"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" 00100|EAP|0964|CRNA HEAD/SAL GLANDS INCL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||11.94||| 00100|EAP|0964|CRNA HEAD/SAL GLANDS INCL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||11.94||| 00300|EAP|0964|CRNA INTEG SYS NECK SUBC|Cigna|CIGNA|||||864.50||| 00300|EAP|0964|CRNA POS INTERGUM PELVIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||692.75||| 00300|EAP|0964|CRNA POS INTERGUM PELVIS|Medicare|MEDICARE ACUTE|||||692.75||| 00300|EAP|0964|CRNA POS INTERGUM PELVIS|Blue Cross PPO Specialty|BCBSTX PPO|||||692.75||| 00400|EAP|0964|CRNA ANT INTEGUM PERVIS E|Blue Cross PPO Specialty|BCBSTX PPO|||||525.50||| 00400|EAP|0964|CRNA NCHEST ANTERIOR INTE|Managed Medicaid|MEDICAID SUPERIOR|||||4.15||| 00400|EAP|0964|CRNA INTEGUMENT SYS UPPER|Blue Cross PPO Specialty|BCBSTX PPO|||||525.50||| 00400|EAP|0964|CRNA ANT INTEGUM PERVIS E|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||525.50||| 00400|EAP|0964|CRNA INTEGUMENT SYS UPPER|Managed Medicaid|MEDICAID SUPERIOR|||||525.50||| 00400|EAP|0964|CRNA INGUEM SYS LOW LEG A|Medicare|MEDICARE ACUTE|||||9.11||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Blue Cross PPO Specialty|BCBSTX PPO|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Cigna|CIGNA|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Managed Medicaid|MEDICAID SUPERIOR|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Aetna|AETNA PPO|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Medicaid|MEDICAID HMO|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Medicaid|MEDICAID|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Managed Medicaid|MEDICAID AMERIGROUP|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Medicare|MEDICARE ACUTE|||||5.20||| 00635|EAP|0964|CRNA DURAMORPH SPINAL 24H|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.20||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||864.50||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|Medicare|MEDICARE ACUTE|||||864.50||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||864.50||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|Blue Cross PPO Specialty|BCBSTX PPO|||||864.50||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|United Healthcare|UNITED HEALTHCARE|||||864.50||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|Blue Cross HMO Specialty|BCBSTX HMO|||||864.50||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|Humana Medicare Advantage|HUMANA MA|||||864.50||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|Cigna|CIGNA|||||864.50||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||864.50||| 00731|EAP|0964|CRNA UPPER GASTRO INT END|Managed Medicaid|MEDICAID SUPERIOR|||||864.50||| 00752|EAP|0964|CRNA HERNIA-LUMBAR VENTRA|Managed Medicaid|MEDICAID AMERIGROUP|||||8.30||| 00752|EAP|0964|CRNA HERNIA-LUMBAR VENTRA|Medicare|MEDICARE ACUTE|||||8.30||| 00752|EAP|0964|CRNA HERNIA-LUMBAR VENTRA|Humana Medicare Advantage|HUMANA MA|||||8.30||| 00752|EAP|0964|CRNA HERNIA-LUMBAR VENTRA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.30||| 00752|EAP|0964|CRNA HERNIA-LUMBAR VENTRA|Blue Cross PPO Specialty|BCBSTX PPO|||||8.30||| 00790|EAP|0964|CRNA INTRAPERITONEAL UPPE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||10.73||| 00790|EAP|0964|CRNA INTRAPERITONEAL UPPE|Medicare|MEDICARE ACUTE|||||10.73||| 00790|EAP|0964|CRNA INTRAPERITONEAL UPPE|Blue Cross PPO Specialty|BCBSTX PPO|||||10.73||| 00800|EAP|0964|CRNA LOWER ANT ABD WALL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||763.50||| 00800|EAP|0964|CRNA LOWER ANT ABD WALL|Medicare|MEDICARE ACUTE|||||763.50||| 00800|EAP|0964|CRNA LOWER ANT ABD WALL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||763.50||| 00800|EAP|0964|CRNA LOWER ANT ABD WALL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||763.50||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|Medicare|MEDICARE ACUTE|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|Humana Medicare Advantage|HUMANA MA|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|Managed Medicare|HEALTHSPRING MA|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|Cigna|CIGNA|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|United Healthcare|UNITED HEALTHCARE|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,037.75||| 00811|EAP|0964|CRNA INTEST ENDOSCOPIC PR|Blue Cross PPO Specialty|BCBSTX PPO|||||1,037.75||| 00830|EAP|0964|CRNA HERNIA REPAIR LOWER|Blue Cross PPO Specialty|BCBSTX PPO|||||6.97||| 00830|EAP|0964|CRNA HERNIA REPAIR LOWER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.97||| 00830|EAP|0964|CRNA HERNIA REPAIR LOWER|Managed Medicaid|MEDICAID AMERIGROUP|||||6.97||| 00830|EAP|0964|CRNA HERNIA REPAIR LOWER|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6.97||| 00840|EAP|0964|CRNA INTRAPERITONEAL LOWE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,106.50||| 00840|EAP|0964|CRNA INTRAPERITONEAL LOWE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,106.50||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Managed Medicaid|MEDICAID AMERIGROUP|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,037.75||| 00840|EAP|0964|CRNA INTRAPERITONEAL LOWE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1,106.50||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Tricare|TRICARE EAST REGION|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Medicaid|MEDICAID|||||1,037.75||| 00840|EAP|0964|CRNA INTRAPERITONEAL LOWE|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,106.50||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|United Healthcare|UNITED HEALTHCARE|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Blue Cross PPO Specialty|BCBSTX PPO|||||1,037.75||| 00840|EAP|0964|CRNA INTRAPERITONEAL LOWE|Managed Medicaid|MEDICAID SUPERIOR|1,106.50||||1,106.50||| 00840|EAP|0964|CRNA INTRAPERITONEAL LOWE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,106.50||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Medicare|MEDICARE ACUTE|||||1,037.75||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,037.75||| 00840|EAP|0964|CRNA INTRAPERITONEAL LOWE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,106.50||| 00840|EAP|0964|CRNA LAPAROSCOPIC PROCEDU|Managed Medicaid|MEDICAID SUPERIOR|1,106.50||||1,037.75||| 00902|EAP|0964|CRNA ANORECTAL PROCEDURE|Blue Cross PPO Specialty|BCBSTX PPO|||||558.50||| 00902|EAP|0964|CRNA ANORECTAL PROCEDURE|Medicare|MEDICARE ACUTE|||||558.50||| 00940|EAP|0964|CRNA VAGINAL PROCEDURE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||522.25||| 00940|EAP|0964|CRNA VAGINAL PROCEDURE|Blue Cross PPO Specialty|BCBSTX PPO|||||522.25||| 00940|EAP|0964|CRNA VAGINAL PROCEDURE|United Healthcare|UNITED HEALTHCARE|||||522.25||| 00940|EAP|0964|CRNA VAGINAL PROCEDURE|NON CONTRACTED|COMMERCIAL OTHER 1|||||522.25||| 00940|EAP|0964|CRNA VAGINAL PROCEDURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||522.25||| 00940|EAP|0964|CRNA VAGINAL PROCEDURE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||522.25||| 00948|EAP|0964|CRNA CERVICAL CERCLASE|Managed Medicaid|MEDICAID SUPERIOR|||||526.75||| 00952|EAP|0964|CRNA HYSTEROSCOPY|United Healthcare|UNITED HEALTHCARE OTHER|||||558.50||| 00952|EAP|0964|CRNA HYSTEROSCOPY|Blue Cross PPO Specialty|BCBSTX PPO|||||558.50||| 00952|EAP|0964|CRNA HYSTEROSCOPY|Cigna|CIGNA|||||558.50||| 00952|EAP|0964|CRNA HYSTEROSCOPY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||558.50||| 00952|EAP|0964|CRNA HYSTEROSCOPY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||558.50||| 00952|EAP|0964|CRNA HYSTEROSCOPY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||558.50||| 00952|EAP|0964|CRNA HYSTEROSCOPY|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||558.50||| 00952|EAP|0964|CRNA HYSTEROSCOPY|Medicare|MEDICARE ACUTE|||||558.50||| 01200|EAP|0964|CRNA CLOSED HIP JOINT|Medicare|MEDICARE ACUTE|||||509.50||| 01200|EAP|0964|CRNA CLOSED HIP JOINT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||509.50||| 01200|EAP|0964|CRNA CLOSED HIP JOINT|Managed Medicaid|MEDICAID SUPERIOR|||||509.50||| 01200|EAP|0964|CRNA CLOSED HIP JOINT|Blue Cross PPO Specialty|BCBSTX PPO|||||509.50||| 01200|EAP|0964|CRNA CLOSED HIP JOINT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||509.50||| 01200|EAP|0964|CRNA CLOSED HIP JOINT|Humana Medicare Advantage|HUMANA MA|||||509.50||| 01210|EAP|0964|CRNA OPEN HIP JOINT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,460.75||| 01210|EAP|0964|CRNA OPEN HIP JOINT|Medicare|MEDICARE ACUTE|||||1,460.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,379.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|Humana Medicare Advantage|HUMANA MA|||||1,379.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|Medicare|MEDICARE ACUTE|||||1,379.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|Veterans Affairs|VETERANS ADMINISTRATION|||||1,379.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,379.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,379.75||||1,379.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,379.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|Blue Cross PPO Specialty|BCBSTX PPO|||||1,379.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|Cigna|CIGNA|||||1,379.75||| 01214|EAP|0964|CRNA TOTAL HIP REPLACEMEN|Managed Medicaid|MEDICAID SUPERIOR|1,379.75||||1,379.75||| 01220|EAP|0964|CRNA CLOSED PROC UPPER 2/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||509.50||| 01230|EAP|0964|CRNA OPEN PROC UPPER FEMU|United Healthcare|UNITED HEALTHCARE|||||1,034.75||| 01230|EAP|0964|CRNA OPEN PROC UPPER FEMU|Humana Medicare Advantage|HUMANA MA|||||1,034.75||| 01230|EAP|0964|CRNA OPEN PROC UPPER FEMU|Medicare|MEDICARE ACUTE|||||1,034.75||| 01230|EAP|0964|CRNA OPEN PROC UPPER FEMU|Blue Cross PPO Specialty|BCBSTX PPO|||||1,034.75||| 01230|EAP|0964|CRNA OPEN PROC UPPER FEMU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,034.75||| 01232|EAP|0964|CRNA AMPUTATION|Blue Cross PPO Specialty|BCBSTX PPO|||||6.32||| 01232|EAP|0964|CRNA AMPUTATION|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.32||| 01232|EAP|0964|CRNA AMPUTATION|Medicare|MEDICARE ACUTE|||||6.32||| 01232|EAP|0964|CRNA AMPUTATION|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.32||| 01250|EAP|0964|CRNA UP LEG NERVE MUSCLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||509.50||| 01250|EAP|0964|CRNA UP LEG NERVE MUSCLE|Managed Medicaid|MEDICAID SUPERIOR|||||509.50||| 01250|EAP|0964|CRNA UP LEG NERVE MUSCLE|Medicare|MEDICARE ACUTE|||||509.50||| 01320|EAP|0964|CRNA NERVES MUSCLE ETC KN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||594.25||| 01320|EAP|0964|CRNA NERVES MUSCLE ETC KN|Blue Cross PPO Specialty|BCBSTX PPO|||||594.25||| 01320|EAP|0964|CRNA NERVES MUSCLE ETC KN|Medicare|MEDICARE ACUTE|||||594.25||| 01360|EAP|0964|CRNA OPEN PROC LOWER FEMU|Blue Cross PPO Specialty|BCBSTX PPO|||||864.50||| 01360|EAP|0964|CRNA OPEN PROC LOWER FEMU|Medicare|MEDICARE ACUTE|||||864.50||| 01360|EAP|0964|CRNA OPEN PROC LOWER FEMU|Workers Compensation|WORKERS COMPENSATION OTHER|||||864.50||| 01380|EAP|0964|CRNA CLOSED KNEE|Medicare|MEDICARE ACUTE|||||3.97||| 01380|EAP|0964|CRNA CLOSED KNEE|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.97||| 01380|EAP|0964|CRNA CLOSED KNEE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3.97||| 01380|EAP|0964|CRNA CLOSED KNEE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.97||| 01380|EAP|0964|CRNA CLOSED KNEE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.97||| 01380|EAP|0964|CRNA CLOSED KNEE|Humana Medicare Advantage|HUMANA MA|||||3.97||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|NON CONTRACTED|COMMERCIAL OTHER 1|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|United Healthcare|UNITED HEALTHCARE|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Medicare|MEDICARE ACUTE|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Cigna|CIGNA|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Managed Medicaid|MEDICAID AMERIGROUP|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Tricare|TRICARE EAST REGION|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Blue Cross PPO Specialty|BCBSTX PPO|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|Managed Medicare|BCBS MEDICARE PPO MA|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||541.25||| 01382|EAP|0964|CRNA ARTHROSCOPIC KNEE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||541.25||| 01392|EAP|0964|CRNA OPEN UP TIBIA FIBULA|Medicare|MEDICARE ACUTE|||||791.50||| 01392|EAP|0964|CRNA OPEN UP TIBIA FIBULA|Cigna|CIGNA|||||791.50||| 01392|EAP|0964|CRNA OPEN UP TIBIA FIBULA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||791.50||| 01392|EAP|0964|CRNA OPEN UP TIBIA FIBULA|Managed Medicaid|MEDICAID SUPERIOR|||||791.50||| 01400|EAP|0964|CRNA OPEN KNEE|Blue Cross PPO Specialty|BCBSTX PPO|||||6.97||| 01400|EAP|0964|CRNA OPEN KNEE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6.97||| 01400|EAP|0964|CRNA OPEN KNEE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.97||| 01400|EAP|0964|CRNA OPEN KNEE|Medicare|MEDICARE ACUTE|||||6.97||| 01402|EAP|0964|CRNA TOTAL KNEE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|Blue Cross PPO Specialty|BCBSTX PPO|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|Humana Medicare Advantage|HUMANA MA|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|Medicare|MEDICARE ACUTE|||||14.36||| 01402|EAP|0964|CRNA TOTAL KNEE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||14.36||| 01462|EAP|0964|CRNA CLOSED LOWER LEG AND|United Healthcare|UNITED HEALTHCARE|||||525.50||| 01462|EAP|0964|CRNA CLOSED LOWER LEG AND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||525.50||| 01470|EAP|0964|CRNA NERVES LOWER LEG ANK|Blue Cross PPO Specialty|BCBSTX PPO|||||671.75||| 01470|EAP|0964|CRNA NERVES LOWER LEG ANK|Workers Compensation|WORKERS COMPENSATION OTHER|||||671.75||| 01470|EAP|0964|CRNA NERVES LOWER LEG ANK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||671.75||| 01470|EAP|0964|CRNA NERVES LOWER LEG ANK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||671.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|Workers Compensation|WORKERS COMPENSATION OTHER|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|Blue Cross PPO Specialty|BCBSTX PPO|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|Managed Medicaid|MEDICAID SUPERIOR|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|Managed Medicaid|MEDICAID AMERIGROUP|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|Cigna|CIGNA|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|United Healthcare|UNITED HEALTHCARE|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|Blue Cross HMO Specialty|BCBSTX HMO|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|Humana Medicare Advantage|HUMANA MA|||||522.75||| 01480|EAP|0964|CRNA OPEN LOWER LEG ANKLE|Medicare|MEDICARE ACUTE|||||522.75||| 01620|EAP|0964|CRNA CLSD HEAD/NECK/ST-AC|Blue Cross PPO Specialty|BCBSTX PPO|||||6.97||| 01620|EAP|0964|CRNA CLSD HEAD/NECK/ST-AC|Medicare|MEDICARE ACUTE|||||6.97||| 01620|EAP|0964|CRNA CLSD HEAD/NECK/ST-AC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.97||| 01620|EAP|0964|CRNA CLSD HEAD/NECK/ST-AC|United Healthcare|UNITED HEALTHCARE OTHER|||||6.97||| 01620|EAP|0964|CRNA CLSD HEAD/NECK/ST-AC|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||6.97||| 01620|EAP|0964|CRNA CLSD HEAD/NECK/ST-AC|United Healthcare|UNITED HEALTHCARE|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|Medicare|MEDICARE ACUTE|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|Managed Medicaid|MEDICAID SUPERIOR|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|Blue Cross PPO Specialty|BCBSTX PPO|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|Humana Medicare Advantage|HUMANA MA|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.97||| 01622|EAP|0964|CRNA ARTHROSCOPIC SHOULDE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.97||| 01630|EAP|0964|CRNA OPN HEAD NCK CLAV SH|Humana Medicare Advantage|HUMANA MA|||||864.50||| 01630|EAP|0964|CRNA OPN HEAD NCK CLAV SH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||864.50||| 01630|EAP|0964|CRNA OPN HEAD NCK CLAV SH|Blue Cross PPO Specialty|BCBSTX PPO|||||864.50||| 01630|EAP|0964|CRNA OPN HEAD NCK CLAV SH|Cigna|CIGNA|||||864.50||| 01630|EAP|0964|CRNA OPN HEAD NCK CLAV SH|Medicare|MEDICARE ACUTE|||||864.50||| 01630|EAP|0964|CRNA OPN HEAD NCK CLAV SH|United Healthcare|UNITED HEALTHCARE|||||864.50||| 01638|EAP|0964|CRNA TOTAL SHOULDER|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|Medicare|MEDICARE ACUTE|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|Blue Cross PPO Specialty|BCBSTX PPO|||||1,301.75||| 01638|EAP|0964|CRNA TOTAL SHOULDER|Humana Medicare Advantage|HUMANA MA|||||1,301.75||| 01710|EAP|0964|CRNA NERVES ETC UPPER ARM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||418.50||| 01710|EAP|0964|CRNA NERVES ETC UPPER ARM|Blue Cross HMO Specialty|BCBSTX HMO|||||418.50||| 01710|EAP|0964|CRNA NERVES ETC UPPER ARM|Medicare|MEDICARE ACUTE|||||418.50||| 01730|EAP|0964|CRNA CLOSED HUMERUS/ELBOW|United Medicare Advantage|UHC MEDICARE GOLD MA|||||418.50||| 01732|EAP|0964|CRNA ARTHROSCOPIC ELBOW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||418.50||| 01740|EAP|0964|CRNA OPEN HUMERUS ELBOW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||558.50||| 01740|EAP|0964|CRNA OPEN HUMERUS ELBOW|Blue Cross PPO Specialty|BCBSTX PPO|||||558.50||| 01740|EAP|0964|CRNA OPEN HUMERUS ELBOW|Managed Medicaid|MEDICAID AMERIGROUP|||||558.50||| 01740|EAP|0964|CRNA OPEN HUMERUS ELBOW|Medicare|MEDICARE ACUTE|||||558.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||525.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||525.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|Medicare|MEDICARE ACUTE|||||525.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||525.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||525.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||525.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||525.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||525.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|Blue Cross PPO Specialty|BCBSTX PPO|||||525.50||| 01810|EAP|0964|CRNA NERVES FOREARM WRIST|Aenta Medicare Advantage|AETNA MEDICARE MA|||||525.50||| 01820|EAP|0964|CRNA CLOSED RADIUS/ULNA/W|Managed Medicare|HEALTHSPRING MA|||||525.50||| 01820|EAP|0964|CRNA CLOSED RADIUS/ULNA/W|Managed Medicaid|MEDICAID AMERIGROUP|||||525.50||| 01820|EAP|0964|CRNA CLOSED RADIUS/ULNA/W|Medicaid|MEDICAID|||||525.50||| 01820|EAP|0964|CRNA CLOSED RADIUS/ULNA/W|Medicare|MEDICARE ACUTE|||||525.50||| 01820|EAP|0964|CRNA CLOSED RADIUS/ULNA/W|Managed Medicaid|MEDICAID SUPERIOR|||||525.50||| 01820|EAP|0964|CRNA CLOSED RADIUS/ULNA/W|Blue Cross PPO Specialty|BCBSTX PPO|||||525.50||| 01820|EAP|0964|CRNA CLOSED RADIUS/ULNA/W|Aetna|AETNA PPO|||||525.50||| 01820|EAP|0964|CRNA CLOSED RADIUS/ULNA/W|NON CONTRACTED|COMMERCIAL OTHER 1|||||525.50||| 01829|EAP|0964|CRNA ARTHROSCOPIC WRIST|Medicare|MEDICARE ACUTE|||||7.10||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Blue Cross PPO Specialty|BCBSTX PPO|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Workers Compensation|WORKERS COMPENSATION OTHER|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Humana Medicare Advantage|HUMANA MA|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Cigna|CIGNA|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Medicare|MEDICARE ACUTE|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|NON CONTRACTED|COMMERCIAL OTHER 1|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Tricare|TRICARE EAST REGION|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||525.50||| 01830|EAP|0964|CRNA OPEN RADIUS ULNA WRI|Managed Medicaid|MEDICAID AMERIGROUP|||||525.50||| 01961|EAP|0964|CRNA CESAREAN SECTION|United Healthcare|UNITED HEALTHCARE|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Medicare|MEDICARE ACUTE|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Managed Medicaid|MEDICAID AMERIGROUP|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Cigna|CIGNA|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Medicaid|MEDICAID|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Managed Medicaid|MEDICAID SUPERIOR|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Medicaid|MEDICAID HMO|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Aetna|AETNA PPO|||||9.67||| 01961|EAP|0964|CRNA CESAREAN SECTION|Blue Cross PPO Specialty|BCBSTX PPO|||||9.67||| 01965|EAP|0964|CRNA INCOMPLETE OR MISSED|Medicaid|MEDICAID|||||522.25||| 01965|EAP|0964|CRNA INCOMPLETE OR MISSED|Blue Cross PPO Specialty|BCBSTX PPO|||||522.25||| 01965|EAP|0964|CRNA INCOMPLETE OR MISSED|Managed Medicaid|MEDICAID AMERIGROUP|||||522.25||| 01965|EAP|0964|CRNA INCOMPLETE OR MISSED|Managed Medicaid|MEDICAID SUPERIOR|||||522.25||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Managed Medicaid|MEDICAID AMERIGROUP|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|NON CONTRACTED|COMMERCIAL OTHER 1|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|United Healthcare|UNITED HEALTHCARE|||||23.74||| 01967|EAP|0964|CRNA OB EPIDURAL|Managed Medicaid|MEDICAID SUPERIOR|23.74||||926.50||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Medicaid|MEDICAID|23.74||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Tricare|TRICARE EAST REGION|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Managed Medicaid|MEDICAID SUPERIOR|23.74||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Blue Cross HMO Specialty|BCBSTX HMO|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Aetna|AETNA PPO|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Blue Cross PPO Specialty|BCBSTX PPO|||||23.74||| 01967|EAP|0964|CRNA EPIDURAL CONT LBR/DE|Cigna|CIGNA|||||23.74||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Humana Medicare Advantage|HUMANA MA|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Veterans Affairs|VETERANS ADMINISTRATION|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Blue Cross PPO Specialty|BCBSTX PPO|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Blue Cross PPO Specialty|BCBSTX PPO|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Veterans Affairs|VETERANS ADMINISTRATION|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Cigna|CIGNA|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Managed Medicaid|MEDICAID SUPERIOR|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Cigna|CIGNA|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Managed Medicaid|MEDICAID AMERIGROUP|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Humana Medicare Advantage|HUMANA MA|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Managed Medicare|BCBS MEDICARE PPO MA|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Medicare|MEDICARE ACUTE|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|United Healthcare|UNITED HEALTHCARE|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.20||| 01996|EAP|0964|CRNA INTERSCALENCE BLOCK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|Medicare|MEDICARE ACUTE|||||5.20||| 01996|EAP|0964|CRNA FEMORAL NERVE BLOCK|United Healthcare|UNITED HEALTHCARE|||||5.20||| 0439T|EAP|0483|MYOCRD CONTRAST PRFUJ ECH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.50||| 0439T|EAP|0483|MYOCRD CONTRAST PRFUJ ECH|Medicare|MEDICARE ACUTE|||||1.50||| 0439T|EAP|0483|MYOCRD CONTRAST PRFUJ ECH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.50||| 0439T|EAP|0483|MYOCRD CONTRAST PRFUJ ECH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.50||| 100|DRG||SEIZURES W MCC|Medicare|MEDICARE ACUTE|290.39|10715.58|10715.58|10715.58|||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||889.85||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Cigna|CIGNA|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Blue Cross PPO Specialty|BCBSTX PPO|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||889.85||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID SUPERIOR|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID AMERIGROUP|||||889.85||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Medicare|MEDICARE ACUTE|889.85||||889.85||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Medicaid|MEDICAID|||||889.85||| 10061|EAP|0450|I&D ABSCESS COMP/MULTIPLE|Managed Medicaid|MEDICAID SUPERIOR|||||1,043.50||| 10061|EAP|0450|I&D ABSCESS COMP/MULTIPLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,043.50||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|United Healthcare|UNITED HEALTHCARE|||||513.50||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Managed Medicaid|MEDICAID SUPERIOR|||||590.53||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Blue Cross PPO Specialty|BCBSTX PPO|||||513.50||| 101|DRG||SEIZURES W/O MCC|Medicare|MEDICARE ACUTE|10,058.45|6668.19|6676.66|6668.19|||| 101|DRG||SEIZURES W/O MCC|Humana Medicare Advantage|HUMANA MA|27,187.59|6676.66|6676.66|6668.19|||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,161.75||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Medicare|MEDICARE ACUTE|||||1,510.28||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,510.28||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Managed Medicare|HEALTHSPRING MA|||||1,510.28||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Managed Medicaid|MEDICAID SUPERIOR|||||1,336.02||| 10140|EAP|0450|I&D HEMATOMA SEROMA FLUID|Veterans Affairs|VETERANS ADMINISTRATION|||||3,546.40||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||513.50||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Blue Cross PPO Specialty|BCBSTX PPO|||||667.55||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||590.53||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Managed Medicaid|MEDICAID AMERIGROUP|||||513.50||| 11730|EAP|0450|AVULSION NAIL PLATE SMPLE|Medicare|MEDICARE ACUTE|||||370.50||| 11760|EAP|0450|RPR NAIL BED|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||756.50||| 11760|EAP|0450|RPR NAIL BED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||983.45||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||841.75||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||841.75||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|NON CONTRACTED|COMMERCIAL OTHER 1|||||744.63||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicaid|MEDICAID SUPERIOR|||||841.75||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicare|MEDICARE ACUTE|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Cigna|CIGNA|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Tricare|TRICARE EAST REGION|||||744.63||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Blue Cross PPO Specialty|BCBSTX PPO|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||841.75||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicaid|MEDICAID AMERIGROUP|||||744.63||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Humana Medicare Advantage|HUMANA MA|||||841.75||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Healthcare|UNITED HEALTHCARE|||||744.63||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicare|HEALTHSPRING MA|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Medicare Advantage|UHC MEDICARE GOLD MA|||||841.75||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicare|BCBS MEDICARE PPO MA|||||841.75||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Workers Compensation|WORKERS COMPENSATION OTHER|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Aetna|AETNA PPO|||||647.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||469.78||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Humana Medicare Advantage|HUMANA MA|||||469.78||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||531.05||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|NON CONTRACTED|COMMERCIAL OTHER 1|||||531.05||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID AMERIGROUP|||||531.05||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Aetna|AETNA OTHER|||||531.05||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicare|MEDICARE ACUTE|||||531.05||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|United Healthcare|UNITED HEALTHCARE OTHER|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Workers Compensation|WORKERS COMPENSATION OTHER|||||469.78||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicaid|MEDICAID|||||531.05||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID SUPERIOR|||||531.05||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicaid|MEDICAID HMO|||||531.05||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Cigna|CIGNA|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||531.05||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Medicaid|MEDICAID|||||558.25||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Managed Medicare|HEALTHSPRING MA|||||452.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|NON CONTRACTED|COMMERCIAL OTHER 2|||||558.25||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|United Healthcare|UNITED HEALTHCARE OTHER|||||452.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Managed Medicaid|MEDICAID AMERIGROUP|||||558.25||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Medicare|MEDICARE ACUTE|||||558.25||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Workers Compensation|WORKERS COMPENSATION OTHER|||||505.38||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||558.25||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||452.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Cigna|CIGNA|||||558.25||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Blue Cross HMO Specialty|BCBSTX HMO|||||558.25||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||832.25||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|Blue Cross PPO Specialty|BCBSTX PPO|||||832.25||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Managed Medicaid|MEDICAID AMERIGROUP|||||774.80||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Managed Medicaid|MEDICAID SUPERIOR|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Workers Compensation|WORKERS COMPENSATION OTHER|||||774.80||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicare|MEDICARE ACUTE|774.80||||685.40||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid|MEDICAID|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Veterans Affairs|VETERANS ADMINISTRATION|||||774.80||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||774.80||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid|MEDICAID HMO|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Humana Medicare Advantage|HUMANA MA|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.96||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Blue Cross PPO Specialty|BCBSTX PPO|||||812.18||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicaid|MEDICAID AMERIGROUP|||||812.18||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|United Medicare Advantage|UHC MEDICARE GOLD MA|812.18||||||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Medicare|MEDICARE ACUTE|||||812.18||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||718.47||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Blue Cross HMO Specialty|BCBSTX HMO|||||812.18||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicaid|MEDICAID SUPERIOR|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|NON CONTRACTED|COMMERCIAL OTHER 1|||||812.18||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||812.18||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|Managed Medicaid|MEDICAID AMERIGROUP|||||1,081.93||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|Workers Compensation|WORKERS COMPENSATION OTHER|||||832.25||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||832.25||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,081.93||| 12014|EAP|0450|RPR LAC SIMPL FACE 5.1-7.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||957.09||| 12031|EAP|0450|RPR SCALP, TRUNK/EXTREM <|United Healthcare|UNITED HEALTHCARE OTHER|||||723.13||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Veterans Affairs|VETERANS ADMINISTRATION|||||681.85||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|NON CONTRACTED|COMMERCIAL OTHER 1|||||681.85||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|United Medicare Advantage|UHC MEDICARE GOLD MA|||||524.50||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Managed Medicaid|MEDICAID SUPERIOR|||||681.85||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||681.85||| 12032|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Blue Cross PPO Specialty|BCBSTX PPO|||||681.85||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|Medicare|MEDICARE ACUTE|||||990.93||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|Blue Cross PPO Specialty|BCBSTX PPO|||||762.25||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||990.93||| 12035|EAP|0450|RPR LAYER CLOSURE 12.6-20|United Healthcare|UNITED HEALTHCARE|||||832.25||| 12042|EAP|0450|RPR LAYER CLOSURE 2.6-7.5|Humana Medicare Advantage|HUMANA MA|||||1,081.93||| 12051|EAP|0450|RPR LAYER CLOS FACE 2.5CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||624.75||| 12051|EAP|0450|RPR LAYER CLOS FACE 2.5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||812.18||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||957.09||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,081.93||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|Medicare|MEDICARE PART B ONLY IP|1,081.93||||||| 12054|EAP|0450|RPR LAYER CLOS FACE 7.6CM|Blue Cross PPO Specialty|BCBSTX PPO|||||746.53||| 148|DRG||EAR, NOSE, MOUTH & THROAT MALIGNANCY W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|27,106.18|7367.53|7367.53|7367.53|||| 149|DRG||DYSEQUILIBRIUM|Medicare|MEDICARE PART B ONLY IP|24,384.93|100.48|7171.07|100.48|||| 149|DRG||DYSEQUILIBRIUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|48,135.29|7171.07|7171.07|100.48|||| 149|DRG||DYSEQUILIBRIUM|Medicare|MEDICARE ACUTE|14,740.21|7113.44|7171.07|100.48|||| 151|DRG||EPISTAXIS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|459.92|16283.84|16283.84|16283.84|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|21,535.15|4430.24|4430.24|4430.24|||| 156|DRG||OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W/O CC/MCC|Medicare|MEDICARE ACUTE|296.47|6566.44|6566.44|6566.44|||| 158|DRG||DENTAL & ORAL DISEASES W CC|Managed Medicaid|MEDICAID SUPERIOR|34,027.25|14485.93|34454.92|14485.93|||| 158|DRG||DENTAL & ORAL DISEASES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|92,330.02|34454.92|34454.92|14485.93|||| 16000|EAP|0450|TX BURN 1ST DEGREE|Workers Compensation|WORKERS COMPENSATION OTHER|||||250.75||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|NON CONTRACTED|COMMERCIAL OTHER 1|||||788.78||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Blue Cross PPO Specialty|BCBSTX PPO|||||788.78||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Medicare|MEDICARE ACUTE|||||788.78||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|United Medicare Advantage|UHC MEDICARE GOLD MA|||||788.78||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Humana Medicare Advantage|HUMANA MA|30,044.75|11637.55|11650.55|11637.55|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|United Medicare Advantage|UHC MEDICARE GOLD MA|52,545.26|11650.55|11650.55|11637.55|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|34,336.25|7802.64|7880.37|7802.64|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|55,778.75|7814.11|7880.37|7802.64|||| 176|DRG||PULMONARY EMBOLISM W/O MCC|Medicare|MEDICARE ACUTE|50,005.26|7880.37|7880.37|7802.64|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Humana Medicare Advantage|HUMANA MA|47,913.28|12845.96|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|24,314.07|17104.51|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|63,844.92|17104.51|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33,961.11||||||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|61,458.39||||||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|61,391.21|45264.53|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|15,968.82|24459.45|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|351.44|14528.85|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|47,171.16|17104.51|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Tricare|TRICARE EAST REGION|100,780.94|11930.61|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Medicare|MEDICARE ACUTE|44,324.36|15133.41|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicare|BCBS MEDICARE PPO MA|55,464.19|17104.51|45264.53|11930.61|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicare|HEALTHSPRING MA|65,436.35|17104.51|45264.53|11930.61|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Humana Medicare Advantage|HUMANA MA|33,145.09|10556.56|27669.97|10540.46|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|75,041.52|27669.97|27669.97|10540.46|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Medicare|MEDICARE ACUTE|42,173.56|10540.46|27669.97|10540.46|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59,435.30|13394.61|27669.97|10540.46|||| 179|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|45,736.99|4874.73|4874.73|4874.73|||| 179|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24,439.44||||||| 181|DRG||RESPIRATORY NEOPLASMS W CC|Blue Cross PPO Specialty|BCBSTX PPO|46,015.75|7100.96|7100.96|7100.96|||| 185|DRG||MAJOR CHEST TRAUMA W/O CC/MCC|Medicare|MEDICARE ACUTE|27,925.80|7078.34|7078.34|7078.34|||| 187|DRG||PLEURAL EFFUSION W CC|Blue Cross PPO Specialty|BCBSTX PPO|40,738.55|6560.1|6560.1|6560.1|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Medicare|MEDICARE ACUTE|41,812.75|10151.93|18918.155|7409.43|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Medicaid|MEDICAID|44,098.92|18918.155|18918.155|7409.43|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Humana Medicare Advantage|HUMANA MA|62,608.33|10374.85|18918.155|7409.43|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|125,611.50|7409.43|18918.155|7409.43|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Blue Cross PPO Specialty|BCBSTX PPO|48,782.22|7459.15|18918.155|7409.43|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|34,855.23|8516.12|18918.155|7409.43|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Medicare|MEDICARE ACUTE|30,548.75|9718.41|10101.19|6298.8|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|83,045.42|6298.8|10101.19|6298.8|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Humana Medicare Advantage|HUMANA MA|33,623.16|9902.82|10101.19|6298.8|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|68,450.13|7789.175|10101.19|6298.8|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|73,188.50|9716.25|10101.19|6298.8|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|30,284.25|10101.19|10101.19|6298.8|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Managed Medicare|HEALTHSPRING