1|328.83||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|357.02||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Medicare|MEDICARE ACUTE|328.83||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Tricare|TRICARE EAST REGION|357.02||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Medicare|MEDICARE ACUTE|357.02||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|328.83||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Managed Medicaid|MEDICAID AMERIGROUP|328.83||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|357.02||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Managed Medicaid|MEDICAID AMERIGROUP|357.02||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Humana Medicare Advantage|HUMANA MA|357.02||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Managed Medicare|HEALTHSPRING MA|328.83||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Humana Medicare Advantage|HUMANA MA|328.83||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Blue Cross HMO Specialty|BCBSTX HMO|328.83||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|357.02||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Blue Cross PPO Specialty|BCBSTX PPO|328.83||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|357.02||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|328.83||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|United Medicare Advantage|UHC AARP MCR HMO MA|328.83||||||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|United Medicare Advantage|UHC AARP MCR HMO MA|357.02||||||| J9312|ERX|0636|RITUXIMAB 500MG/50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|328.83||||||| J9355|ERX|0636|TRASTUZUMAB 150MG VIAL|Medicare|MEDICARE ACUTE|433.55||||||| J9395|ERX|0636|FULVESTRANT 250MG 5ML|Blue Cross PPO Specialty|BCBSTX PPO|816.38||||||| L0112|EAP|0274|IMPL CRANIAL CUSTOM ACSS-|NON CONTRACTED|COMMERCIAL OTHER 1|46,582.50||||||| L0637|EAP|0274|TRI MOD LSO CMTIQBACK|Workers Compensation|WORKERS COMPENSATION OTHER|5,726.26||||||| L0637|EAP|0274|TRI MOD LSO CMTIQBACK|United Medicare Advantage|UHC MEDICARE GOLD MA|5,726.26||||||| L0637|EAP|0274|TRI MOD LSO CMTIQBACK|Humana Medicare Advantage|HUMANA MA|5,726.26||||||| L0637|EAP|0274|TRI MOD LSO CMTIQBACK|Blue Cross PPO Specialty|BCBSTX PPO|5,726.26||||||| L0637|EAP|0274|TRI MOD LSO CMTIQBACK|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5,726.26||| L0637|EAP|0274|TRI MOD LSO CMTIQBACK|Medicare|MEDICARE PART B ONLY IP|5,726.26||||||| L0637|EAP|0274|TRI MOD LSO CMTIQBACK|Medicare|MEDICARE ACUTE|5,726.26||||||| L0637|EAP|0274|TRI MOD LSO CMTIQBACK|United Healthcare|UNITED HEALTHCARE|5,726.26||||||| L0637|EAP|0274|TRI MOD LSO CMTIQBACK|Tricare|TRICARE EAST REGION|||||5,726.26||| L8606|EAP|0278|3YNTHETIC IMPLNT URINARY|Medicare|MEDICARE ACUTE|||||274.50||| L8670|EAP|0278|ON-X AORTIC PROST VASC GR|Medicare|MEDICARE ACUTE|218.75||||||| L8670|EAP|0278|ON-X AORTIC PROST VASC GR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|218.75||||||| L8670|EAP|0278|ON-X AORTIC PROST VASC GR|Blue Cross PPO Specialty|BCBSTX PPO|218.75||||||| L8670|EAP|0278|ON-X AORTIC PROST VASC GR|Humana Medicare Advantage|HUMANA MA|218.75||||||| L8699|EAP|0510|PROSTHETIC IMPLANT NOS|Medicare|MEDICARE ACUTE|||||32.63||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|United Healthcare|UNITED HEALTHCARE|12,889.75||||||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|Managed Medicare|HEALTHSPRING MA|540.80||||12,889.75||| L8699|EAP|0278|ATRICURE ATRI CLIP 45MM|Managed Medicare|BCBS MEDICARE PPO MA|45.50||||||| L8699|EAP|0278|ATRICURE ATRI CLIP 35MM|Managed Medicare|BCBS MEDICARE PPO MA|45.50||||||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|Medicaid|MEDICAID|12,889.75||||||| L8699|EAP|0278|EDWARDS SAPIEN XT HEART V|Medicare|MEDICARE ACUTE|1,137.50||||12,889.75||| L8699|EAP|0278|TRI-AD TRICUSPID RING 30M|Medicare|MEDICARE ACUTE|83.72||||12,889.75||| L8699|EAP|0278|ATRICURE ATRI CLIP 50MM|Medicare|MEDICARE ACUTE|45.50||||12,889.75||| L8699|EAP|0278|COIL TARGET 360 SOFT|Medicare|MEDICARE ACUTE|11,041.75||||12,889.75||| L8699|EAP|0278|TRI-AD TRICUSPID RING 28M|Medicare|MEDICARE ACUTE|83.72||||12,889.75||| L8699|EAP|0278|PUMP SET IMPELLA 2.5 AIC|Medicare|MEDICARE ACUTE|540.80||||12,889.75||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|Medicare|MEDICARE ACUTE|45.50||||12,889.75||| L8699|EAP|0278|TRI-AD TRICUSPID RING 32M|Medicare|MEDICARE ACUTE|107.38||||12,889.75||| L8699|EAP|0278|ATRICURE ATRI CLIP 45MM|Medicare|MEDICARE ACUTE|45.50||||12,889.75||| L8699|EAP|0278|ATRICURE ATRI CLIP 35MM|United Medicare Advantage|UHC MEDICARE GOLD MA|45.50||||||| L8699|EAP|0278|PUMP SET IMPELLA 2.5 AIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|540.80||||||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12,889.75||||||| L8699|EAP|0278|COIL TARGET 360 SOFT|Workers Compensation|WORKERS COMPENSATION OTHER|11,041.75||||||| L8699|EAP|0278|PUMP SET IMPELLA 2.5 AIC|Veterans Affairs|VETERANS ADMINISTRATION|540.80||||||| L8699|EAP|0278|COIL TARGET 360 SOFT|Medicaid|MEDICAID|11,041.75||||||| L8699|EAP|0278|COIL TARGET 360 SOFT|Veterans Affairs|VETERANS ADMINISTRATION|11,041.75||||||| L8699|EAP|0278|COIL TARGET 360 SOFT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11,041.75||||||| L8699|EAP|0278|PUMP SET IMPELLA 2.5 AIC|Humana Medicare Advantage|HUMANA MA|540.80||||||| L8699|EAP|0278|COIL TARGET 360 SOFT|Humana Medicare Advantage|HUMANA MA|11,041.75||||||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|Humana Medicare Advantage|HUMANA MA|12,889.75||||||| L8699|EAP|0278|ATRICURE ATRI CLIP 35MM|Humana Medicare Advantage|HUMANA MA|45.50||||||| L8699|EAP|0278|PUMP SET IMPELLA 2.5 AIC|Blue Cross HMO Specialty|BCBSTX HMO|540.80||||||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|Blue Cross HMO Specialty|BCBSTX HMO|12,889.75||||||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|Blue Cross PPO Specialty|BCBSTX PPO|12,889.75||||12,889.75||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|Blue Cross PPO Specialty|BCBSTX PPO|45.50||||12,889.75||| L8699|EAP|0278|ONYX 18 EMBOLIZATION MATE|Aetna|AETNA OTHER|12,889.75||||||| L8699|EAP|0278|ATRICURE ATRI CLIP 40MM|Aenta Medicare Advantage|AETNA MEDICARE MA|45.50||||||| L8699|EAP|0278|ATRICURE ATRI CLIP 40MM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45.50||||||| P9012|EAP|0390|CRYOPRECIPITATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|303.60||||||| P9012|EAP|0390|CRYOPRECIPITATE|Aenta Medicare Advantage|AETNA MEDICARE MA|2.53||||||| P9012|EAP|0390|CRYOPRECIPITATE|Blue Cross PPO Specialty|BCBSTX PPO|303.60||||||| P9012|EAP|0390|CRYOPRECIPITATE|Blue Cross HMO Specialty|BCBSTX HMO|2.53||||||| P9012|EAP|0390|CRYOPRECIPITATE|Cigna|CIGNA|2.53||||||| P9012|EAP|0390|CRYOPRECIPITATE|Humana Medicare Advantage|HUMANA MA|303.60||||||| P9012|EAP|0390|CRYOPRECIPITATE|Veterans Affairs|VETERANS ADMINISTRATION|303.60||||||| P9012|EAP|0390|CRYOPRECIPITATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|303.60||||||| P9012|EAP|0390|CRYOPRECIPITATE|Medicaid|MEDICAID|2.53||||||| P9012|EAP|0390|CRYOPRECIPITATE|Managed Medicare|HEALTHSPRING MA|2.53||||||| P9012|EAP|0390|CRYOPRECIPITATE|United Healthcare|UNITED HEALTHCARE OTHER|303.60||||||| P9012|EAP|0390|CRYOPRECIPITATE|United Healthcare|UNITED HEALTHCARE|2.53||||||| P9012|EAP|0390|CRYOPRECIPITATE|Medicare|MEDICARE ACUTE|2.53||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|NON CONTRACTED|COMMERCIAL OTHER 1|718.30||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|PHCS|HUMANA|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|PHCS|GROUP AND PENSION|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicare|MEDICARE PART B ONLY IP|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Tricare|TRICARE EAST REGION|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.53||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|United Healthcare|UNITED HEALTHCARE OTHER|6.53||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|United Healthcare|UNITED HEALTHCARE|783.60||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|United Healthcare|UNITED HEALTHCARE|||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|United Healthcare|TML GROUP BENEFITS|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicare|OTHER INSTITUTIONS|||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicare|HEALTHSPRING MA|6.53||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|6.53||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicaid|SMITH COUNTY INDIGENT HEALTH|||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicaid|MEDICAID|6.53||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicaid|CRIME VICTIMS COMPENSATION|6.53||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicaid|COUNTY INDIGENT HEALTH OTHER|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicaid|MOLINA HEALTHCARE OF TEXAS|6.53||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicaid|SMITH COUNTY JAIL|6.53||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|United Medicare Advantage|UHC MEDICARE GOLD MA|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|United Medicare Advantage|UHC AARP MCR HMO MA|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|United Medicare Advantage|UHC AARP WELLMED HMO MA|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicaid|LAW ENFORCEMENT OTHER|||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.53||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Access Direct Platinum|HEALTHFIRST TPA UMR|6.53||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicare|BCBS MEDICARE PPO MA|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Access Direct Platinum|HEALTHFIRST TPA|783.60||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Workers Compensation|ZURICH COMPANY|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Workers Compensation|WORKERS COMPENSATION OTHER|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.53||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Workers Compensation|TEXAS MUTUAL INSURANCE|6.53||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|6.53||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Veterans Affairs|VETERANS ADMINISTRATION|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicaid|MEDICAID SUPERIOR|6.53||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Managed Medicaid|MEDICAID AMERIGROUP|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Humana Medicare Advantage|HUMANA MA|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Medicare|MEDICARE ACUTE|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Cigna|CIGNA OTHER|6.53||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Cigna|CIGNA|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Rusk State Hospital|RUSK STATE HOSP|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Cigna|CIGNA|783.60||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|ChampVA|CHAMPVA CENTER|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Blue Cross HMO Specialty|BCBSTX HMO|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Blue Cross PPO Specialty|BCBSTX PPO|783.60||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Blue Cross PPO Specialty|BCBSTX OTHER|783.60||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.53||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Aenta Medicare Advantage|AETNA MEDICARE MA|6.53||||783.60||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Aetna|AETNA QHP HMO|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Aetna|AETNA PPO|6.53||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Aetna|AETNA OTHER|6.53||||6.53||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Aetna|BOON CHAPMAN|783.60||||||| P9016|EAP|0390|BLOOD LEUKOREDUCED EACH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|783.60||||6.53||| P9017|EAP|0390|FRESH FROZEN PLASMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Aenta Medicare Advantage|AETNA MEDICARE MA|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Aetna|AETNA PPO|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Aetna|AETNA OTHER|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Blue Cross PPO Specialty|BCBSTX PPO|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Cigna|CIGNA OTHER|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Cigna|CIGNA|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Cigna|CIGNA|2.74||||2.74||| P9017|EAP|0390|FRESH FROZEN PLASMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|301.40||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Managed Medicaid|MEDICAID SUPERIOR|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Managed Medicaid|MEDICAID AMERIGROUP|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Workers Compensation|WORKERS COMPENSATION OTHER|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Workers Compensation|BROOKSHIRES WORKERS COMP|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Veterans Affairs|VETERANS ADMINISTRATION|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Humana Medicare Advantage|HUMANA MA|2.74||||328.80||| P9017|EAP|0390|FRESH FROZEN PLASMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Access Direct Platinum|HEALTHFIRST TPA UMR|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.74||||2.74||| P9017|EAP|0390|FRESH FROZEN PLASMA|Blue Cross HMO Specialty|BCBSTX HMO|328.80||||328.80||| P9017|EAP|0390|FRESH FROZEN PLASMA|United Medicare Advantage|UHC MEDICARE GOLD MA|2.74||||328.80||| P9017|EAP|0390|FRESH FROZEN PLASMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|United Medicare Advantage|UHC AARP MCR HMO MA|328.80||||328.80||| P9017|EAP|0390|FRESH FROZEN PLASMA|Medicaid|MEDICAID|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Aetna|AETNA QHP HMO|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Medicaid|CRIME VICTIMS COMPENSATION|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Managed Medicare|BCBS MEDICARE PPO MA|301.40||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Managed Medicare|HEALTHSPRING MA|2.74||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.74||| P9017|EAP|0390|FRESH FROZEN PLASMA|United Healthcare|UNITED HEALTHCARE OTHER|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Tricare|TRICARE EAST REGION|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|UTMB|UTMB CORRECTIONAL MANAGED CARE|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Medicare|MEDICARE PART B ONLY IP|328.80||||||| P9017|EAP|0390|FRESH FROZEN PLASMA|Medicare|MEDICARE ACUTE|2.74||||2.74||| P9017|EAP|0390|FRESH FROZEN PLASMA|NON CONTRACTED|COMMERCIAL OTHER 1|301.