MA|50,079.50|8100.88|19018.72|81|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|39,858.75|8100.88|19018.72|81|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|31,662.05|8096.12|19018.72|81|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Medicare|MEDICARE ACUTE|36,598.74|81|19018.72|81|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|223.51|19018.72|19018.72|81|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Humana Medicare Advantage|HUMANA MA|58,180.50|8105.22|19018.72|81|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Blue Cross PPO Specialty|BCBSTX PPO|260.08|5688.11|19018.72|81|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28,924.50|4282.54|19018.72|81|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|42,466.05|6911.62|6917.78|6911.62|||| 192|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC|Medicare|MEDICARE ACUTE|23,662.65|6917.78|6917.78|6911.62|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23,180.55|23180.55|23180.55|143.1|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Humana Medicare Advantage|HUMANA MA|57,448.95|10942.94|23180.55|143.1|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|14,357.31|6965.34|23180.55|143.1|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Medicare|MEDICARE PART B ONLY IP|44,992.88|143.1|23180.55|143.1|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|38,557.10|10937.72|23180.55|143.1|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Managed Medicare|HEALTHSPRING MA|26,591.75|10938.6|23180.55|143.1|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Medicare|MEDICARE ACUTE|10,379.88|8629.86|23180.55|143.1|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Medicare|MEDICARE ACUTE|35,697.48|8072.96|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Medicare|MEDICARE PART B ONLY IP|66,111.70|231.08|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Medicaid|MEDICAID|29,568.30|6226.36|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|23,600.79|7844.97|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|52,394.84|8073.84|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|23,469.58|4218.34|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Blue Cross PPO Specialty|BCBSTX PPO|275.92|5602.84|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|37,332.75|8045.68|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicaid|MEDICAID AMERIGROUP|25,879.90|12641.445|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|307.24|9899.91|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Humana Medicare Advantage|HUMANA MA|40,671.53|8082.97|12641.445|231.08|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|34,698.18|12641.445|12641.445|231.08|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|24,671.24|9645.24|9645.24|3176.8|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|20,812.25|9645.24|9645.24|3176.8|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29,268.05|3176.8|9645.24|3176.8|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Medicare|MEDICARE ACUTE|25,855.83|6744.17|9645.24|3176.8|||| 201|DRG||PNEUMOTHORAX W/O CC/MCC|Medicare|MEDICARE ACUTE|47,234.50|6975.32|6975.32|6975.32|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16,800.75|10673.45|10673.45|10673.45|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|31,924.84|3266.14|6819.49|3266.14|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Medicare|MEDICARE ACUTE|63,562.50|6819.49|6819.49|3266.14|||| 205|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|47,457.60|13108.88|13108.88|10036.43|||| 205|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC|Humana Medicare Advantage|HUMANA MA|345.42|10036.43|13108.88|10036.43|||| 205|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC|Managed Medicare|HEALTHSPRING MA|36,479.83|13108.88|13108.88|10036.43|||| 206|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|37,155.43|9884.71|9884.71|9884.71|||| 20610|EAP|0450|ASP JOINT MAJOR|Humana Medicare Advantage|HUMANA MA|||||802.13||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||637.25||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Medicare|MEDICARE ACUTE|828.43||||828.43||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|United Medicare Advantage|UHC MEDICARE GOLD MA|||||828.43||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Blue Cross PPO Specialty|BCBSTX PPO|||||828.43||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||828.43||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Managed Medicaid|MEDICAID SUPERIOR|||||828.43||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|United Healthcare|UNITED HEALTHCARE OTHER|||||637.25||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||828.43||| 239|DRG||AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC|Medicare|MEDICARE ACUTE|123,609.45|32392.71|32392.71|32392.71|||| 24600|EAP|0450|TX DISLOC ELBOW WO ANESTH|Managed Medicaid|MEDICAID SUPERIOR|||||665.25||| 24640|EAP|0450|TX RAD HD SUBLUX W MANIP|Blue Cross PPO Specialty|BCBSTX PPO|||||962.98||| 24640|EAP|0450|TX RAD HD SUBLUX W MANIP|Managed Medicaid|MEDICAID AMERIGROUP|||||851.87||| 256|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC|NON CONTRACTED|COMMERCIAL OTHER 1|425.20|23938.76|23938.76|10883.91|||| 256|DRG||UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC|Blue Cross PPO Specialty|BCBSTX PPO|28,781.11|10883.91|23938.76|10883.91|||| 25605|EAP|0450|TX DSTL FRACT RAD/ULNA W/|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1,185.75||| 25605|EAP|0450|TX DSTL FRACT RAD/ULNA W/|Managed Medicaid|MEDICAID AMERIGROUP|||||1,185.75||| 26770|EAP|0450|CLSD TRT FINGER JOINT DIS|Medicare|MEDICARE ACUTE|||||2.80||| 26770|EAP|0450|CLSD TRT FINGER JOINT DIS|Blue Cross PPO Specialty|BCBSTX PPO|||||3.64||| 27265|EAP|0450|TX DISLOC HIP POST ARTHO|Medicare|MEDICARE ACUTE|||||754.50||| 27818|EAP|0450|TRT ANKLE DISCOLATION|Blue Cross PPO Specialty|BCBSTX PPO|||||2.89||| 27818|EAP|0450|TRT ANKLE DISCOLATION|Blue Cross HMO Specialty|BCBSTX HMO|||||2.89||| 27840|EAP|0450|TX DISLOC ANKLE WO ANESTH|Humana Medicare Advantage|HUMANA MA|||||789.75||| 27840|EAP|0450|TX DISLOC ANKLE WO ANESTH|United Healthcare|UNITED HEALTHCARE|||||607.50||| 27840|EAP|0450|TX DISLOC ANKLE WO ANESTH|Medicare|MEDICARE ACUTE|789.75||||||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Managed Medicare|HEALTHSPRING MA|459.01|12852.75|12852.75|10088.735|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Medicare|MEDICARE ACUTE|31,867.99|10088.735|12852.75|10088.735|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Humana Medicare Advantage|HUMANA MA|24,092.68|8748.73|8748.73|8662.46|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Medicare|MEDICARE ACUTE|36,534.26|8662.46|8748.73|8662.46|||| 28190|EAP|0450|RMV FB FOOT SUBQ|Managed Medicaid|MEDICAID SUPERIOR|||||1,966.25||| 291|DRG||HEART FAILURE & SHOCK W MCC|Blue Cross PPO Specialty|BCBSTX PPO|38,631.17|8373.77|28072.9|4290.63|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|31,238.50|4290.63|28072.9|4290.63|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44,852.25|28072.9|28072.9|4290.63|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Humana Medicare Advantage|HUMANA MA|35,085.25|8854.2|28072.9|4290.63|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46,025.45|21173.625|28072.9|4290.63|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicare|WELLCARE CHOICE MA|47,246.66|10998.19|28072.9|4290.63|||| 291|DRG||HEART FAILURE & SHOCK W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37,780.28|10998.19|28072.9|4290.63|||| 291|DRG||HEART FAILURE & SHOCK W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|31,544.75|10989.66|28072.9|4290.63|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Medicare|MEDICARE ACUTE|36,082.62|10989.66|28072.9|4290.63|||| 29105|EAP|0450|APPLY LONG ARM SPLINT|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.96||||5.96||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Managed Medicaid|MEDICAID SUPERIOR|||||5.96||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Managed Medicaid|MEDICAID AMERIGROUP|||||774.80||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Blue Cross PPO Specialty|BCBSTX PPO|||||5.96||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||774.80||| 29105|EAP|0450|APPLY LONG ARM SPLINT|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.96||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|NON CONTRACTED|COMMERCIAL OTHER 1|||||534.75||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||604.50||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Humana Medicare Advantage|HUMANA MA|||||534.75||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Tricare|TRICARE EAST REGION|||||604.50||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Healthcare|UNITED HEALTHCARE|||||604.50||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross PPO Specialty|BCBSTX PPO|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Healthcare|UNITED HEALTHCARE|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicare|MEDICARE ACUTE|604.50||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicaid|MEDICAID HMO|||||604.50||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicaid|MEDICAID|||||534.75||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID SUPERIOR|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||604.50||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||534.75||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Healthcare|UNITED HEALTHCARE OTHER|||||604.50||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||604.50||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID AMERIGROUP|||||604.50||| 292|DRG||HEART FAILURE & SHOCK W CC|Medicaid|MEDICAID|32,768.71|11980.58|19620.6|7818.25|||| 292|DRG||HEART FAILURE & SHOCK W CC|Humana Medicare Advantage|HUMANA MA|29,774.89|8243.56|19620.6|7818.25|||| 292|DRG||HEART FAILURE & SHOCK W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|35,775.90|8180.49|19620.6|7818.25|||| 292|DRG||HEART FAILURE & SHOCK W CC|Managed Medicare|HEALTHSPRING MA|29,991.50|7818.25|19620.6|7818.25|||| 292|DRG||HEART FAILURE & SHOCK W CC|Medicare|MEDICARE ACUTE|32,583.51|8181.77|19620.6|7818.25|||| 292|DRG||HEART FAILURE & SHOCK W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28,903.28|17329.69|19620.6|7818.25|||| 292|DRG||HEART FAILURE & SHOCK W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32,168.07|19620.6|19620.6|7818.25|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33,222.15|6676.97|15723.18|4142.69|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,142.75|15723.18|15723.18|4142.69|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|15,972.50|6551.33|15723.18|4142.69|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|22,141.66|4142.69|15723.18|4142.69|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|31,418.03|6676.97|15723.18|4142.69|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Medicare|MEDICARE ACUTE|25,651.50|6571.59|15723.18|4142.69|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|Medicaid|MEDICAID|348.94|9888.79|15723.18|4142.69|||| 29505|EAP|0450|APPLY LONG LEG SPLINT|United Medicare Advantage|UHC MEDICARE GOLD MA|432.58||||||| 29505|EAP|0450|APPLY LONG LEG SPLINT|NON CONTRACTED|COMMERCIAL OTHER 1|||||332.75||| 29505|EAP|0450|APPLY LONG LEG SPLINT|Managed Medicaid|MEDICAID SUPERIOR|||||432.58||| 29505|EAP|0450|APPLY LONG LEG SPLINT|Medicare|MEDICARE ACUTE|||||432.58||| 29505|EAP|0450|APPLY LONG LEG SPLINT|Managed Medicaid|MEDICAID AMERIGROUP|||||382.67||| 29515|EAP|0450|APPLICATION LOWER LEG SPL|Workers Compensation|WORKERS COMPENSATION OTHER|||||283.40||| 29515|EAP|0450|APPLICATION LOWER LEG SPL|Medicare|MEDICARE ACUTE|2.18||||2.18||| 29515|EAP|0450|APPLICATION LOWER LEG SPL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||2.18||| 29515|EAP|0450|APPLICATION LOWER LEG SPL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.18||| 29515|EAP|0450|APPLICATION LOWER LEG SPL|Medicaid|MEDICAID|||||2.18||| 29515|EAP|0450|APPLICATION LOWER LEG SPL|Managed Medicaid|MEDICAID AMERIGROUP|||||2.18||| 29515|EAP|0450|APPLICATION LOWER LEG SPL|Blue Cross HMO Specialty|BCBSTX HMO|||||2.18||| 29515|EAP|0450|APPLICATION LOWER LEG SPL|Blue Cross PPO Specialty|BCBSTX PPO|||||2.18||| 29515|EAP|0450|APPLICATION LOWER LEG SPL|Managed Medicaid|MEDICAID SUPERIOR|||||2.18||| 29530|EAP|0450|STRAPPING KNEE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||487.18||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Medicaid|MEDICAID|391.00|17859.11|17859.11|1359.31|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|23,768.54|9906.36|17859.11|1359.31|||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13,442.20|1359.31|17859.11|1359.31|||| 300|DRG||PERIPHERAL VASCULAR DISORDERS W CC|Medicare|MEDICARE ACUTE|33,243.50|8968.9|8968.9|8968.9|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|22,566.53|6715.25|6997.38|108.87|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|18,429.32|108.87|6997.38|108.87|||| 301|DRG||PERIPHERAL VASCULAR DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|25,619.50|6997.38|6997.38|108.87|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Medicare|MEDICARE ACUTE|223.60|6702.95|6702.95|3930.26|||| 303|DRG||ATHEROSCLEROSIS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|39,814.55|3930.26|6702.95|3930.26|||| 30300|EAP|0450|REM FB INTRANASAL|Blue Cross PPO Specialty|BCBSTX PPO|||||748.48||| 30300|EAP|0450|REM FB INTRANASAL|Tricare|TRICARE EAST REGION|||||575.75||| 30300|EAP|0450|REM FB INTRANASAL|Managed Medicaid|MEDICAID SUPERIOR|||||748.48||| 30300|EAP|0450|REM FB INTRANASAL|Managed Medicaid|MEDICAID AMERIGROUP|||||575.75||| 30300|EAP|0450|REM FB INTRANASAL|Medicaid|MEDICAID|||||748.48||| 305|DRG||HYPERTENSION W/O MCC|Medicare|MEDICARE ACUTE|26,881.72|7061.39|7061.39|7061.39|||| 306|DRG||CARDIAC CONGENITAL & VALVULAR DISORDERS W MCC|Medicare|MEDICARE ACUTE|45,898.49|11548.665|11548.665|11548.665|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Medicare|MEDICARE PART B ONLY IP|29,036.50|9971.63|15446.98|9971.63|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|40,521.96|15446.98|15446.98|9971.63|||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|52,392.05|9997.63|15446.98|9971.63|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Medicare|MEDICARE ACUTE|21,527.58|7221.06|13680.09|7221.06|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|65,518.86|13680.09|13680.09|7221.06|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Humana Medicare Advantage|HUMANA MA|38,294.52|7350.38|13680.09|7221.06|||| 30901|EAP|0450|CONTROL NOSE BLEED ANT/SI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||389.50||| 30901|EAP|0450|CONTROL NOSE BLEED ANT/SI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||389.50||| 30901|EAP|0450|CONTROL NOSE BLEED ANT/SI|Medicare|MEDICARE ACUTE|||||447.93||| 30903|EAP|0450|CONTROL NOSEBLEED ANT COM|Medicare|MEDICARE ACUTE|||||462.50||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|36,337.47|6046.19|13680.09|3417.13|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|13,466.93|3417.13|13680.09|3417.13|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|29,178.88|5952.99|13680.09|3417.13|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20,292.76|5666.34|13680.09|3417.13|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|29,104.75|5953.43|13680.09|3417.13|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29,794.60|13680.09|13680.09|3417.13|||| 311|DRG||ANGINA PECTORIS|NON CONTRACTED|COMMERCIAL OTHER 1|37,812.85|102.75|102.75|102.75|||| 312|DRG||SYNCOPE & COLLAPSE|Blue Cross HMO Specialty|BCBSTX HMO|19,975.10|1413.31|7582.06|1413.31|||| 312|DRG||SYNCOPE & COLLAPSE|Medicare|MEDICARE ACUTE|33,237.50|7582.06|7582.06|1413.31|||| 313|DRG||CHEST PAIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|19,268.09|7014.13|7014.13|6957.06|||| 313|DRG||CHEST PAIN|Aenta Medicare Advantage|AETNA MEDICARE MA|14,297.50|6957.06|7014.13|6957.06|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|30,581.25|16494.8|16494.8|8600.57|||| 315|DRG||OTHER CIRCULATORY SYSTEM DIAGNOSES W CC|Medicare|MEDICARE ACUTE|31,593.09|8600.57|16494.8|8600.57|||| 31500|EAP|0450|INTUBATION EMERGENCY|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicare|MEDICARE ACUTE|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicaid|MEDICAID HMO|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID SUPERIOR|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicare|WELLCARE CHOICE MA|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicare|HEALTHSPRING MA|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Blue Cross PPO Specialty|BCBSTX PPO|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Cigna|CIGNA|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Humana Medicare Advantage|HUMANA MA|||||1,147.50||| 32551|EAP|0450|TUBE THORACOSTOMY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||934.25||| 32551|EAP|0450|TUBE THORACOSTOMY|Medicare|MEDICARE ACUTE|934.25||||1,214.53||| 32551|EAP|0450|TUBE THORACOSTOMY|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||934.25||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|171,994.21|36261.36|36261.36|36261.36|||| 327|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|144,709.60|40188.84|40188.84|40188.84|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|52,108.78|18973.76|18973.76|18621.56|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|75,724.20|18621.56|18973.76|18621.56|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Medicare|MEDICARE ACUTE|62,797.95|18973.76|18973.76|18621.56|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|45,853.15|35395.67|35395.67|12189.28|||| 337|DRG||PERITONEAL ADHESIOLYSIS W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|55,517.85|12189.28|35395.67|12189.28|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|22,693.60|6754.91|6754.91|6754.91|||| 345|DRG||MINOR SMALL & LARGE BOWEL PROCEDURES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|66,905.20|12868.19|12868.19|12868.19|||| 349|DRG||ANAL & STOMAL PROCEDURES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|23,239.03|5910.93|5910.93|5910.93|||| 351|DRG||INGUINAL & FEMORAL HERNIA PROCEDURES W CC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|44,101.44|11953.12|11953.12|11953.12|||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|78.75||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|78.75||||0.18||| 36415|EAP|0300|COLLECTION FOR PKU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Workers Compensation|WORKERS COMPENSATION OTHER|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Veterans Affairs|VETERANS ADMINISTRATION|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicaid|MEDICAID AMERIGROUP|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|78.75||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|Cigna|CIGNA|78.75||||0.18||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Workers Compensation|UT EMPLOYEE INJURY|||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|Managed Medicaid|MEDICAID AMERIGROUP|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|78.75||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|Managed Medicaid|MEDICAID SUPERIOR|78.75||||0.18||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.25||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Cigna|CIGNA|78.75||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|Aetna|AETNA PPO|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross PPO Specialty|BCBSTX OTHER|||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||48.38||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|78.75||||0.18||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|95.25||||0.18||| 36415|EAP|0300|COLLECTION FOR PKU|Blue Cross HMO Specialty|BCBSTX HMO|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Aetna|AETNA OTHER|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|78.75||||0.18||| 36415|EAP|0300|COLLECTION FOR PKU|Medicaid|MOLINA HEALTHCARE OF TEXAS|78.75||||0.18||| 36415|EAP|0300|COLLECTION FOR PKU|Blue Cross PPO Specialty|BCBSTX PPO|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|COUNTY INDIGENT HEALTH OTHER|78.75||||48.38||| 36415|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Aetna|AETNA PPO|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|Medicaid|MEDICAID|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|SUPERIOR HEALTHPLAN CHIP|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicare|HEALTHSPRING MA|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross PPO Specialty|BCBSTX PPO|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST TPA UMR|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Cigna|CIGNA|0.87||||0.18||| 36415|EAP|0300|COLLECTION FOR PKU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|78.75||||0.18||| 36415|EAP|0300|COLLECTION FOR PKU|Medicaid|SUPERIOR HEALTHPLAN CHIP|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|MEDICAID HMO|95.25||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicare|BCBS MEDICARE PPO MA|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|MEDICAID|78.75||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|NON CONTRACTED|COMMERCIAL OTHER 1|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicare|WELLCARE CHOICE MA|78.75||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|Medicaid|MEDICAID HMO|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|PHCS|MULTIPLAN PHCS|||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|MOLINA HEALTHCARE OF TEXAS|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Tricare|TRICARE EAST REGION|0.87||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|UTMB|UTMB CORRECTIONAL MANAGED CARE|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Healthcare|TML GROUP BENEFITS|||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Aenta Medicare Advantage|AETNA MEDICARE MA|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|NON CONTRACTED|COMMERCIAL OTHER 1|78.75||||48.38||| 36415|EAP|0300|COLLECTION FOR PKU|Tricare|TRICARE EAST REGION|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|United Healthcare|GEHA|||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|United Medicare Advantage|UHC MEDICARE GOLD MA|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicaid|MEDICAID SUPERIOR|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|United Healthcare|UNITED HEALTHCARE|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|ChampVA|CHAMPVA CENTER|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicare|MEDICARE PART B ONLY IP|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|PHCS|HUMANA INSURANCE|||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|MEDICAID TEXAS CHILDRENS|||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicare|MEDICARE ACUTE|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|NON CONTRACTED|COMMERCIAL OTHER 2|||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Humana Medicare Advantage|HUMANA MA|78.75||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|United Healthcare|UNITED HEALTHCARE|78.75||||0.18||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|United Healthcare|UNITED HEALTHCARE|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross HMO Specialty|BCBSTX HMO|78.75||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|Tricare|TRICARE FOR LIFE|||||48.38||| 36415|EAP|0300|COLLECTION FOR PKU|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.18||| 36415|EAP|0300|PHLEBOTOMY FEE|United Healthcare|UMR UNITED MEDICAL RESOURCES|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Healthcare|UNITED HEALTHCARE OTHER|78.75||||78.75||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.81||||13.81||| 36430|EAP|0391|TRANSFUSION|Medicare|MEDICARE ACUTE|1,795.44||||13.18||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Medicare|MEDICARE ACUTE|13.81||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,795.30||||1,795.30||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,588.15||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Managed Medicaid|MEDICAID AMERIGROUP|13.81||||1,795.30||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Medicare|MEDICARE ACUTE|1,795.44||||13.81||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Medicaid|MEDICAID|13.81||||1,795.30||| 36430|EAP|0391|TRANSFUSION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,795.30||||1,381.11||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Managed Medicaid|MEDICAID SUPERIOR|13.81||||||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Aetna|AETNA PPO|13.81||||||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Managed Medicare|HEALTHSPRING MA|||||1,795.30||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Aenta Medicare Advantage|AETNA MEDICARE MA|13.81||||||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,588.15||||||| 36430|EAP|0391|TRANSFUSION|Blue Cross PPO Specialty|BCBSTX PPO|13.81||||13.18||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,795.30||||1,795.30||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,795.30||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.81||||13.81||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Humana Medicare Advantage|HUMANA MA|1,795.30||||1,795.30||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Humana Medicare Advantage|HUMANA MA|1,795.30||||10.27||| 36430|EAP|0391|TRANSFUSION|Humana Medicare Advantage|HUMANA MA|1,795.30||||1,556.72||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,795.30||||13.81||| 36430|EAP|0391|TRANSFUSION|United Medicare Advantage|UHC MEDICARE GOLD MA|1,795.30||||1,381.11||| 36430|EAP|0391|TRANSFUSION|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.81||||13.18||| 36430|EAP|0391|TRANSFUSION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,795.30||||13.18||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,795.30||||1,795.30||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,795.30||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross PPO Specialty|BCBSTX PPO|13.81||||1,588.15||| 36430|EAP|0391|TRANSFUSION|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,795.30||||1,381.11||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,795.30||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|United Medicare Advantage|UHC MEDICARE GOLD MA|1,795.30||||13.81||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.81||||518.64||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross PPO Specialty|BCBSTX PPO|13.81||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Veterans Affairs|VETERANS ADMINISTRATION|1,795.30||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Medicare|MEDICARE ACUTE|2,068.75||||||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Humana Medicare Advantage|HUMANA MA|2,068.75||||2,068.75||| 36569|EAP|0450|INSERTION OF PICC LINE|Blue Cross PPO Specialty|BCBSTX PPO|||||2,482.03||| 36571|EAP|0964|CRNA CENTRAL LINE PLACEME|Managed Medicaid|MEDICAID AMERIGROUP|||||60.82||| 36600|EAP|0412|ARTERIAL PUNCTURE|NON CONTRACTED|COMMERCIAL OTHER 1|||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Veterans Affairs|VETERANS ADMINISTRATION|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|264.23||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Workers Compensation|WORKERS COMPENSATION OTHER|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Medicare Advantage|UHC MEDICARE GOLD MA|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||233.74||| 36600|EAP|0940|ARTERIAL PUNCTURE BY NURS|Blue Cross PPO Specialty|BCBSTX PPO|203.25||||||| 36600|EAP|0940|ARTERIAL PUNCTURE BY NURS|Aetna|AETNA PPO|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Aenta Medicare Advantage|AETNA MEDICARE MA|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Blue Cross HMO Specialty|BCBSTX HMO|203.25||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|264.23||||233.74||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Humana Medicare Advantage|HUMANA MA|264.23||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Blue Cross PPO Specialty|BCBSTX OTHER|||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Medicare|MEDICARE PART B ONLY IP|264.23||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Medicare|MEDICARE ACUTE|203.25||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Blue Cross PPO Specialty|BCBSTX PPO|264.23||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Healthcare|UNITED HEALTHCARE OTHER|||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Tricare|TRICARE EAST REGION|264.23||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicare|HEALTHSPRING MA|264.23||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Healthcare|UNITED HEALTHCARE|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicare|WELLCARE CHOICE MA|||||264.23||| 36600|EAP|0940|ARTERIAL PUNCTURE BY NURS|Managed Medicaid|MEDICAID SUPERIOR|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicaid|MEDICAID AMERIGROUP|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Medicaid|MEDICAID|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicaid|MEDICAID SUPERIOR|203.25||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||264.23||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|264.23||||264.23||| 37195|EAP|0480|THROMBOLYSIS CEREBRAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.20||| 37195|EAP|0480|THROMBOLYSIS CEREBRAL|Blue Cross PPO Specialty|BCBSTX PPO|||||6.76||| 37195|EAP|0480|THROMBOLYSIS CEREBRAL|Medicare|MEDICARE ACUTE|||||6.76||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Veterans Affairs|VETERANS ADMINISTRATION|40,650.20|9089.68|9089.68|6262.18|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Blue Cross HMO Specialty|BCBSTX HMO|74,413.60|6262.18|9089.68|6262.18|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|60,461.01|9089.68|9089.68|6262.18|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Medicare|MEDICARE ACUTE|30,544.75|9089.68|9089.68|6262.18|||| 378|DRG||G.I. HEMORRHAGE W CC|United Healthcare|UNITED HEALTHCARE|41,749.84|9872.11|9872.11|5751.94|||| 378|DRG||G.I. HEMORRHAGE W CC|Humana Medicare Advantage|HUMANA MA|24,842.86|8876.44|9872.11|5751.94|||| 378|DRG||G.I. HEMORRHAGE W CC|Blue Cross PPO Specialty|BCBSTX PPO|19,018.80|5751.94|9872.11|5751.94|||| 378|DRG||G.I. HEMORRHAGE W CC|Medicare|MEDICARE ACUTE|32,630.48|8686.37|9872.11|5751.94|||| 384|DRG||UNCOMPLICATED PEPTIC ULCER W/O MCC|Managed Medicare|HEALTHSPRING MA|333.78|8088.98|8088.98|8088.98|||| 386|DRG||INFLAMMATORY BOWEL DISEASE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|45,399.17|8844.59|8844.59|8844.59|||| 388|DRG||G.I. OBSTRUCTION W MCC|Medicare|MEDICARE ACUTE|50,441.52|9294.17|9294.17|9294.17|||| 389|DRG||G.I. OBSTRUCTION W CC|Medicare|MEDICARE ACUTE|32,066.46|7758.08|7758.08|7758.08|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|ChampVA|CHAMPVA CENTER|20,742.15|2303.75|6187.09|2303.75|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Medicare|MEDICARE ACUTE|25,234.40|6083.28|6187.09|2303.75|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|20,942.55|6083.28|6187.09|2303.75|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|18,906.55|3678.38|6187.09|2303.75|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|12,642.39|6187.09|6187.09|2303.75|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31,886.55|12161.56|12161.56|885.745|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Medicare|MEDICARE PART B ONLY IP|41,896.75|885.745|12161.56|885.745|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|32,490.06|7255.43|12161.56|885.745|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|26,074.26|4701.61|12161.56|885.745|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17,382.58|3539.8|12161.56|885.745|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|28,443.15|7255.43|12161.56|885.745|||| 393|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC|Humana Medicare Advantage|HUMANA MA|100,983.25|12784.25|12784.25|12784.25|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|37,156.58|8391.7|8391.7|8391.7|||| 406|DRG||PANCREAS, LIVER & SHUNT PROCEDURES W CC|Medicare|MEDICARE ACUTE|126,491.94|20294.86|20294.86|20294.86|||| 415|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC|Medicare|MEDICARE ACUTE|86,143.79|15852.09|15852.09|15852.09|||| 416|DRG||CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|34,316.50|8670.65|8670.65|8670.65|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Managed Medicaid|MEDICAID SUPERIOR|45,726.24|32778.63|32778.63|32778.63|||| 41800|EAP|0450|DRAIN ABSCESS CYST HEMATO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.38||| 41800|EAP|0450|DRAIN ABSCESS CYST HEMATO|Managed Medicaid|MEDICAID AMERIGROUP|||||4.38||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|33,976.15|24739.35|24739.35|24739.35|||| 43235|EAP|0750|EGD DX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,046.25||||||| 43235|EAP|0750|EGD DX|Medicare|MEDICARE ACUTE|3,046.25||||||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Blue Cross PPO Specialty|BCBSTX PPO|22.77||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Medicare|MEDICARE PART B ONLY IP|22.77||||||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Managed Medicaid|MEDICAID SUPERIOR|22.77||||||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|United Healthcare|UNITED HEALTHCARE|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Humana Medicare Advantage|HUMANA MA|22.77||||||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Medicare|MEDICARE ACUTE|||||22.77||| 43247|EAP|0750|EGD W/RMVE FB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,784.25||| 43247|EAP|0750|EGD W/RMVE FB|Blue Cross HMO Specialty|BCBSTX HMO|||||2,784.25||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Medicare|MEDICARE ACUTE|248.43|8996.33|8996.33|8510.4|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8,510.40|8510.4|8996.33|8510.4|||| 435|DRG||MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC|Medicare|MEDICARE ACUTE|15,990.66|13522.16|13522.16|13522.16|||| 43752|EAP|0450||Medicare|MEDICARE ACUTE|516.50||||||| 43752|EAP|0450||Managed Medicaid|MEDICAID UNITED HEALTHCARE|516.50||||||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||849.57||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Blue Cross HMO Specialty|BCBSTX HMO|||||960.38||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Veterans Affairs|VETERANS ADMINISTRATION|960.38||||||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Blue Cross PPO Specialty|BCBSTX PPO|||||738.75||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Medicaid|MEDICAID HMO|||||738.75||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Medicare|MEDICARE ACUTE|||||738.75||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||960.38||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|18,931.80|13187.98|55392.45|7060.93|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Humana Medicare Advantage|HUMANA MA|52,740.21|7060.93|55392.45|7060.93|||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|55,392.45|55392.45|55392.45|7060.93|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Blue Cross HMO Specialty|BCBSTX HMO|34,221.21|4040.74|7937.86|4040.74|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Blue Cross PPO Specialty|BCBSTX PPO|32,103.49|5366.96|7937.86|4040.74|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Medicare|MEDICARE ACUTE|36,535.56|7937.86|7937.86|4040.74|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|50,877.32|7673.46|7937.86|4040.74|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Veterans Affairs|VETERANS ADMINISTRATION|35,922.07|7937.86|7937.86|4040.74|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Medicare|MEDICARE ACUTE|25,129.78|6416.11|6416.11|3866.97|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|48,868.15|4188.06|6416.11|3866.97|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|323.01|6098.58|6416.11|3866.97|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32,027.93|6058.84|6416.11|3866.97|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|26,958.64|3866.97|6416.11|3866.97|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Medicare|MEDICARE ACUTE|19,522.25|8361.44|8361.44|8361.44|||| 443|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC/MCC|Medicare|MEDICARE ACUTE|29,479.65|6731.7|6731.7|6731.7|||| 445|DRG||DISORDERS OF THE BILIARY TRACT W CC|Blue Cross PPO Specialty|BCBSTX PPO|28,690.21|1661.19|1661.19|1661.19|||| 45300|EAP|0750|PROCTOSIGMOIDOSCOPY DX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||23.42||| 45378|EAP|0750|COLONOSCOPY|Medicare|MEDICARE ACUTE|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|Humana Medicare Advantage|HUMANA MA|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|Blue Cross PPO Specialty|BCBSTX PPO|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,712.25||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|Cigna|CIGNA|||||3,712.25||| 45384|EAP|0750|COLON W/ HOT BIOPSY|Medicare|MEDICARE ACUTE|||||3,710.50||| 45384|EAP|0750|COLON W/ HOT BIOPSY|Cigna|CIGNA|||||3,710.50||| 45384|EAP|0750|COLON W/ HOT BIOPSY|Humana Medicare Advantage|HUMANA MA|||||3,710.50||| 45384|EAP|0750|COLON W/ HOT BIOPSY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,710.50||| 45385|EAP|0750|COLON W/ POLYPECTOMY|United Healthcare|UNITED HEALTHCARE|||||4,048.50||| 45385|EAP|0750|COLON W/ POLYPECTOMY|Medicare|MEDICARE ACUTE|||||4,048.50||| 45385|EAP|0750|COLON W/ POLYPECTOMY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4,048.50||| 45385|EAP|0750|COLON W/ POLYPECTOMY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,048.50||| 45385|EAP|0750|COLON W/ POLYPECTOMY|Humana Medicare Advantage|HUMANA MA|||||4,048.50||| 45385|EAP|0750|COLON W/ POLYPECTOMY|Blue Cross PPO Specialty|BCBSTX PPO|||||4,048.50||| 45385|EAP|0750|COLON W/ POLYPECTOMY|Cigna|CIGNA|||||4,048.50||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|62,920.55|21336.71|21336.71|21336.71|||| 465|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|67,051.90|11435.98|11435.98|11435.98|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|159,294.63|25447.72|49298.14|24938.77|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|90,340.69|25207.325|49298.14|24938.77|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Managed Medicaid|MEDICAID SUPERIOR|74,102.30|49298.14|49298.14|24938.77|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Humana Medicare Advantage|HUMANA MA|114,550.79|24938.77|49298.14|24938.77|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|49.24|49.24|27142.79|49.24|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27,142.79|27142.79|27142.79|49.24|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Managed Medicare|BCBS MEDICARE PPO MA|67,087.90|20458.64|27142.79|49.24|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|93,109.85|20446.96|27142.79|49.24|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95,525.94|20653.925|27142.79|49.24|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|70,071.60|20848.33|27142.79|49.24|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Medicare|MEDICARE ACUTE|91,284.81|20653.485|27142.79|49.24|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|46,058.47|15022.05|53690.29|7883.29|||| 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|50,096.23|15164.7|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Medicare|MEDICARE ACUTE|56,219.38|15026.81|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|102,342.71|15304.75|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicare|HEALTHSPRING MA|46,881.49|14689.12|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Cigna|CIGNA|40,792.12|7883.29|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|48,420.31|15026.37|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|65,693.75|53690.29|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Humana Medicare Advantage|HUMANA MA|69,166.28|15174.195|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|88,485.10|15304.75|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|48,033.93|9324.2|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|47,021.11|12384.52|53690.29|7883.29|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|39,836.05|21074.03|53690.29|7883.29|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Medicare|MEDICARE ACUTE|68,776.30|18312.36|18312.36|18312.36|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Blue Cross PPO Specialty|BCBSTX PPO|107,940.90|16880.52|16880.52|15795.65|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Humana Medicare Advantage|HUMANA MA|80,315.68|16116.32|16880.52|15795.65|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Medicare|MEDICARE ACUTE|66,130.55|15795.65|16880.52|15795.65|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|45,095.42|16438.19|16438.19|10359.85|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Medicare|MEDICARE ACUTE|53,666.72|13064.07|16438.19|10359.85|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33,363.81|11052.13|16438.19|10359.85|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|45,143.95|10359.85|16438.19|10359.85|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Humana Medicare Advantage|HUMANA MA|52,579.47|17926.91|32011.35|11169.08|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Blue Cross PPO Specialty|BCBSTX PPO|43,312.15|14834.9|32011.35|11169.08|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Aenta Medicare Advantage|AETNA MEDICARE MA|52,531.55|18088.71|32011.35|11169.08|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|61,273.25|17754.22|32011.35|11169.08|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|United Medicare Advantage|UHC MEDICARE GOLD MA|127,981.75|18088.71|32011.35|11169.08|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|49,521.95|18088.71|32011.35|11169.08|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|66,166.61|32011.35|32011.35|11169.08|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Access Direct Platinum|HEALTHFIRST TPA UMR|38,215.40|27292.29|32011.35|11169.08|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32,557.85|11169.08|32011.35|11169.08|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Medicare|MEDICARE ACUTE|55,010.20|17755.1|32011.35|11169.08|||| 486|DRG||KNEE PROCEDURES W PDX OF INFECTION W CC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|379.82|16199.16|16199.16|16199.16|||| 487|DRG||KNEE PROCEDURES W PDX OF INFECTION W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|53,727.05|12700.12|12700.12|12700.12|||| 488|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28,925.55|11866.79|11866.79|11866.79|||| 489|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC|Medicare|MEDICARE ACUTE|35,378.35|10458.91|15035.02|7853.955|||| 489|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|54,257.32|15035.02|15035.02|7853.955|||| 489|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27,614.05|10456.75|15035.02|7853.955|||| 489|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|41,551.27|7853.955|15035.02|7853.955|||| 489|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|63,103.33|10446.72|15035.02|7853.955|||| 49083|EAP|0400|US GUIDED PARACENTESIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|993.50||||||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Medicare|MEDICARE ACUTE|48,306.55|15606.01|15606.01|15606.01|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|36,736.28|14296.65|27058.41|9278.13|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|33,265.62|9278.13|27058.41|9278.13|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|27,058.41|27058.41|27058.41|9278.13|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Medicare|MEDICARE ACUTE|40,122.89|14273.19|27058.41|9278.13|||| 500|DRG||SOFT TISSUE PROCEDURES W MCC|Managed Medicaid|MEDICAID SUPERIOR|184,200.85|75882.91|75882.91|75882.91|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Medicare|MEDICARE ACUTE|51,067.49|13396.67|13396.67|13396.67|||| 512|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|46,699.35|12317.79|17302.42|12317.79|||| 512|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W/O CC/MCC|Workers Compensation|WORKERS COMPENSATION OTHER|28,945.20|17302.42|17302.42|12317.79|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|Cigna|CIGNA|23,627.60|18.9|18.9|18.9|||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Aenta Medicare Advantage|AETNA MEDICARE MA|259.90||||259.90||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross HMO Specialty|BCBSTX HMO|2.26||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Humana Medicare Advantage|HUMANA MA|293.80||||293.80||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|UTMB|UTMB CORRECTIONAL MANAGED CARE|293.80||||259.90||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicare|MEDICARE ACUTE|293.80||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|293.80||||293.80||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID SUPERIOR|293.80||||293.80||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Healthcare|UNITED HEALTHCARE|||||293.80||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.26||||259.90||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||293.80||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID AMERIGROUP|2.26||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|BCBS MEDICARE PPO MA|||||259.90||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|293.80||||293.80||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|293.80||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|UHC MEDICARE GOLD MA|293.80||||293.80||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicaid|MEDICAID HMO|||||259.90||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross PPO Specialty|BCBSTX PPO|2.26||||259.90||| 51702|EAP|0450|INSERT FOLEY SIMPL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Blue Cross PPO Specialty|BCBSTX PPO|294.50||||338.68||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Medicare Advantage|UHC MEDICARE GOLD MA|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Humana Medicare Advantage|HUMANA MA|382.85||||338.68||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Medicaid|MEDICAID|||||382.85||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|294.50||||382.85||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|382.85||||338.68||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID AMERIGROUP|294.50||||382.85||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID SUPERIOR|382.85||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Healthcare|UNITED HEALTHCARE|382.85||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Medicare|MEDICARE ACUTE|294.50||||382.85||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Healthcare|UNITED HEALTHCARE|||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|NON CONTRACTED|COMMERCIAL OTHER 1|||||382.85||| 535|DRG||FRACTURES OF HIP & PELVIS W MCC|Humana Medicare Advantage|HUMANA MA|10,746.80|6601.1|6601.1|6601.1|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|Humana Medicare Advantage|HUMANA MA|250.63|7227.45|7235.23|7227.45|||| 536|DRG||FRACTURES OF HIP & PELVIS W/O MCC|Medicare|MEDICARE ACUTE|25,212.95|7235.23|7235.23|7227.45|||| 543|DRG||PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC|Medicare|MEDICARE ACUTE|82,983.80|9125.51|9125.51|9125.51|||| 545|DRG||CONNECTIVE TISSUE DISORDERS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32,419.55|32419.55|32419.55|32419.55|||| 546|DRG||CONNECTIVE TISSUE DISORDERS W CC|Blue Cross PPO Specialty|BCBSTX PPO|21,209.12|7558.43|7558.43|7558.43|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|41,828.51|8362.98|8362.98|8292.99|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Medicare|MEDICARE ACUTE|37,839.85|8292.99|8362.98|8292.99|||| 556|DRG||SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC|Medicare|MEDICARE ACUTE|26,546.32|7450.52|7450.52|7450.52|||| 558|DRG||TENDONITIS, MYOSITIS & BURSITIS W/O MCC|Humana Medicare Advantage|HUMANA MA|40,628.80|8042.31|8042.31|7898.7|||| 558|DRG||TENDONITIS, MYOSITIS & BURSITIS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|36,076.75|7898.7|8042.31|7898.7|||| 558|DRG||TENDONITIS, MYOSITIS & BURSITIS W/O MCC|Medicare|MEDICARE ACUTE|43,573.90|8031.16|8042.31|7898.7|||| 561|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|12,862.75|7267.48|7267.48|7267.48|||| 562|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W MCC|Medicare|MEDICARE ACUTE|7,326.32|6689.1|6689.1|6689.1|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|119.96|7851.06|7982.55|7851.06|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|Medicare|MEDICARE ACUTE|44,345.14|7982.55|7982.55|7851.06|||| 56405|EAP|0450|I&D ABSCESS VULVA PERINEA|Blue Cross PPO Specialty|BCBSTX PPO|||||1,075.75||| 56405|EAP|0450|I&D ABSCESS VULVA PERINEA|Humana Medicare Advantage|HUMANA MA|||||1,075.75||| 56420|EAP|0450|I&D BARTHOLIN'S GLAND ABS|Blue Cross PPO Specialty|BCBSTX PPO|||||742.50||| 56420|EAP|0450|I&D BARTHOLIN'S GLAND ABS|Managed Medicaid|MEDICAID AMERIGROUP|||||965.25||| 565|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC|Medicare|MEDICARE ACUTE|44,265.50|8637.44|8813.71|8637.44|||| 565|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|34,002.27|8813.71|8813.71|8637.44|||| 565|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC|Managed Medicare|HEALTHSPRING MA|33,914.50|8665.6|8813.71|8637.44|||| 566|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC|Medicare|MEDICARE ACUTE|58,802.84|7349.79|7349.79|7349.79|||| 57|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|38,838.50|10147.66|10147.66|153.93|||| 57|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC|Medicare|MEDICARE PART B ONLY IP|52,807.50|153.93|10147.66|153.93|||| 579|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC|Medicare|MEDICARE ACUTE|89,259.39|21991.61|21991.61|21991.61|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Medicare|MEDICARE ACUTE|41,338.81|12683.43|12683.43|12683.43|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|22,929.30|9084.06|9084.06|9084.06|||| 58340|EAP|0320|CATH/INTRO CONTRAST MATER|Blue Cross PPO Specialty|BCBSTX PPO|||||264.25||| 59000|EAP|0360|AMNIOINFUSION|Managed Medicaid|MEDICAID SUPERIOR|717.25||||||| 59000|EAP|0360|AMNIOINFUSION|Managed Medicaid|MEDICAID AMERIGROUP|932.43||||||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,643.88||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Workers Compensation|WORKERS COMPENSATION OTHER|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Cigna|CIGNA|||||2,643.88||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,643.88||||2,643.88||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Tricare|TRICARE EAST REGION|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Medicare|MEDICARE ACUTE|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Aetna|AETNA PPO|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|United Healthcare|UNITED HEALTHCARE|||||2,338.82||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||2,643.88||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Medicaid|MEDICAID|2,643.88||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Aetna|AETNA OTHER|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2,643.88||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Cigna|CIGNA|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Managed Medicaid|MEDICAID SUPERIOR|2,033.75||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Medicaid|MEDICAID HMO|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Blue Cross HMO Specialty|BCBSTX HMO|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Blue Cross PPO Specialty|BCBSTX PPO|2,338.82||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Managed Medicaid|MEDICAID AMERIGROUP|2,338.82||||2,643.88||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,643.88||| 594|DRG||SKIN ULCERS W/O CC/MCC|Medicare|MEDICARE ACUTE|43,816.47|7691.45|7691.45|7691.45|||| 59400|EAP|0720|LABOR & DELIVERY|Blue Cross HMO Specialty|BCBSTX HMO|110.96||||||| 59400|EAP|0720|LABOR & DELIVERY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Aetna|AETNA PPO|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Aetna|AETNA OTHER|13,004.13||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL II|Blue Cross PPO Specialty|BCBSTX PPO|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Blue Cross PPO Specialty|BCBSTX PPO|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Cigna|CIGNA|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|United Healthcare|UMR UNITED MEDICAL RESOURCES|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|NON CONTRACTED|COMMERCIAL OTHER 1|13,004.13||||||| 59400|EAP|0720|LABOR & DELIVERY|United Healthcare|UNITED HEALTHCARE|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL II|United Healthcare|UNITED HEALTHCARE|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Medicaid|MEDICAID|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL II|Access Direct Platinum|HEALTHFIRST TPA UMR|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL II|Managed Medicaid|MEDICAID SUPERIOR|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Managed Medicaid|MEDICAID SUPERIOR|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL II|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Medicaid|MEDICAID HMO|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Medicaid|MOLINA HEALTHCARE OF TEXAS|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Tricare|TRICARE EAST REGION|13,004.13||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL II|Medicaid|MEDICAID|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL II|Managed Medicaid|MEDICAID AMERIGROUP|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Managed Medicaid|MEDICAID AMERIGROUP|14,912.25||||||| 59409|EAP|0450|DELIVERY VAGINAL|Medicaid|MEDICAID|2,633.25||||||| 59409|EAP|0450|DELIVERY VAGINAL|Blue Cross PPO Specialty|BCBSTX PPO|2,633.25||||||| 602|DRG||CELLULITIS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|17,383.18|11765.86|11765.86|11648.2|||| 602|DRG||CELLULITIS W MCC|Medicare|MEDICARE ACUTE|52,137.55|11648.2|11765.86|11648.2|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicare|HEALTHSPRING MA|24,803.25|7782.57|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|36,145.75|10578.41|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36,980.42|26237.13|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|22,163.50|5276.08|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|53,200.50|3972.32|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|Medicare|MEDICARE ACUTE|36,800.80|7783.45|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|Medicare|MEDICARE PART B ONLY IP|56,866.53|342.33|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|38,771.50|7776.09|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|22,010.87|12652.5|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|34,185.34|7913.56|26237.13|342.33|||| 603|DRG||CELLULITIS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|23,932.68|7783.01|26237.13|342.33|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Medicare|MEDICARE ACUTE|5,536.89|8125.11|8125.11|8125.11|||| 607|DRG||MINOR SKIN DISORDERS W/O MCC|Tricare|TRICARE EAST REGION|20,126.42|3054.55|3054.55|3054.55|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Blue Cross PPO Specialty|BCBSTX PPO|57,787.75|12906.09|15849.46|12906.09|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|Medicare|MEDICARE ACUTE|65,570.55|13546.32|15849.46|12906.09|||| 617|DRG||AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL DIS W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|47,178.46|15849.46|15849.46|12906.09|||| 622|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC|Medicare|MEDICARE ACUTE|52,641.69|16794.15|16794.15|16794.15|||| 62270|EAP|0450|SPINAL TAP DX|Humana Medicare Advantage|HUMANA MA|805.75||||||| 62322|EAP|0964|CRNA EPIDURAL BLD CLT/PTC|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,656.75||| 62322|EAP|0964|CRNA EPIDURAL BLD CLT/PTC|Managed Medicaid|MEDICAID SUPERIOR|||||1,656.75||| 62322|EAP|0964|CRNA EPIDURAL BLD CLT/PTC|Managed Medicaid|MEDICAID AMERIGROUP|||||1,656.75||| 629|DRG||OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC|Managed Medicaid|MEDICAID SUPERIOR|145,863.20|39618.68|39618.68|39618.68|||| 637|DRG||DIABETES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|82,195.64|11274.73|15993.66|9573.71|||| 637|DRG||DIABETES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|354.78|11274.73|15993.66|9573.71|||| 637|DRG||DIABETES W MCC|Aetna|AETNA PPO|28,407.93|15993.66|15993.66|9573.71|||| 637|DRG||DIABETES W MCC|Managed Medicaid|MEDICAID SUPERIOR|14,597.55|14597.55|15993.66|9573.71|||| 637|DRG||DIABETES W MCC|Humana Medicare Advantage|HUMANA MA|20,731.51|9573.71|15993.66|9573.71|||| 637|DRG||DIABETES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|37,129.77|9630.23|15993.66|9573.71|||| 638|DRG||DIABETES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|43,524.50|8043.99|8104.235|5428.57|||| 638|DRG||DIABETES W CC|Medicare|MEDICARE ACUTE|25,311.54|8044.43|8104.235|5428.57|||| 638|DRG||DIABETES W CC|Humana Medicare Advantage|HUMANA MA|37,804.40|8104.235|8104.235|5428.57|||| 638|DRG||DIABETES W CC|Blue Cross PPO Specialty|BCBSTX PPO|48,873.25|5428.57|8104.235|5428.57|||| 639|DRG||DIABETES W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|23,250.25|6300.49|14926.86|3342.75|||| 639|DRG||DIABETES W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34,484.41|14926.86|14926.86|3342.75|||| 639|DRG||DIABETES W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|15,431.53|3342.75|14926.86|3342.75|||| 639|DRG||DIABETES W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|47,937.98|4850.63|14926.86|3342.75|||| 639|DRG||DIABETES W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28,938.75|11074.46|14926.86|3342.75|||| 639|DRG||DIABETES W/O CC/MCC|Medicare|MEDICARE ACUTE|28,578.34|6349.975|14926.86|3342.75|||| 639|DRG||DIABETES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|36,607.05|6272.33|14926.86|3342.75|||| 639|DRG||DIABETES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|56,404.95|6187.475|14926.86|3342.75|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Medicare|MEDICARE ACUTE|38,472.78|8100.61|8100.61|8100.61|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|52,096.05|10142.26|10156.34|10142.26|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|75,129.06|10142.26|10156.34|10142.26|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|70,464.83|10142.26|10156.34|10142.26|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Medicare|MEDICARE ACUTE|46,816.59|10156.34|10156.34|10142.26|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34,083.30|5355.72|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Humana Medicare Advantage|HUMANA MA|33,901.79|7210.11|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43,646.28|15648.105|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|20,083.32|7342.56|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36,931.88|3431.1|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|60,023.98|3977.55|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|67,893.87|7342.56|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Medicare|MEDICARE ACUTE|31,410.97|7223.87|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Managed Medicare|BCBS MEDICARE PPO MA|26,514.36|7342.56|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|47,586.12|7342.56|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41,896.05|7223.87|15648.105|3431.1|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|43,556.86|7269.135|15648.105|3431.1|||| 643|DRG||ENDOCRINE DISORDERS W MCC|Medicare|MEDICARE ACUTE|69,238.75|13051.72|13051.72|13051.72|||| 644|DRG||ENDOCRINE DISORDERS W CC|Medicare|MEDICARE ACUTE|53,756.08|9035.205|9035.205|9035.205|||| 64415|EAP|0370|BRACHIAL PLEXUS BLOCK|Medicare|MEDICARE ACUTE|||||16.65||| 64415|EAP|0370|BRACHIAL PLEXUS BLOCK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||16.65||| 64415|EAP|0964|CRNA BRACHIAL PLEXUS BLOC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.00||| 64445|EAP|0370|SCIATIC NERVE BLOCK|Blue Cross PPO Specialty|BCBSTX PPO|1,839.50||||14.15||| 64445|EAP|0370|SCIATIC NERVE BLOCK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||14.15||| 64445|EAP|0370|SCIATIC NERVE BLOCK|Humana Medicare Advantage|HUMANA MA|||||1,839.50||| 64445|EAP|0370|SCIATIC NERVE BLOCK|Cigna|CIGNA|||||1,839.50||| 64445|EAP|0370|SCIATIC NERVE BLOCK|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,839.50||| 64445|EAP|0370|SCIATIC NERVE BLOCK|Managed Medicaid|MEDICAID AMERIGROUP|||||14.15||| 64445|EAP|0370|SCIATIC NERVE BLOCK|Managed Medicaid|MEDICAID SUPERIOR|1,839.50||||1,839.50||| 64445|EAP|0370|SCIATIC NERVE BLOCK|Medicare|MEDICARE ACUTE|||||1,839.50||| 64445|EAP|0964|CRNA SCIATIC NERVE BLOCK|Medicare|MEDICARE ACUTE|||||3.40||| 64447|EAP|0964|CRNA FEMORAL NERVE BLOCK|Medicare|MEDICARE ACUTE|||||3.00||| 64447|EAP|0964|CRNA FEMORAL NERVE BLOCK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.00||| 64450|EAP|0964|CRNA OTHER PERIPHERAL NER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.00||| 64450|EAP|0964|CRNA OTHER PERIPHERAL NER|Medicare|MEDICARE ACUTE|||||2.00||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|28,844.20|7278.36|7278.36|1002.91|||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|132,704.54|1002.91|7278.36|1002.91|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Medicare|MEDICARE ACUTE|41,361.88|8969.52|8969.52|8969.52|||| 65220|EAP|0450|RMV FB EYE CORNEAL WO SLI|Managed Medicaid|MEDICAID SUPERIOR|||||1,172.93||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|45,084.81|7019.43|7019.43|4523.6|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30,572.50|6968.87|7019.43|4523.6|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Medicare|MEDICARE ACUTE|36,684.93|6967.99|7019.43|4523.6|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|50,654.51|4523.6|7019.43|4523.6|||| 661|DRG||KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|97,147.15|13688.07|13688.07|13688.07|||| 68|DRG||NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC|Medicare|MEDICARE ACUTE|29,925.25|8169.13|8169.13|8169.13|||| 682|DRG||RENAL FAILURE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|77,311.86|12082.57|12082.57|11840.92|||| 682|DRG||RENAL FAILURE W MCC|Medicare|MEDICARE ACUTE|78,836.50|11840.92|12082.57|11840.92|||| 683|DRG||RENAL FAILURE W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|65,579.88|11541.98|11541.98|8122.82|||| 683|DRG||RENAL FAILURE W CC|Medicare|MEDICARE ACUTE|38,961.11|8129.86|11541.98|8122.82|||| 683|DRG||RENAL FAILURE W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|70,480.10|8122.82|11541.98|8122.82|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|40,717.80|6314.01|6414.13|6314.01|||| 684|DRG||RENAL FAILURE W/O CC/MCC|Medicare|MEDICARE ACUTE|27,249.78|6414.13|6414.13|6314.01|||| 686|DRG||KIDNEY & URINARY TRACT NEOPLASMS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|28,105.55|13647.43|13647.43|13647.43|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Medicare|MEDICARE ACUTE|58,841.24|9721.11|9721.11|8038.64|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|41,000.50|8038.64|9721.11|8038.64|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Blue Cross PPO Specialty|BCBSTX PPO|23,474.75|4764.47|7437.375|4764.47|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Medicare|MEDICARE ACUTE|375.53|7437.375|7437.375|4764.47|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28,131.95|13987.98|13987.98|7444.08|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|19,790.85|8580.94|13987.98|7444.08|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Medicare|MEDICARE ACUTE|23,117.79|7444.08|13987.98|7444.08|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Humana Medicare Advantage|HUMANA MA|34,302.60|7454.12|13987.98|7444.08|||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Managed Medicaid|MEDICAID AMERIGROUP|||||307.92||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Managed Medicaid|MEDICAID SUPERIOR|||||267.75||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Humana Medicare Advantage|HUMANA MA|||||348.08||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Cigna|CIGNA|||||348.08||| 69209|EAP|0450|REMVL IMPACT CERUMEN IRR/|Managed Medicaid|MEDICAID AMERIGROUP|||||3.64||| 69209|EAP|0450|REMVL IMPACT CERUMEN IRR/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.64||| 69209|EAP|0450|REMVL IMPACT CERUMEN IRR/|Medicaid|MEDICAID HMO|||||3.64||| 694|DRG||URINARY STONES W/O MCC|Humana Medicare Advantage|HUMANA MA|31,220.81|7245.71|7245.71|4369.87|||| 694|DRG||URINARY STONES W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|29,811.55|4369.87|7245.71|4369.87|||| 694|DRG||URINARY STONES W/O MCC|Medicare|MEDICARE ACUTE|23,550.55|7118.68|7245.71|4369.87|||| 696|DRG||KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC|Medicare|MEDICARE ACUTE|28,440.50|6698.61|6698.61|6698.61|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Humana Medicare Advantage|HUMANA MA|33,761.25|12782.24|12782.24|10819.77|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|43,996.33|10819.77|12782.24|10819.77|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16,316.50|16021.56|16021.56|16021.56|||| 70|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC|Medicare|MEDICARE ACUTE|358.93|12525.67|12525.67|12525.67|||| 70110|EAP|0320|XR MANDIBLE|Workers Compensation|WORKERS COMPENSATION OTHER|||||573.75||| 70140|EAP|0320|FACIAL BONES LESS THAN 3|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|Managed Medicaid|MEDICAID SUPERIOR|||||660.75||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.71||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||660.75||| 70160|EAP|0320|XR NASAL BONES|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||618.84||| 70160|EAP|0320|XR NASAL BONES|Medicare|MEDICARE ACUTE|||||573.75||| 70160|EAP|0320|XR NASAL BONES|Blue Cross PPO Specialty|BCBSTX PPO|||||663.93||| 70160|EAP|0320|XR NASAL BONES|Managed Medicaid|MEDICAID SUPERIOR|||||663.93||| 70160|EAP|0320|XR NASAL BONES|Managed Medicaid|MEDICAID AMERIGROUP|||||663.93||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Blue Cross PPO Specialty|BCBSTX PPO|||||663.93||| 70250|EAP|0320|XR SKULL 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||573.75||| 70250|EAP|0320|XR SKULL 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||573.75||| 70250|EAP|0320|XR SKULL 2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|663.93||||||| 70250|EAP|0320|XR SKULL 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|663.93||||||| 70360|EAP|0320|XR SOFT TISSUE NECK|Medicare|MEDICARE ACUTE|||||461.25||| 70360|EAP|0320|XR SOFT TISSUE NECK|Blue Cross PPO Specialty|BCBSTX PPO|||||561.21||| 70360|EAP|0320|XR SOFT TISSUE NECK|Managed Medicaid|MEDICAID SUPERIOR|||||461.25||| 70370|EAP|0320|ESOPHAGUS BA SWALLOW W-FL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||714.50||| 70370|EAP|0320|ESOPHAGUS BA SWALLOW W-FL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||714.50||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Medicaid|MEDICAID HMO|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Managed Medicaid|MEDICAID AMERIGROUP|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Managed Medicaid|MEDICAID SUPERIOR|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Medicaid|MEDICAID|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Medicare|MEDICARE PART B ONLY IP|3,627.75||||||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Managed Medicare|BCBS MEDICARE PPO MA|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Tricare|TRICARE EAST REGION|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|United Healthcare|UNITED HEALTHCARE|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|United Healthcare|UNITED HEALTHCARE OTHER|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Cigna|CIGNA|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Aenta Medicare Advantage|AETNA MEDICARE MA|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Veterans Affairs|VETERANS ADMINISTRATION|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Managed Medicare|HEALTHSPRING MA|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Workers Compensation|UT EMPLOYEE INJURY|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Workers Compensation|WORKERS COMPENSATION OTHER|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Aetna|AETNA PPO|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Aetna|AETNA OTHER|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,627.75||||||| 70460|EAP|0350|HEAD SCAN W/CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,738.75||| 70460|EAP|0350|HEAD SCAN W/CONTRAST|Humana Medicare Advantage|HUMANA MA|4,738.75||||||| 70460|EAP|0350|HEAD SCAN W/CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,738.75||||||| 70460|EAP|0350|HEAD SCAN W/CONTRAST|Medicare|MEDICARE ACUTE|||||4,738.75||| 70460|EAP|0350|HEAD SCAN W/CONTRAST|United Healthcare|UNITED HEALTHCARE|||||4,738.75||| 70460|EAP|0350|HEAD SCAN W/CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|4,738.75||||||| 70470|EAP|0350|HEAD SCAN W&W/O CONTRAST|Managed Medicaid|MEDICAID AMERIGROUP|||||53.74||| 70470|EAP|0350|HEAD SCAN W&W/O CONTRAST|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||53.74||| 70470|EAP|0350|HEAD SCAN W&W/O CONTRAST|Medicare|MEDICARE ACUTE|||||53.74||| 70470|EAP|0350|HEAD SCAN W&W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||53.74||| 70470|EAP|0350|HEAD SCAN W&W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|53.74||||53.74||| 70470|EAP|0350|HEAD SCAN W&W/O CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||53.74||| 70480|EAP|0350|INT AUD CANAL AXIAL W/O C|Medicare|MEDICARE ACUTE|||||3,627.75||| 70480|EAP|0350|INT AUD CANAL AXIAL W/O C|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3,627.75||| 70480|EAP|0350|INT AUD CANAL AXIAL W/O C|Managed Medicaid|MEDICAID SUPERIOR|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|3,627.75||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Humana Medicare Advantage|HUMANA MA|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Managed Medicare|HEALTHSPRING MA|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Workers Compensation|WORKERS COMPENSATION OTHER|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Blue Cross PPO Specialty|BCBSTX PPO|3,627.75||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Managed Medicaid|MEDICAID SUPERIOR|3,627.75||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Medicaid|MEDICAID|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Managed Medicaid|MEDICAID AMERIGROUP|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|United Healthcare|UNITED HEALTHCARE|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Medicare|MEDICARE PART B ONLY IP|3,627.75||||||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|United Healthcare|UNITED HEALTHCARE OTHER|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 70487|EAP|0350|FACIAL BONES/SINUSES W/CO|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||4,738.75||| 70487|EAP|0350|FACIAL BONES/SINUSES W/CO|United Healthcare|UNITED HEALTHCARE OTHER|||||4,738.75||| 70487|EAP|0350|FACIAL BONES/SINUSES W/CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,738.75||| 70487|EAP|0350|FACIAL BONES/SINUSES W/CO|United Medicare Advantage|UHC MEDICARE GOLD MA|4,738.75||||||| 70488|EAP|0350|FACIAL BONES/SINUSES W&W/|Humana Medicare Advantage|HUMANA MA|||||53.74||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Managed Medicare|BCBS MEDICARE PPO MA|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Managed Medicaid|MEDICAID AMERIGROUP|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Managed Medicaid|MEDICAID SUPERIOR|3,627.75||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Medicaid|MEDICAID|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Medicare|MEDICARE ACUTE|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Blue Cross PPO Specialty|BCBSTX PPO|3,627.75||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Aenta Medicare Advantage|AETNA MEDICARE MA|3,627.75||||||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Humana Medicare Advantage|HUMANA MA|3,627.75||||||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Humana Medicare Advantage|HUMANA MA|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Tricare|TRICARE EAST REGION|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Medicare|MEDICARE ACUTE|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|United Healthcare|UNITED HEALTHCARE OTHER|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|NON CONTRACTED|COMMERCIAL OTHER 1|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Managed Medicaid|MEDICAID SUPERIOR|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4,738.75||| 70492|EAP|0350|SOFT TISSUE CT W & WO CON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||53.74||| 70496|EAP|0350|CT ANGIO HEAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,394.25||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,394.25||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Veterans Affairs|VETERANS ADMINISTRATION|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|United Healthcare|UNITED HEALTHCARE|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|United Medicare Advantage|UHC MEDICARE GOLD MA|3,394.25||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Cigna|CIGNA|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Medicare|MEDICARE ACUTE|3,394.25||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Humana Medicare Advantage|HUMANA MA|3,394.25||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Blue Cross PPO Specialty|BCBSTX PPO|3,394.25||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Aenta Medicare Advantage|AETNA MEDICARE MA|3,394.25||||||| 70498|EAP|0350|CT ANGIO NECK|Humana Medicare Advantage|HUMANA MA|3,300.50||||||| 70498|EAP|0350|CT ANGIO NECK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|Medicare|MEDICARE ACUTE|||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|Managed Medicaid|MEDICAID SUPERIOR|||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|Medicaid|MEDICAID|||||3,300.50||| 70543|EAP|0610|MRI NECK SOFT TISSUE W&W/|Humana Medicare Advantage|HUMANA MA|||||7,914.25||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|Medicare|MEDICARE ACUTE|58.50||||58.50||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||58.50||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|58.50||||||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||58.50||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|Humana Medicare Advantage|HUMANA MA|58.50||||||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 70547|EAP|0610|MRA NECK W/O CONTRAST|Medicare|MEDICARE ACUTE|58.50||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Aenta Medicare Advantage|AETNA MEDICARE MA|58.50||||||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|58.50||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|58.50||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58.50||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Cigna|CIGNA|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|58.50||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|58.50||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|58.50||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Medicaid|MEDICAID HMO|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Managed Medicaid|MEDICAID AMERIGROUP|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Managed Medicaid|MEDICAID SUPERIOR|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Tricare|TRICARE FOR LIFE|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Medicare|MEDICARE ACUTE|58.50||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|UTMB|UTMB CORRECTIONAL MANAGED CARE|58.50||||||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|United Healthcare|UNITED HEALTHCARE OTHER|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Managed Medicare|HEALTHSPRING MA|||||58.50||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|United Healthcare|UNITED HEALTHCARE|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Medicare|MEDICARE ACUTE|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|United Healthcare|GEHA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Managed Medicare|HEALTHSPRING MA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Managed Medicare|BCBS MEDICARE PPO MA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Humana Medicare Advantage|HUMANA MA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7,914.25||| 71|DRG||NONSPECIFIC CEREBROVASCULAR DISORDERS W CC|Medicare|MEDICARE ACUTE|28,512.73|8312.91|8312.91|8312.91|||| 71045|EAP|0324|CHEST 1 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|452.25||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|452.25||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||520.09||| 71045|EAP|0324|CHEST 1 VIEW|Aetna|AETNA OTHER|||||520.09||| 71045|EAP|0324|CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|452.25||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|587.93||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|587.93||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Humana Medicare Advantage|HUMANA MA|587.93||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Cigna|CIGNA|||||520.09||| 71045|EAP|0324|CHEST 1 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|587.93||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|587.93||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|587.93||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|PHCS|HUMANA