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|NON CONTRACTED|COMMERCIAL OTHER 1|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|PHCS|HUMANA|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Medicare|MEDICARE ACUTE|3,536.40||||3,536.40||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|United Healthcare|UNITED HEALTHCARE|||||29.47||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|United Healthcare|UNITED HEALTHCARE OTHER|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|29.47||||29.47||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Managed Medicare|HEALTHSPRING MA|29.47||||29.47||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Managed Medicare|BCBS MEDICARE PPO MA|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Medicaid|SMITH COUNTY JAIL|||||29.47||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Medicaid|MEDICAID|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Medicaid|CRIME VICTIMS COMPENSATION|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Medicaid|COUNTY INDIGENT HEALTH OTHER|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,536.40||||3,241.70||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|United Medicare Advantage|UHC AARP MCR HMO MA|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|United Medicare Advantage|UHC MEDICARE GOLD MA|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Access Direct Platinum|HEALTHFIRST TPA UMR|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Managed Medicare|WELLCARE CHOICE MA|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Workers Compensation|WORKERS COMPENSATION OTHER|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Veterans Affairs|VETERANS ADMINISTRATION|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,536.40||||3,536.40||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Managed Medicaid|MEDICAID AMERIGROUP|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Humana Medicare Advantage|HUMANA MA|29.47||||29.47||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Cigna|CIGNA|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Blue Cross HMO Specialty|BCBSTX HMO|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Blue Cross PPO Specialty|BCBSTX PPO|29.47||||3,536.40||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Aenta Medicare Advantage|AETNA MEDICARE MA|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Aetna|AETNA QHP HMO|3,536.40||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Aetna|AETNA OTHER|29.47||||||| P9035|EAP|0390|PLATELET LEUKOREDUCED APH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,536.40||||3,536.40||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,267.20||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Blue Cross PPO Specialty|BCBSTX PPO|4,267.20||||35.56||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Blue Cross HMO Specialty|BCBSTX HMO|4,267.20||||4,267.20||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Humana Medicare Advantage|HUMANA MA|4,267.20||||35.56||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,267.20||||35.56||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Veterans Affairs|VETERANS ADMINISTRATION|4,267.20||||4,267.20||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||35.56||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4,267.20||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|United Medicare Advantage|UHC AARP MCR HMO MA|4,267.20||||||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,267.20||||||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Cigna|CIGNA|35.56||||||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|United Medicare Advantage|UHC MEDICARE GOLD MA|4,267.20||||35.56||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Medicaid|MEDICAID|35.56||||||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Medicaid|COUNTY INDIGENT HEALTH OTHER|4,267.20||||||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|35.56||||||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Managed Medicare|HEALTHSPRING MA|4,267.20||||||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Managed Medicare|BCBS MEDICARE PPO MA|||||4,267.20||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|United Healthcare|UNITED HEALTHCARE OTHER|4,267.20||||4,267.20||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|UTMB|UTMB CORRECTIONAL MANAGED CARE|4,267.20||||||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|Medicare|MEDICARE ACUTE|35.56||||4,267.20||| P9037|EAP|0390|PLATELET LEUKOREDUCED IRR|NON CONTRACTED|COMMERCIAL OTHER 1|35.56||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|NON CONTRACTED|COMMERCIAL OTHER 1|9.81||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Medicare|MEDICARE PART B ONLY IP|9.81||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Medicare|MEDICARE ACUTE|1,177.20||||1,177.20||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,177.50||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|United Healthcare|UNITED HEALTHCARE OTHER|1,177.20||||9.81||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|United Healthcare|UNITED HEALTHCARE|||||9.81||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.81||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Managed Medicare|HEALTHSPRING MA|1,177.20||||1,177.50||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Medicaid|MEDICAID|1,177.20||||9.81||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Managed Medicare|BCBS MEDICARE PPO MA|9.81||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|United Medicare Advantage|UHC AARP MCR HMO MA|1,177.50||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,177.50||||1,177.20||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|United Medicare Advantage|UHC MEDICARE GOLD MA|1,177.50||||9.81||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Access Direct Platinum|HEALTHFIRST TPA UMR|9.81||||1,177.20||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Access Direct Platinum|HEALTHFIRST TPA|9.81||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,177.50||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|PHCS|HUMANA|||||1,177.50||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.81||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Veterans Affairs|VETERANS ADMINISTRATION|1,177.20||||1,177.20||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,177.50||||1,177.20||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,177.20||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Managed Medicaid|MEDICAID AMERIGROUP|9.81||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Humana Medicare Advantage|HUMANA MA|1,177.50||||1,177.20||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Cigna|CIGNA|1,177.20||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Blue Cross HMO Specialty|BCBSTX HMO|1,177.20||||1,177.50||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Blue Cross PPO Specialty|BCBSTX PPO|9.81||||1,177.20||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,177.20||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Aenta Medicare Advantage|AETNA MEDICARE MA|9.81||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Aetna|AETNA PPO|1,177.50||||||| P9040|EAP|0390|BLOOD LEUKOREDUCED IRRADI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,177.20||||1,177.20||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Aetna|BOON CHAPMAN|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Aetna|AETNA QHP HMO|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Aetna|AETNA OTHER|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Aenta Medicare Advantage|AETNA MEDICARE MA|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Blue Cross PPO Specialty|BCBSTX OTHER|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Blue Cross PPO Specialty|BCBSTX PPO|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Blue Cross HMO Specialty|BCBSTX HMO|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|ChampVA|CHAMPVA CENTER|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Cigna|CIGNA OTHER|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Humana Medicare Advantage|HUMANA MA|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Managed Medicaid|MEDICAID AMERIGROUP|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Veterans Affairs|VETERANS ADMINISTRATION|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Workers Compensation|WORKERS COMPENSATION OTHER|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Access Direct Platinum|HEALTHFIRST TPA UMR|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Access Direct Platinum|HEALTHFIRST TPA|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Managed Medicaid|MEDICAID SUPERIOR|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|United Medicare Advantage|UHC AARP MCR HMO MA|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Cigna|CIGNA|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Medicaid|SMITH COUNTY JAIL|||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Medicaid|MEDICAID|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Medicaid|CRIME VICTIMS COMPENSATION|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Aetna|AETNA PPO|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Managed Medicare|HEALTHSPRING MA|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Managed Medicare|BCBS MEDICARE PPO MA|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|United Healthcare|UNITED HEALTHCARE|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|United Healthcare|UNITED HEALTHCARE|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|United Healthcare|UNITED HEALTHCARE OTHER|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Tricare|TRICARE EAST REGION|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Medicare|MEDICARE PART B ONLY IP|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Medicare|MEDICARE ACUTE|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|PHCS|GROUP AND PENSION|821.75||||||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|NON CONTRACTED|COMMERCIAL OTHER 1|821.75||||821.75||| P9045|ERX|0636|ALBUMIN 5% 12.5 G 250ML|Rusk State Hospital|RUSK STATE HOSP|821.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|PHCS|GROUP AND PENSION|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|NON CONTRACTED|COMMERCIAL OTHER 2|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|NON CONTRACTED|COMMERCIAL OTHER 1|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Medicare|MEDICARE ACUTE|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Medicare|MEDICARE PART B ONLY IP|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Tricare|TRICARE EAST REGION|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|United Healthcare|UNITED HEALTHCARE|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|United Healthcare|UNITED HEALTHCARE OTHER|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicare|WELLCARE CHOICE MA|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicare|HEALTHSPRING MA|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Medicaid|SMITH COUNTY JAIL|||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Medicaid|SMITH COUNTY INDIGENT HEALTH|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Medicaid|CRIME VICTIMS COMPENSATION|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|United Medicare Advantage|UHC AARP WELLMED HMO MA|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Medicaid|MEDICAID|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|United Medicare Advantage|UHC AARP MCR HMO MA|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Access Direct Platinum|HEALTHFIRST TPA UMR|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Access Direct Platinum|HEALTHFIRST TPA|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicare|BCBS MEDICARE PPO MA|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Veterans Affairs|VETERANS ADMINISTRATION|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Workers Compensation|ZURICH COMPANY|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Workers Compensation|UT EMPLOYEE INJURY|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Workers Compensation|TEXAS MUTUAL INSURANCE|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicaid|MEDICAID SUPERIOR|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Managed Medicaid|MEDICAID AMERIGROUP|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Rusk State Hospital|RUSK STATE HOSP|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Humana Medicare Advantage|HUMANA MA|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|ChampVA|CHAMPVA CENTER|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|PHCS|HUMANA|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Cigna|CIGNA|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Cigna|CIGNA OTHER|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Blue Cross HMO Specialty|BCBSTX HMO|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Blue Cross PPO Specialty|BCBSTX OTHER|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Blue Cross PPO Specialty|BCBSTX PPO|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,155.75||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Aetna|AETNA QHP HMO|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Aetna|AETNA PPO|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Aetna|AETNA OTHER|1,155.75||||||| P9059|EAP|0390|FROZEN PLASMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|301.40||||||| P9059|EAP|0390|FROZEN PLASMA|Blue Cross PPO Specialty|BCBSTX PPO|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Blue Cross HMO Specialty|BCBSTX HMO|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Humana Medicare Advantage|HUMANA MA|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|301.40||||2.74||| P9059|EAP|0390|FROZEN PLASMA|Managed Medicaid|MEDICAID SUPERIOR|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Veterans Affairs|VETERANS ADMINISTRATION|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|United Medicare Advantage|UHC AARP MCR HMO MA|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|United Medicare Advantage|UHC MEDICARE GOLD MA|328.80||||328.80||| P9059|EAP|0390|FROZEN PLASMA|Medicaid|MEDICAID|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Medicaid|CRIME VICTIMS COMPENSATION|2.74||||||| P9059|EAP|0390|FROZEN