INSURANCE|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|452.25||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 2|||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Tricare|TRICARE FOR LIFE|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|UNITED HEALTHCARE|587.93||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Cigna|CIGNA|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|UNITED HEALTHCARE|587.93||||520.09||| 71045|EAP|0324|CHEST 1 VIEW|Medicare|MEDICARE ACUTE|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|452.25||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Aetna|AETNA PPO|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|TML GROUP BENEFITS|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicare|MEDICARE PART B ONLY IP|587.93||||520.09||| 71045|EAP|0324|CHEST 1 VIEW|Tricare|TRICARE EAST REGION|587.93||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|587.93||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|MEDICAID|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|MEDICAID HMO|||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicare|HEALTHSPRING MA|452.25||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicare|WELLCARE CHOICE MA|||||587.93||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|587.93||||||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||520.09||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|452.25||||452.25||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|MEDICAID|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||587.93||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicare|HEALTHSPRING MA|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||551.84||| 71046|EAP|0324|CHEST 2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Tricare|TRICARE EAST REGION|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicare|MEDICARE PART B ONLY IP|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||551.84||| 71046|EAP|0324|CHEST 2 VIEWS|Cigna|CIGNA|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||551.84||| 71046|EAP|0324|CHEST 2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Aetna|AETNA PPO|||||515.75||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||660.75||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|||||660.75||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||660.75||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||660.75||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||615.88||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Humana Medicare Advantage|HUMANA MA|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||615.88||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||660.75||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||660.75||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|||||615.88||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||660.75||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Cigna|CIGNA|||||660.75||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Aetna|AETNA OTHER|||||660.75||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|United Healthcare|UNITED HEALTHCARE|||||660.75||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Medicare|MEDICARE ACUTE|615.88||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Tricare|TRICARE EAST REGION|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Medicare|MEDICARE ACUTE|660.75||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Medicaid|MEDICAID|||||660.75||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||660.75||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Managed Medicare|HEALTHSPRING MA|||||660.75||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Managed Medicare|HEALTHSPRING MA|||||615.88||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Humana Medicare Advantage|HUMANA MA|||||5.71||| 71111|EAP|0320|RIBS BILAT W PA CHEST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||757.37||| 71120|EAP|0320|STERNUM 2 VIEWS|Managed Medicare|HEALTHSPRING MA|||||596.81||| 71120|EAP|0320|STERNUM 2 VIEWS|Medicare|MEDICARE ACUTE|||||556.28||| 71120|EAP|0320|STERNUM 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||596.81||| 71120|EAP|0320|STERNUM 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 71120|EAP|0320|STERNUM 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||596.81||| 71120|EAP|0320|STERNUM 2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||596.81||| 71120|EAP|0320|STERNUM 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||596.81||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Veterans Affairs|VETERANS ADMINISTRATION|||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|United Medicare Advantage|UHC MEDICARE GOLD MA|4,171.92||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Workers Compensation|WORKERS COMPENSATION OTHER|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4,716.08||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,171.92||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Blue Cross HMO Specialty|BCBSTX HMO|3,627.75||||4,171.92||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Blue Cross PPO Specialty|BCBSTX PPO|4,716.08||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Humana Medicare Advantage|HUMANA MA|3,627.75||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|United Healthcare|UNITED HEALTHCARE|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,627.75||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Medicare|MEDICARE ACUTE|3,627.75||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Medicare|MEDICARE PART B ONLY IP|4,171.92||||||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|NON CONTRACTED|COMMERCIAL OTHER 1|3,627.75||||||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicaid|MEDICAID SUPERIOR|||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Medicaid|MEDICAID|||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,716.08||||4,171.92||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Aenta Medicare Advantage|AETNA MEDICARE MA|4,716.08||||4,171.92||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicare|HEALTHSPRING MA|3,627.75||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|United Healthcare|UNITED HEALTHCARE|4,716.08||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,716.08||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3,627.75||||||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicare|HEALTHSPRING MA|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5,449.57||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicaid|MEDICAID SUPERIOR|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,738.75||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Medicare|MEDICARE ACUTE|6,160.38||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicare|BCBS MEDICARE PPO MA|6,160.38||||||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Cigna|CIGNA|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Humana Medicare Advantage|HUMANA MA|5,449.57||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Healthcare|UNITED HEALTHCARE|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,160.38||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Blue Cross HMO Specialty|BCBSTX HMO|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Blue Cross PPO Specialty|BCBSTX PPO|4,738.75||||5,449.57||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Workers Compensation|WORKERS COMPENSATION OTHER|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Veterans Affairs|VETERANS ADMINISTRATION|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6,160.38||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6,160.38||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,738.75||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Medicare Advantage|UHC MEDICARE GOLD MA|6,160.38||||4,738.75||| 71270|EAP|0350|CHEST W&W/O CONTRAST E|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||53.74||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Medicare|MEDICARE ACUTE|4,769.38||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Healthcare|UNITED HEALTHCARE|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|NON CONTRACTED|COMMERCIAL OTHER 1|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicare|WELLCARE CHOICE MA|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicare|HEALTHSPRING MA|||||4,219.07||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicaid|MEDICAID AMERIGROUP|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicaid|MEDICAID SUPERIOR|||||4,219.07||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,668.75||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Medicare Advantage|UHC MEDICARE GOLD MA|4,769.38||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,769.38||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Veterans Affairs|VETERANS ADMINISTRATION|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3,668.75||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Tricare|TRICARE EAST REGION|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4,769.38||||||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Aetna|AETNA PPO|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Blue Cross PPO Specialty|BCBSTX OTHER|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,769.38||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Blue Cross PPO Specialty|BCBSTX PPO|4,769.38||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Blue Cross HMO Specialty|BCBSTX HMO|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Humana Medicare Advantage|HUMANA MA|4,769.38||||4,769.38||| 71550|EAP|0610|MRI CHEST W/O CONTRAST|Medicare|MEDICARE ACUTE|||||58.50||| 71552|EAP|0610|MRI CHEST W/WO CONTRAST|Humana Medicare Advantage|HUMANA MA|||||7,914.25||| 71552|EAP|0610|MRI CHEST W/WO CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7,914.25||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Medicaid|MEDICAID HMO|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicare|BCBS MEDICARE PPO MA|||||596.81||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|United Healthcare|UNITED HEALTHCARE|596.81||||||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Medicare|MEDICARE ACUTE|596.81||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Workers Compensation|WORKERS COMPENSATION OTHER|||||556.28||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicare|HEALTHSPRING MA|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|United Healthcare|UNITED HEALTHCARE|||||596.81||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|United Medicare Advantage|UHC MEDICARE GOLD MA|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||556.28||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Blue Cross PPO Specialty|BCBSTX PPO|||||596.81||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Blue Cross HMO Specialty|BCBSTX HMO|||||556.28||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||596.81||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||596.81||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|596.81||||||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Humana Medicare Advantage|HUMANA MA|||||515.75||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|Managed Medicaid|MEDICAID AMERIGROUP|||||767.79||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||715.65||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|Blue Cross PPO Specialty|BCBSTX PPO|||||663.50||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||663.50||| 72052|EAP|0320|SPINE CERVICAL 6 MOS OR M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||859.20||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||652.07||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Tricare|TRICARE EAST REGION|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||607.79||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Medicaid|MEDICAID|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||652.07||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||652.07||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Medicare|MEDICARE ACUTE|607.79||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||652.07||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||652.07||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||652.07||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|652.07||||||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||652.07||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||652.07||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Cigna|CIGNA|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||563.50||| 72081|EAP|0320|SCOLIOSIS SERIES|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Humana Medicare Advantage|HUMANA MA|||||597.10||| 72081|EAP|0320|SCOLIOSIS SERIES|Managed Medicaid|MEDICAID SUPERIOR|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Blue Cross HMO Specialty|BCBSTX HMO|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Blue Cross PPO Specialty|BCBSTX PPO|||||556.55||| 72081|EAP|0320|SCOLIOSIS SERIES|Medicaid|MEDICAID HMO|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||597.10||| 72081|EAP|0320|SCOLIOSIS SERIES|Tricare|TRICARE EAST REGION|||||5.16||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Medicare|MEDICARE PART B ONLY IP|596.81||||||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||556.28||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||556.28||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Medicaid|MEDICAID|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Tricare|TRICARE EAST REGION|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|515.75||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||556.28||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Cigna|CIGNA|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|596.81||||||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||556.28||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||596.81||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,617.50||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,617.50||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,871.73||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|Managed Medicare|HEALTHSPRING MA|||||1,871.73||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|Medicare|MEDICARE ACUTE|||||1,617.50||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|United Healthcare|UNITED HEALTHCARE|||||1,617.50||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|United Healthcare|UNITED HEALTHCARE OTHER|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Medicaid|MEDICAID HMO|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Medicaid|MEDICAID|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Managed Medicare|HEALTHSPRING MA|3,627.75||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,627.75||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Managed Medicaid|MEDICAID SUPERIOR|3,627.75||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Managed Medicaid|MEDICAID AMERIGROUP|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|United Healthcare|UNITED HEALTHCARE|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Workers Compensation|WORKERS COMPENSATION OTHER|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Managed Medicare|BCBS MEDICARE PPO MA|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Veterans Affairs|VETERANS ADMINISTRATION|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|3,627.75||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Blue Cross HMO Specialty|BCBSTX HMO|3,627.75||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Blue Cross PPO Specialty|BCBSTX PPO|3,627.75||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Humana Medicare Advantage|HUMANA MA|3,627.75||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Cigna|CIGNA|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Medicare|MEDICARE PART B ONLY IP|3,627.75||||||| 72127|EAP|0350|SPINE-CERVICAL W&W/O CONT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||53.74||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Medicaid|MEDICAID HMO|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Managed Medicaid|MEDICAID SUPERIOR|||||4,716.08||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,627.75||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Medicare|MEDICARE ACUTE|3,627.75||||4,716.08||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|United Healthcare|UNITED HEALTHCARE|||||4,716.08||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Medicare|MEDICARE PART B ONLY IP|3,627.75||||||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Humana Medicare Advantage|HUMANA MA|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4,716.08||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Cigna|CIGNA|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Blue Cross PPO Specialty|BCBSTX PPO|4,716.08||||4,716.08||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Blue Cross PPO Specialty|BCBSTX OTHER|||||4,716.08||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Blue Cross HMO Specialty|BCBSTX HMO|||||4,171.92||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Workers Compensation|WORKERS COMPENSATION OTHER|||||4,171.92||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|4,716.08||||4,171.92||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4,716.08||| 72129|EAP|0350|SPINE-THORACIC W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|10.95||||||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Tricare|TRICARE EAST REGION|||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Medicare|MEDICARE ACUTE|4,171.92||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Medicare|MEDICARE PART B ONLY IP|4,171.92||||||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Managed Medicare|HEALTHSPRING MA|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Managed Medicaid|MEDICAID AMERIGROUP|||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4,171.92||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Managed Medicaid|MEDICAID SUPERIOR|||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|United Healthcare|UNITED HEALTHCARE|||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,627.75||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4,716.08||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Veterans Affairs|VETERANS ADMINISTRATION|||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|4,716.08||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Workers Compensation|WORKERS COMPENSATION OTHER|||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Cigna|CIGNA|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Humana Medicare Advantage|HUMANA MA|4,716.08||||4,171.92||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Blue Cross HMO Specialty|BCBSTX HMO|4,716.08||||4,716.08||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Blue Cross PPO Specialty|BCBSTX PPO|4,716.08||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Blue Cross PPO Specialty|BCBSTX OTHER|||||4,171.92||| 72132|EAP|0350|SPINE-LUMBAR W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|43.55||||||| 72132|EAP|0350|SPINE-LUMBAR W/CONTRAST|Humana Medicare Advantage|HUMANA MA|||||3,627.75||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Managed Medicare|HEALTHSPRING MA|||||58.20||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.20||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.35||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Managed Medicare|BCBS MEDICARE PPO MA|||||58.20||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Tricare|TRICARE EAST REGION|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|United Healthcare|UNITED HEALTHCARE|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Medicare|MEDICARE ACUTE|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Blue Cross PPO Specialty|BCBSTX PPO|||||58.20||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Humana Medicare Advantage|HUMANA MA|||||58.35||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||58.35||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.20||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Blue Cross HMO Specialty|BCBSTX HMO|||||58.20||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.35||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6,193.56||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,193.56||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,193.56||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Medicare|MEDICARE ACUTE|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|United Healthcare|UNITED HEALTHCARE|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Managed Medicaid|MEDICAID AMERIGROUP|||||6,193.56||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Managed Medicaid|MEDICAID AMERIGROUP|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6,193.56||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Managed Medicare|BCBS MEDICARE PPO MA|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Healthcare|GEHA|||||6,193.56||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Tricare|TRICARE EAST REGION|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Medicaid|MEDICAID|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||6,193.56||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Medicare|MEDICARE ACUTE|||||6,193.56||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||6,021.78||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Healthcare|UNITED HEALTHCARE|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Managed Medicare|HEALTHSPRING MA|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,193.56||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,193.56||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6,021.78||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Workers Compensation|WORKERS COMPENSATION OTHER|||||6,021.78||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Humana Medicare Advantage|HUMANA MA|||||6,193.56||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6,021.78||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6,021.78||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,193.56||| 72156|EAP|0612|MRI C SPINE W/WO CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 72156|EAP|0612|MRI C SPINE W/WO CONTRAST|United Healthcare|TML GROUP BENEFITS|||||7,914.25||| 72157|EAP|0612|MRI T SPINE W/WO CONTRAST|Managed Medicare|BCBS MEDICARE PPO MA|||||7,914.25||| 72157|EAP|0612|MRI T SPINE W/WO CONTRAST|Medicare|MEDICARE ACUTE|||||7,914.25||| 72157|EAP|0612|MRI T SPINE W/WO CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7,914.25||| 72157|EAP|0612|MRI T SPINE W/WO CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7,914.25||| 72157|EAP|0612|MRI T SPINE W/WO CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||8,146.65||| 72158|EAP|0612|MRI L SPINE W/WO CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 72158|EAP|0612|MRI L SPINE W/WO CONTRAST|Humana Medicare Advantage|HUMANA MA|||||7,914.25||| 72158|EAP|0612|MRI L SPINE W/WO CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7,914.25||| 72158|EAP|0612|MRI L SPINE W/WO CONTRAST|Medicare|MEDICARE ACUTE|||||8,379.04||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Medicaid|MEDICAID HMO|||||597.10||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|United Healthcare|UNITED HEALTHCARE|597.10||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||597.10||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|597.10||||||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||597.10||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|597.10||||597.10||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Cigna|CIGNA|||||597.10||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||597.10||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||597.10||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.16||||597.10||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Humana Medicare Advantage|HUMANA MA|597.10||||556.55||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||556.55||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Medicare|MEDICARE ACUTE|597.10||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||597.10||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|4,171.92||||3,627.75||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||4,171.92||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,716.08||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Aenta Medicare Advantage|AETNA MEDICARE MA|3,627.75||||||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,716.08||||4,716.08||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,716.08||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||4,716.08||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Workers Compensation|WORKERS COMPENSATION OTHER|||||4,171.92||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,627.75||||3,627.75||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Medicare|MEDICARE ACUTE|4,716.08||||4,171.92||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Managed Medicaid|MEDICAID AMERIGROUP|||||4,716.08||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4,716.08||| 72193|EAP|0350|CT PELVIS W/CONTRAST|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||6,160.38||| 72193|EAP|0350|CT PELVIS W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||5,449.57||| 72193|EAP|0350|CT PELVIS W/CONTRAST|Medicare|MEDICARE ACUTE|||||6,160.38||| 72193|EAP|0350|CT PELVIS W/CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,738.75||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|Medicare|MEDICARE ACUTE|||||6,193.56||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|||||6,193.56||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6,193.56||| 72197|EAP|0612|MRI PELVIS W/WO CONTRAST|Managed Medicaid|MEDICAID AMERIGROUP|||||8,379.04||| 72197|EAP|0612|MRI PELVIS W/WO CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8,379.04||| 72197|EAP|0612|MRI PELVIS W/WO CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||8,379.04||| 72197|EAP|0612|MRI PELVIS W/WO CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||8,146.65||| 72220|EAP|0320|SACRUM 2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||596.81||| 72220|EAP|0320|SACRUM 2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||596.81||| 72220|EAP|0320|SACRUM 2 VIEWS|Humana Medicare Advantage|HUMANA MA|596.81||||596.81||| 72220|EAP|0320|SACRUM 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||556.28||| 72220|EAP|0320|SACRUM 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Medicare|MEDICARE ACUTE|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||596.81||| 723|DRG||MALIGNANCY, MALE REPRODUCTIVE SYSTEM W CC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|40,840.32|9482.72|9482.72|9482.72|||| 728|DRG||INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|33,868.50|7519.43|7519.43|7519.43|||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|Humana Medicare Advantage|HUMANA MA|||||596.81||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||596.81||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|Managed Medicaid|MEDICAID SUPERIOR|596.81||||596.81||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|Medicare|MEDICARE ACUTE|||||596.81||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||596.81||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|Medicare|MEDICARE ACUTE|||||515.75||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|NON CONTRACTED|COMMERCIAL OTHER 1|||||596.81||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|NON CONTRACTED|COMMERCIAL OTHER 1|||||596.81||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|United Healthcare|UNITED HEALTHCARE|||||556.28||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|||||556.28||| 73010|EAP|0320|SCAPULA RT. 2 VIEWS|Cigna|CIGNA|||||596.81||| 73020|EAP|0320|SHOULDER LT.1 VIEW|Medicare|MEDICARE ACUTE|||||523.33||| 73020|EAP|0320|SHOULDER LT.1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|||||523.33||| 73020|EAP|0320|SHOULDER LT.1 VIEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||523.33||| 73030|EAP|0320|SHOULDER 3V LEFT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||596.81||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|515.75||||||| 73030|EAP|0320|SHOULDER 3V LEFT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|515.75||||556.28||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|596.81||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Blue Cross PPO Specialty|BCBSTX PPO|596.81||||596.81||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Blue Cross HMO Specialty|BCBSTX HMO|||||596.81||| 73030|EAP|0320|SHOULDER 3V LEFT|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Blue Cross HMO Specialty|BCBSTX HMO|||||556.28||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|556.28||||||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Aetna|AETNA OTHER|||||596.81||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Humana Medicare Advantage|HUMANA MA|556.28||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||596.81||| 73030|EAP|0320|SHOULDER 3V LEFT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||596.81||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|556.28||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|Managed Medicaid|MEDICAID SUPERIOR|||||556.28||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Cigna|CIGNA|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Cigna|CIGNA|||||596.81||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Managed Medicaid|MEDICAID AMERIGROUP|||||556.28||| 73030|EAP|0320|SHOULDER 3V RIGHT|Humana Medicare Advantage|HUMANA MA|556.28||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Cigna|CIGNA|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Medicare Advantage|UHC MEDICARE GOLD MA|596.81||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|515.75||||556.28||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|596.81||||556.28||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|596.81||||596.81||| 73030|EAP|0320|SHOULDER 3V LEFT|Workers Compensation|WORKERS COMPENSATION OTHER|||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|515.75||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|Workers Compensation|WORKERS COMPENSATION OTHER|||||556.28||| 73030|EAP|0320|SHOULDER 3V LEFT|Workers Compensation|UT EMPLOYEE INJURY|||||596.81||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|596.81||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|Veterans Affairs|VETERANS ADMINISTRATION|||||596.81||| 73030|EAP|0320|SHOULDER 3V LEFT|United Medicare Advantage|UHC MEDICARE GOLD MA|596.81||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Humana Medicare Advantage|HUMANA MA|515.75||||596.81||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|596.81||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|515.75||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|Managed Medicare|BCBS MEDICARE PPO MA|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||556.28||| 73030|EAP|0320|SHOULDER 3V RIGHT|Cigna|CIGNA|||||556.28||| 73030|EAP|0320|SHOULDER 3V LEFT|Managed Medicare|HEALTHSPRING MA|||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Medicaid|MEDICAID HMO|||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|Managed Medicare|HEALTHSPRING MA|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||596.81||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Medicaid|MEDICAID|||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|515.75||||596.81||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|596.81||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||596.81||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||596.81||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 2|||||596.81||| 73030|EAP|0320|SHOULDER 3V LEFT|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Healthcare|UNITED HEALTHCARE OTHER|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|United Healthcare|UNITED HEALTHCARE|||||596.81||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||596.81||| 73030|EAP|0320|SHOULDER 3V LEFT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Medicare|MEDICARE ACUTE|596.81||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|NON CONTRACTED|COMMERCIAL OTHER 1|||||596.81||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||596.81||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|United Healthcare|GOLDEN RULE|||||596.81||| 73030|EAP|0320|SHOULDER 3V LEFT|United Healthcare|UNITED HEALTHCARE OTHER|||||596.81||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Healthcare|UNITED HEALTHCARE|||||596.81||| 73040|EAP|0322|ARTHROGRAM RT.SHOULDER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||914.25||| 73040|EAP|0322|ARTHROGRAM RT.SHOULDER|Blue Cross PPO Specialty|BCBSTX PPO|||||914.25||| 73050|EAP|0320|ACROMIOCLAVICULAR JOINTS|United Healthcare|GOLDEN RULE|||||660.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||596.81||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||596.81||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|596.81||||596.81||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|596.81||||596.81||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||596.81||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||556.28||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Medicare|MEDICARE PART B ONLY IP|596.81||||||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||556.28||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||556.28||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||596.81||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||515.75||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||556.28||| 73070|EAP|0320|ELBOW RT.2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||596.81||| 73070|EAP|0320|ELBOW LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||596.81||| 73070|EAP|0320|ELBOW RT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||596.81||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||556.28||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||596.81||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Medicaid|MEDICAID HMO|||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||556.28||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||596.81||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|515.75||||||| 73070|EAP|0320|ELBOW LT.2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||596.81||| 73070|EAP|0320|ELBOW RT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||515.75||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||515.75||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Humana Medicare Advantage|HUMANA MA|||||556.55||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.16||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|5.16||||5.16||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Blue Cross PPO Specialty|BCBSTX PPO|5.16||||5.16||| 73080|EAP|0320|ELBOW RT.3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||543.50||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||597.10||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||660.75||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||660.75||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||615.88||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Cigna|CIGNA|||||5.16||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Managed Medicaid|MEDICAID AMERIGROUP|||||597.10||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Managed Medicaid|MEDICAID SUPERIOR|||||5.16||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Medicaid|MEDICAID|||||5.16||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Medicaid|MEDICAID|||||660.75||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||660.75||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||660.75||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Medicare|MEDICARE ACUTE|||||588.38||| 73080|EAP|0320|ELBOW RT.3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.16||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Medicare|MEDICARE ACUTE|||||5.16||| 73090|EAP|0320|FOREARM RT.2 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||596.81||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Tricare|TRICARE EAST REGION|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|515.75||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|515.75||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||596.81||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|515.75||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|596.81||||||| 73090|EAP|0320|FOREARM RT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||596.81||| 73090|EAP|0320|FOREARM LT.2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||596.81||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||596.81||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Cigna|CIGNA|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||596.81||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Cigna|CIGNA|||||596.81||| 73100|EAP|0320|WRIST,LT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||596.81||| 73100|EAP|0320|WRIST RT.2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||596.81||| 73100|EAP|0320|WRIST RT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||556.28||| 73100|EAP|0320|WRIST,LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 73100|EAP|0320|WRIST,LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 73100|EAP|0320|WRIST RT.2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||596.81||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Tricare|TRICARE EAST REGION|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Medicare|MEDICARE ACUTE|660.75||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|United Healthcare|UNITED HEALTHCARE OTHER|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Medicare|MEDICARE ACUTE|660.75||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Medicaid|MEDICAID|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Managed Medicaid|MEDICAID AMERIGROUP|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Managed Medicare|HEALTHSPRING MA|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Medicaid|MEDICAID|||||615.88||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Medicaid|MEDICAID HMO|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||660.75||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Humana Medicare Advantage|HUMANA MA|||||615.88||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Cigna|CIGNA|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Cigna|CIGNA|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||660.75||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Aetna|AETNA PPO|||||660.75||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||660.75||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Workers Compensation|WORKERS COMPENSATION OTHER|5.71||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|5.71||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||660.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||660.75||| 73120|EAP|0320|HAND LEFT 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||596.81||| 73120|EAP|0320|HAND LEFT 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73120|EAP|0320|HAND LEFT 2 VIEWS|Managed Medicare|HEALTHSPRING MA|||||596.81||| 73130|EAP|0320|HAND LT.3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.71||||660.75||| 73130|EAP|0320|HAND LT.3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||615.88||| 73130|EAP|0320|HAND LT.3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.71||||615.88||| 73130|EAP|0320|HAND LT.3 VIEWS|Medicare|MEDICARE ACUTE|660.75||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicare|MEDICARE ACUTE|660.75||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||615.88||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicaid|MEDICAID|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicaid|MEDICAID HMO|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||615.88||| 73130|EAP|0320|HAND LT.3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||660.75||| 73130|EAP|0320|HAND LT.3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Medicaid|MEDICAID|||||615.88||| 73130|EAP|0320|HAND LT.3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|5.71||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||660.75||| 73130|EAP|0320|HAND LT.3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||660.75||| 73130|EAP|0320|HAND LT.3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||615.88||| 73130|EAP|0320|HAND RT.3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||615.88||| 73130|EAP|0320|HAND LT.3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|5.71||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|Cigna|CIGNA|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|Cigna|CIGNA|5.71||||||| 73130|EAP|0320|HAND LT.3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||615.88||| 73130|EAP|0320|HAND RT.3 VIEWS|Tricare|TRICARE EAST REGION|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||615.88||| 73130|EAP|0320|HAND RT.3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||660.75||| 73130|EAP|0320|HAND LT.3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Cigna|CIGNA|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||660.75||| 73130|EAP|0320|HAND RT.3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|5.71||||||| 73130|EAP|0320|HAND RT.3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||660.75||| 73130|EAP|0320|HAND LT.3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||660.75||| 73130|EAP|0320|HAND LT.3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||597.10||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Aetna|AETNA PPO|||||597.10||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Aetna|AETNA PPO|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||597.10||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||597.10||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Cigna|CIGNA|5.16||||||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||597.10||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||597.10||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.16||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||597.10||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Medicaid|MEDICAID|||||597.10||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Medicaid|MEDICAID|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||556.55||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Medicare|MEDICARE ACUTE|||||5.16||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||597.10||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Medicare|MEDICARE ACUTE|||||556.55||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Tricare|TRICARE EAST REGION|||||597.10||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.16||| 73200|EAP|0350|EXTREMITY LT.UPPER W/O CO|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 73200|EAP|0350|EXTREMITY RT.UPPER W/O CO|Managed Medicaid|MEDICAID SUPERIOR|||||4,716.08||| 73200|EAP|0350|EXTREMITY LT.UPPER W/O CO|Managed Medicaid|MEDICAID SUPERIOR|||||3,627.75||| 73200|EAP|0350|EXTREMITY RT.UPPER W/O CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4,716.08||| 73200|EAP|0350|EXTREMITY LT.UPPER W/O CO|Humana Medicare Advantage|HUMANA MA|||||4,716.08||| 73200|EAP|0350|EXTREMITY RT.UPPER W/O CO|Humana Medicare Advantage|HUMANA MA|||||4,716.08||| 73201|EAP|0350|EXTREMITY RT.UPPER W/CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,738.75||| 73201|EAP|0350|EXTREMITY LT.UPPER W/CONT|Blue Cross HMO Specialty|BCBSTX HMO|4,738.75||||||| 73201|EAP|0350|EXTREMITY LT.UPPER W/CONT|NON CONTRACTED|COMMERCIAL OTHER 1|6,160.38||||4,738.75||| 73201|EAP|0350|EXTREMITY RT.UPPER W/CONT|Medicare|MEDICARE ACUTE|4,738.75||||||| 73201|EAP|0350|EXTREMITY LT.UPPER W/CONT|Medicare|MEDICARE PART B ONLY IP|6,160.38||||||| 73201|EAP|0350|EXTREMITY LT.UPPER W/CONT|Medicare|MEDICARE ACUTE|4,738.75||||||| 73202|EAP|0350|EXTREMITY LT.UPPER W&W/O|NON CONTRACTED|COMMERCIAL OTHER 1|||||53.74||| 73202|EAP|0350|EXTREMITY LT.UPPER W&W/O|Tricare|TRICARE EAST REGION|||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|NON CONTRACTED|COMMERCIAL OTHER 1|||||53.74||| 73202|EAP|0350|EXTREMITY LT.UPPER W&W/O|Medicare|MEDICARE ACUTE|53.74||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|Medicare|MEDICARE ACUTE|6,986.20||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|Blue Cross HMO Specialty|BCBSTX HMO|||||6,986.20||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,986.20||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||53.74||| 73202|EAP|0350|EXTREMITY LT.UPPER W&W/O|Aenta Medicare Advantage|AETNA MEDICARE MA|||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|6,986.20||||||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||53.74||| 73202|EAP|0350|EXTREMITY LT.UPPER W&W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|53.74||||||| 73218|EAP|0610|MRI UPPER EXT RT W/O CONT|Managed Medicare|BCBS MEDICARE PPO MA|||||6,193.56||| 73218|EAP|0610|MRI UPPER EXT LT W/O CONT|Medicare|MEDICARE ACUTE|||||58.50||| 73218|EAP|0610|MRI UPPER EXT RT W/O CONT|United Healthcare|TML GROUP BENEFITS|||||6,193.56||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Workers Compensation|WORKERS COMPENSATION OTHER|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Workers Compensation|WORKERS COMPENSATION OTHER|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,193.56||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6,021.78||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Humana Medicare Advantage|HUMANA MA|||||6,021.78||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Humana Medicare Advantage|HUMANA MA|||||6,193.56||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Access Direct Platinum|HEALTHFIRST TPA UMR|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,193.56||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,193.56||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6,193.56||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,021.78||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,021.78||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||6,021.78||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|United Healthcare|UNITED HEALTHCARE|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Tricare|TRICARE EAST REGION|||||6,021.78||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,021.78||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|United Healthcare|UNITED HEALTHCARE OTHER|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Medicare|MEDICARE ACUTE|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Tricare|TRICARE EAST REGION|||||6,193.56||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||6,193.56||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|United Healthcare|TML GROUP BENEFITS|||||6,193.56||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Medicare|MEDICARE ACUTE|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||6,021.78||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|United Healthcare|UNITED HEALTHCARE|||||6,021.78||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Managed Medicaid|MEDICAID SUPERIOR|||||6,193.56||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Managed Medicaid|MEDICAID SUPERIOR|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Managed Medicare|HEALTHSPRING MA|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Managed Medicaid|MEDICAID AMERIGROUP|||||58.50||| 73222|EAP|0610|MRI UPPER EXT JOINT W/CON|Managed Medicaid|MEDICAID SUPERIOR|||||3,598.50||| 73222|EAP|0610|MRI UPPER EXT JOINT W/CON|Blue Cross PPO Specialty|BCBSTX PPO|||||3,598.50||| 73223|EAP|0610|MRI UPPER EXT LT JOINT W&|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8,379.04||| 73501|EAP|0320|HIP LT 1 VW INC/PELVIS|Medicare|MEDICARE ACUTE|||||452.25||| 73501|EAP|0320|HIP RT 1 VW INC/PELVIS|Medicare|MEDICARE ACUTE|||||452.25||| 73501|EAP|0320|HIP LT 1 VW INC/PELVIS|Managed Medicaid|MEDICAID SUPERIOR|452.25||||||| 73501|EAP|0320|HIP RT 1 VW INC/PELVIS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|452.25||||||| 73501|EAP|0320|HIP RT 1 VW INC/PELVIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||452.25||| 73501|EAP|0320|HIP LT 1 VW INC/PELVIS|Blue Cross PPO Specialty|BCBSTX PPO|452.25||||||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Cigna|CIGNA|596.81||||596.81||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Humana Medicare Advantage|HUMANA MA|556.28||||596.81||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Blue Cross HMO Specialty|BCBSTX HMO|515.75||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Blue Cross PPO Specialty|BCBSTX OTHER|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Blue Cross HMO Specialty|BCBSTX HMO|515.75||||596.81||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||596.81||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Aenta Medicare Advantage|AETNA MEDICARE MA|515.75||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Aenta Medicare Advantage|AETNA MEDICARE MA|515.75||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|596.81||||556.28||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|United Medicare Advantage|UHC MEDICARE GOLD MA|596.81||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|United Medicare Advantage|UHC MEDICARE GOLD MA|596.81||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Workers Compensation|WORKERS COMPENSATION OTHER|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Workers Compensation|WORKERS COMPENSATION OTHER|||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|515.75||||556.28||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Veterans Affairs|VETERANS ADMINISTRATION|596.81||||596.81||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|596.81||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|596.81||||556.28||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|596.81||||556.28||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|596.81||||556.28||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|596.81||||556.28||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Managed Medicare|HEALTHSPRING MA|596.81||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|515.75||||556.28||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Managed Medicare|BCBS MEDICARE PPO MA|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Managed Medicaid|MEDICAID SUPERIOR|515.75||||596.81||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Humana Medicare Advantage|HUMANA MA|556.28||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Managed Medicare|HEALTHSPRING MA|596.81||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|NON CONTRACTED|COMMERCIAL OTHER 1|||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|United Healthcare|UNITED HEALTHCARE|||||556.28||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Tricare|TRICARE EAST REGION|||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|United Healthcare|UNITED HEALTHCARE OTHER|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Medicare|MEDICARE ACUTE|556.28||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Tricare|TRICARE EAST REGION|||||596.81||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|United Healthcare|UNITED HEALTHCARE|||||596.81||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|United Healthcare|UNITED HEALTHCARE|||||596.81||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Medicare|MEDICARE PART B ONLY IP|596.81||||||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Medicare|MEDICARE ACUTE|538.50||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||623.14||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||623.14||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||580.82||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Blue Cross PPO Specialty|BCBSTX PPO|||||623.14||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Humana Medicare Advantage|HUMANA MA|||||623.14||| 73522|EAP|0320|HIP BILATERAL INC/PELVIS|United Medicare Advantage|UHC MEDICARE GOLD MA|7.00||||||| 73522|EAP|0320|HIP BILATERAL INC/PELVIS|Medicare|MEDICARE ACUTE|||||7.00||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|596.81||||||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||596.81||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|596.81||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Cigna|CIGNA|||||596.81||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||596.81||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||596.81||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||596.81||| 73560|EAP|0320|KNEE RT. 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|523.33||||523.33||| 73560|EAP|0320|XR KNEE STANDING AP & LAT|United Medicare Advantage|UHC MEDICARE GOLD MA|523.33||||661.33||| 73560|EAP|0320|KNEE RT. 2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|452.25||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|452.25||||||| 73560|EAP|0320|KNEE LT.2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|487.79||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||523.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|452.25||||523.33||| 73560|EAP|0320|XR KNEE LT 1 VIEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|452.25||||523.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|452.25||||487.79||| 73560|EAP|0320|KNEE LT.2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|523.33||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|523.33||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Aetna|AETNA PPO|||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Humana Medicare Advantage|HUMANA MA|487.79||||523.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|452.25||||523.33||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Cigna|CIGNA|||||523.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||523.33||| 73560|EAP|0320|XR KNEE STANDING AP & LAT|Humana Medicare Advantage|HUMANA MA|523.33||||661.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|Cigna|CIGNA|||||487.79||| 73560|EAP|0320|XR KNEE STANDING AP & LAT|Blue Cross PPO Specialty|BCBSTX PPO|523.33||||661.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|523.33||||523.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|Medicare|MEDICARE ACUTE|487.79||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Medicare|MEDICARE ACUTE|487.79||||452.25||| 73560|EAP|0320|XR KNEE STANDING AP & LAT|Medicare|MEDICARE ACUTE|487.79||||661.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|452.25||||523.33||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|523.33||||487.79||| 73560|EAP|0320|KNEE LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|523.33||||523.33||| 73560|EAP|0320|KNEE RT. 2 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||523.33||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||452.25||| 73560|EAP|0320|XR KNEE STANDING AP & LAT|Tricare|TRICARE EAST REGION|||||661.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|452.25||||523.33||| 73560|EAP|0320|XR KNEE STANDING AP & LAT|Medicare|MEDICARE ACUTE|487.79||||571.50||| 73560|EAP|0320|KNEE RT. 2 VIEWS|United Healthcare|UNITED HEALTHCARE|523.33||||523.33||| 73560|EAP|0320|KNEE RT. 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||523.33||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|452.25||||||| 73560|EAP|0320|KNEE LT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|452.25||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Managed Medicare|HEALTHSPRING MA|||||523.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|487.79||||523.33||| 73560|EAP|0320|KNEE LT.2 VIEWS|Medicaid|MEDICAID|||||523.33||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|523.33||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||487.79||| 73560|EAP|0320|KNEE LT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|523.33||||487.79||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||487.79||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|452.25||||523.33||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||523.33||| 73562|EAP|0320|KNEE LT.3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Medicaid|MEDICAID|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Medicaid|MEDICAID|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Tricare|TRICARE EAST REGION|||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Medicare|MEDICARE ACUTE|660.75||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Medicare|MEDICARE ACUTE|5.71||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Tricare|TRICARE EAST REGION|||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Tricare|TRICARE FOR LIFE|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Humana Medicare Advantage|HUMANA MA|5.71||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Cigna|CIGNA|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Humana Medicare Advantage|HUMANA MA|5.71||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||615.88||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|660.75||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|660.75||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Aetna|AETNA PPO|||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Aetna|AETNA PPO|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|660.75||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.71||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||660.75||| 73562|EAP|0320|KNEE RT. 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|660.75||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||660.75||| 73562|EAP|0320|KNEE LT.3 VIEWS|Workers Compensation|WORKERS COMP PHYSICIAN|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.71||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|615.88||||615.88||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Humana Medicare Advantage|HUMANA MA|||||7.16||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Medicare|MEDICARE ACUTE|||||7.16||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Managed Medicaid|MEDICAID SUPERIOR|||||7.16||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.16||| 73590|EAP|0320|LEG RT. 2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||596.81||| 73590|EAP|0320|LEG LT.2 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 73590|EAP|0320|LEG LT.2 VIEWS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|515.75||||||| 73590|EAP|0320|LEG RT. 2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||596.81||| 73590|EAP|0320|LEG LT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Medicaid|MEDICAID|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||596.81||| 73590|EAP|0320|LEG LT.2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|596.81||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Aetna|AETNA PPO|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Cigna|CIGNA|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||515.75||| 73600|EAP|0320|ANKLE RT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||596.81||| 73600|EAP|0320|ANKLE RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||596.81||| 73600|EAP|0320|ANKLE RT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73600|EAP|0320|ANKLE LT.2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||596.81||| 73600|EAP|0320|ANKLE RT.2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||||| 73600|EAP|0320|ANKLE RT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73600|EAP|0320|ANKLE LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Medicaid|MEDICAID|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Medicaid|MEDICAID HMO|||||615.88||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Medicaid|MEDICAID HMO|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||660.75||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||660.75||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||615.88||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE|660.75||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Medicare|MEDICARE ACUTE|660.75||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Medicare|MEDICARE ACUTE|660.75||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||615.88||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|660.75||||||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Aetna|AETNA PPO|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|660.75||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||660.75||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||615.88||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|660.75||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|660.75||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Cigna|CIGNA|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Cigna|CIGNA|||||615.88||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|660.75||||660.75||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|ChampVA|CHAMPVA CENTER|||||660.75||| 73620|EAP|0320|FOOT RT.2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||596.81||| 73620|EAP|0320|FOOT LT.2 VIEWS|Medicare|MEDICARE ACUTE|596.81||||596.81||| 73620|EAP|0320|FOOT RT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 73620|EAP|0320|FOOT LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||596.81||| 73620|EAP|0320|XR FOOT RT 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|515.75||||||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||660.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Medicaid|MEDICAID|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||660.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||660.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||615.88||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.71||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|660.75||||||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Medicaid|MEDICAID|||||615.88||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Medicare|MEDICARE ACUTE|660.75||||660.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Medicare|MEDICARE ACUTE|5.71||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Tricare|TRICARE EAST REGION|||||615.88||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.71||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||615.88||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|615.88||||615.88||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Medicaid|MEDICAID HMO|||||615.88||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||660.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|660.75||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|615.88||||615.88||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|660.75||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|5.71||||660.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|ChampVA|CHAMPVA CENTER|||||660.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Cigna|CIGNA|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|5.71||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|660.75||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||660.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||660.75||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||615.88||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|660.75||||660.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.71||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73650|EAP|0320|OS CALCIS RT. 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73650|EAP|0320|OS CALCIS RT. 2 VIEWS|Medicare|MEDICARE ACUTE|||||515.75||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||596.81||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73660|EAP|0320|XR TOE LEFT|Medicaid|MEDICAID HMO|||||5.16||| 73660|EAP|0320|XR TOE RIGHT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||597.10||| 73660|EAP|0320|XR TOE LEFT|Medicaid|MEDICAID|||||5.16||| 73660|EAP|0320|XR TOE LEFT|Managed Medicaid|MEDICAID SUPERIOR|||||597.10||| 73660|EAP|0320|XR TOE RIGHT|Managed Medicare|HEALTHSPRING MA|||||597.10||| 73660|EAP|0320|XR TOE LEFT|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 73660|EAP|0320|XR TOE RIGHT|United Healthcare|UNITED HEALTHCARE|||||597.10||| 73660|EAP|0320|XR TOE RIGHT|NON CONTRACTED|COMMERCIAL OTHER 1|5.16||||||| 73660|EAP|0320|XR TOE LEFT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||597.10||| 73660|EAP|0320|XR TOE LEFT|Medicare|MEDICARE ACUTE|||||556.55||| 73660|EAP|0320|XR TOE LEFT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||597.10||| 73660|EAP|0320|XR TOE RIGHT|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.16||| 73660|EAP|0320|XR TOE LEFT|Workers Compensation|WORKERS COMPENSATION OTHER|||||597.10||| 73660|EAP|0320|XR TOE LEFT|Humana Medicare Advantage|HUMANA MA|597.10||||597.10||| 73660|EAP|0320|XR TOE RIGHT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|597.10||||5.16||| 73660|EAP|0320|XR TOE RIGHT|Blue Cross PPO Specialty|BCBSTX OTHER|||||597.10||| 73660|EAP|0320|XR TOE RIGHT|Aetna|AETNA PPO|597.10||||||| 73660|EAP|0320|XR TOE RIGHT|Blue Cross PPO Specialty|BCBSTX PPO|597.10||||5.16||| 73660|EAP|0320|XR TOE LEFT|Blue Cross PPO Specialty|BCBSTX PPO|597.10||||597.10||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,716.08||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Blue Cross PPO Specialty|BCBSTX PPO|3,627.75||||4,716.08||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,716.08||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Humana Medicare Advantage|HUMANA MA|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Humana Medicare Advantage|HUMANA MA|||||4,171.92||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|ChampVA|CHAMPVA CENTER|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Workers Compensation|WORKERS COMPENSATION OTHER|||||4,716.08||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,627.75||||||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Blue Cross PPO Specialty|BCBSTX PPO|3,627.75||||4,716.08||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Workers Compensation|WORKERS COMPENSATION OTHER|||||4,716.08||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Veterans Affairs|VETERANS ADMINISTRATION|4,716.08||||||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4,716.08||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|United Medicare Advantage|UHC MEDICARE GOLD MA|4,716.08||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Medicare|MEDICARE ACUTE|4,716.08||||4,716.08||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|United Healthcare|UNITED HEALTHCARE|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Managed Medicaid|MEDICAID SUPERIOR|3,627.75||||4,171.92||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Managed Medicaid|MEDICAID AMERIGROUP|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,716.08||||4,716.08||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Managed Medicare|BCBS MEDICARE PPO MA|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Managed Medicaid|MEDICAID SUPERIOR|3,627.75||||4,716.08||| 73701|EAP|0350|EXTREMITY LT.LOWER W/CONT|Managed Medicaid|MEDICAID SUPERIOR|||||6,160.38||| 73701|EAP|0350|EXTREMITY RT LOWER W/CONT|Medicare|MEDICARE ACUTE|4,738.75||||||| 73701|EAP|0350|EXTREMITY LT.LOWER W/CONT|NON CONTRACTED|COMMERCIAL OTHER 1|||||4,738.75||| 73701|EAP|0350|EXTREMITY RT LOWER W/CONT|Blue Cross PPO Specialty|BCBSTX PPO|||||6,160.38||| 73706|EAP|0350|CTA ANGIO LOWER EXTREMITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,429.75||||||| 73706|EAP|0350|CTA ANGIO LOWER EXTREMITY|Humana Medicare Advantage|HUMANA MA|4,459.33||||3,430.25||| 73706|EAP|0350|CTA ANGIO LOWER EXTREMITY|Humana Medicare Advantage|HUMANA MA|3,429.75||||3,430.25||| 73706|EAP|0350|CTA ANGIO LOWER EXTREMITY|Blue Cross PPO Specialty|BCBSTX PPO|4,459.33||||||| 73706|EAP|0350|CTA ANGIO LOWER EXTREMITY|Medicare|MEDICARE ACUTE|4,459.33||||3,429.75||| 73706|EAP|0350|CTA ANGIO LOWER EXTREMITY|Medicare|MEDICARE ACUTE|4,458.68||||3,429.75||| 73706|EAP|0350|CTA ANGIO LOWER EXTREMITY|NON CONTRACTED|COMMERCIAL OTHER 1|3,430.25||||||| 73718|EAP|0610|MRI LOWER EXT RT W/O CONT|Managed Medicaid|MEDICAID AMERIGROUP|||||6,193.56||| 73718|EAP|0610|MRI LOWER EXT LT W/O CONT|Medicare|MEDICARE ACUTE|||||6,021.78||| 73718|EAP|0610|MRI LOWER EXT RT W/O CONT|Medicare|MEDICARE ACUTE|||||6,021.78||| 73718|EAP|0610|MRI LOWER EXT LT W/O CONT|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 73718|EAP|0610|MRI LOWER EXT LT W/O CONT|Blue Cross PPO Specialty|BCBSTX PPO|58.50||||6,193.56||| 73718|EAP|0610|MRI LOWER EXT RT W/O CONT|Humana Medicare Advantage|HUMANA MA|||||6,193.56||| 73718|EAP|0610|MRI LOWER EXT RT W/O CONT|Blue Cross PPO Specialty|BCBSTX PPO|6,193.56||||58.50||| 73718|EAP|0610|MRI LOWER EXT RT W/O CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|6,021.78||||6,193.56||| 73718|EAP|0610|MRI LOWER EXT RT W/O CONT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,193.56||| 73720|EAP|0610|MRI LOWER RT.EXT W&W/O CO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7,914.25||||||| 73720|EAP|0610|MRI LOWER LT.EXT.W&W/0 CO|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 73720|EAP|0610|MRI LOWER RT.EXT W&W/O CO|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 73720|EAP|0610|MRI LOWER RT.EXT W&W/O CO|NON CONTRACTED|COMMERCIAL OTHER 1|||||7,914.25||| 73720|EAP|0610|MRI LOWER RT.EXT W&W/O CO|Medicare|MEDICARE ACUTE|||||8,379.04||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Managed Medicaid|MEDICAID AMERIGROUP|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Managed Medicaid|MEDICAID SUPERIOR|||||6,193.56||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6,193.56||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6,193.56||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6,193.56||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Managed Medicaid|MEDICAID AMERIGROUP|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6,021.78||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Medicare|MEDICARE ACUTE|||||6,021.78||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|United Healthcare|UNITED HEALTHCARE|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|United Healthcare|GEHA|||||6,193.56||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Medicare|MEDICARE ACUTE|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||6,193.56||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||6,193.56||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Tricare|TRICARE EAST REGION|||||6,193.56||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|United Healthcare|UNITED HEALTHCARE|||||6,021.78||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,193.56||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,021.78||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Managed Medicare|HEALTHSPRING MA|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,193.56||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,193.56||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Aetna|AETNA PPO|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Cigna|CIGNA|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Managed Medicaid|MEDICAID SUPERIOR|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Humana Medicare Advantage|HUMANA MA|||||6,193.56||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||6,021.78||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Cigna|CIGNA|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Humana Medicare Advantage|HUMANA MA|||||6,193.56||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Workers Compensation|WORKERS COMPENSATION OTHER|||||6,193.56||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Workers Compensation|WORKERS COMPENSATION OTHER|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6,193.56||| 73723|EAP|0610|MRI LOWER EXT LT JOINT W&|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 73723|EAP|0610|MRI LOWER EXT LT JOINT W&|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||7,914.25||| 73723|EAP|0610|MRI LOWER EXT LT JOINT W&|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||83,790.04||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|52,513.13|8863.64|8863.64|4563.7|||| 74|DRG||CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30,532.98|4563.7|8863.64|4563.7|||| 74018|EAP|0320|KUB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|452.25||||550.26||| 74018|EAP|0320|KUB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||550.26||| 74018|EAP|0320|KUB|Humana Medicare Advantage|HUMANA MA|||||550.26||| 74018|EAP|0320|KUB|ChampVA|CHAMPVA CENTER|452.25||||||| 74018|EAP|0320|KUB|Cigna|CIGNA|452.25||||||| 74018|EAP|0320|KUB|Blue Cross PPO Specialty|BCBSTX PPO|452.25||||452.25||| 74018|EAP|0320|KUB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||550.26||| 74018|EAP|0320|KUB|Blue Cross HMO Specialty|BCBSTX HMO|||||452.25||| 74018|EAP|0320|KUB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||452.25||| 74018|EAP|0320|KUB|Aenta Medicare Advantage|AETNA MEDICARE MA|||||550.26||| 74018|EAP|0320|KUB|Tricare|TRICARE EAST REGION|||||452.25||| 74018|EAP|0320|KUB|UTMB|UTMB CORRECTIONAL MANAGED CARE|452.25||||452.25||| 74018|EAP|0320|KUB|United Healthcare|UNITED HEALTHCARE OTHER|||||452.25||| 74018|EAP|0320|KUB|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||550.26||| 74018|EAP|0320|KUB|Medicare|MEDICARE ACUTE|550.26||||452.25||| 74018|EAP|0320|KUB|NON CONTRACTED|COMMERCIAL OTHER 1|||||550.26||| 74018|EAP|0320|KUB|United Healthcare|UNITED HEALTHCARE|||||550.26||| 74018|EAP|0320|KUB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|550.26||||||| 74018|EAP|0320|KUB|Managed Medicaid|MEDICAID AMERIGROUP|||||501.26||| 74018|EAP|0320|KUB|Medicaid|MEDICAID|||||452.25||| 74018|EAP|0320|KUB|Managed Medicare|HEALTHSPRING MA|550.26||||550.26||| 74018|EAP|0320|KUB|Medicaid|MEDICAID HMO|||||452.25||| 74018|EAP|0320|KUB|Managed Medicaid|MEDICAID SUPERIOR|550.26||||452.25||| 74018|EAP|0320|KUB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|452.25||||501.26||| 74018|EAP|0320|KUB|Medicaid|COUNTY INDIGENT HEALTH OTHER|550.26||||||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||627.52||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Medicare|MEDICARE ACUTE|627.52||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||627.52||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|627.52||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||627.52||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||627.52||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||627.52||| 74022|EAP|0320|ABD ACUTE SERIES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|853.50||||945.98||| 74022|EAP|0320|ABD ACUTE SERIES|Humana Medicare Advantage|HUMANA MA|1,038.46||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Blue Cross PPO Specialty|BCBSTX PPO|853.50||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,038.46||| 74022|EAP|0320|ABD ACUTE SERIES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,038.46||| 74022|EAP|0320|ABD ACUTE SERIES|United Healthcare|UNITED HEALTHCARE OTHER|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Medicare|MEDICARE PART B ONLY IP|853.50||||||| 74022|EAP|0320|ABD ACUTE SERIES|UTMB|UTMB CORRECTIONAL MANAGED CARE|853.50||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|United Healthcare|UNITED HEALTHCARE|||||945.98||| 74022|EAP|0320|ABD ACUTE SERIES|Medicare|MEDICARE ACUTE|853.50||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicaid|MEDICAID SUPERIOR|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicare|HEALTHSPRING MA|1,038.46||||||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|853.50||||||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|853.50||||||| 74022|EAP|0320|ABD ACUTE SERIES|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,038.46||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicaid|MEDICAID AMERIGROUP|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Medicaid|MEDICAID|853.50||||1,038.46||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|Managed Medicare|HEALTHSPRING MA|4,716.08||||3,627.75||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,627.75||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|Medicare|MEDICARE ACUTE|3,627.75||||4,716.08||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||4,716.08||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,627.75||||||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,716.08||||4,716.08||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,716.08||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||4,716.08||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|||||4,171.92||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4,716.08||||||| 74160|EAP|0350|ABDOMEN W/CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,160.38||| 74160|EAP|0350|ABDOMEN W/CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Cigna|CIGNA|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Humana Medicare Advantage|HUMANA MA|||||6,160.38||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6,160.38||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||5,449.57||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,449.57||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Medicare|MEDICARE ACUTE|||||6,160.38||| 74160|EAP|0350|ABDOMEN W/CONTRAST|United Healthcare|UNITED HEALTHCARE|||||6,160.38||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5,449.57||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6,160.38||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Medicaid|MEDICAID|||||6,160.38||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Managed Medicaid|MEDICAID