PLASMA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|301.40||||||| P9059|EAP|0390|FROZEN PLASMA|Managed Medicare|HEALTHSPRING MA|301.40||||||| P9059|EAP|0390|FROZEN PLASMA|Managed Medicare|BCBS MEDICARE PPO MA|2.74||||||| P9059|EAP|0390|FROZEN PLASMA|United Healthcare|UNITED HEALTHCARE OTHER|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|United Healthcare|UNITED HEALTHCARE|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Tricare|TRICARE EAST REGION|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|UTMB|UTMB CORRECTIONAL MANAGED CARE|328.80||||||| P9059|EAP|0390|FROZEN PLASMA|Medicare|MEDICARE ACUTE|328.80||||||| Q0162|ERX|0636|ONDANSETRON 8MG TABLET|Medicare|MEDICARE ACUTE|8.80||||8.80||| Q0162|ERX|0636|ONDANSETRON 8MG TABLET|United Healthcare|UNITED HEALTHCARE|8.80||||||| Q0162|ERX|0636|ONDANSETRON 8MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|8.80||||||| Q0162|ERX|0636|ONDANSETRON 8MG TABLET|United Medicare Advantage|UHC AARP MCR HMO MA|8.80||||||| Q0162|ERX|0636|ONDANSETRON 8MG TABLET|Humana Medicare Advantage|HUMANA MA|8.80||||||| Q0162|ERX|0636|ONDANSETRON 8MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.80||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.16||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33.60||||33.60||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Blue Cross HMO Specialty|BCBSTX HMO|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Blue Cross PPO Specialty|BCBSTX PPO|1.16||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Blue Cross PPO Specialty|BCBSTX PPO|33.60||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicaid|MEDICAID AMERIGROUP|||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.60||||33.60||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.16||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.60||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicaid|MEDICAID SUPERIOR|1.16||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.16||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Cigna|CIGNA|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Cigna|CIGNA|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Humana Medicare Advantage|HUMANA MA|1.16||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.16||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|33.60||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Veterans Affairs|VETERANS ADMINISTRATION|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Veterans Affairs|VETERANS ADMINISTRATION|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|United Medicare Advantage|UHC MEDICARE GOLD MA|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.16||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33.60||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|United Medicare Advantage|UHC AARP MCR HMO MA|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|United Medicare Advantage|UHC MEDICARE GOLD MA|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|United Medicare Advantage|UHC AARP MCR HMO MA|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Humana Medicare Advantage|HUMANA MA|33.60||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicaid|MEDICAID SUPERIOR|33.60||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicare|MA PART B ONLY IP|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicare|HEALTHSPRING MA|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicare|BCBS MEDICARE PPO MA|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Blue Cross HMO Specialty|BCBSTX HMO|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Managed Medicare|HEALTHSPRING MA|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Managed Medicare|BCBS MEDICARE PPO MA|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Medicaid|SMITH COUNTY JAIL|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Aenta Medicare Advantage|AETNA MEDICARE MA|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Medicaid|MEDICAID|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Medicaid|SMITH COUNTY JAIL|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Medicaid|MEDICAID|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|UTMB|UTMB CORRECTIONAL MANAGED CARE|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|United Healthcare|UNITED HEALTHCARE OTHER|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|NON CONTRACTED|COMMERCIAL OTHER 1|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|NON CONTRACTED|COMMERCIAL OTHER 1|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Medicare|MEDICARE ACUTE|33.60||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Medicare|MEDICARE PART B ONLY IP|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Medicare|MEDICARE ACUTE|1.16||||1.16||| Q2037|ERX|0636||Medicare|MEDICARE ACUTE|158.25||||158.25||| Q2037|ERX|0636||Managed Medicare|OTHER INSTITUTIONS|||||158.25||| Q2037|ERX|0636||Managed Medicare|HEALTHSPRING MA|||||158.25||| Q2050|ERX|0636|DOXORUBICIN LIPOSOM 50MG/|Medicaid|MEDICAID|1,017.49||||||| Q2050|ERX|0636|DOXORUBICIN LIPOSOM 50MG/|Medicare|MEDICARE ACUTE|1,017.49||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|United Medicare Advantage|UHC AARP MCR HMO MA|178.25||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|178.25||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Humana Medicare Advantage|HUMANA MA|178.25||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|United Medicare Advantage|UHC MEDICARE GOLD MA|178.25||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.55||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Managed Medicaid|MEDICAID SUPERIOR|178.25||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.55||||166.63||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Blue Cross PPO Specialty|BCBSTX PPO|1.55||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Blue Cross HMO Specialty|BCBSTX HMO|1.55||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Aetna|AETNA PPO|178.25||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Aenta Medicare Advantage|AETNA MEDICARE MA|1.55||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Medicare|MEDICARE ACUTE|178.25||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|178.25||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Medicaid|SMITH COUNTY INDIGENT HEALTH|1.55||||||| Q3014|EAP|0780|TELEHEALTH FACILITY FEE|Medicaid|MEDICAID HMO|178.25||||||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Medicare|MEDICARE ACUTE|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Medicaid|MEDICAID|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Managed Medicare|HEALTHSPRING MA|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|United Healthcare|UNITED HEALTHCARE|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Blue Cross PPO Specialty|BCBSTX PPO|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Blue Cross HMO Specialty|BCBSTX HMO|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Managed Medicaid|MEDICAID SUPERIOR|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Managed Medicaid|MEDICAID AMERIGROUP|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|Humana Medicare Advantage|HUMANA MA|||||0.90||| Q4006|EAP|0270|CAST SUP LONG ARM ADLT FB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.90||| Q4007|EAP|0270|CAST SUP LONG ARM PED PLS|Managed Medicaid|MEDICAID SUPERIOR|||||0.50||| Q4007|EAP|0270|CAST SUP LONG ARM PED PLS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.50||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|United Healthcare|UNITED HEALTHCARE ERS|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Medicaid|MEDICAID|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Medicare|MEDICARE ACUTE|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|United Healthcare|UNITED HEALTHCARE|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Access Direct Platinum|HEALTHFIRST TPA|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Blue Cross PPO Specialty|BCBSTX PPO|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Blue Cross HMO Specialty|BCBSTX HMO|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Cigna|CIGNA|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Cigna|CIGNA OTHER|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Managed Medicaid|MEDICAID SUPERIOR|||||0.45||| Q4008|EAP|0270|CAST SUP LONG ARM PED FBR|Managed Medicaid|MEDICAID AMERIGROUP|||||0.45||| Q4009|EAP|0270|CAST SUP SHT ARM ADULT PL|Blue Cross HMO Specialty|BCBSTX HMO|||||0.40||| Q4009|EAP|0270|CAST SUP SHT ARM ADULT PL|Managed Medicare|HEALTHSPRING MA|||||0.40||| Q4009|EAP|0270|CAST SUP SHT ARM ADULT PL|Medicare|MEDICARE ACUTE|||||0.40||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|United Healthcare|UNITED HEALTHCARE|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|United Healthcare|UNITED HEALTHCARE ERS|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|United Healthcare|GOLDEN RULE|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Tricare|TRICARE EAST REGION|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Medicaid|MEDICAID|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Medicaid|MEDICAID HMO|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Managed Medicare|OTHER INSTITUTIONS|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Managed Medicare|HEALTHSPRING MA|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Workers Compensation|TEXAS MUTUAL INSURANCE|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Medicare|MEDICARE ACUTE|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Workers Compensation|UT EMPLOYEE INJURY|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Managed Medicaid|MEDICAID SUPERIOR|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Managed Medicaid|MEDICAID AMERIGROUP|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|PHCS|HUMANA|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|United Healthcare|UNITED HEALTHCARE OTHER|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Humana Medicare Advantage|HUMANA MA|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Cigna|CIGNA OTHER|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Cigna|CIGNA|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Aetna|AETNA PPO|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Aetna|BOON CHAPMAN|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Aetna|AETNA OTHER|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Blue Cross PPO Specialty|BCBSTX PPO|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.95||| Q4010|EAP|0270|CAST SUP SHT ARM ADULT FB|Blue Cross HMO Specialty|BCBSTX HMO|||||0.95||| Q4011|EAP|0270|CAST SUP SHT ARM PED PLAS|Tricare|TRICARE EAST REGION|||||0.45||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Blue Cross PPO Specialty|BCBSTX PPO|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Aetna|AETNA OTHER|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Aetna|AETNA PPO|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Cigna|CIGNA OTHER|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Cigna|CIGNA|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Managed Medicaid|MEDICAID SUPERIOR|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Managed Medicaid|MEDICAID AMERIGROUP|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Medicaid|MEDICAID|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|United Healthcare|UNITED HEALTHCARE|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|United Healthcare|UNITED HEALTHCARE OTHER|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.30||| Q4012|EAP|0270|CAST SUP SHT ARM PED FBRG|Tricare|TRICARE EAST REGION|||||0.30||| Q4017|EAP|0270|CAST SUP LNG ARM SPLINT P|Medicare|MEDICARE ACUTE|||||0.35||| Q4017|EAP|0270|CAST SUP LNG ARM SPLINT P|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.35||| Q4017|EAP|0270|CAST SUP LNG ARM SPLINT P|Workers Compensation|ZURICH COMPANY|||||0.35||| Q4017|EAP|0270|CAST SUP LNG ARM SPLINT P|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|||||0.35||| Q4017|EAP|0270|CAST SUP LNG ARM SPLINT P|Cigna|CIGNA OTHER|||||0.35||| Q4017|EAP|0270|CAST SUP LNG ARM SPLINT P|Blue Cross PPO Specialty|BCBSTX PPO|||||0.35||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Blue Cross PPO Specialty|BCBSTX PPO|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Blue Cross HMO Specialty|BCBSTX HMO|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Humana Medicare Advantage|HUMANA MA|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Cigna|CIGNA|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Managed Medicaid|MEDICAID AMERIGROUP|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|United Medicare Advantage|UHC AARP MCR HMO MA|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Managed Medicare|HEALTHSPRING MA|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Medicaid|SMITH COUNTY JAIL|||||0.25||| Q4021|EAP|0270|CAST SUP SHT ARM SPLINT P|Medicare|MEDICARE ACUTE|||||0.25||| Q4022|EAP|0270|CAST SUP SHT ARM SPLINT F|Medicare|MEDICARE ACUTE|||||0.80||| Q4022|EAP|0270|CAST SUP SHT ARM SPLINT F|Workers Compensation|BROOKSHIRES WORKERS COMP|||||0.80||| Q4022|EAP|0270|CAST SUP SHT ARM SPLINT F|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.80||| Q4022|EAP|0270|CAST SUP SHT ARM SPLINT F|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.80||| Q4022|EAP|0270|CAST SUP SHT ARM SPLINT F|Blue Cross PPO Specialty|BCBSTX PPO|||||0.80||| Q4022|EAP|0270|CAST SUP SHT ARM SPLINT F|Aetna|AETNA OTHER|||||0.80||| Q4022|EAP|0270|CAST SUP SHT ARM SPLINT F|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.80||| Q4030|EAP|0270|CAST SUP LNG LEG FIBERGLA|Blue Cross PPO Specialty|BCBSTX PPO|||||2.00||| Q4030|EAP|0270|CAST SUP LNG LEG FIBERGLA|Blue Cross HMO Specialty|BCBSTX HMO|||||2.00||| Q4030|EAP|0270|CAST SUP LNG LEG FIBERGLA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.00||| Q4032|EAP|0270|CAST SUP LNG LEG PED FBRG|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.20||| Q4032|EAP|0270|CAST SUP LNG LEG PED FBRG|Medicaid|MEDICAID|||||1.20||| Q4032|EAP|0270|CAST SUP LNG LEG PED FBRG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.20||| Q4032|EAP|0270|CAST SUP LNG LEG PED FBRG|Cigna|CIGNA|||||1.20||| Q4032|EAP|0270|CAST SUP LNG LEG PED FBRG|Managed Medicaid|MEDICAID SUPERIOR|||||1.20||| Q4032|EAP|0270|CAST SUP LNG LEG PED FBRG|Managed Medicaid|MEDICAID AMERIGROUP|||||1.20||| Q4032|EAP|0270|CAST SUP LNG LEG PED FBRG|Blue Cross PPO Specialty|BCBSTX PPO|||||1.20||| Q4032|EAP|0270|CAST SUP LNG LEG PED FBRG|Blue Cross HMO Specialty|BCBSTX HMO|||||1.20||| Q4037|EAP|0270|CAST SUP SHRT LEG PLASTER|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.55||| Q4037|EAP|0270|CAST SUP SHRT LEG PLASTER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.55||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Managed Medicare|OTHER INSTITUTIONS|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Managed Medicare|HEALTHSPRING MA|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Medicaid|LAW ENFORCEMENT OTHER|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Medicaid|MEDICAID|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Medicaid|MEDICAID HMO|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|United Healthcare|UNITED HEALTHCARE|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|United Healthcare|UNITED HEALTHCARE OTHER|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Tricare|TRICARE FOR LIFE|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Tricare|TRICARE EAST REGION|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|PHCS|GROUP AND PENSION|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Aetna|AETNA PPO|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Blue Cross PPO Specialty|BCBSTX PPO|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Blue Cross HMO Specialty|BCBSTX HMO|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Managed Medicaid|MEDICAID SUPERIOR|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Managed Medicaid|MEDICAID AMERIGROUP|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Humana Medicare Advantage|HUMANA MA|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Medicare|MEDICARE ACUTE|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Cigna|CIGNA OTHER|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Cigna|CIGNA|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Workers Compensation|UT EMPLOYEE INJURY|||||1.90||| Q4038|EAP|0270|CAST SUP SHRT LEG FIBERGL|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.90||| Q4039|EAP|0270|CAST SUP SHRT LEG PED PLS|Medicare|MEDICARE ACUTE|||||0.30||| Q4040|EAP|0270|CAST SUP SHRT LEG PED FBR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.70||| Q4040|EAP|0270|CAST SUP SHRT LEG PED FBR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.70||| Q4040|EAP|0270|CAST SUP SHRT LEG PED FBR|Cigna|CIGNA|||||0.70||| Q4040|EAP|0270|CAST SUP SHRT LEG PED FBR|Managed Medicaid|MEDICAID SUPERIOR|||||0.70||| Q4040|EAP|0270|CAST SUP SHRT LEG PED FBR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.70||| Q4040|EAP|0270|CAST SUP SHRT LEG PED FBR|Managed Medicaid|MEDICAID AMERIGROUP|||||0.70||| Q4040|EAP|0270|CAST SUP SHRT LEG PED FBR|Blue Cross PPO Specialty|BCBSTX PPO|||||0.70||| Q4040|EAP|0270|CAST SUP SHRT LEG PED FBR|Aetna|AETNA OTHER|||||0.70||| Q4041|EAP|0270|CAST SUP LNG LEG SPLNT PL|Medicare|MEDICARE ACUTE|||||0.65||| Q4041|EAP|0270|CAST SUP LNG LEG SPLNT PL|Blue Cross HMO Specialty|BCBSTX HMO|||||0.65||| Q4045|EAP|0270|CAST SUP SHT LEG SPLNT PL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.40||| Q4045|EAP|0270|CAST SUP SHT LEG SPLNT PL|Humana Medicare Advantage|HUMANA MA|||||0.40||| Q4045|EAP|0270|CAST SUP SHT LEG SPLNT PL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.40||| Q4045|EAP|0270|CAST SUP SHT LEG SPLNT PL|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.40||| Q4046|EAP|0270|CAST SUP SHT LEG SPLNT FB|Medicaid|MEDICAID|||||0.70||| Q4046|EAP|0270|CAST SUP SHT LEG SPLNT FB|Medicare|MEDICARE ACUTE|0.70||||0.70||| Q4046|EAP|0270|CAST SUP SHT LEG SPLNT FB|Blue Cross PPO Specialty|BCBSTX PPO|||||0.70||| Q4100|EAP|0278|TISSUE MATRIX NOS G1|United Medicare Advantage|UHC AARP MCR HMO MA|62.00||||||| Q4100|EAP|0278|TISSUE MATRIX NOS G1|Workers Compensation|WORKERS COMPENSATION OTHER|62.00||||||| Q4100|EAP|0278|TISSUE MATRIX NOS G2|Workers Compensation|ZURICH COMPANY|34.12||||||| Q4100|EAP|0278|TISSUE MATRIX NOS G1|Workers Compensation|TEXAS MUTUAL INSURANCE|62.00||||||| Q4100|EAP|0278|TISSUE MATRIX NOS G3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|238.63||||||| Q4100|EAP|0278|TISSUE MATRIX NOS G2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|134.12||||||| Q4100|EAP|0278|TISSUE MATRIX NOS G2|Managed Medicaid|MEDICAID AMERIGROUP|134.12||||||| Q4100|EAP|0278|TISSUE MATRIX NOS G1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||62.00||| Q4100|EAP|0278|TISSUE MATRIX NOS G1|United Medicare Advantage|UHC MEDICARE GOLD MA|62.00||||||| Q4100|EAP|0278|TISSUE MATRIX NOS G3|Humana Medicare Advantage|HUMANA MA|238.63||||238.63||| Q4100|EAP|0278|TISSUE MATRIX NOS G3|Humana Medicare Advantage|HUMANA MA|62.00||||238.63||| Q4100|EAP|0278|TISSUE MATRIX NOS G2|Humana Medicare Advantage|HUMANA MA|134.12||||238.63||| Q4100|EAP|0278|TISSUE MATRIX NOS G3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||238.63||| Q4100|EAP|0278|TISSUE MATRIX NOS G3|Blue Cross PPO Specialty|BCBSTX PPO|238.63||||238.63||| Q4100|EAP|0278|TISSUE MATRIX NOS G2|Blue Cross PPO Specialty|BCBSTX PPO|238.63||||34.12||| Q4100|EAP|0278|TISSUE MATRIX NOS G1|Blue Cross PPO Specialty|BCBSTX PPO|134.12||||62.00||| Q4100|EAP|0278|CARTIFORM ALLOGRAFT 12X19|Blue Cross PPO Specialty|BCBSTX PPO|62.00||||218.75||| Q4100|EAP|0278|TISSUE MATRIX NOS G1|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||62.00||| Q4100|EAP|0278|TISSUE MATRIX NOS G3|Medicare|MEDICARE ACUTE|238.63||||238.63||| Q4100|EAP|0278|TISSUE MATRIX NOS G2|Medicare|MEDICARE ACUTE|62.00||||134.12||| Q4101|EAP|0278|APLIGRAF PER SQ CM (H)|Blue Cross PPO Specialty|BCBSTX PPO|||||0.82||| Q4104|EAP|0278|INTEGRA BMWD /SQ CM|Managed Medicare|HEALTHSPRING MA|||||22.85||| Q4104|EAP|0278|INTEGRA BMWD /SQ CM|Workers Compensation|WORKERS COMPENSATION OTHER|||||22.85||| Q4104|EAP|0278|INTEGRA BMWD /SQ CM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||22.85||| Q4104|EAP|0278|INTEGRA BMWD /SQ CM|Blue Cross PPO Specialty|BCBSTX PPO|22.85||||||| Q4107|EAP|0278|GRAFTJACKET /SQ CM|Medicare|MEDICARE ACUTE|58.49||||||| Q4108|EAP|0278|INTEGRA MATRIX /SQ CM|Managed Medicare|HEALTHSPRING MA|||||2.08||| Q4108|EAP|0278|INTEGRA MATRIX /SQ CM|Medicaid|CRIME VICTIMS COMPENSATION|2.08||||||| Q4108|EAP|0278|INTEGRA MATRIX /SQ CM|Medicare|MEDICARE ACUTE|2.08||||2.08||| Q4110|EAP|0278|SKIN SUBSTITUTE 1 SQ CM P|Humana Medicare Advantage|HUMANA MA|||||7.72||| Q4110|EAP|0278|SKIN SUBSTITUTE 1 SQ CM P|Blue Cross PPO Specialty|BCBSTX PPO|||||7.72||| Q4110|EAP|0278|SKIN SUBSTITUTE 1 SQ CM P|Medicare|MEDICARE ACUTE|||||7.72||| Q4116|EAP|0278|ALLODERM /SQ CM|United Healthcare|UNITED HEALTHCARE|215.75||||||| Q4116|EAP|0278|ALLODERM /SQ CM|Tricare|TRICARE EAST REGION|||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Managed Medicare|HEALTHSPRING MA|215.75||||||| Q4116|EAP|0278|ALLODERM /SQ CM|Medicaid|MEDICAID|||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Medicare|MEDICARE PART B ONLY IP|215.75||||||| Q4116|EAP|0278|ALLODERM /SQ CM|Medicare|MEDICARE ACUTE|215.75||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|United Medicare Advantage|UHC MEDICARE GOLD MA|215.75||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|PHCS|GROUP AND PENSION|||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|215.75||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|215.75||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|215.75||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Aetna|AETNA PPO|215.75||||||| Q4116|EAP|0278|ALLODERM /SQ CM|Blue Cross HMO Specialty|BCBSTX HMO|||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Blue Cross PPO Specialty|BCBSTX PPO|215.75||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|215.75||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|215.75||||||| Q4116|EAP|0278|ALLODERM /SQ CM|Managed Medicaid|MEDICAID AMERIGROUP|215.75||||215.75||| Q4116|EAP|0278|ALLODERM /SQ CM|Humana Medicare Advantage|HUMANA MA|215.75||||215.75||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Humana Medicare Advantage|HUMANA MA|30.94||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|30.94||||||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Managed Medicaid|MEDICAID SUPERIOR|30.94||||||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Blue Cross PPO Specialty|BCBSTX PPO|30.94||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Aenta Medicare Advantage|AETNA MEDICARE MA|30.94||||||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30.94||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Veterans Affairs|VETERANS ADMINISTRATION|30.94||||||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Workers Compensation|WORKERS COMPENSATION OTHER|||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|United Medicare Advantage|UHC MEDICARE GOLD MA|30.94||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30.94||||||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|United Medicare Advantage|UHC AARP MCR HMO MA|30.94||||||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Medicaid|MEDICAID|30.94||||||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Medicaid|CRIME VICTIMS COMPENSATION|30.94||||||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Managed Medicare|HEALTHSPRING MA|30.94||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|Medicare|MEDICARE ACUTE|30.94||||30.94||| Q4118|EAP|0636|ACELL MICROMATRIX POWER P|NON CONTRACTED|COMMERCIAL OTHER 1|30.94||||||| Q4121|EAP|0636|THERASKIN PER SQ CM (H)|Medicare|MEDICARE ACUTE|||||90.50||| Q4121|EAP|0636|THERASKIN PER SQ CM (H)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||90.50||| Q4121|EAP|0636|THERASKIN PER SQ CM (H)|Managed Medicare|HEALTHSPRING MA|||||90.50||| Q4121|EAP|0636|THERASKIN PER SQ CM (H)|Managed Medicare|BCBS MEDICARE PPO MA|||||90.50||| Q4121|EAP|0636|THERASKIN PER SQ CM (H)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||90.50||| Q4121|EAP|0636|THERASKIN PER SQ CM (H)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||90.50||| Q4121|EAP|0636|THERASKIN PER SQ CM (H)|Veterans Affairs|VETERANS ADMINISTRATION|||||90.50||| Q4121|EAP|0636|THERASKIN PER SQ CM (H)|Humana Medicare Advantage|HUMANA MA|||||90.50||| Q4125|EAP|0278|GRAFT, ARTHROFLEX, PR SQ|Blue Cross PPO Specialty|BCBSTX PPO|||||821.43||| Q4125|EAP|0278|GRAFT, ARTHROFLEX, PR SQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||821.43||| Q4125|EAP|0278|GRAFT, ARTHROFLEX, PR SQ|Humana Medicare Advantage|HUMANA MA|||||821.43||| Q4125|EAP|0278|GRAFT, ARTHROFLEX, PR SQ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||821.43||| Q4125|EAP|0278|GRAFT, ARTHROFLEX, PR SQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|821.43||||||| Q4125|EAP|0278|GRAFT, ARTHROFLEX, PR SQ|Medicare|MEDICARE ACUTE|||||821.43||| Q4125|EAP|0278|GRAFT, ARTHROFLEX, PR SQ|Managed Medicare|HEALTHSPRING MA|||||821.43||| Q4137|EAP|0636|AMNIOEXCEL PLUS 17MM DISK|Medicare|MEDICARE ACUTE|||||1,465.80||| Q4160|EAP|0636|NUSHIELD (PER SQ CM)|Medicare|MEDICARE ACUTE|||||231.88||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|United Medicare Advantage|UHC MEDICARE GOLD MA|2.63||||2.63||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|United Medicare Advantage|UHC AARP MCR HMO MA|2.63||||||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.63||| Q4166|EAP|0278|CYTAL, PER SQUARE CENTIME|Veterans Affairs|VETERANS ADMINISTRATION|||||12.41||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.63||||||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Access Direct Platinum|HEALTHFIRST TPA|2.63||||||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Humana Medicare Advantage|HUMANA MA|2.63||||2.63||| Q4166|EAP|0278|CYTAL, PER SQUARE CENTIME|Humana Medicare Advantage|HUMANA MA|||||12.41||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Managed Medicaid|MEDICAID SUPERIOR|||||2.63||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Veterans Affairs|VETERANS ADMINISTRATION|2.63||||||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.63||||2.63||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G1|Aenta Medicare Advantage|AETNA MEDICARE MA|101.42||||||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Blue Cross PPO Specialty|BCBSTX PPO|2.63||||2.63||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G1|Blue Cross PPO Specialty|BCBSTX PPO|2.63||||101.42||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.63||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G1|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||101.42||| Q4166|EAP|0278|CYTAL, PER SQUARE CENTIME|Managed Medicare|HEALTHSPRING MA|||||12.41||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Medicaid|CRIME VICTIMS COMPENSATION|2.63||||||| Q4166|EAP|0278|CYTAL, PER SQUARE CENTIME|Medicare|MEDICARE ACUTE|||||12.41||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|NON CONTRACTED|COMMERCIAL OTHER 1|2.63||||||| Q4166|EAP|0636|ACELL MATRIX/SQ CM G2|Medicare|MEDICARE ACUTE|2.63||||2.63||| Q4186|EAP|0636|EPIFIX PER SQUARE CENTIME|Medicare|MEDICARE ACUTE|||||1,540.75||| Q4196|EAP|0636|PURAPLY AM PER SQ CM|Humana Medicare Advantage|HUMANA MA|||||503.53||| Q4196|EAP|0636|PURAPLY AM PER SQ CM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||503.53||| Q4196|EAP|0636|PURAPLY AM PER SQ CM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||503.53||| Q4196|EAP|0636|PURAPLY AM PER SQ CM|Managed Medicare|HEALTHSPRING MA|||||503.53||| Q4196|EAP|0636|PURAPLY AM PER SQ CM|Medicare|MEDICARE ACUTE|||||503.53||| Q5104|ERX|0636|RENFLEXIS 100 MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|286.28||||||| Q5104|ERX|0636|RENFLEXIS 100 MG VIAL|Medicare|MEDICARE ACUTE|286.28||||||| Q5104|ERX|0636|RENFLEXIS 100 MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|286.28||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Access Direct Platinum|HEALTHFIRST TPA|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Access Direct Platinum|HEALTHFIRST TPA|5.52||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|5.52||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Veterans Affairs|VETERANS ADMINISTRATION|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Veterans Affairs|VETERANS ADMINISTRATION|5.52||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|United Medicare Advantage|UHC MEDICARE GOLD MA|5.52||||4.74||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|United Medicare Advantage|UHC AARP MCR HMO MA|5.52||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|UHC MEDICARE GOLD MA|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|UHC AARP MCR