AMERIGROUP|||||6,160.38||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||6,986.20||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|Blue Cross PPO Specialty|BCBSTX PPO|||||53.74||| 74174|EAP|0350|CTA ABD & PELVIS W/CONTRA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||57.00||| 74174|EAP|0350|CTA ABD & PELVIS W/CONTRA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||57.00||| 74174|EAP|0350|CTA ABD & PELVIS W/CONTRA|Medicare|MEDICARE ACUTE|||||74.10||| 74175|EAP|0350|CT ANGIO ABDOMEN|Medicare|MEDICARE ACUTE|||||3,573.50||| 74175|EAP|0350|CT ANGIO ABDOMEN|NON CONTRACTED|COMMERCIAL OTHER 1|3,573.50||||||| 74175|EAP|0350|CT ANGIO ABDOMEN|Humana Medicare Advantage|HUMANA MA|||||4,645.55||| 74175|EAP|0350|CT ANGIO ABDOMEN|Blue Cross HMO Specialty|BCBSTX HMO|||||3,573.50||| 74175|EAP|0350|CT ANGIO ABDOMEN|Blue Cross PPO Specialty|BCBSTX PPO|||||3,573.50||| 74175|EAP|0350|CT ANGIO ABDOMEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,573.50||| 74175|EAP|0350|CT ANGIO ABDOMEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4,109.53||| 74175|EAP|0350|CT ANGIO ABDOMEN|United Medicare Advantage|UHC MEDICARE GOLD MA|4,645.55||||4,645.55||| 74175|EAP|0350|CT ANGIO ABDOMEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,573.50||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Veterans Affairs|VETERANS ADMINISTRATION|||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Workers Compensation|WORKERS COMPENSATION OTHER|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6,257.15||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7,073.30||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Blue Cross HMO Specialty|BCBSTX HMO|54.41||||6,257.15||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6,257.15||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Blue Cross PPO Specialty|BCBSTX OTHER|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Aetna|AETNA PPO|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Blue Cross PPO Specialty|BCBSTX PPO|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Humana Medicare Advantage|HUMANA MA|54.41||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Cigna|CIGNA|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Medicaid|MEDICAID|||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Aenta Medicare Advantage|AETNA MEDICARE MA|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicare|BCBS MEDICARE PPO MA|||||6,257.15||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6,257.15||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicaid|MEDICAID SUPERIOR|54.41||||6,257.15||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Medicaid|MEDICAID HMO|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|54.41||||6,257.15||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Medicare Advantage|UHC MEDICARE GOLD MA|54.41||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicare|HEALTHSPRING MA|||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicaid|MEDICAID AMERIGROUP|||||6,257.15||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|NON CONTRACTED|COMMERCIAL OTHER 1|54.41||||6,257.15||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|PHCS|MULTIPLAN PHCS|||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Medicare|MEDICARE ACUTE|7,073.30||||7,073.30||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Healthcare|UNITED HEALTHCARE OTHER|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Healthcare|TML GROUP BENEFITS|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Healthcare|UNITED HEALTHCARE|||||7,073.30||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicare|MEDICARE PART B ONLY IP|8,175.07||||||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|UTMB|UTMB CORRECTIONAL MANAGED CARE|7,108.75||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|NON CONTRACTED|COMMERCIAL OTHER 1|7,108.75||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Tricare|TRICARE EAST REGION|||||8,175.07||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Healthcare|UNITED HEALTHCARE OTHER|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Healthcare|UNITED HEALTHCARE|||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicare|MEDICARE ACUTE|9,241.38||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|PHCS|HUMANA INSURANCE|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8,175.07||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicaid|MEDICAID SUPERIOR|9,241.38||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicaid|MEDICAID AMERIGROUP|||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicare|WELLCARE CHOICE MA|9,241.38||||||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicare|HEALTHSPRING MA|||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicare|BCBS MEDICARE PPO MA|9,241.38||||||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicaid|MEDICAID|9,241.38||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7,108.75||||8,175.07||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicaid|MEDICAID HMO|||||8,175.07||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9,241.38||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|9,241.38||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Cigna|CIGNA|||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|ChampVA|CHAMPVA CENTER|7,108.75||||||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Healthcare|UNITED HEALTHCARE|9,241.38||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Humana Medicare Advantage|HUMANA MA|8,175.07||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross PPO Specialty|BCBSTX OTHER|||||8,175.07||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|NON CONTRACTED|COMMERCIAL OTHER 2|||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Aetna|AETNA PPO|||||8,175.07||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross PPO Specialty|BCBSTX PPO|9,241.38||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|9,241.38||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Aenta Medicare Advantage|AETNA MEDICARE MA|9,241.38||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross HMO Specialty|BCBSTX HMO|9,241.38||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9,241.38||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||8,175.07||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Medicare Advantage|UHC MEDICARE GOLD MA|9,241.38||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7,108.75||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Medicare Advantage|AARP UHC WEST COMPLETE MA|9,241.38||||9,241.38||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Workers Compensation|WORKERS COMPENSATION OTHER|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Veterans Affairs|VETERANS ADMINISTRATION|9,241.38||||9,241.38||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10,479.30||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Blue Cross PPO Specialty|BCBSTX PPO|||||10,479.30||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Managed Medicaid|MEDICAID AMERIGROUP|||||10,479.30||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Medicare|MEDICARE ACUTE|||||10,479.30||| 74182|EAP|0610|MRI ABDOMEN W/CONTRAST|Medicare|MEDICARE ACUTE|34.62||||34.62||| 74182|EAP|0610|MRI ABDOMEN W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|34.62||||||| 74182|EAP|0610|MRI ABDOMEN W/CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||34.62||| 74182|EAP|0610|MRI ABDOMEN W/CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||34.62||| 74182|EAP|0610|MRI ABDOMEN W/CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||34.62||| 74182|EAP|0610|MRI ABDOMEN W/CONTRAST|Veterans Affairs|VETERANS ADMINISTRATION|34.62||||||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8,379.04||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,379.04||||8,379.04||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Humana Medicare Advantage|HUMANA MA|||||8,379.04||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Managed Medicare|HEALTHSPRING MA|8,379.04||||||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 1|7,914.25||||||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Medicare|MEDICARE ACUTE|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|United Healthcare|UNITED HEALTHCARE|||||8,379.04||| 74240|EAP|0320|UPPER GI SERIES|Medicare|MEDICARE ACUTE|||||1,485.50||| 74240|EAP|0320|UPPER GI SERIES|United Healthcare|UNITED HEALTHCARE|||||1,485.50||| 74240|EAP|0320|UPPER GI SERIES|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,485.50||| 74240|EAP|0320|UPPER GI SERIES|Blue Cross PPO Specialty|BCBSTX PPO|||||1,485.50||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|28,961.57|6943.49|20062.56|6943.49|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Medicare|MEDICARE ACUTE|46,448.57|9917.57|20062.56|6943.49|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|35,635.10|20062.56|20062.56|6943.49|||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Medicare|MEDICARE ACUTE|1,800.12||||1,479.50||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Medicaid|MEDICAID|||||1,800.12||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Managed Medicaid|MEDICAID AMERIGROUP|1,479.50||||1,800.12||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Managed Medicaid|MEDICAID SUPERIOR|1,479.50||||1,800.12||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,800.12||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,800.12||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,639.81||| 74740|EAP|0320|HYSTEROSALPINGOGRAM|Blue Cross PPO Specialty|BCBSTX PPO|||||21.84||| 75635|EAP|0350|CT ANGIO AORTA/ILIOFEM RU|NON CONTRACTED|COMMERCIAL OTHER 1|||||4,103.75||| 75635|EAP|0350|CT ANGIO AORTA/ILIOFEM RU|Medicare|MEDICARE ACUTE|||||4,103.75||| 75635|EAP|0350|CT ANGIO AORTA/ILIOFEM RU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5,334.88||| 75635|EAP|0350|CT ANGIO AORTA/ILIOFEM RU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,103.75||| 75635|EAP|0350|CT ANGIO AORTA/ILIOFEM RU|Blue Cross HMO Specialty|BCBSTX HMO|||||4,103.75||| 759|DRG||INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC|Medicaid|MEDICAID|31,771.51|8153.2|8153.2|8153.2|||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Cigna|CIGNA|987.03||||987.03||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Humana Medicare Advantage|HUMANA MA|595.42||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Cigna|CIGNA|987.03||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Blue Cross PPO Specialty|BCBSTX PPO|873.14||||517.15||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Blue Cross HMO Specialty|BCBSTX HMO|||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Aenta Medicare Advantage|AETNA MEDICARE MA|517.15||||987.03||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Aetna|AETNA PPO|||||595.42||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|752.09||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Blue Cross PPO Specialty|BCBSTX PPO|873.14||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Workers Compensation|WORKERS COMPENSATION OTHER|517.15||||987.03||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|987.03||||517.15||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|United Medicare Advantage|UHC MEDICARE GOLD MA|987.03||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|752.09||||517.15||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|United Medicare Advantage|AARP UHC WEST COMPLETE MA|752.09||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Workers Compensation|WORKERS COMPENSATION OTHER|517.15||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Medicare Advantage|UHC MEDICARE GOLD MA|987.03||||873.14||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Blue Cross HMO Specialty|BCBSTX HMO|||||987.03||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||987.03||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Medicare|MEDICARE ACUTE|673.08||||595.42||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Healthcare|UNITED HEALTHCARE|||||517.15||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|NON CONTRACTED|COMMERCIAL OTHER 1|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Humana Medicare Advantage|HUMANA MA|987.03||||987.03||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Medicare|MEDICARE ACUTE|987.03||||752.09||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Tricare|TRICARE EAST REGION|||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Healthcare|UNITED HEALTHCARE|673.08||||987.03||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||987.03||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Cigna|CIGNA|517.15||||||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Managed Medicaid|MEDICAID AMERIGROUP|||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|987.03||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|987.03||||517.15||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Managed Medicare|HEALTHSPRING MA|987.03||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Managed Medicaid|MEDICAID SUPERIOR|638.20||||517.15||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Managed Medicaid|MEDICAID SUPERIOR|595.42||||595.42||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Medicaid|MEDICAID|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||673.08||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Managed Medicaid|MEDICAID AMERIGROUP|||||673.08||| 76499|EAP|0320|XR MRI CLEARANCE FOR META|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||618.75||| 76499|EAP|0320|XR MRI CLEARANCE FOR META|Managed Medicare|HEALTHSPRING MA|||||804.38||| 76499|EAP|0320|XR MRI CLEARANCE FOR META|Medicare|MEDICARE ACUTE|||||804.38||| 76499|EAP|0320|XR MRI CLEARANCE FOR META|Humana Medicare Advantage|HUMANA MA|||||618.75||| 76536|EAP|0400|THYROID ULTRASOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,422.53||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,422.53||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Blue Cross PPO Specialty|BCBSTX PPO|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|Aenta Medicare Advantage|AETNA MEDICARE MA|1,422.53||||||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||380.25||| 76536|EAP|0400|THYROID ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|||||1,258.39||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Cigna|CIGNA|||||380.25||| 76536|EAP|0400|THYROID ULTRASOUND|Cigna|CIGNA|||||1,258.39||| 76536|EAP|0400|THYROID ULTRASOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Humana Medicare Advantage|HUMANA MA|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Humana Medicare Advantage|HUMANA MA|||||380.25||| 76536|EAP|0400|THYROID ULTRASOUND|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|NON CONTRACTED|COMMERCIAL OTHER 1|||||737.25||| 76536|EAP|0400|THYROID ULTRASOUND|Medicare|MEDICARE ACUTE|1,094.25||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Medicare|MEDICARE ACUTE|1,094.25||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|United Healthcare|UNITED HEALTHCARE|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|United Healthcare|UNITED HEALTHCARE|||||1,258.39||| 76536|EAP|0400|THYROID ULTRASOUND|Medicaid|MEDICAID|||||1,422.53||| 76536|EAP|0400|THYROID ULTRASOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,422.53||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|Managed Medicare|HEALTHSPRING MA|||||1,422.53||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|Managed Medicaid|MEDICAID AMERIGROUP|||||778.05||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|Medicare|MEDICARE ACUTE|||||778.05||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Cigna|CIGNA|||||3.38||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Humana Medicare Advantage|HUMANA MA|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||439.40||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|||||3.38||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.38||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||439.40||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.38||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Blue Cross HMO Specialty|BCBSTX HMO|||||3.38||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Blue Cross HMO Specialty|BCBSTX HMO|||||3.38||| 76641|EAP|0402|US LEFT BREAST COMPLETE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||439.40||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||388.70||| 76641|EAP|0402|US LEFT BREAST COMPLETE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.38||| 76641|EAP|0402|US LEFT BREAST COMPLETE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||439.40||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||439.40||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||388.70||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Medicare|MEDICARE ACUTE|||||439.40||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Medicare|MEDICARE ACUTE|||||439.40||| 76641|EAP|0402|US LEFT BREAST COMPLETE|NON CONTRACTED|COMMERCIAL OTHER 1|||||439.40||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||388.70||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||388.70||| 76641|EAP|0402|US LEFT BREAST COMPLETE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||439.40||| 76641|EAP|0402|US LEFT BREAST COMPLETE|United Healthcare|UNITED HEALTHCARE|||||388.70||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|NON CONTRACTED|COMMERCIAL OTHER 1|||||388.70||| 76641|EAP|0402|US LEFT BREAST COMPLETE|United Healthcare|UNITED HEALTHCARE OTHER|||||3.38||| 76641|EAP|0402|US LEFT BREAST COMPLETE|United Healthcare|UNITED HEALTHCARE|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|United Healthcare|UNITED HEALTHCARE OTHER|||||3.38||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Tricare|TRICARE EAST REGION|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Humana Medicare Advantage|HUMANA MA|||||388.70||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Managed Medicaid|MEDICAID SUPERIOR|||||388.70||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|||||439.40||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||439.40||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|||||439.40||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Managed Medicare|HEALTHSPRING MA|||||439.40||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Managed Medicare|HEALTHSPRING MA|||||439.40||| 76641|EAP|0402|US LEFT BREAST COMPLETE|Managed Medicaid|MEDICAID SUPERIOR|||||3.38||| 76641|EAP|0402|US RIGHT BREAST COMPLETE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||388.70||| 76642|EAP|0402|US LEFT BREAST LIMITED|Managed Medicaid|MEDICAID SUPERIOR|||||2.86||| 76642|EAP|0402|US RIGHT BREAST LIMITED|Managed Medicare|HEALTHSPRING MA|||||371.80||| 76642|EAP|0402|US LEFT BREAST LIMITED|Medicare|MEDICARE ACUTE|||||328.90||| 76642|EAP|0402|US LEFT BREAST LIMITED|United Healthcare|UNITED HEALTHCARE|||||371.80||| 76642|EAP|0402|US RIGHT BREAST LIMITED|Medicare|MEDICARE ACUTE|||||371.80||| 76642|EAP|0402|US LEFT BREAST LIMITED|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||371.80||| 76642|EAP|0402|US RIGHT BREAST LIMITED|United Medicare Advantage|UHC MEDICARE GOLD MA|||||371.80||| 76642|EAP|0402|US RIGHT BREAST LIMITED|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||371.80||| 76642|EAP|0402|US LEFT BREAST LIMITED|Veterans Affairs|VETERANS ADMINISTRATION|||||371.80||| 76642|EAP|0402|US LEFT BREAST LIMITED|United Medicare Advantage|UHC MEDICARE GOLD MA|||||328.90||| 76642|EAP|0402|US LEFT BREAST LIMITED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||371.80||| 76642|EAP|0402|US LEFT BREAST LIMITED|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.86||| 76642|EAP|0402|US LEFT BREAST LIMITED|Blue Cross PPO Specialty|BCBSTX PPO|||||371.80||| 76642|EAP|0402|US RIGHT BREAST LIMITED|Managed Medicaid|MEDICAID SUPERIOR|||||371.80||| 76642|EAP|0402|US RIGHT BREAST LIMITED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||371.80||| 76642|EAP|0402|US RIGHT BREAST LIMITED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||371.80||| 76642|EAP|0402|US RIGHT BREAST LIMITED|Blue Cross PPO Specialty|BCBSTX PPO|||||371.80||| 76642|EAP|0402|US LEFT BREAST LIMITED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.86||| 76642|EAP|0402|US RIGHT BREAST LIMITED|Cigna|CIGNA|||||371.80||| 76642|EAP|0402|US LEFT BREAST LIMITED|Cigna|CIGNA|||||328.90||| 76642|EAP|0402|US RIGHT BREAST LIMITED|Humana Medicare Advantage|HUMANA MA|||||2.86||| 76642|EAP|0402|US LEFT BREAST LIMITED|Humana Medicare Advantage|HUMANA MA|||||371.80||| 76700|EAP|0400||Cigna|CIGNA|||||13.16||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Humana Medicare Advantage|HUMANA MA|||||2,139.87||| 76700|EAP|0400||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Blue Cross HMO Specialty|BCBSTX HMO|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,418.98||| 76700|EAP|0400||Blue Cross PPO Specialty|BCBSTX PPO|||||1,710.80||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Aetna|AETNA PPO|||||2,418.98||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|1,860.75||||2,418.98||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,139.87||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Tricare|TRICARE EAST REGION|||||2,418.98||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Medicare|MEDICARE ACUTE|1,860.75||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,860.75||| 76700|EAP|0400||United Healthcare|UNITED HEALTHCARE|||||1,785.78||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,860.75||| 76700|EAP|0400||Humana Medicare Advantage|HUMANA MA|||||1,860.75||| 76700|EAP|0400||Tricare|TRICARE EAST REGION|||||13.16||| 76700|EAP|0400||NON CONTRACTED|COMMERCIAL OTHER 1|||||1,860.75||| 76700|EAP|0400||Medicare|MEDICARE ACUTE|1,710.80||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|United Healthcare|UNITED HEALTHCARE|1,860.75||||||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Medicaid|MEDICAID|||||2,418.98||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,418.98||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Managed Medicaid|MEDICAID SUPERIOR|2,418.98||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,860.75||||||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Managed Medicaid|MEDICAID AMERIGROUP|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Managed Medicare|HEALTHSPRING MA|||||2,139.87||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Medicaid|MEDICAID HMO|||||1,860.75||| 76700|EAP|0400||Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,710.80||||13.16||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Managed Medicaid|MEDICAID SUPERIOR|1,395.75||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Managed Medicaid|MEDICAID AMERIGROUP|||||1,814.48||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,395.75||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Managed Medicaid|MEDICAID SUPERIOR|1,395.75||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Managed Medicaid|MEDICAID AMERIGROUP|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Medicaid|MEDICAID|||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Medicaid|MEDICAID|||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Managed Medicare|HEALTHSPRING MA|||||1,155.50||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Medicaid|MEDICAID HMO|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|NON CONTRACTED|COMMERCIAL OTHER 1|1,395.75||||1,814.48||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Medicare|MEDICARE ACUTE|1,395.75||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Tricare|TRICARE EAST REGION|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|United Healthcare|UNITED HEALTHCARE|||||1,814.48||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Medicare|MEDICARE ACUTE|1,605.12||||1,605.12||| 76705|EAP|0450|US ABDOMINAL FAST BEDSIDE|United Healthcare|UNITED HEALTHCARE|||||917.73||| 76705|EAP|0400|US EXAM ABDOMEN LIMITED|Medicare|MEDICARE ACUTE|||||1,710.80||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|PHCS|HUMANA INSURANCE|||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|NON CONTRACTED|COMMERCIAL OTHER 1|1,395.75||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|1,395.75||||1,814.48||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Healthcare|UNITED HEALTHCARE|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Managed Medicare|HEALTHSPRING MA|||||1,814.48||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,814.48||| 76705|EAP|0400|US EXAM ABDOMEN LIMITED|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,710.80||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1,814.48||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Medicare Advantage|UHC MEDICARE GOLD MA|1,395.75||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,814.48||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Aetna|AETNA PPO|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,605.12||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|1,814.48||||1,814.48||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Blue Cross HMO Specialty|BCBSTX HMO|||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Blue Cross PPO Specialty|BCBSTX PPO|1,395.75||||1,395.75||| 76705|EAP|0400|US EXAM ABDOMEN LIMITED|Blue Cross PPO Specialty|BCBSTX PPO|||||1,710.80||| 76705|EAP|0400|US EXAM ABDOMEN LIMITED|Humana Medicare Advantage|HUMANA MA|||||1,710.80||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Humana Medicare Advantage|HUMANA MA|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Humana Medicare Advantage|HUMANA MA|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,814.48||| 76706|EAP|0402|US AORTA SCREENING|Humana Medicare Advantage|HUMANA MA|||||795.93||| 76706|EAP|0402|US AORTA SCREENING|Blue Cross PPO Specialty|BCBSTX PPO|||||795.93||| 76706|EAP|0402|US AORTA SCREENING|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||795.93||| 76706|EAP|0402|US AORTA SCREENING|Medicare|MEDICARE ACUTE|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||795.93||| 76706|EAP|0402|US AORTA SCREENING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Managed Medicare|HEALTHSPRING MA|||||795.93||| 76770|EAP|0400|RETROPERITONEAL ULTRASOUN|Medicare|MEDICARE ACUTE|||||11.28||| 76770|EAP|0400|RETROPERITONEAL ULTRASOUN|Humana Medicare Advantage|HUMANA MA|||||1,466.40||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,435.50||||1,866.15||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Veterans Affairs|VETERANS ADMINISTRATION|||||1,650.83||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,866.15||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Blue Cross PPO Specialty|BCBSTX PPO|1,435.50||||1,866.15||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Blue Cross HMO Specialty|BCBSTX HMO|||||1,866.15||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Aetna|AETNA OTHER|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,650.83||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,866.15||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,866.15||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Aetna|AETNA PPO|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,866.15||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Humana Medicare Advantage|HUMANA MA|1,435.50||||1,650.83||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Managed Medicaid|MEDICAID SUPERIOR|1,435.50||||||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Managed Medicare|BCBS MEDICARE PPO MA|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Managed Medicare|HEALTHSPRING MA|||||1,866.15||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Medicaid|MEDICAID|||||1,650.83||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,866.15||||||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,866.15||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Managed Medicaid|MEDICAID AMERIGROUP|1,435.50||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|Medicare|MEDICARE ACUTE|1,650.83||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|United Healthcare|UNITED HEALTHCARE OTHER|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|United Healthcare|UNITED HEALTHCARE|||||1,435.50||| 76775|EAP|0400|RETROPERITONEAL LIMITED U|PHCS|HUMANA INSURANCE|||||1,435.50||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|United Healthcare|UMR UNITED MEDICAL RESOURCES|28,615.28|51.79|9812.89|51.79|||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|Managed Medicaid|MEDICAID SUPERIOR|29,677.23|9812.89|9812.89|51.79|||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Blue Cross PPO Specialty|BCBSTX PPO|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Aetna|AETNA PPO|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Blue Cross HMO Specialty|BCBSTX HMO|||||1,205.78||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Cigna|CIGNA|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Managed Medicaid|MEDICAID AMERIGROUP|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Medicaid|MEDICAID HMO|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Medicaid|MEDICAID|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Managed Medicaid|MEDICAID SUPERIOR|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Medicare|MEDICARE ACUTE|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|United Healthcare|TML GROUP BENEFITS|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,205.78||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|United Healthcare|UNITED HEALTHCARE|||||1,363.05||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|United Healthcare|UNITED HEALTHCARE|||||1,205.78||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Tricare|TRICARE EAST REGION|||||1,363.05||| 76802|EAP|0400|US @ADD GEST BEFORE 14WKS|Managed Medicaid|MEDICAID AMERIGROUP|||||453.70||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Cigna|CIGNA|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Cigna|CIGNA|||||1,738.80||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Blue Cross HMO Specialty|BCBSTX HMO|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Aetna|AETNA PPO|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Blue Cross PPO Specialty|BCBSTX PPO|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Medicare|MEDICARE ACUTE|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|NON CONTRACTED|COMMERCIAL OTHER 1|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|United Healthcare|UNITED HEALTHCARE|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Tricare|TRICARE EAST REGION|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Medicaid|MEDICAID|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Managed Medicaid|MEDICAID SUPERIOR|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Managed Medicaid|MEDICAID AMERIGROUP|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,738.80||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Medicaid|MEDICAID HMO|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,965.60||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,965.60||| 76810|EAP|0400|US @ ADD GEST AFTER 14WKS|Managed Medicaid|MEDICAID SUPERIOR|453.70||||453.70||| 76810|EAP|0400|US @ ADD GEST AFTER 14WKS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.49||| 76810|EAP|0400|US @ ADD GEST AFTER 14WKS|Managed Medicaid|MEDICAID AMERIGROUP|3.49||||3.49||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||626.60||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Aetna|AETNA PPO|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Workers Compensation|WORKERS COMPENSATION OTHER|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Blue Cross PPO Specialty|BCBSTX PPO|554.30||||626.60||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|NON CONTRACTED|COMMERCIAL OTHER 1|||||626.60||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||626.60||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||626.60||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||626.60||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Managed Medicaid|MEDICAID SUPERIOR|626.60||||626.60||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Medicaid|MEDICAID|626.60||||626.60||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||626.60||| 76815|EAP|0450|US PREGNANCY (KNOWN PREG)|Managed Medicaid|MEDICAID SUPERIOR|||||874.13||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Managed Medicaid|MEDICAID AMERIGROUP|||||626.60||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Medicaid|MEDICAID|904.15||||799.83||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||904.15||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||904.15||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Managed Medicaid|MEDICAID SUPERIOR|695.50||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||904.15||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Medicaid|MEDICAID HMO|||||799.83||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Managed Medicaid|MEDICAID AMERIGROUP|904.15||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Medicare|MEDICARE ACUTE|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|NON CONTRACTED|COMMERCIAL OTHER 1|||||799.83||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Tricare|TRICARE EAST REGION|||||799.83||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|United Healthcare|UNITED HEALTHCARE|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||904.15||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Cigna|CIGNA|||||799.83||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Aetna|AETNA OTHER|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Blue Cross PPO Specialty|BCBSTX PPO|904.15||||904.15||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Blue Cross HMO Specialty|BCBSTX HMO|||||904.15||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|904.15||||904.15||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Aetna|AETNA PPO|||||904.15||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||799.83||| 76817|EAP|0400|US TRANSVAGINAL PREG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,528.48||| 76817|EAP|0400|US TRANSVAGINAL PREG|Blue Cross PPO Specialty|BCBSTX PPO|1,175.75||||1,528.48||| 76817|EAP|0400|US TRANSVAGINAL PREG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,528.48||| 76817|EAP|0400|US TRANSVAGINAL PREG|Blue Cross HMO Specialty|BCBSTX HMO|||||1,528.48||| 76817|EAP|0400|US TRANSVAGINAL PREG|Access Direct Platinum|HEALTHFIRST TPA UMR|1,175.75||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,528.48||| 76817|EAP|0400|US TRANSVAGINAL PREG|Cigna|CIGNA|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Cigna|CIGNA|||||1,528.48||| 76817|EAP|0400|US TRANSVAGINAL PREG|NON CONTRACTED|COMMERCIAL OTHER 1|1,528.48||||1,352.12||| 76817|EAP|0400|US TRANSVAGINAL PREG|United Healthcare|UNITED HEALTHCARE|||||1,528.48||| 76817|EAP|0400|US TRANSVAGINAL PREG|United Healthcare|UNITED HEALTHCARE|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Medicaid|MEDICAID|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Managed Medicaid|MEDICAID AMERIGROUP|||||1,528.48||| 76817|EAP|0400|US TRANSVAGINAL PREG|Managed Medicaid|MEDICAID SUPERIOR|1,528.48||||1,528.48||| 76818|EAP|0320|FETAL BIOPHYS PROFILE W/N|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||984.10||| 76818|EAP|0320|FETAL BIOPHYS PROFILE W/N|Managed Medicaid|MEDICAID SUPERIOR|984.10||||984.10||| 76818|EAP|0320|FETAL BIOPHYS PROFILE W/N|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||984.10||| 76818|EAP|0320|FETAL BIOPHYS PROFILE W/N|Managed Medicaid|MEDICAID AMERIGROUP|||||984.10||| 76818|EAP|0320|FETAL BIOPHYS PROFILE W/N|Cigna|CIGNA|984.10||||||| 76818|EAP|0320|FETAL BIOPHYS PROFILE W/N|Blue Cross PPO Specialty|BCBSTX PPO|||||984.10||| 76818|EAP|0320|FETAL BIOPHYS PROFILE W/N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||984.10||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|984.10||||984.10||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|984.10||||984.10||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Aetna|AETNA PPO|||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Blue Cross PPO Specialty|BCBSTX PPO|870.55||||870.55||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Cigna|CIGNA|||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|United Healthcare|UNITED HEALTHCARE|||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Medicare|MEDICARE ACUTE|7.57||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||984.10||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Managed Medicaid|MEDICAID AMERIGROUP|984.10||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Managed Medicaid|MEDICAID SUPERIOR|7.57||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.57||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Medicaid|MEDICAID|984.10||||7.57||| 76819|EAP|0320|FETAL BIOPHYSICAL PROFILE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||984.10||| 76820|EAP|0402|UMBILICAL ARTERY,ECHO|Managed Medicaid|MEDICAID SUPERIOR|||||5.04||| 76820|EAP|0402|UMBILICAL ARTERY,ECHO|Managed Medicaid|MEDICAID AMERIGROUP|||||5.04||| 76820|EAP|0402|UMBILICAL ARTERY,ECHO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||655.20||| 76820|EAP|0402|UMBILICAL ARTERY,ECHO|Blue Cross PPO Specialty|BCBSTX PPO|||||655.20||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,397.50||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Cigna|CIGNA|||||1,236.25||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Humana Medicare Advantage|HUMANA MA|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,397.50||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Blue Cross PPO Specialty|BCBSTX OTHER|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Blue Cross PPO Specialty|BCBSTX PPO|||||1,397.50||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Blue Cross HMO Specialty|BCBSTX HMO|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Aetna|AETNA PPO|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Medicare|MEDICARE ACUTE|||||1,397.50||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Healthcare|UNITED HEALTHCARE|||||1,236.25||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Healthcare|TML GROUP BENEFITS|||||1,397.50||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|PHCS|HUMANA INSURANCE|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Healthcare|UNITED HEALTHCARE|||||1,397.50||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|NON CONTRACTED|COMMERCIAL OTHER 1|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Tricare|TRICARE EAST REGION|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Medicaid|MEDICAID|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,397.50||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Managed Medicaid|MEDICAID SUPERIOR|||||1,236.25||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Managed Medicaid|MEDICAID AMERIGROUP|||||1,397.50||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,965.60||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicare|HEALTHSPRING MA|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicaid|MEDICAID SUPERIOR|15.12||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicaid|MEDICAID AMERIGROUP|||||1,738.80||| 76856|EAP|0402|PELVIC ULTRASOUND|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|Tricare|TRICARE EAST REGION|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Medicaid|MEDICAID|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|PHCS|HUMANA INSURANCE|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|United Healthcare|TML GROUP BENEFITS|||||1,738.80||| 76856|EAP|0402|PELVIC ULTRASOUND|United Healthcare|UNITED HEALTHCARE|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Medicare|MEDICARE ACUTE|15.12||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|United Healthcare|UNITED HEALTHCARE|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,738.80||| 76856|EAP|0402|PELVIC ULTRASOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|Aetna|AETNA PPO|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|1,738.80||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|Blue Cross HMO Specialty|BCBSTX HMO|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,738.80||| 76856|EAP|0402|PELVIC ULTRASOUND|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|Cigna|CIGNA|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Humana Medicare Advantage|HUMANA MA|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,965.60||| 76856|EAP|0402|PELVIC ULTRASOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,965.60||| 76857|EAP|0402|US PELVIS LIMITED|United Medicare Advantage|UHC MEDICARE GOLD MA|||||631.25||| 76857|EAP|0402|US PELVIS LIMITED|Aenta Medicare Advantage|AETNA MEDICARE MA|||||820.63||| 76857|EAP|0402|US PELVIS LIMITED|Blue Cross PPO Specialty|BCBSTX PPO|||||749.82||| 76857|EAP|0450|US PELVIC LIMITED - BEDSI|Blue Cross PPO Specialty|BCBSTX PPO|||||6.79||| 76857|EAP|0402|US PELVIS LIMITED|Medicare|MEDICARE ACUTE|6.79||||820.63||| 76857|EAP|0450|US PELVIC LIMITED - BEDSI|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||6.79||| 76857|EAP|0450|US PELVIC LIMITED - BEDSI|Managed Medicaid|MEDICAID AMERIGROUP|||||6.79||| 76857|EAP|0402|US PELVIS LIMITED|Medicaid|MEDICAID HMO|||||6.79||| 76857|EAP|0402|US PELVIS LIMITED|Managed Medicaid|MEDICAID SUPERIOR|820.63||||||| 76870|EAP|0400|SCROTUM ULTRASOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||994.18||| 76870|EAP|0400|SCROTUM ULTRASOUND|Managed Medicaid|MEDICAID AMERIGROUP|||||1,123.85||| 76870|EAP|0400|SCROTUM ULTRASOUND|Medicaid|MEDICAID|864.50||||||| 76870|EAP|0400|SCROTUM ULTRASOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,123.85||| 76870|EAP|0400|SCROTUM ULTRASOUND|Managed Medicare|HEALTHSPRING MA|||||1,123.85||| 76870|EAP|0400|SCROTUM ULTRASOUND|Medicare|MEDICARE ACUTE|||||1,123.85||| 76870|EAP|0400|SCROTUM ULTRASOUND|United Healthcare|UNITED HEALTHCARE|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|NON CONTRACTED|COMMERCIAL OTHER 1|||||994.18||| 76870|EAP|0400|SCROTUM ULTRASOUND|UTMB|UTMB CORRECTIONAL MANAGED CARE|864.50||||||| 76870|EAP|0400|SCROTUM ULTRASOUND|Cigna|CIGNA|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Humana Medicare Advantage|HUMANA MA|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|||||1,123.85||| 76870|EAP|0400|SCROTUM ULTRASOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,123.85||| 76870|EAP|0400|SCROTUM ULTRASOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||864.50||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||348.40||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Veterans Affairs|VETERANS ADMINISTRATION|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Blue Cross PPO Specialty|BCBSTX PPO|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Humana Medicare Advantage|HUMANA MA|||||348.40||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Medicare|MEDICARE ACUTE|2.68||||348.40||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.68||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Managed Medicaid|MEDICAID SUPERIOR|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Managed Medicare|BCBS MEDICARE PPO MA|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Managed Medicaid|MEDICAID AMERIGROUP|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|United Healthcare|UNITED HEALTHCARE|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Medicare|MEDICARE ACUTE|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Humana Medicare Advantage|HUMANA MA|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Cigna|CIGNA|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Blue Cross PPO Specialty|BCBSTX PPO|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.08||| 76942|EAP|0964|CRNA US GUIDANCE NERVE BL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8.08||| 770|DRG||ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY|Managed Medicaid|MEDICAID SUPERIOR|22,805.52|12216.69|12216.69|12216.69|||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Medicare|MEDICARE ACUTE|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||500.25||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|NON CONTRACTED|COMMERCIAL OTHER 1|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|United Healthcare|UNITED HEALTHCARE|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Managed Medicare|HEALTHSPRING MA|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Managed Medicaid|MEDICAID SUPERIOR|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Aenta Medicare Advantage|AETNA MEDICARE MA|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Tricare|TRICARE EAST REGION|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Medicare|MEDICARE ACUTE|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||500.25||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Blue Cross PPO Specialty|BCBSTX PPO|||||565.50||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Blue Cross HMO Specialty|BCBSTX HMO|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Cigna|CIGNA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Humana Medicare Advantage|HUMANA MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Humana Medicare Advantage|HUMANA MA|||||565.50||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Blue Cross HMO Specialty|BCBSTX HMO|||||5.35||| 77066|EAP|0403||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||600.60||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||695.50||| 77066|EAP|0403||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||600.60||| 77066|EAP|0403||Blue Cross PPO Specialty|BCBSTX PPO|||||600.60||| 77066|EAP|0403||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.62||| 77066|EAP|0403||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||600.60||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||695.50||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Humana Medicare Advantage|HUMANA MA|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||695.50||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Managed Medicare|HEALTHSPRING MA|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Managed Medicaid|MEDICAID SUPERIOR|||||615.25||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Medicare|MEDICARE ACUTE|||||695.50||| 77066|EAP|0403||Medicare|MEDICARE ACUTE|||||567.80||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|United Healthcare|UNITED HEALTHCARE|||||695.50||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.35||| 77066|EAP|0403||United Healthcare|UNITED HEALTHCARE|||||5.35||| 77066|EAP|0403||NON CONTRACTED|COMMERCIAL OTHER 1|||||4.62||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|United Healthcare|UNITED HEALTHCARE OTHER|||||5.35||| 77067|EAP|0403|SCREENING MAMMO LEFT W/CA|Medicare|MEDICARE ACUTE|||||565.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Medicare|MEDICARE ACUTE|||||5.35||| 77067|EAP|0403|SCREEN MAMO/IMPLANTS/RT|Medicare|MEDICARE ACUTE|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Tricare|TRICARE FOR LIFE|||||695.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Tricare|TRICARE EAST REGION|||||5.35||| 77067|EAP|0403|SCREENING MAMMO RIGHT W/C|Medicare|MEDICARE ACUTE|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Medicaid|MEDICAID|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||695.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicare|BCBS MEDICARE PPO MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicare|HEALTHSPRING MA|||||695.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicaid|MEDICAID SUPERIOR|||||5.35||| 77067|EAP|0403|SCREENING MAMMO RIGHT W/C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||565.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||695.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||615.25||| 77067|EAP|0403|SCREENING MAMMO RIGHT W/C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Healthcare|UNITED HEALTHCARE|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||695.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Veterans Affairs|VETERANS ADMINISTRATION|||||615.25||| 77067|EAP|0403|SCREENING MAMMO RIGHT W/C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||565.50||| 77067|EAP|0403|SCREENING MAMMO LEFT W/CA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Aenta Medicare Advantage|AETNA MEDICARE MA|||||695.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Blue Cross PPO Specialty|BCBSTX PPO|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||695.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Aetna|AETNA PPO|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Blue Cross HMO Specialty|BCBSTX HMO|||||615.25||| 77067|EAP|0403|SCREENING MAMMO LEFT W/CA|Blue Cross HMO Specialty|BCBSTX HMO|||||565.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|ChampVA|CHAMPVA CENTER|||||695.50||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Humana Medicare Advantage|HUMANA MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Cigna|CIGNA|||||5.35||| 77072|EAP|0320|BONE AGE|Blue Cross PPO Specialty|BCBSTX PPO|||||596.81||| 77072|EAP|0320|BONE AGE|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|NON CONTRACTED|COMMERCIAL OTHER 1|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Medicare|MEDICARE ACUTE|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|United Healthcare|UNITED HEALTHCARE|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicare|BCBS MEDICARE PPO MA|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicare|HEALTHSPRING MA|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicaid|MEDICAID SUPERIOR|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|United Medicare Advantage|UHC MEDICARE GOLD MA|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Workers Compensation|WORKERS COMPENSATION OTHER|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Humana Medicare Advantage|HUMANA MA|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Aenta Medicare Advantage|AETNA MEDICARE MA|||||489.95||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Blue Cross PPO Specialty|BCBSTX PPO|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Access Direct Platinum|HEALTHFIRST TPA UMR|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||525.65||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||454.25||| 77081|EAP|0320|BONE DENSITY RADIUS WRIST|Blue Cross PPO Specialty|BCBSTX PPO|||||525.65||| 77081|EAP|0320|BONE DENSITY RADIUS WRIST|Medicare|MEDICARE ACUTE|||||489.95||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Medicaid|MEDICAID|7,389.25|4793.19|9639.55|4793.19|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Managed Medicaid|MEDICAID AMERIGROUP|29,246.13|9639.55|9639.55|4793.19|||| 779|DRG||ABORTION W/O D&C|Managed Medicaid|MEDICAID SUPERIOR|24,559.69|10722.85|10722.85|10722.85|||| 78|DRG||HYPERTENSIVE ENCEPHALOPATHY W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|43,074.57|8692.16|8692.16|8544.32|||| 78|DRG||HYPERTENSIVE ENCEPHALOPATHY W CC|Medicare|MEDICARE ACUTE|491.01|8545.6|8692.16|8544.32|||| 78|DRG||HYPERTENSIVE ENCEPHALOPATHY W CC|Humana Medicare Advantage|HUMANA MA|74,838.40|8544.32|8692.16|8544.32|||| 78014|EAP|0341|THYROID IMAGING W/UPTAKE|Medicare|MEDICARE ACUTE|||||2,142.75||| 78071|EAP|0341|PARATHYROID IDENTITY SCAN|Medicare|MEDICARE ACUTE|1,513.50||||1,513.50||| 78227|EAP|0341|HIDA W/CCK|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Blue Cross PPO Specialty|BCBSTX PPO|3,143.25||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Blue Cross HMO Specialty|BCBSTX HMO|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Aetna|BOON CHAPMAN|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Humana Medicare Advantage|HUMANA MA|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Managed Medicaid|MEDICAID SUPERIOR|3,143.25||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Managed Medicaid|MEDICAID AMERIGROUP|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Medicare|MEDICARE ACUTE|||||3,143.25||| 78264|EAP|0341|GASTROINTESTINAL SCAN - D|Medicare|MEDICARE ACUTE|||||1,980.75||| 78264|EAP|0341|GASTROINTESTINAL SCAN - D|Humana Medicare Advantage|HUMANA MA|||||1,980.75||| 78278|EAP|0341|GASTROINTESTINAL BLOOD LO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.76||||||| 783|DRG||CESAREAN SECTION W STERILIZATION W MCC|Medicaid|MEDICAID HMO|39,115.30|11038.35|17550.98|11038.35|||| 783|DRG||CESAREAN SECTION W STERILIZATION W MCC|Managed Medicaid|MEDICAID SUPERIOR|21,927.10|17550.98|17550.98|11038.35|||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Blue Cross PPO Specialty|BCBSTX PPO|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Humana Medicare Advantage|HUMANA MA|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Medicare|MEDICARE ACUTE|27.11||||27.11||| 78315|EAP|0341|BONE 3 PHASE|Managed Medicare|HEALTHSPRING MA|||||1,979.50||| 78315|EAP|0341|BONE 3 PHASE|Medicare|MEDICARE ACUTE|||||1,979.50||| 78315|EAP|0341|BONE 3 PHASE|Humana Medicare Advantage|HUMANA MA|||||1,979.50||| 78315|EAP|0341|BONE 3 PHASE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,979.50||| 78315|EAP|0341|BONE 3 PHASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,979.50||| 78315|EAP|0341|BONE 3 PHASE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,979.50||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Blue Cross PPO Specialty|BCBSTX PPO|24,659.60|6859.47|6859.47|6859.47|||| 78451|EAP|0341|CARDIAC SPECT PERF R|Medicare|MEDICARE ACUTE|||||39.01||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Veterans Affairs|VETERANS ADMINISTRATION|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Humana Medicare Advantage|HUMANA MA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Cigna|CIGNA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Blue Cross HMO Specialty|BCBSTX HMO|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Blue Cross PPO Specialty|BCBSTX OTHER|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Aetna|AETNA PPO|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Blue Cross PPO Specialty|BCBSTX PPO|6,381.50||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Aetna|AETNA OTHER|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Medicaid|MEDICAID|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Managed Medicaid|MEDICAID SUPERIOR|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|ChampVA|CHAMPVA CENTER|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Managed Medicaid|MEDICAID AMERIGROUP|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Managed Medicare|HEALTHSPRING MA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Managed Medicare|BCBS MEDICARE PPO MA|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Medicare|MEDICARE ACUTE|6,381.50||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|NON CONTRACTED|COMMERCIAL OTHER 1|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|NON CONTRACTED|COMMERCIAL OTHER 2|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Tricare|TRICARE EAST REGION|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|United Healthcare|UNITED HEALTHCARE|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|United Healthcare|TML GROUP BENEFITS|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|United Healthcare|UNITED HEALTHCARE OTHER|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Tricare|TRICARE FOR LIFE|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|PHCS|HUMANA INSURANCE|||||6,381.50||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29,631.50|7879.39|17761.54|37.8|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Medicaid|MEDICAID|54,515.98|8324.22|17761.54|37.8|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|30,372.47|5262.39|17761.54|37.8|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Aetna|AETNA PPO|31,548.03|17761.54|17761.54|37.8|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25,454.88|13235.51|17761.54|37.8|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Cigna|CIGNA|39,276.60|37.8|17761.54|37.8|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|36,102.04|13235.51|17761.54|37.8|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|31,452.05|13235.51|17761.54|37.8|||| 78582|EAP|0341|VQ LUNG SCAN W/AEROSOL|United Medicare Advantage|UHC MEDICARE GOLD MA|35.39||||||| 78582|EAP|0341|VQ LUNG SCAN W/AEROSOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||35.39||| 78582|EAP|0341|VQ LUNG SCAN W/AEROSOL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|35.39||||||| 78582|EAP|0341|VQ LUNG SCAN W/AEROSOL|Humana Medicare Advantage|HUMANA MA|||||35.39||| 78582|EAP|0341|VQ LUNG SCAN W/AEROSOL|Blue Cross PPO Specialty|BCBSTX PPO|||||35.39||| 78582|EAP|0341|VQ LUNG SCAN W/AEROSOL|Managed Medicare|HEALTHSPRING MA|35.39||||||| 78582|EAP|0341|VQ LUNG SCAN W/AEROSOL|Medicare|MEDICARE ACUTE|35.39||||35.39||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Medicaid|MEDICAID|46,360.60|15868.96|15868.96|43.05|||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Managed Medicaid|MEDICAID SUPERIOR|119,157.02|10202.4|15868.96|43.05|||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Cigna|CIGNA|57,499.74|43.05|15868.96|43.05|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Blue Cross PPO Specialty|BCBSTX PPO|59,093.18|6728.77|17550.98|6728.77|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Managed Medicaid|MEDICAID SUPERIOR|53,514.55|17550.98|17550.98|6728.77|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Managed Medicaid|MEDICAID AMERIGROUP|60,903.62|17550.98|17550.98|6728.77|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|44,999.14|73.28|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|40,201.81|8325.52|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Medicaid|MEDICAID|37,749.30|8324.22|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Medicare|MEDICARE ACUTE|29,179.41|8255.905|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|39,248.52|13235.51|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Cigna|CIGNA|38,094.98|37.8|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|42,930.55|13235.51|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28,204.74|13235.51|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|42,376.80|8046.44|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|465.46|5605.96|13235.51|37.8|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49,837.55|4220.68|13235.51|37.8|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Aetna|AETNA PPO|3,038.50|1710.68|2845.38|1710.68|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Managed Medicaid|MEDICAID SUPERIOR|5,533.97|2845.38|2845.38|1710.68|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Managed Medicaid|MEDICAID AMERIGROUP|4,641.35|2845.38|2845.38|1710.68|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Medicaid|MEDICAID|14,847.50|2541.42|5884.55|27.42|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Medicaid|MEDICAID HMO|13,418.44|1189.33|5884.55|27.42|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Managed Medicaid|MEDICAID AMERIGROUP|6,250.14|1891.03|5884.55|27.42|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|6,100.78|1891.03|5884.55|27.42|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Aetna|AETNA PPO|10,452.13|5884.55|5884.55|27.42|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Blue Cross PPO Specialty|BCBSTX PPO|5,539.33|27.42|5884.55|27.42|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Blue Cross PPO Specialty|BCBSTX PPO|9,894.25|41.13|3168.2|11|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|4,792.35|3168.2|3168.2|11|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Cigna|CIGNA|4,977.16|11|3168.2|11|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Medicaid|MEDICAID|2,782.35|1189.33|4285.91|21.44|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Medicaid|SUPERIOR HEALTHPLAN CHIP|77.97|1992.58|4285.91|21.44|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,285.91|4285.91|4285.91|21.44|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Managed Medicaid|MEDICAID AMERIGROUP|6,190.66|1947.77|4285.91|21.44|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|7,718.34|3168.2|4285.91|21.44|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross PPO Specialty|BCBSTX PPO|8,955.12|41.13|4285.91|21.44|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,462.76|21.44|4285.91|21.44|||| 795|DRG||NORMAL NEWBORN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5,635.85|3052.69|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Blue Cross PPO Specialty|BCBSTX PPO|4,498.13|1147.71|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5,640.53|864.1|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Managed Medicaid|MEDICAID AMERIGROUP|4,814.93|1891.03|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Cigna|CIGNA|4,895.03|11|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,743.75|1891.03|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Managed Medicaid|MEDICAID SUPERIOR|4,625.76|1891.03|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Tricare|TRICARE EAST REGION|3,948.24|688.61|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|United Healthcare|UNITED HEALTHCARE|3,983.06|8.24|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Medicaid|SUPERIOR HEALTHPLAN CHIP|5,074.75|5645.44|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Medicaid|MEDICAID|4,154.18|1189.33|5645.44|8.24|||| 795|DRG||NORMAL NEWBORN|Medicaid|MEDICAID HMO|6,207.93|1189.33|5645.44|8.24|||| 798|DRG||VAGINAL DELIVERY W STERILIZATION/D&C W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|38,538.61|5271.11|5271.11|5271.11|||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||421.53||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicare|BCBS MEDICARE PPO MA|421.53||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicare|HEALTHSPRING MA|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|MEDICAID HMO|||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Healthcare|UNITED HEALTHCARE|421.53||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Tricare|TRICARE EAST REGION|421.53||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Healthcare|UNITED HEALTHCARE OTHER|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicare|MEDICARE ACUTE|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicare|MEDICARE PART B ONLY IP|421.53||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Healthcare|UNITED HEALTHCARE|||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|421.53||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|421.53||||372.89||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Veterans Affairs|VETERANS ADMINISTRATION|421.53||||240.77||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Workers Compensation|WORKERS COMPENSATION OTHER|||||192.13||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|421.53||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Cigna|CIGNA|||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Cigna|CIGNA|421.53||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicaid|MEDICAID AMERIGROUP|421.53||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|MEDICAID|324.25||||372.89||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Humana Medicare Advantage|HUMANA MA|421.53||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|421.53||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicaid|MEDICAID SUPERIOR|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|ChampVA|CHAMPVA CENTER|||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Blue Cross PPO Specialty|BCBSTX PPO|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|324.25||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Aetna|AETNA PPO|421.53||||372.89||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Blue Cross HMO Specialty|BCBSTX HMO|421.53||||0.60||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|421.53||||324.25||| 80051|EAP|0300|ELECTROLYTES 4 TESTS|Blue Cross HMO Specialty|BCBSTX HMO|||||60.30||| 80051|EAP|0300|ELECTROLYTES 4 TESTS|Managed Medicaid|MEDICAID AMERIGROUP|||||268.75||| 80051|EAP|0300|ELECTROLYTES 4 TESTS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||60.30||| 80051|EAP|0300|ELECTROLYTES 4 TESTS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||268.75||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|MOLINA HEALTHCARE OF TEXAS|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|MEDICAID TEXAS CHILDRENS|||||526.83||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|MEDICAID HMO|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|MEDICAID|405.25||||466.04||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicare|BCBS MEDICARE PPO MA|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicare|HEALTHSPRING MA|526.83||||90.84||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicare|WELLCARE CHOICE MA|526.83||||526.83||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|NON CONTRACTED|COMMERCIAL OTHER 1|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|NON CONTRACTED|COMMERCIAL OTHER 2|||||526.83||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|PHCS|MULTIPLAN PHCS|||||526.83||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|PHCS|HUMANA INSURANCE|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|UNITED HEALTHCARE OTHER|405.25||||466.04||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|TML GROUP BENEFITS|||||248.05||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicare|MEDICARE PART B ONLY IP|526.83||||466.04||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|GEHA|||||90.84||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|UTMB|UTMB CORRECTIONAL MANAGED CARE|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Tricare|TRICARE EAST REGION|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|UNITED HEALTHCARE|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Tricare|TRICARE FOR LIFE|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|UNITED HEALTHCARE|405.25||||526.83||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Medicare Advantage|UHC MEDICARE GOLD MA|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||308.84||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Medicare Advantage|AARP UHC WEST COMPLETE MA|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Workers Compensation|WORKERS COMPENSATION OTHER|466.04||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicare|MEDICARE ACUTE|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Veterans Affairs|VETERANS ADMINISTRATION|526.83||||526.83||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicaid|MEDICAID SUPERIOR|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Cigna|CIGNA|526.83||||90.84||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Cigna|CIGNA|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|ChampVA|CHAMPVA CENTER|405.25||||||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|COUNTY INDIGENT HEALTH OTHER|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||526.83||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Cigna|CIGNA|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicaid|MEDICAID AMERIGROUP|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Humana Medicare Advantage|HUMANA MA|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Aetna|AETNA PPO|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross PPO Specialty|BCBSTX PPO|526.83||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross HMO Specialty|BCBSTX HMO|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross PPO Specialty|BCBSTX OTHER|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||248.05||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|405.25||||90.84||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|466.04||||90.84||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Access Direct Platinum|HEALTHFIRST TPA UMR|405.25||||248.05||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Aetna|AETNA OTHER|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Aenta Medicare Advantage|AETNA MEDICARE MA|405.25||||405.25||| 80061|EAP|0301|LIPID PANEL I|Aenta Medicare Advantage|AETNA MEDICARE MA|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|667.55||||115.14||| 80061|EAP|0301|LIPID PANEL I|Blue Cross HMO Specialty|BCBSTX HMO|513.50||||115.14||| 80061|EAP|0301|LIPID PANEL I|Blue Cross PPO Specialty|BCBSTX PPO|667.55||||115.14||| 80061|EAP|0301|LIPID PANEL I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Blue Cross PPO Specialty|BCBSTX OTHER|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Aetna|AETNA PPO|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Access Direct Platinum|HEALTHFIRST TPA UMR|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|590.53||||115.14||| 80061|EAP|0301|LIPID PANEL I|Managed Medicaid|MEDICAID SUPERIOR|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Managed Medicaid|MEDICAID AMERIGROUP|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Humana Medicare Advantage|HUMANA MA|667.55||||115.14||| 80061|EAP|0301|LIPID PANEL I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|513.50||||115.14||| 80061|EAP|0301|LIPID PANEL I|Veterans Affairs|VETERANS ADMINISTRATION|||||391.35||| 80061|EAP|0301|LIPID PANEL I|Workers Compensation|WORKERS COMPENSATION OTHER|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Cigna|CIGNA|||||115.14||| 80061|EAP|0301|LIPID PANEL I|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||115.14||| 80061|EAP|0301|LIPID PANEL I|United Medicare Advantage|UHC MEDICARE GOLD MA|513.50||||115.14||| 80061|EAP|0301|LIPID PANEL I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|513.50||||115.14||| 80061|EAP|0301|LIPID PANEL I|United Medicare Advantage|AARP UHC WEST COMPLETE MA|667.55||||115.14||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|TML GROUP BENEFITS|||||115.14||| 80061|EAP|0301|LIPID PANEL I|NON CONTRACTED|COMMERCIAL OTHER 1|513.50||||115.14||| 80061|EAP|0301|LIPID PANEL I|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||115.14||| 80061|EAP|0301|LIPID PANEL I|PHCS|HUMANA INSURANCE|||||115.14||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|UNITED HEALTHCARE|667.55||||115.14||| 80061|EAP|0301|LIPID PANEL I|Medicare|MEDICARE ACUTE|513.50||||115.14||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|GEHA|||||115.14||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|UNITED HEALTHCARE|||||115.14||| 80061|EAP|0301|LIPID PANEL I|NON CONTRACTED|COMMERCIAL OTHER 2|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Aetna|AETNA OTHER|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Tricare|TRICARE EAST REGION|||||115.14||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||115.14||| 80061|EAP|0301|LIPID PANEL I|UTMB|UTMB CORRECTIONAL MANAGED CARE|513.50||||||| 80061|EAP|0301|LIPID PANEL I|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Managed Medicare|WELLCARE CHOICE MA|667.55||||||| 80061|EAP|0301|LIPID PANEL I|Managed Medicare|HEALTHSPRING MA|513.50||||115.14||| 80061|EAP|0301|LIPID PANEL I|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||391.35||| 80061|EAP|0301|LIPID PANEL I|Managed Medicare|BCBS MEDICARE PPO MA|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||115.14||| 80061|EAP|0301|LIPID PANEL I|Medicaid|MEDICAID|513.50||||115.14||| 80061|EAP|0301|LIPID PANEL I|Medicaid|MEDICAID HMO|||||115.14||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|HEALTHSPRING MA|||||904.48||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|BCBS MEDICARE PPO MA|904.48||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|MEDICAID HMO|||||904.48||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|||||800.12||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicare|MEDICARE ACUTE|695.75||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Healthcare|UNITED HEALTHCARE|||||904.48||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Workers Compensation|WORKERS COMPENSATION OTHER|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||904.48||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Veterans Affairs|VETERANS ADMINISTRATION|||||904.48||| 80069|EAP|0300|RENAL FUNCTION PANEL|Cigna|CIGNA|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||800.12||| 80069|EAP|0300|RENAL FUNCTION PANEL|Humana Medicare Advantage|HUMANA MA|695.75||||904.48||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||904.48||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross HMO Specialty|BCBSTX HMO|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||904.48||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross PPO Specialty|BCBSTX PPO|||||904.48||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross PPO Specialty|BCBSTX PPO|406.90||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Humana Medicare Advantage|HUMANA MA|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID AMERIGROUP|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID SUPERIOR|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.13||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Veterans Affairs|VETERANS ADMINISTRATION|||||238.55||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross HMO Specialty|BCBSTX HMO|||||3.13||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Healthcare|UNITED HEALTHCARE|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicare|MEDICARE ACUTE|3.13||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|PHCS|HUMANA INSURANCE|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|MEDICAID|||||406.90||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|MEDICAID HMO|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||406.90||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||70.20||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicare|HEALTHSPRING MA|||||70.20||| 801|DRG||SPLENECTOMY W/O CC/MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|55,025.95|14412.95|14412.95|14412.95|||| 80101|EAP|0300||Medicare|MEDICARE ACUTE|||||495.14||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||125.10||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.58||||125.10||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|Managed Medicaid|MEDICAID SUPERIOR|||||5.58||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|Blue Cross PPO Specialty|BCBSTX PPO|||||125.10||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|Medicaid|MEDICAID HMO|||||5.58||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.58||| 80162|EAP|0300|DIGOXIN|Medicare|MEDICARE ACUTE|508.50||||508.50||| 80162|EAP|0300|DIGOXIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|508.50||||||| 80162|EAP|0300|DIGOXIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||114.12||| 80162|EAP|0300|DIGOXIN|Blue Cross PPO Specialty|BCBSTX PPO|||||114.12||| 80162|EAP|0300|DIGOXIN|Humana Medicare Advantage|HUMANA MA|508.50||||508.50||| 80162|EAP|0300|DIGOXIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|508.50||||508.50||| 80165|EAP|0300|VALPORIC ACID|United Medicare Advantage|UHC MEDICARE GOLD MA|||||116.40||| 80165|EAP|0300|VALPORIC ACID|Humana Medicare Advantage|HUMANA MA|||||519.25||| 80165|EAP|0300|VALPORIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||519.25||| 80165|EAP|0300|VALPORIC ACID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||519.25||| 80165|EAP|0300|VALPORIC ACID|Medicaid|MEDICAID HMO|||||519.25||| 80165|EAP|0300|VALPORIC ACID|Managed Medicare|HEALTHSPRING MA|||||116.40||| 80165|EAP|0300|VALPORIC ACID|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||519.25||| 80165|EAP|0300|VALPORIC ACID|Medicare|MEDICARE ACUTE|519.25||||116.40||| 80170|EAP|0301|GENTAMYCIN TROUGH|Medicare|MEDICARE ACUTE|6.28||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Medicare|MEDICARE ACUTE|6.28||||||| 80170|EAP|0301|GENTAMYCIN TROUGH|Blue Cross PPO Specialty|BCBSTX PPO|373.75||||||| 80170|EAP|0301|GENTAMYCIN TROUGH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.28||||||| 80170|EAP|0301|GENTAMYCIN TROUGH|Managed Medicaid|MEDICAID AMERIGROUP|6.28||||||| 80170|EAP|0301|GENTAMYCIN TROUGH|Managed Medicaid|MEDICAID SUPERIOR|119.50||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Managed Medicaid|MEDICAID SUPERIOR|6.28||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Managed Medicaid|MEDICAID AMERIGROUP|6.28||||||| 80170|EAP|0301|GENTAMYCIN TROUGH|United Medicare Advantage|UHC MEDICARE GOLD MA|6.28||||||| 80170|EAP|0300|GENTAMYCIN PEAK|United Medicare Advantage|UHC MEDICARE GOLD MA|6.28||||||| 80170|EAP|0300|GENTAMYCIN PEAK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.28||||||| 80170|EAP|0301|GENTAMYCIN TROUGH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.28||||||| 80175|EAP|0301|LAMOTRIGINE (LAMICTAL)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||117.66||| 80175|EAP|0301|LAMOTRIGINE (LAMICTAL)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||117.66||| 80175|EAP|0301|LAMOTRIGINE (LAMICTAL)|Blue Cross HMO Specialty|BCBSTX HMO|||||117.66||| 80175|EAP|0301|LAMOTRIGINE (LAMICTAL)|Managed Medicare|HEALTHSPRING MA|||||117.66||| 80175|EAP|0301|LAMOTRIGINE (LAMICTAL)|Medicare|MEDICARE ACUTE|||||485.75||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Medicare|MEDICARE ACUTE|691.50||||691.50||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||691.50||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||691.50||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Blue Cross HMO Specialty|BCBSTX HMO|||||803.73||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||155.16||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||155.16||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||155.16||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Managed Medicaid|MEDICAID SUPERIOR|||||155.16||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||691.50||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Humana Medicare Advantage|HUMANA MA|||||155.16||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||155.16||| 