HMO MA|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Blue Cross HMO Specialty|BCBSTX HMO|5.52||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross HMO Specialty|BCBSTX HMO|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Blue Cross PPO Specialty|BCBSTX PPO|5.52||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross PPO Specialty|BCBSTX PPO|4.74||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Aenta Medicare Advantage|AETNA MEDICARE MA|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.52||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Aetna|AETNA QHP HMO|4.74||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Aetna|AETNA PPO|4.74||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Aetna|AETNA OTHER|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Humana Medicare Advantage|HUMANA MA|5.52||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Humana Medicare Advantage|HUMANA MA|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.52||||5.52||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.52||||4.74||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Managed Medicaid|MEDICAID AMERIGROUP|5.52||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Medicaid|MEDICAID|5.52||||5.52||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Medicaid|LAW ENFORCEMENT OTHER|||||5.52||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicaid|SMITH COUNTY JAIL|||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicaid|SMITH COUNTY INDIGENT HEALTH|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.52||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicaid|MEDICAID|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicaid|LAW ENFORCEMENT OTHER|||||4.74||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.52||||5.52||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.74||||5.52||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Managed Medicare|HEALTHSPRING MA|5.52||||5.52||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||5.52||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Managed Medicare|HEALTHSPRING MA|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Managed Medicare|BCBS MEDICARE PPO MA|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.52||||5.52||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Tricare|TRICARE EAST REGION|5.52||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Tricare|TRICARE EAST REGION|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.52||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Access Direct Platinum|HEALTHFIRST TPA UMR|5.52||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|United Healthcare|UNITED HEALTHCARE|5.52||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Healthcare|UNITED HEALTHCARE OTHER|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.52||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|United Healthcare|UNITED HEALTHCARE OTHER|5.52||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Medicare|MEDICARE ACUTE|5.52||||5.52||| Q5105|ERX|0636|RETACRIT 40000 UNIT/1ML (|Medicare|MEDICARE ACUTE|4.74||||5.52||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicare|MEDICARE PART B ONLY IP|4.74||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicare|MEDICARE ACUTE|4.74||||4.74||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|Medicare|MEDICARE PART B ONLY IP|5.52||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|PHCS|GROUP AND PENSION|5.52||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|PHCS|GROUP AND PENSION|4.74||||||| Q5105|ERX|0636|RETACRIT 4000 UNIT/1ML (E|NON CONTRACTED|COMMERCIAL OTHER 1|5.52||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|NON CONTRACTED|COMMERCIAL OTHER 1|4.74||||||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Rusk State Hospital|RUSK STATE HOSP|4.74||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|NON CONTRACTED|COMMERCIAL OTHER 1|55.15||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|NON CONTRACTED|COMMERCIAL OTHER 1|47.43||||||| Q5106|ERX|0636|RETACRIT 40000 UNIT/1ML (|Medicare|MEDICARE ACUTE|47.43||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|Medicare|MEDICARE ACUTE|55.15||||||| Q5106|ERX|0636|RETACRIT 3000 UNIT/1ML (N|Medicare|MEDICARE ACUTE|55.15||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Healthcare|UNITED HEALTHCARE OTHER|47.43||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|Managed Medicare|HEALTHSPRING MA|55.15||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||47.43||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicaid|MEDICAID|47.43||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|55.15||||||| Q5106|ERX|0636|RETACRIT 3000 UNIT/1ML (N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55.15||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|55.15||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Managed Medicaid|MEDICAID UNITED HEALTHCARE|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47.43||||||| Q5106|ERX|0636|RETACRIT 40000 UNIT/1ML (|Humana Medicare Advantage|HUMANA MA|47.43||||47.43||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Humana Medicare Advantage|HUMANA MA|47.43||||47.43||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|47.43||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|55.15||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Managed Medicare|HEALTHSPRING MA|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicare|MEDICARE ACUTE|47.43||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|Aenta Medicare Advantage|AETNA MEDICARE MA|55.15||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Aenta Medicare Advantage|AETNA MEDICARE MA|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross PPO Specialty|BCBSTX PPO|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross PPO Specialty|BCBSTX OTHER|47.43||||||| Q5106|ERX|0636|RETACRIT 40000 UNIT/1ML (|Blue Cross PPO Specialty|BCBSTX PPO|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross HMO Specialty|BCBSTX HMO|47.43||||||| Q5106|ERX|0636|RETACRIT 40000 UNIT/1ML (|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47.43||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|55.15||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|United Medicare Advantage|UHC AARP MCR HMO MA|55.15||||||| Q5106|ERX|0636|RETACRIT 2000 UNIT/1ML (N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.58||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|UHC MEDICARE GOLD MA|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|UHC AARP MCR HMO MA|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Veterans Affairs|VETERANS ADMINISTRATION|47.43||||||| Q5106|ERX|0636|RETACRIT 4000 UNIT/1ML (N|Access Direct Platinum|HEALTHFIRST TPA|55.15||||||| Q5107|ERX|0636|BEVACIZUMAB-AWWB 400 MG/1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|237.09||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Medicaid|MEDICAID|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Managed Medicare|OTHER INSTITUTIONS|||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Managed Medicare|HEALTHSPRING MA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Managed Medicare|BCBS MEDICARE PPO MA|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Tricare|TRICARE EAST REGION|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|United Healthcare|UNITED HEALTHCARE OTHER|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|United Healthcare|UNITED HEALTHCARE|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|United Healthcare|TML GROUP BENEFITS|||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|United Healthcare|GEHA|||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Medicare|MEDICARE ACUTE|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|PHCS|HUMANA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Medicare|UTSW MC KIDNEY PROGRAM|||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Texas Workforce Commission|DIS DETER SERV (DDS)|||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Access Direct Platinum|HEALTHFIRST TPA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Veterans Affairs|VETERANS ADMINISTRATION|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|United Medicare Advantage|UHC AARP MCR HMO MA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Cigna|CIGNA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Humana Medicare Advantage|HUMANA MA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Managed Medicaid|MEDICAID AMERIGROUP|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Blue Cross HMO Specialty|BCBSTX HMO|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.35||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Aetna|AETNA QHP HMO|||||4.35||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Aetna|AETNA PPO|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Managed Medicaid|MEDICAID SUPERIOR|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Managed Medicaid|MEDICAID AMERIGROUP|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Cigna|CIGNA|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|United Medicare Advantage|UHC AARP MCR HMO MA|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Workers Compensation|UT EMPLOYEE INJURY|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||2.75||| Q9966|EAP|0255|ISOVUE 270 50/ML NDC 0270|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Veterans Affairs|VETERANS ADMINISTRATION|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Tricare|TRICARE EAST REGION|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|United Healthcare|UNITED HEALTHCARE|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|United Healthcare|UNITED HEALTHCARE OTHER|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Managed Medicare|HEALTHSPRING MA|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Medicare|MEDICARE ACUTE|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 270 50/ML NDC 0270|Medicare|MEDICARE ACUTE|2.75||||2.75||| Q9966|EAP|0255|ISOVUE 200M 20ML NDC 0270|Medicaid|MEDICAID|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Medicaid|COUNTY INDIGENT HEALTH OTHER|184.25||||184.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Medicaid|MEDICAID|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Medicaid|MEDICAID HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Medicaid|MEDICAID BCBSTX|||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid|SMITH COUNTY JAIL|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Medicaid|MEDICAID|158.50||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid|MEDICAID|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Medicaid|SMITH COUNTY JAIL|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Medicaid|MEDICAID|184.25||||184.25||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Medicaid|MEDICAID HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Medicaid|MEDICAID HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Medicaid|CRIME VICTIMS COMPENSATION|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Medicaid|MEDICAID|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid|LAW ENFORCEMENT OTHER|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Medicaid|SMITH COUNTY JAIL|2.75||||106.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Medicaid|MEDICAID|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid|LAW ENFORCEMENT OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid|CRIME VICTIMS COMPENSATION|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid|MEDICAID HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Medicare|UTSW MC KIDNEY PROGRAM|||||106.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Medicare|MEDICARE PART B ONLY IP|467.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Medicare|MEDICARE ACUTE|258.75||||158.50||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Medicare|MEDICARE ACUTE|258.75||||258.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Medicare|UTSW MC KIDNEY PROGRAM|||||184.25||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicare|UTSW MC KIDNEY PROGRAM|||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicare|MEDICARE PART B ONLY IP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Medicare|MEDICARE ACUTE|158.50||||184.25||| Q9967|EAP|0255|ISOVUE 300|Medicare|MEDICARE PART B ONLY IP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Medicare|MEDICARE ACUTE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicare|MEDICARE ACUTE|258.75||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Medicare|MEDICARE ACUTE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 PER ML|Medicare|MEDICARE ACUTE|184.25||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Medicare|MEDICARE PART B ONLY IP|258.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Medicare|MEDICARE PART B ONLY IP|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 100ML NDC 0270|Medicare|MEDICARE ACUTE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Medicare|MEDICARE PART B ONLY IP|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Medicare|MEDICARE ACUTE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Medicare|MEDICARE ACUTE|258.75||||106.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Medicare|MEDICARE ACUTE|258.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicare|OTHER INSTITUTIONS|||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicare|MA PART B ONLY IP|2.75||||||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicare|HEALTHSPRING MA|467.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicare|ETMC REHABILITATION HOSPITAL|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicare|BCBS MEDICARE PPO MA|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Managed Medicare|BCBS MEDICARE PPO MA|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Managed Medicare|HEALTHSPRING MA|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Managed Medicare|BCBS MEDICARE PPO MA|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Managed Medicare|BCBS MEDICARE PPO MA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Managed Medicare|HEALTHSPRING MA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Managed Medicare|BCBS MEDICARE PPO MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Managed Medicare|HEALTHSPRING MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Managed Medicare|BCBS MEDICARE PPO MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Managed Medicare|HEALTHSPRING MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicare|OTHER INSTITUTIONS|||||2.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicare|HEALTHSPRING MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||2.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicare|ETMC REHABILITATION HOSPITAL|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicare|BCBS MEDICARE PPO MA|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|158.50||||258.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Managed Medicare|HEALTHSPRING MA|258.75||||258.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Managed Medicare|BCBS MEDICARE PPO MA|258.75||||258.75||| Q9967|EAP|0255|VISIPAQUE 200MLB OTTLES V|Managed Medicare|HEALTHSPRING MA|258.75||||7.95||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|158.50||||467.25||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Managed Medicare|HEALTHSPRING MA|258.75||||467.25||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Managed Medicare|BCBS MEDICARE PPO MA|258.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Managed Medicare|BCBS MEDICARE PPO MA|258.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|158.50||||106.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Managed Medicare|HEALTHSPRING MA|258.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Managed Medicare|BCBS MEDICARE PPO MA|258.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|UTMB|UTMB CORRECTIONAL MANAGED CARE|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|UTMB|UTMB CORRECTIONAL MANAGED CARE|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100ML NDC 0270|United Healthcare|UNITED HEALTHCARE OTHER|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|United Healthcare|TML GROUP BENEFITS|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|United Healthcare|UNITED HEALTHCARE|106.75||||184.25||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|United Healthcare|UNITED HEALTHCARE OTHER|158.50||||467.25||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|United Healthcare|UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|United Healthcare|GEHA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|United Healthcare|UNITED HEALTHCARE OTHER|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|United Healthcare|UNITED HEALTHCARE|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|United Healthcare|TML GROUP BENEFITS|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|United Healthcare|UNITED HEALTHCARE|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|United Healthcare|UNITED HEALTHCARE OTHER|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 300|United Healthcare|UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|United Healthcare|UNITED HEALTHCARE|106.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|United Healthcare|UNITED HEALTHCARE|106.75||||467.25||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|United Healthcare|UNITED HEALTHCARE|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|United Healthcare|UNITED HEALTHCARE|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|United Healthcare|UNITED HEALTHCARE OTHER|158.50||||106.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|United Healthcare|UNITED HEALTHCARE OTHER|158.50||||258.75||| Q9967|EAP|0255|ISOVUE 300|United Healthcare|GEHA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|United Healthcare|TML GROUP BENEFITS|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|United Healthcare|UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|United Healthcare|UNITED HEALTHCARE OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|United Healthcare|UNITED HEALTHCARE OTHER|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|United Healthcare|UNITED HEALTHCARE|106.75||||258.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|United Healthcare|UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|United Healthcare|UNITED HEALTHCARE OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|United Healthcare|UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|United Healthcare|UNITED HEALTHCARE OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|United Healthcare|GOLDEN RULE|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Multiplan|WEB TPA|||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Multiplan|NALC|2.75||||||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|NON CONTRACTED|COMMERCIAL OTHER 1|106.75||||258.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|NON CONTRACTED|COMMERCIAL OTHER 1|106.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 PER ML|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|NON CONTRACTED|COMMERCIAL OTHER 1|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|NON CONTRACTED|COMMERCIAL OTHER 4|||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|NON CONTRACTED|COMMERCIAL OTHER 2|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|NON CONTRACTED|COMMERCIAL OTHER 1|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|NON CONTRACTED|COMMERCIAL OTHER 1|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|NON CONTRACTED|COMMERCIAL OTHER 1|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 PER ML|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|NON CONTRACTED|COMMERCIAL OTHER 1|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|NON CONTRACTED|COMMERCIAL OTHER 1|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|NON CONTRACTED|COMMERCIAL OTHER 1|2.75||||2.75||| Q9967|EAP|0636|VISIPAQUE 320 PER ML|Medicare|MEDICARE ACUTE|6.75||||6.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Rusk State Hospital|RUSK STATE HOSP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Texas Workforce Commission|DIS DETER SERV (DDS)|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|PHCS|HUMANA|158.50||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|PHCS|MULTIPLAN PHCS|||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|PHCS|HUMANA|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|PHCS|HUMANA INSURANCE|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|PHCS|HUMANA|158.50||||184.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|PHCS|GROUP AND PENSION|184.25||||184.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|PHCS|HUMANA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|PHCS|HUMANA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300|PHCS|GROUP AND PENSION|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Optum Behavioral Health|BH OPTUM UHC|2.75||||||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Tricare|TRICARE FOR LIFE|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Tricare|TRICARE EAST REGION|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Tricare|TRICARE EAST REGION|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Tricare|TRICARE EAST REGION|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 300|Tricare|TRICARE EAST REGION|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Tricare|TRICARE EAST REGION|106.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Tricare|TRICARE FOR LIFE|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Tricare|TRICARE EAST REGION|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300|Access Direct Platinum|HEALTHFIRST TPA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300/ML LOCM (1ML)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.75||||0.01||| Q9967|EAP|0255|ISOVUE 300|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA OTHER 2|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Access Direct Platinum|HEALTHFIRST TPA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Access Direct Platinum|HEALTHFIRST TPA|2.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|158.50||||106.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|158.50||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Access Direct Platinum|HEALTHFIRST TPA UMR|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Access Direct Platinum|HEALTHFIRST TPA UMR|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Access Direct Platinum|HEALTHFIRST TPA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA UMR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|158.50||||158.50||| Q9967|EAP|0255|ISOVUE 300|Access Direct Platinum|HEALTHFIRST TPA UMR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|158.50||||184.25||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Access Direct Platinum|HEALTHFIRST TPA|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 300 100ML NDC 0270|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Access Direct Platinum|HEALTHFIRST TPA UMR|467.25||||158.50||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Workers Compensation|UT EMPLOYEE INJURY|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Workers Compensation|BROOKSHIRES WORKERS COMP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Workers Compensation|TRAVELERS INSURANCE COMPANY|2.75||||||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Workers Compensation|TEXAS MUTUAL INSURANCE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Workers Compensation|TEXAS MUTUAL INSURANCE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Workers Compensation|GALLAGHER BASSETT|||||2.75||| Q9967|EAP|0255|ISOVUE 300|Workers Compensation|WORKERS COMPENSATION OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Workers Compensation|UT EMPLOYEE INJURY|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Workers Compensation|WORKERS COMPENSATION OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Workers Compensation|WORKERS COMPENSATION OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Workers Compensation|ZURICH COMPANY|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Workers Compensation|WORKERS COMPENSATION OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Veterans Affairs|VETERANS ADMINISTRATION|158.50||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Veterans Affairs|VETERANS ADMINISTRATION|258.75||||258.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Veterans Affairs|VETERANS ADMINISTRATION|258.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Veterans Affairs|VETERANS ADMINISTRATION|258.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Veterans Affairs|VETERANS ADMINISTRATION|467.25||||106.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Veterans Affairs|VETERANS ADMINISTRATION|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Veterans Affairs|VETERANS ADMINISTRATION|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Veterans Affairs|VETERANS ADMINISTRATION|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Veterans Affairs|VETERANS ADMINISTRATION|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Veterans Affairs|VETERANS ADMINISTRATION|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Veterans Affairs|VETERANS ADMINISTRATION|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|158.50||||258.75||| Q9967|EAP|0255|ISOVUE 300|United Medicare Advantage|UHC AARP WELLMED HMO MA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|United Medicare Advantage|UHC MEDICARE GOLD MA|258.75||||258.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|467.25||||258.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|United Medicare Advantage|UHC AARP MCR HMO MA|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|United Medicare Advantage|UHC MEDICARE GOLD MA|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|United Medicare Advantage|UHC AARP MCR HMO MA|258.75||||258.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|United Medicare Advantage|UHC MEDICARE GOLD MA|258.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|United Medicare Advantage|UHC AARP MCR HMO MA|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|467.25||||467.25||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|158.50||||2.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|United Medicare Advantage|UHC AARP MCR HMO MA|258.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|United Medicare Advantage|UHC MEDICARE GOLD MA|258.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|United Medicare Advantage|UHC MEDICARE GOLD MA|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|467.25||||158.50||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|United Medicare Advantage|UHC AARP MCR HMO MA|258.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA UMR|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|United Medicare Advantage|UHC MEDICARE GOLD MA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|United Medicare Advantage|UHC MEDICARE GOLD MA|258.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|467.25||||106.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Access Direct Platinum|HEALTHFIRST TPA UMR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|158.50||||158.50||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|United Medicare Advantage|UHC AARP MCR HMO MA|467.25||||106.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|United Medicare Advantage|UHC AARP MCR HMO MA|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|United Medicare Advantage|UHC MEDICARE GOLD MA|467.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|United Medicare Advantage|UHC AARP MCR HMO MA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|United Medicare Advantage|UHC MEDICARE GOLD MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Tricare|TRICARE EAST REGION|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Cigna|CIGNA OTHER|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Tricare|TRICARE EAST REGION|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Cigna|CIGNA|184.25||||184.25||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Cigna|CIGNA OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Cigna|CIGNA OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Cigna|CIGNA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Cigna|CIGNA OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Cigna|CIGNA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Tricare|TRICARE EAST REGION|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Cigna|CIGNA OTHER|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Cigna|CIGNA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Cigna|CIGNA|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Cigna|CIGNA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|PHCS|GROUP AND PENSION|2.75||||184.25||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Cigna|CIGNA|258.75||||258.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Cigna|CIGNA|467.25||||467.25||| Q9967|EAP|0255|ISOVUE 300|Cigna|CIGNA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300|Cigna|CIGNA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|PHCS|HUMANA INSURANCE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Cigna|CIGNA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Cigna|CIGNA|2.75||||106.75||| Q9967|EAP|0255|ISOVUE 300|NON CONTRACTED|COMMERCIAL OTHER 2|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Cigna|CIGNA|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Cigna|CIGNA OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Humana Medicare Advantage|HUMANA MA|6.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Humana Medicare Advantage|HUMANA MA|467.25||||106.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Humana Medicare Advantage|HUMANA MA|258.75||||258.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|NON CONTRACTED|COMMERCIAL OTHER 1|106.75||||2.75||| Q9967|EAP|0255|ORAL OMNIPAQUE|Humana Medicare Advantage|HUMANA MA|258.75||||6.50||| Q9967|EAP|0255|VISIPAQUE 200MLB OTTLES V|Humana Medicare Advantage|HUMANA MA|258.75||||7.95||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Humana Medicare Advantage|HUMANA MA|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Humana Medicare Advantage|HUMANA MA|7.95||||158.50||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|NON CONTRACTED|COMMERCIAL OTHER 1|106.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Humana Medicare Advantage|HUMANA MA|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 300 100ML NDC 0270|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Humana Medicare Advantage|HUMANA MA|258.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Multiplan|WEB TPA|||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Humana Medicare Advantage|HUMANA MA|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Magellan Behavioral Health|BH MAGELLAN|||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Managed Medicaid|MEDICAID SUPERIOR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Managed Medicaid|MEDICAID UNITED HEALTHCARE|467.25||||258.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Managed Medicaid|MEDICAID UNITED HEALTHCARE|467.25||||467.25||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|United Healthcare|UNITED HEALTHCARE OTHER|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|United Healthcare|GEHA|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicaid|MEDICAID UNITED HEALTHCARE|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicaid|MEDICAID SUPERIOR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|United Healthcare|GOLDEN RULE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicaid|BH SUPERIOR HEALTH MEDICAID|2.75||||||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Managed Medicaid|MEDICAID SUPERIOR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Managed Medicaid|MEDICAID SUPERIOR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|United Healthcare|TML GROUP BENEFITS|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|United Healthcare|UNITED HEALTHCARE|106.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|United Healthcare|UNITED HEALTHCARE|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Managed Medicaid|MEDICAID SUPERIOR|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|UTMB|UTMB CORRECTIONAL MANAGED CARE|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Managed Medicaid|MEDICAID SUPERIOR|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|184.25||||184.25||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Managed Medicaid|MEDICAID AMERIGROUP|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Managed Medicare|ETMC AFFILIATE HOSPITALS|2.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|258.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Managed Medicaid|MEDICAID SUPERIOR|2.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|158.50||||106.75||| Q9967|EAP|0255|VISIPAQUE 200MLB OTTLES V|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|258.75||||7.95||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Managed Medicare|HEALTHSPRING MA|258.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|258.75||||106.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Managed Medicaid|MEDICAID AMERIGROUP|2.75||||258.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicaid|MEDICAID SUPERIOR|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Blue Cross HMO Specialty|BCBSTX HMO|106.75||||258.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Blue Cross HMO Specialty|BCBSTX HMO|106.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Blue Cross HMO Specialty|BCBSTX HMO|106.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Blue Cross HMO Specialty|BCBSTX HMO|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 300|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Blue Cross HMO Specialty|BCBSTX HMO|184.25||||184.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Blue Cross PPO Specialty|BCBSTX PPO|258.75||||258.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Managed Medicare|OTHER INSTITUTIONS|||||2.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Blue Cross PPO Specialty|BCBSTX PPO|258.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Blue Cross PPO Specialty|BCBSTX PPO|158.50||||158.50||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Blue Cross PPO Specialty|BCBSTX PPO|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Blue Cross PPO Specialty|BCBSTX OTHER|467.25||||106.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Managed Medicare|HEALTHSPRING MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Blue Cross PPO Specialty|BCBSTX OTHER|467.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Blue Cross PPO Specialty|BCBSTX OTHER|467.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Managed Medicare|ETMC SPECIALTY HOSPITAL|||||184.25||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Managed Medicare|HEALTHSPRING MA|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Blue Cross PPO Specialty|BCBSTX PPO|184.25||||184.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Blue Cross PPO Specialty|BCBSTX OTHER|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Blue Cross PPO Specialty|BCBSTX OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Blue Cross PPO Specialty|BCBSTX OTHER|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Managed Medicare|WELLCARE CHOICE MA|||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Blue Cross PPO Specialty|BCBSTX OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Blue Cross PPO Specialty|BCBSTX OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Medicare|MEDICARE ACUTE|467.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300/ML LOCM (1ML)|Medicare|MEDICARE ACUTE|2.75||||0.01||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|ChampVA|CHAMPVA CENTER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Medicare|MEDICARE ACUTE|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 200MLB OTTLES V|Medicare|MEDICARE ACUTE|258.75||||7.95||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|ChampVA|CHAMPVA CENTER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|ChampVA|CHAMPVA CENTER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Aetna|AETNA OTHER|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Aetna|BH AETNA|2.75||||||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Medicare|MEDICARE ACUTE|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Aetna|AETNA OTHER|106.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Aetna|AETNA PPO|106.75||||158.50||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Aetna|BOON CHAPMAN|2.75||||||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Aetna|AETNA PPO|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Aetna|AETNA PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Aetna|AETNA OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Medicaid|MEDICAID|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Aetna|AETNA PPO|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Aetna|AETNA PPO|106.75||||467.25||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Aetna|AETNA OTHER|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Aetna|AETNA PPO|106.75||||106.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Aetna|AETNA PPO|106.75||||258.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Aetna|AETNA PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Medicaid|SMITH COUNTY INDIGENT HEALTH|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Medicaid|SMITH COUNTY INDIGENT HEALTH|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Aetna|AETNA PPO|106.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Aetna|AETNA PPO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Aetna|AETNA QHP HMO|2.75||||184.25||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Aetna|AETNA OTHER|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Aetna|AETNA QHP HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Aetna|AETNA OTHER|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Aetna|AETNA PPO|184.25||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Aetna|AETNA PPO|106.75||||184.25||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Medicaid|MEDICAID|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Aetna|AETNA QHP HMO|184.25||||2.75||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Aenta Medicare Advantage|AETNA MEDICARE MA|158.50||||258.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.75||||467.25||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Aenta Medicare Advantage|AETNA MEDICARE MA|158.50||||467.25||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Aenta Medicare Advantage|AETNA MEDICARE MA|158.50||||158.50||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Aenta Medicare Advantage|AETNA MEDICARE MA|106.75||||106.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Aenta Medicare Advantage|AETNA MEDICARE MA|184.25||||184.25||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Medicaid|MEDICAID HMO|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Aetna Value Network|AETNA VALUE NETWORK|||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300|Aetna Value Network|AETNA VALUE NETWORK|||||2.75||| Q9967|EAP|0255|ISOVUE 300 50/ML NDC 0270|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 50ML10/BX BRAC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.95||||106.75||| Q9967|EAP|0255|ISOVUE 370 150/ML NDC 270|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|158.50||||2.75||| Q9967|EAP|0255|ISOVUE 300|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 100/ML NDC 027|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 75ML 10/BX BRA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|258.75||||158.50||| Q9967|EAP|0255|ISOVUE 300/ML LOCM (1ML)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|184.25||||0.01||| Q9967|EAP|0255|ISOVUE 370 500/ML NDC 027|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|467.25||||2.75||| Q9967|EAP|0255|ISOVUE 300M 15ML NDC 0270|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||2.75||| Q9967|EAP|0255|VISIPAQUE 100ML V045 0407|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|258.75||||467.25||| Q9967|EAP|0255|VISIPAQUE 50ML V041 0407|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|258.75||||258.75||| Q9967|EAP|0255|ISOVUE 370 100/ML NDC 027|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 100ML 10/BX BR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|106.75||||184.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Aetna|AETNA PPO|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Aetna|AETNA OTHER|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Blue Cross PPO Specialty|BCBSTX PPO|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Blue Cross PPO Specialty|BCBSTX OTHER|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicaid|MEDICAID SUPERIOR|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Humana Medicare Advantage|HUMANA MA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Cigna|CIGNA OTHER|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Cigna|CIGNA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|United Medicare Advantage|UHC AARP WELLMED HMO MA|0.25||||||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|United Medicare Advantage|UHC AARP MCR HMO MA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Veterans Affairs|VETERANS ADMINISTRATION|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Workers Compensation|ZURICH COMPANY|0.25||||||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Workers Compensation|LIBERTY MUTUAL INSURANCE WKCP|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Access Direct Platinum|HEALTHFIRST TPA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|PHCS|HUMANA|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|PHCS|GROUP AND PENSION|0.25||||||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|NON CONTRACTED|COMMERCIAL OTHER 1|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Multiplan|WEB TPA|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicare|UTSW MC KIDNEY PROGRAM|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicare|MEDICARE PART B ONLY IP|0.25||||||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicare|MEDICARE ACUTE|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|United Healthcare|UNITED HEALTHCARE OTHER|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|United Healthcare|UNITED HEALTHCARE|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|United Healthcare|UNITED HEALTHCARE|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Cigna|CIGNA|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicaid|MEDICAID AMERIGROUP|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|United Healthcare|GOLDEN RULE|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|United Healthcare|GEHA|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Blue Cross HMO Specialty|BCBSTX HMO|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Tricare|TRICARE SOUTH PHYSICIAN|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Tricare|TRICARE FOR LIFE|0.25||||||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Tricare|TRICARE EAST REGION|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicare|OTHER INSTITUTIONS|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Aetna|BOON CHAPMAN|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicare|HEALTHSPRING MA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicare|ETMC REHABILITATION HOSPITAL|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicare|ETMC AFFILIATE HOSPITALS|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Managed Medicare|BCBS MEDICARE PPO MA|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicaid|SMITH COUNTY JAIL|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicaid|SMITH COUNTY INDIGENT HEALTH|0.25||||||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicaid|MEDICAID HMO|0.25||||||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicaid|MEDICAID|0.25||||0.25||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicaid|LAW ENFORCEMENT OTHER|0.25||||||| Q9969|EAP|0636|NON-HEU TC-99 ADD-ON/DOSE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.25||||0.25||| S2095|EAP|0278||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||577.50||| S9443|EAP|0722|LACTATION CONSULTATION|Medicaid|MEDICAID HMO|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Medicaid|MEDICAID|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|United Healthcare|UNITED HEALTHCARE OTHER|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|United Healthcare|UNITED HEALTHCARE|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|United Healthcare|TML GROUP BENEFITS|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Tricare|TRICARE EAST REGION|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|NON CONTRACTED|COMMERCIAL OTHER 1|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Access Direct Platinum|HEALTHFIRST TPA UMR|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Access Direct Platinum|HEALTHFIRST TPA|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Cigna|CIGNA|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Managed Medicaid|MEDICAID SUPERIOR|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Managed Medicaid|MEDICAID AMERIGROUP|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Blue Cross HMO Specialty|BCBSTX HMO|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Blue Cross PPO Specialty|BCBSTX PPO|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Aetna|AETNA PPO|1.50||||||| S9443|EAP|0722|LACTATION CONSULTATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Aetna|AETNA PPO|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Blue Cross PPO Specialty|BCBSTX PPO|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Blue Cross HMO Specialty|BCBSTX HMO|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Managed Medicaid|MEDICAID SUPERIOR|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Managed Medicaid|MEDICAID AMERIGROUP|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Cigna|CIGNA|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Access Direct Platinum|HEALTHFIRST TPA|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|NON CONTRACTED|COMMERCIAL OTHER 1|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|United Healthcare|UNITED HEALTHCARE OTHER|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|United Healthcare|UNITED HEALTHCARE|1.50||||||| S9445|EAP|0722|PT EDUCATION NOC INDIVID|Medicaid|MEDICAID|1.50||||||| U0001|EAP|0300|COVID - 19PCR|Managed Medicare|HEALTHSPRING MA|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Managed Medicare|BCBS MEDICARE PPO MA|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Medicaid|SMITH COUNTY JAIL|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Medicaid|MEDICAID HMO|||||1.80||| U0001|EAP|0300|COVID - 19PCR|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.80||||||| U0001|EAP|0300|COVID - 19PCR|United Healthcare|UNITED HEALTHCARE OTHER|||||1.80||| U0001|EAP|0300|COVID - 19PCR|United Healthcare|GEHA|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Medicare|MEDICARE ACUTE|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|NON CONTRACTED|COMMERCIAL OTHER 1|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|1.80||||||| U0001|EAP|0300|COVID - 19PCR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|United Medicare Advantage|UHC AARP MCR HMO MA|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Veterans Affairs|VETERANS ADMINISTRATION|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Workers Compensation|UT EMPLOYEE INJURY|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Tricare|TRICARE EAST REGION|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Workers Compensation|WORKERS COMPENSATION OTHER|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Access Direct Platinum|HEALTHFIRST TPA|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Medicaid|MEDICAID|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Humana Medicare Advantage|HUMANA MA|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Cigna|CIGNA OTHER|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Cigna|CIGNA|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Managed Medicaid|MEDICAID SUPERIOR|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Managed Medicaid|MEDICAID AMERIGROUP|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Blue Cross HMO Specialty|BCBSTX HMO|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Blue Cross PPO Specialty|BCBSTX PPO|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Aetna|AETNA PPO|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.80||||1.80||| U0002|EAP|0300|COVID-19 NON CDC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.14||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Aenta Medicare Advantage|AETNA MEDICARE MA|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Aetna|AETNA PPO|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Blue Cross PPO Specialty|BCBSTX PPO|1.14||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross PPO Specialty|BCBSTX PPO|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.54||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Blue Cross HMO Specialty|BCBSTX HMO|1.54||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross HMO Specialty|BCBSTX HMO|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.14||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.14||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Managed Medicaid|MEDICAID AMERIGROUP|1.14||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicaid|MEDICAID AMERIGROUP|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Cigna|CIGNA OTHER|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Cigna|CIGNA|||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Humana Medicare Advantage|HUMANA MA|1.14||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Humana Medicare Advantage|HUMANA MA|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.14||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Access Direct Platinum|HEALTHFIRST TPA|||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Veterans Affairs|VETERANS ADMINISTRATION|1.14||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Veterans Affairs|VETERANS ADMINISTRATION|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Workers Compensation|UT EMPLOYEE INJURY|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|United Medicare Advantage|UHC MEDICARE GOLD MA|1.14||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.14||||1.14||| U0002|EAP|0300|COVID-19 NON CDC|United Medicare Advantage|UHC AARP MCR HMO MA|1.14||||1.14||| U0002|EAP|0300|COVID-19 NON CDC|Workers Compensation|TEXAS MUTUAL INSURANCE|1.14||||||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Medicare Advantage|UHC MEDICARE GOLD MA|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Medicare Advantage|UHC AARP MCR HMO MA|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Rusk State Hospital|RUSK STATE HOSP|1.14||||||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.14||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Rusk State Hospital|RUSK STATE HOSP|1.54||||||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|PHCS|HUMANA|1.14||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|NON CONTRACTED|COMMERCIAL OTHER 1|1.14||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|NON CONTRACTED|COMMERCIAL OTHER 4|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|NON CONTRACTED|COMMERCIAL OTHER 1|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Medicare|MEDICARE PART B ONLY IP|1.14||||||| U0002|EAP|0300|COVID-19 NON CDC|Medicare|MEDICARE ACUTE|1.14||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicare|MEDICARE ACUTE|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|United Healthcare|UNITED HEALTHCARE|1.14||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Healthcare|UNITED HEALTHCARE|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Healthcare|TML GROUP BENEFITS|1.54||||||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Healthcare|GEHA|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Healthcare|UNITED HEALTHCARE OTHER|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|United Healthcare|UNITED HEALTHCARE OTHER|1.14||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.14||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicaid|MEDICAID SUPERIOR|1.54||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Managed Medicaid|MEDICAID SUPERIOR|1.54||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Tricare|TRICARE EAST REGION|||||1.14||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Tricare|TRICARE FOR LIFE|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Tricare|TRICARE EAST REGION|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Aenta Medicare Advantage|AETNA MEDICARE MA|1.14||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|MEDICAID BCBSTX|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|BH TEXAS CHILDRENS MEDICAID|||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Medicaid|MEDICAID|1.14||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|MEDICAID HMO|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|SMITH COUNTY JAIL|1.54||||||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|MEDICAID|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Managed Medicare|WELLCARE CHOICE MA|1.14||||||| U0002|EAP|0300|COVID-19 NON CDC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.14||||||| U0002|EAP|0300|COVID-19 NON CDC|Managed Medicare|HEALTHSPRING MA|1.14||||1.54||| U0002|EAP|0300|COVID-19 NON CDC|Managed Medicare|BCBS MEDICARE PPO MA|1.14||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicare|HEALTHSPRING MA|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicare|BCBS MEDICARE PPO MA|1.54||||1.54||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Managed Medicare|WELLCARE CHOICE MA|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Managed Medicare|OTHER INSTITUTIONS|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Managed Medicare|BCBS MEDICARE PPO MA|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Medicaid|MEDICAID HMO|||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Medicaid|CRIME VICTIMS COMPENSATION|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Medicaid|LAW ENFORCEMENT OTHER|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Tricare|TRICARE EAST REGION|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|United Healthcare|UNITED HEALTHCARE|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|United Healthcare|UNITED HEALTHCARE OTHER|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|United Healthcare|UNITED HEALTHCARE|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|United Healthcare|TML GROUP BENEFITS|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Medicare|MEDICARE PART B ONLY IP|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Medicare|MEDICARE ACUTE|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|PHCS|HUMANA|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|NON CONTRACTED|COMMERCIAL OTHER 4|||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|NON CONTRACTED|COMMERCIAL OTHER 1|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|United Medicare Advantage|UHC AARP WELLMED HMO MA|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|United Medicare Advantage|UHC AARP MCR HMO MA|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Rusk State Hospital|RUSK STATE HOSP|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Veterans Affairs|VETERANS ADMINISTRATION|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Workers Compensation|UT EMPLOYEE INJURY|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Workers Compensation|TEXAS MUTUAL INSURANCE|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Workers Compensation|CLAIMS ADMINISTRATIVE WKCP|||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|United Healthcare|GOLDEN RULE|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Workers Compensation|WORKERS COMPENSATION OTHER|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Access Direct Platinum|HEALTHFIRST TPA UMR|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Medicaid|MEDICAID|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Access Direct Platinum|HEALTHFIRST TPA|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Magellan Behavioral Health|BH MAGELLAN|||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Humana Medicare Advantage|HUMANA MA|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Cigna|CIGNA OTHER|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Managed Medicare|HEALTHSPRING MA|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Cigna|CIGNA|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Cigna|CIGNA|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Managed Medicaid|MEDICAID SUPERIOR|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Managed Medicaid|MEDICAID AMERIGROUP|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Blue Cross HMO Specialty|BCBSTX HMO|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Blue Cross PPO Specialty|BCBSTX PPO|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Blue Cross PPO Specialty|BCBSTX OTHER|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Aenta Medicare Advantage|AETNA MEDICARE MA|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Aetna|AETNA PPO|2.20||||2.20||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Aetna|AETNA OTHER|2.20||||||| U0003|EAP|0300|COVID-19 CEPHEID C19 PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.20||||2.20|||