80178|EAP|0300|LITHIUM|Managed Medicaid|MEDICAID AMERIGROUP|||||253.25||| 80178|EAP|0300|LITHIUM|Cigna|CIGNA|||||56.76||| 80178|EAP|0300|LITHIUM|Blue Cross PPO Specialty|BCBSTX PPO|||||56.76||| 80178|EAP|0300|LITHIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|253.25||||||| 80178|EAP|0300|LITHIUM|United Medicare Advantage|UHC MEDICARE GOLD MA|253.25||||||| 80178|EAP|0300|LITHIUM|Medicaid|MEDICAID|||||56.76||| 80178|EAP|0300|LITHIUM|Medicare|MEDICARE ACUTE|||||56.76||| 80185|EAP|0300|PHENYTOIN TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||113.94||| 80185|EAP|0300|PHENYTOIN TOTAL|Medicare|MEDICARE ACUTE|5.08||||5.08||| 80185|EAP|0300|PHENYTOIN TOTAL|Medicaid|MEDICAID HMO|||||5.08||| 80185|EAP|0300|PHENYTOIN TOTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.08||| 80185|EAP|0300|PHENYTOIN TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||113.94||| 80185|EAP|0300|PHENYTOIN TOTAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.08||| 80185|EAP|0300|PHENYTOIN TOTAL|Humana Medicare Advantage|HUMANA MA|||||113.94||| 80197|EAP|0300|PROGRAF/TACROLIMUS|Aetna|AETNA PPO|||||117.96||| 80197|EAP|0300|PROGRAF/TACROLIMUS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||117.96||| 80197|EAP|0300|PROGRAF/TACROLIMUS|Medicare|MEDICARE ACUTE|||||117.96||| 80200|EAP|0300|TOBRAMYCIN PEAK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|617.50||||||| 80200|EAP|0301|TOBRAMYCIN TROUGH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|617.50||||||| 80200|EAP|0301|TOBRAMYCIN TROUGH|Humana Medicare Advantage|HUMANA MA|617.50||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicare|HEALTHSPRING MA|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|NON CONTRACTED|COMMERCIAL OTHER 1|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Medicare|MEDICARE ACUTE|519.25||||519.25||| 80202|EAP|0300|VANCOMYCIN TROUGH|UTMB|UTMB CORRECTIONAL MANAGED CARE|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Tricare|TRICARE EAST REGION|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|United Healthcare|UNITED HEALTHCARE OTHER|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Blue Cross HMO Specialty|BCBSTX HMO|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Blue Cross PPO Specialty|BCBSTX PPO|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Aenta Medicare Advantage|AETNA MEDICARE MA|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Aetna|AETNA PPO|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Humana Medicare Advantage|HUMANA MA|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicaid|MEDICAID AMERIGROUP|519.25||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicaid|MEDICAID SUPERIOR|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|United Medicare Advantage|UHC MEDICARE GOLD MA|519.25||||116.40||| 80202|EAP|0300|VANCOMYCIN TROUGH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Veterans Affairs|VETERANS ADMINISTRATION|519.25||||||| 80203|EAP|0301|ZONEGRAM (ZONISAMIDE)|Blue Cross HMO Specialty|BCBSTX HMO|||||155.16||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|NON CONTRACTED|COMMERCIAL OTHER 2|||||613.40||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|NON CONTRACTED|COMMERCIAL OTHER 1|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Healthcare|UNITED HEALTHCARE|613.40||||570.58||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Healthcare|UNITED HEALTHCARE|613.40||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||118.32||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicare|MEDICARE PART B ONLY IP|570.58||||||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Tricare|TRICARE EAST REGION|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|UTMB|UTMB CORRECTIONAL MANAGED CARE|570.58||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|MEDICAID|527.75||||118.32||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||118.32||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicare|HEALTHSPRING MA|||||613.40||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|MEDICAID HMO|613.40||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|MOLINA HEALTHCARE OF TEXAS|613.40||||118.32||| 80307|EAP|0300|MECONIUM DRUG SCREEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|527.75||||||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicare|BCBS MEDICARE PPO MA|||||613.40||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|570.58||||570.58||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Medicare Advantage|UHC MEDICARE GOLD MA|527.75||||613.40||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Veterans Affairs|VETERANS ADMINISTRATION|||||613.40||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Workers Compensation|UT EMPLOYEE INJURY|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Healthcare|TML GROUP BENEFITS|||||323.04||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|570.58||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicaid|MEDICAID SUPERIOR|527.75||||118.32||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicare|MEDICARE ACUTE|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicaid|MEDICAID AMERIGROUP|527.75||||118.32||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Cigna|CIGNA|570.58||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Humana Medicare Advantage|HUMANA MA|613.40||||613.40||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Cigna|CIGNA|613.40||||527.75||| 80307|EAP|0300|MECONIUM DRUG SCREEN|Managed Medicaid|MEDICAID SUPERIOR|527.75||||||| 80307|EAP|0300|MECONIUM DRUG SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|527.75||||||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|613.40||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|613.40||||118.32||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Aenta Medicare Advantage|AETNA MEDICARE MA|613.40||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Blue Cross PPO Specialty|BCBSTX PPO|613.40||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Aetna|AETNA OTHER|||||613.40||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Blue Cross HMO Specialty|BCBSTX HMO|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Aetna|AETNA PPO|613.40||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Access Direct Platinum|HEALTHFIRST TPA UMR|527.75||||118.32||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|527.75||||613.40||| 80320|EAP|0301|ALCOHOL|Blue Cross HMO Specialty|BCBSTX HMO|481.19||||4.14||| 80320|EAP|0301|ALCOHOL|Aetna|AETNA OTHER|||||481.19||| 80320|EAP|0301|ALCOHOL|Blue Cross PPO Specialty|BCBSTX PPO|481.19||||4.14||| 80320|EAP|0301|ALCOHOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.14||||481.19||| 80320|EAP|0301|ALCOHOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|481.19||||481.19||| 80320|EAP|0301|ALCOHOL|Access Direct Platinum|HEALTHFIRST TPA UMR|4.14||||||| 80320|EAP|0301|ALCOHOL|Humana Medicare Advantage|HUMANA MA|481.19||||481.19||| 80320|EAP|0301|ALCOHOL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.14||| 80320|EAP|0301|ALCOHOL|Cigna|CIGNA|447.60||||447.60||| 80320|EAP|0301|ALCOHOL|Cigna|CIGNA|481.19||||481.19||| 80320|EAP|0301|ALCOHOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|481.19||||481.19||| 80320|EAP|0301|ALCOHOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|447.60||||481.19||| 80320|EAP|0301|ALCOHOL|Managed Medicaid|MEDICAID AMERIGROUP|||||447.60||| 80320|EAP|0301|ALCOHOL|Managed Medicaid|MEDICAID SUPERIOR|||||4.14||| 80320|EAP|0301|ALCOHOL|Veterans Affairs|VETERANS ADMINISTRATION|||||481.19||| 80320|EAP|0301|ALCOHOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|United Medicare Advantage|UHC MEDICARE GOLD MA|4.14||||||| 80320|EAP|0301|ALCOHOL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|447.60||||481.19||| 80320|EAP|0301|ALCOHOL|Aetna|AETNA PPO|481.19||||4.14||| 80320|EAP|0301|ALCOHOL|Medicaid|MEDICAID|||||4.14||| 80320|EAP|0301|ALCOHOL|Medicaid|MOLINA HEALTHCARE OF TEXAS|481.19||||||| 80320|EAP|0301|ALCOHOL|Managed Medicare|HEALTHSPRING MA|||||481.19||| 80320|EAP|0301|ALCOHOL|Medicaid|MEDICAID HMO|||||4.14||| 80320|EAP|0301|ALCOHOL|United Healthcare|UNITED HEALTHCARE|481.19||||481.19||| 80320|EAP|0301|ALCOHOL|NON CONTRACTED|COMMERCIAL OTHER 1|447.60||||4.14||| 80320|EAP|0301|ALCOHOL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||481.19||| 80320|EAP|0301|ALCOHOL|Medicare|MEDICARE ACUTE|4.14||||447.60||| 80320|EAP|0301|ALCOHOL|Tricare|TRICARE EAST REGION|||||481.19||| 80320|EAP|0301|ALCOHOL|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.14||||481.19||| 80320|EAP|0301|ALCOHOL|United Healthcare|UNITED HEALTHCARE|481.19||||4.14||| 80324|EAP|0300|AMPHETAMINES QTN|Managed Medicaid|MEDICAID SUPERIOR|475.96||||||| 80329|EAP|0300||Managed Medicaid|MEDICAID UNITED HEALTHCARE|316.14||||316.14||| 80329|EAP|0300||Managed Medicaid|MEDICAID SUPERIOR|||||316.14||| 80329|EAP|0301||Managed Medicaid|MEDICAID AMERIGROUP|||||838.16||| 80329|EAP|0300||Humana Medicare Advantage|HUMANA MA|316.14||||316.14||| 80329|EAP|0300||Cigna|CIGNA|||||775.25||| 80329|EAP|0300||Cigna|CIGNA|||||316.14||| 80329|EAP|0300||Managed Medicaid|MEDICAID AMERIGROUP|||||316.14||| 80329|EAP|0301||Humana Medicare Advantage|HUMANA MA|901.07||||901.07||| 80329|EAP|0301||Cigna|CIGNA|||||901.07||| 80329|EAP|0301||Managed Medicaid|MEDICAID SUPERIOR|||||775.25||| 80329|EAP|0300||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|775.25||||316.14||| 80329|EAP|0301||Cigna|CIGNA|||||775.25||| 80329|EAP|0301||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||775.25||| 80329|EAP|0301||United Healthcare|UNITED HEALTHCARE|||||775.25||| 80329|EAP|0300||United Medicare Advantage|AARP UHC WEST COMPLETE MA|316.14||||||| 80329|EAP|0300||Blue Cross HMO Specialty|BCBSTX HMO|||||2.72||| 80329|EAP|0301||Managed Medicaid|MEDICAID UNITED HEALTHCARE|901.07||||901.07||| 80329|EAP|0300||NON CONTRACTED|COMMERCIAL OTHER 1|||||294.07||| 80329|EAP|0300||Medicaid|MEDICAID|||||775.25||| 80329|EAP|0300||United Healthcare|UMR UNITED MEDICAL RESOURCES|||||316.14||| 80329|EAP|0300||UTMB|UTMB CORRECTIONAL MANAGED CARE|775.25||||316.14||| 80329|EAP|0300||Veterans Affairs|VETERANS ADMINISTRATION|||||316.14||| 80329|EAP|0300||United Healthcare|UNITED HEALTHCARE|||||775.25||| 80329|EAP|0301||United Healthcare|UMR UNITED MEDICAL RESOURCES|||||901.07||| 80329|EAP|0301||Tricare|TRICARE EAST REGION|||||901.07||| 80329|EAP|0301||Medicare|MEDICARE ACUTE|775.25||||901.07||| 80329|EAP|0301||Aetna|AETNA OTHER|||||901.07||| 80329|EAP|0301||Blue Cross HMO Specialty|BCBSTX HMO|||||775.25||| 80329|EAP|0301||Veterans Affairs|VETERANS ADMINISTRATION|||||838.16||| 80329|EAP|0300||Blue Cross PPO Specialty|BCBSTX PPO|775.25||||316.14||| 80329|EAP|0301||Medicaid|MEDICAID|||||775.25||| 80329|EAP|0300||Aetna|AETNA PPO|||||2.72||| 80329|EAP|0301||NON CONTRACTED|COMMERCIAL OTHER 1|||||838.16||| 80329|EAP|0300||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||316.14||| 80329|EAP|0301||Blue Cross PPO Specialty|BCBSTX PPO|775.25||||775.25||| 80329|EAP|0301||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||901.07||| 80329|EAP|0301||United Healthcare|UNITED HEALTHCARE|||||901.07||| 80329|EAP|0301||Managed Medicare|HEALTHSPRING MA|||||901.07||| 80329|EAP|0301||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|775.25||||901.07||| 80329|EAP|0301||UTMB|UTMB CORRECTIONAL MANAGED CARE|||||901.07||| 80329|EAP|0300||Tricare|TRICARE EAST REGION|||||316.14||| 80329|EAP|0301||Medicaid|MEDICAID HMO|||||775.25||| 80329|EAP|0300||Medicare|MEDICARE ACUTE|2.72||||316.14||| 80329|EAP|0301||Aetna|AETNA PPO|||||775.25||| 80329|EAP|0300||Aetna|AETNA OTHER|||||316.14||| 80329|EAP|0300||Medicaid|MEDICAID HMO|||||775.25||| 80329|EAP|0300||Managed Medicare|HEALTHSPRING MA|||||316.14||| 80329|EAP|0301||United Medicare Advantage|AARP UHC WEST COMPLETE MA|901.07||||||| 80329|EAP|0300||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||545.70||| 80329|EAP|0300||United Healthcare|UNITED HEALTHCARE|316.14||||316.14||| 80345|EAP|0300|PHENOBARBITAL|Medicare|MEDICARE ACUTE|4.39||||||| 80349|EAP|0300|THC QNT|Managed Medicaid|MEDICAID SUPERIOR|206.50||||||| 80365|EAP|0301|OPIATE, QNT, URINE|Managed Medicaid|MEDICAID SUPERIOR|589.86||||||| 80365|EAP|0301|OPIATE, QNT, URINE|Managed Medicaid|MEDICAID AMERIGROUP|507.50||||||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|Humana Medicare Advantage|HUMANA MA|||||117.66||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||117.66||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|Blue Cross HMO Specialty|BCBSTX HMO|||||117.66||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|Medicare|MEDICARE ACUTE|524.75||||||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||117.66||| 805|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC|Managed Medicaid|MEDICAID AMERIGROUP|29,985.13|9978.71|9978.71|9978.71|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Managed Medicaid|MEDICAID SUPERIOR|25,616.75|9978.71|15023.34|4402.86|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Managed Medicaid|MEDICAID AMERIGROUP|27,794.75|15023.34|15023.34|4402.86|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Blue Cross PPO Specialty|BCBSTX PPO|27,203.28|4402.86|15023.34|4402.86|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|27,562.41|8352.44|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|21,909.79|17763.41|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Aetna|AETNA PPO|31,499.91|17734.445|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|24,631.34|3821.54|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Tricare|TRICARE EAST REGION|26,422.16|2292.39|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|28,064.22|8352.44|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|25,615.25|6047.68|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Cigna|CIGNA|10,163.84|29.4|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Aetna|AETNA OTHER|21,526.80|12119.585|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|34,452.70|4837.26|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27,111.88|8352.44|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Medicaid|MEDICAID HMO|22,838.24|5253.11|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29,065.85|2877.2|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|18,248.75|3252.17|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Cigna|CIGNA|25,543.18|29.4|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|23,681.50|51.79|17763.41|29.4|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Medicaid|MEDICAID|25,700.34|5253.11|17763.41|29.4|||| 809|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC|Medicare|MEDICARE ACUTE|60,147.33|10360.42|10360.42|10360.42|||| 81003|EAP|0307|PROTEIN RANDOM URINE DIPS|Blue Cross PPO Specialty|BCBSTX PPO|||||21.96||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|19.32||||19.32||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.86||||0.86||| 81003|EAP|0307|PROTEIN RANDOM URINE DIPS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||21.96||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Medicare Advantage|UHC MEDICARE GOLD MA|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Aenta Medicare Advantage|AETNA MEDICARE MA|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|NON CONTRACTED|COMMERCIAL OTHER 1|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Access Direct Platinum|HEALTHFIRST TPA UMR|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Aetna|AETNA OTHER|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Humana Medicare Advantage|HUMANA MA|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.86||||19.32||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicaid|MEDICAID AMERIGROUP|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.86||||19.32||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.86||||0.86||| 81003|EAP|0307|PROTEIN RANDOM URINE DIPS|Humana Medicare Advantage|HUMANA MA|||||21.96||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|PHCS|HUMANA INSURANCE|||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicare|MEDICARE PART B ONLY IP|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Cigna|CIGNA|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross PPO Specialty|BCBSTX PPO|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Veterans Affairs|VETERANS ADMINISTRATION|0.86||||0.86||| 81003|EAP|0307|PROTEIN RANDOM URINE DIPS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||21.96||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Aetna|AETNA PPO|0.86||||0.86||| 81003|EAP|0307|PROTEIN URINE DIPSTICK|Medicare|MEDICARE ACUTE|||||21.96||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicaid|MEDICAID SUPERIOR|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|ChampVA|CHAMPVA CENTER|0.86||||19.32||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Healthcare|UNITED HEALTHCARE OTHER|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|PHCS|MULTIPLAN PHCS|||||0.86||| 81003|EAP|0307|PROTEIN RANDOM URINE DIPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21.96||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross HMO Specialty|BCBSTX HMO|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Healthcare|UNITED HEALTHCARE|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Healthcare|TML GROUP BENEFITS|||||52.66||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicare|BCBS MEDICARE PPO MA|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicare|MEDICARE ACUTE|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|MEDICAID HMO|0.86||||0.86||| 81003|EAP|0307|PROTEIN RANDOM URINE DIPS|Medicare|MEDICARE ACUTE|||||21.96||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|MEDICAID|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Tricare|TRICARE EAST REGION|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicare|WELLCARE CHOICE MA|0.86||||||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.86||||0.86||| 81003|EAP|0307|PROTEIN RANDOM URINE DIPS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||21.96||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicare|HEALTHSPRING MA|0.86||||0.86||| 81003|EAP|0307|PROTEIN RANDOM URINE DIPS|NON CONTRACTED|COMMERCIAL OTHER 1|||||21.96||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.86||| 81015|EAP|0300|URINE MICROSCOPIC|Workers Compensation|WORKERS COMPENSATION OTHER|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Medicare Advantage|UHC MEDICARE GOLD MA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|NON CONTRACTED|COMMERCIAL OTHER 1|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Medicare|MEDICARE PART B ONLY IP|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicare|BCBS MEDICARE PPO MA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicare|HEALTHSPRING MA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|MEDICAID|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Medicare|MEDICARE ACUTE|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Healthcare|TML GROUP BENEFITS|||||71.30||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|MEDICAID HMO|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Tricare|TRICARE EAST REGION|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Healthcare|UNITED HEALTHCARE OTHER|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|MOLINA HEALTHCARE OF TEXAS|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|NON CONTRACTED|COMMERCIAL OTHER 2|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Healthcare|UNITED HEALTHCARE|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Humana Medicare Advantage|HUMANA MA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|PHCS|HUMANA INSURANCE|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Healthcare|UMR UNITED MEDICAL RESOURCES|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|UTMB|UTMB CORRECTIONAL MANAGED CARE|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicaid|MEDICAID SUPERIOR|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Cigna|CIGNA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicaid|MEDICAID AMERIGROUP|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|ChampVA|CHAMPVA CENTER|116.50||||26.10||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Aenta Medicare Advantage|AETNA MEDICARE MA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross HMO Specialty|BCBSTX HMO|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Access Direct Platinum|HEALTHFIRST TPA UMR|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Aetna|AETNA PPO|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross PPO Specialty|BCBSTX PPO|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||26.10||| 81015|EAP|0300|URINE MICROSCOPIC|Aetna|AETNA OTHER|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross PPO Specialty|BCBSTX OTHER|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Veterans Affairs|VETERANS ADMINISTRATION|116.50||||116.50||| 81025|EAP|0300|PREGNANCY TEST URINE|Aetna|AETNA OTHER|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Aetna|AETNA PPO|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Blue Cross PPO Specialty|BCBSTX PPO|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Blue Cross HMO Specialty|BCBSTX HMO|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Managed Medicaid|MEDICAID SUPERIOR|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Cigna|CIGNA|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||54.36||| 81025|EAP|0300|PREGNANCY TEST URINE|NON CONTRACTED|COMMERCIAL OTHER 1|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|United Healthcare|TML GROUP BENEFITS|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Blue Cross PPO Specialty|BCBSTX OTHER|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|United Healthcare|UNITED HEALTHCARE OTHER|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Workers Compensation|WORKERS COMPENSATION OTHER|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Managed Medicaid|MEDICAID AMERIGROUP|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|PHCS|HUMANA INSURANCE|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Tricare|TRICARE EAST REGION|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|PHCS|MULTIPLAN PHCS|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Cigna|CIGNA|||||148.31||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|MEDICAID|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|MEDICAID HMO|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|United Healthcare|UNITED HEALTHCARE|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicare|MEDICARE ACUTE|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||148.31||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Medicaid|MEDICAID HMO|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Managed Medicaid|MEDICAID SUPERIOR|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Medicare|MEDICARE ACUTE|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|PHCS|HUMANA INSURANCE|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Veterans Affairs|VETERANS ADMINISTRATION|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Medicaid|MEDICAID|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Aetna|AETNA PPO|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Blue Cross PPO Specialty|BCBSTX PPO|92.75||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Managed Medicaid|MEDICAID AMERIGROUP|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||0.25||| 81050|EAP|0307|VOLUME MEASURE FOR TIMED|Humana Medicare Advantage|HUMANA MA|||||0.25||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|49,416.60|11080.08|22863.52|11080.08|||| 811|DRG||RED BLOOD CELL DISORDERS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|49,420.48|22863.52|22863.52|11080.08|||| 81162|EAP|0300|BRC ADVANTAGE, COMPREHENS|Managed Medicaid|MEDICAID SUPERIOR|||||53.19||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|18,520.94|8092.27|15641.45|4138.68|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Medicaid|MEDICAID|39,606.30|7124.04|15641.45|4138.68|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|48,637.25|7943.42|15641.45|4138.68|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42,807.05|7930.42|15641.45|4138.68|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|34,920.56|4138.68|15641.45|4138.68|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Humana Medicare Advantage|HUMANA MA|31,441.62|7293.4|15641.45|4138.68|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33,037.77|15641.45|15641.45|4138.68|||| 81240|EAP|0301|PROTHROMBIN 20210 ASSAY|Medicare|MEDICARE ACUTE|||||4.03||| 81240|EAP|0301|PROTHROMBIN 20210 ASSAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.03||| 81240|EAP|0301|PROTHROMBIN 20210 ASSAY|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.03||| 81240|EAP|0301|PROTHROMBIN 20210 ASSAY|Blue Cross PPO Specialty|BCBSTX PPO|||||4.03||| 81241|EAP|0305|FACTOR V LEIDEN|Medicare|MEDICARE ACUTE|1,803.25||||500.25||| 81241|EAP|0305|FACTOR V LEIDEN|NON CONTRACTED|COMMERCIAL OTHER 1|||||500.25||| 81241|EAP|0305|FACTOR V LEIDEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||500.25||| 81241|EAP|0305|FACTOR V LEIDEN|Blue Cross PPO Specialty|BCBSTX PPO|||||500.25||| 81241|EAP|0305|FACTOR V LEIDEN|Managed Medicaid|MEDICAID SUPERIOR|||||500.25||| 81257|EAP|0300|ALPHA GLOBIN GENE ANALYSI|Blue Cross PPO Specialty|BCBSTX PPO|||||706.25||| 81257|EAP|0300|ALPHA GLOBIN GENE ANALYSI|Medicaid|MEDICAID|||||706.25||| 81257|EAP|0300|ALPHA GLOBIN GENE ANALYSI|Managed Medicaid|MEDICAID SUPERIOR|||||953.50||| 81270|EAP|0300|JAK2 GENE ANALYSIS|Medicare|MEDICARE ACUTE|759.25||||||| 81270|EAP|0300|JAK2 GENE ANALYSIS|Blue Cross PPO Specialty|BCBSTX PPO|||||562.50||| 81291|EAP|0300|METHYLENETETRAHYDROFOLATE|Managed Medicaid|MEDICAID SUPERIOR|||||235.75||| 81291|EAP|0300|METHYLENETETRAHYDROFOLATE|Blue Cross PPO Specialty|BCBSTX PPO|||||235.75||| 81291|EAP|0300|METHYLENETETRAHYDROFOLATE|NON CONTRACTED|COMMERCIAL OTHER 1|||||235.75||| 81291|EAP|0300|METHYLENETETRAHYDROFOLATE|Medicare|MEDICARE ACUTE|235.75||||235.75||| 813|DRG||COAGULATION DISORDERS|Medicare|MEDICARE ACUTE|60,317.40|12544.83|12544.83|10029.98|||| 813|DRG||COAGULATION DISORDERS|Blue Cross PPO Specialty|BCBSTX PPO|27,169.50|10029.98|12544.83|10029.98|||| 815|DRG||RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|28,579.50|8873.57|8873.57|8873.57|||| 81511|EAP|0310|AFP QUAD|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.90||| 81511|EAP|0310|AFP QUAD|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.90||| 81511|EAP|0310|AFP QUAD|Medicare|MEDICARE ACUTE|||||0.90||| 81511|EAP|0310|AFP QUAD|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.90||| 81511|EAP|0310|AFP QUAD|Medicaid|MEDICAID|||||0.90||| 81511|EAP|0310|AFP QUAD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.90||| 81511|EAP|0310|AFP QUAD|Tricare|TRICARE EAST REGION|||||0.90||| 81511|EAP|0310|AFP QUAD|United Healthcare|UNITED HEALTHCARE|||||0.90||| 81511|EAP|0310|AFP QUAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.90||| 81511|EAP|0310|AFP QUAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.90||| 81511|EAP|0310|AFP QUAD|Managed Medicaid|MEDICAID AMERIGROUP|||||0.90||| 81511|EAP|0310|AFP QUAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.90||| 81511|EAP|0310|AFP QUAD|Aetna|AETNA PPO|||||0.90||| 81511|EAP|0310|AFP QUAD|Managed Medicaid|MEDICAID SUPERIOR|||||0.90||| 81511|EAP|0310|AFP QUAD|Blue Cross PPO Specialty|BCBSTX PPO|||||0.90||| 81511|EAP|0310|AFP QUAD|Blue Cross HMO Specialty|BCBSTX HMO|||||0.90||| 816|DRG||RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|6,771.41|172.03|172.03|172.03|||| 817|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|18,153.45|15757.3|27942.09|15757.3|||| 817|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W MCC|Managed Medicaid|MEDICAID SUPERIOR|27,942.09|27942.09|27942.09|15757.3|||| 818|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W CC|Managed Medicaid|MEDICAID SUPERIOR|58,915.53|18714.63|18714.63|18714.63|||| 819|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|26,331.55|7639.67|26507.86|7639.67|||| 819|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|26,507.86|26507.86|26507.86|7639.67|||| 819|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|18,297.30|13875.85|26507.86|7639.67|||| 82009|EAP|0300|ACETONE,QUALITATIVE|Veterans Affairs|VETERANS ADMINISTRATION|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Medicare Advantage|UHC MEDICARE GOLD MA|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Managed Medicaid|MEDICAID AMERIGROUP|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Aetna|AETNA PPO|167.25||||||| 82009|EAP|0300|ACETONE,QUALITATIVE|Humana Medicare Advantage|HUMANA MA|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Managed Medicare|HEALTHSPRING MA|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Managed Medicaid|MEDICAID SUPERIOR|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Medicaid|MEDICAID|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Medicare|MEDICARE ACUTE|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|167.25||||||| 82009|EAP|0300|ACETONE,QUALITATIVE|Blue Cross PPO Specialty|BCBSTX OTHER|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Medicaid|MEDICAID HMO|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|NON CONTRACTED|COMMERCIAL OTHER 1|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Tricare|TRICARE EAST REGION|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Blue Cross PPO Specialty|BCBSTX PPO|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|UTMB|UTMB CORRECTIONAL MANAGED CARE|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Healthcare|UNITED HEALTHCARE OTHER|||||167.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Blue Cross PPO Specialty|BCBSTX PPO|||||331.92||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||331.92||| 82040|EAP|0301|ALBUMIN SERUM|Medicare|MEDICARE ACUTE|||||42.54||| 82040|EAP|0301|ALBUMIN SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|189.75||||||| 82040|EAP|0301|ALBUMIN SERUM|Humana Medicare Advantage|HUMANA MA|||||42.54||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Workers Compensation|WORKERS COMPENSATION OTHER|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Humana Medicare Advantage|HUMANA MA|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Blue Cross PPO Specialty|BCBSTX PPO|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Managed Medicaid|MEDICAID SUPERIOR|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Managed Medicare|HEALTHSPRING MA|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Managed Medicaid|MEDICAID AMERIGROUP|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Cigna|CIGNA|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Blue Cross HMO Specialty|BCBSTX HMO|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|United Healthcare|UNITED HEALTHCARE|||||47.88||| 82043|EAP|0300|MICROALBUMIN, RANDOM URIN|Medicare|MEDICARE ACUTE|||||47.88||| 82044|EAP|0300|MICROALBUMIN REAGENT STX|Medicare|MEDICARE ACUTE|||||39.36||| 82044|EAP|0300|MICROALBUMIN REAGENT STX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||39.36||| 82044|EAP|0300|MICROALBUMIN REAGENT STX|Managed Medicare|HEALTHSPRING MA|||||39.36||| 82044|EAP|0300|MICROALBUMIN REAGENT STX|Blue Cross PPO Specialty|BCBSTX PPO|||||39.36||| 82085|EAP|0300|ALDOLASE|Humana Medicare Advantage|HUMANA MA|||||83.40||| 82085|EAP|0300|ALDOLASE|Blue Cross PPO Specialty|BCBSTX PPO|||||83.40||| 82085|EAP|0300|ALDOLASE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||83.40||| 82085|EAP|0300|ALDOLASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||83.40||| 82085|EAP|0300|ALDOLASE|Medicare|MEDICARE ACUTE|||||83.40||| 82088|EAP|0301|ALDOSTERONE SERUM|Blue Cross PPO Specialty|BCBSTX PPO|||||350.22||| 82088|EAP|0301|ALDOSTERONE SERUM|Medicare|MEDICARE ACUTE|||||350.22||| 82088|EAP|0301|ALDOSTERONE SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||350.22||| 82103|EAP|0301|ALPHA I ANTITRYPSIN|Humana Medicare Advantage|HUMANA MA|||||115.44||| 82105|EAP|0300|ALPHA-FETOPROTEIN;SERUM|Managed Medicaid|MEDICAID SUPERIOR|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Medicare|MEDICARE ACUTE|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Blue Cross PPO Specialty|BCBSTX PPO|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Humana Medicare Advantage|HUMANA MA|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Blue Cross HMO Specialty|BCBSTX HMO|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Managed Medicaid|MEDICAID AMERIGROUP|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Managed Medicaid|MEDICAID AMERIGROUP|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Managed Medicaid|MEDICAID SUPERIOR|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||144.18||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Cigna|CIGNA|||||144.18||| 82106|EAP|0300|ALPHA FETO PROTEIN AMNIOT|Managed Medicaid|MEDICAID SUPERIOR|||||144.18||| 82140|EAP|0300|AMMONIA BLOOD|Managed Medicaid|MEDICAID SUPERIOR|558.50||||||| 82140|EAP|0300|AMMONIA BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|558.50||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Veterans Affairs|VETERANS ADMINISTRATION|558.50||||||| 82140|EAP|0300|AMMONIA BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|558.50||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|558.50||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Medicare|MEDICARE ACUTE|558.50||||125.22||| 82140|EAP|0300|AMMONIA BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Humana Medicare Advantage|HUMANA MA|558.50||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|558.50||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|558.50||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|558.50||||341.86||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicaid|MEDICAID SUPERIOR|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicaid|MEDICAID AMERIGROUP|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Cigna|CIGNA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Cigna|CIGNA|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Access Direct Platinum|HEALTHFIRST TPA UMR|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|ChampVA|CHAMPVA CENTER|2.48||||||| 82150|EAP|0300|AMYLASE SERUM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Aetna|AETNA OTHER|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Aetna|AETNA PPO|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.48||||151.87||| 82150|EAP|0300|AMYLASE SERUM|Blue Cross HMO Specialty|BCBSTX HMO|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Humana Medicare Advantage|HUMANA MA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Aenta Medicare Advantage|AETNA MEDICARE MA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicare|WELLCARE CHOICE MA|2.48||||||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Blue Cross PPO Specialty|BCBSTX PPO|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|MEDICAID|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicare|BCBS MEDICARE PPO MA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicare|HEALTHSPRING MA|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Veterans Affairs|VETERANS ADMINISTRATION|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|MEDICAID HMO|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|PHCS|HUMANA INSURANCE|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Tricare|TRICARE EAST REGION|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|PHCS|MULTIPLAN PHCS|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicare|MEDICARE PART B ONLY IP|2.48||||||| 82150|EAP|0300|AMYLASE SERUM|Medicare|MEDICARE ACUTE|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Healthcare|UNITED HEALTHCARE|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Healthcare|UNITED HEALTHCARE OTHER|2.48||||2.48||| 82157|EAP|0301|ANDROSTENEDIONE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,121.75||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|Blue Cross PPO Specialty|BCBSTX PPO|||||125.46||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||125.46||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||125.46||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||125.46||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|United Healthcare|UNITED HEALTHCARE|||||125.46||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|Blue Cross HMO Specialty|BCBSTX HMO|||||125.46||| 82172|EAP|0301|APOLIPOPROTEIN B|Medicare|MEDICARE ACUTE|||||133.14||| 82175|EAP|0301|ARSENIC|Medicare|MEDICARE ACUTE|||||163.02||| 82180|EAP|0301|VITAMIN C|Medicare|MEDICARE ACUTE|378.75||||||| 82232|EAP|0301|BETA 2 MICROGLOBIN SERUM|Humana Medicare Advantage|HUMANA MA|||||139.02||| 82247|EAP|0300|BILIRUBIN TOTAL|Tricare|TRICARE EAST REGION|192.25||||||| 82247|EAP|0300|BILIRUBIN TOTAL|United Healthcare|UNITED HEALTHCARE|192.25||||43.14||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|MEDICAID|192.25||||43.14||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|192.25||||43.14||| 82247|EAP|0300|BILIRUBIN TOTAL|Cigna|CIGNA|192.25||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|MEDICAID HMO|192.25||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|192.25||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|192.25||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Aetna|AETNA PPO|192.25||||43.14||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicare|HEALTHSPRING MA|||||43.14||| 82247|EAP|0300|BILIRUBIN TOTAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|192.25||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|||||43.14||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicaid|MEDICAID SUPERIOR|192.25||||43.14||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicaid|MEDICAID AMERIGROUP|192.25||||43.14||| 82248|EAP|0300|BILIRUBIN DIRECT|Aenta Medicare Advantage|AETNA MEDICARE MA|192.25||||||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID AMERIGROUP|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Humana Medicare Advantage|HUMANA MA|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Cigna|CIGNA|||||117.70||| 82248|EAP|0300|BILIRUBIN DIRECT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Veterans Affairs|VETERANS ADMINISTRATION|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross HMO Specialty|BCBSTX HMO|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross PPO Specialty|BCBSTX PPO|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Aetna|AETNA PPO|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|192.25||||43.14||| 82248|EAP|0300|BILIRUBIN DIRECT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|NON CONTRACTED|COMMERCIAL OTHER 2|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicare|MEDICARE ACUTE|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Access Direct Platinum|HEALTHFIRST TPA UMR|192.25||||||| 82248|EAP|0300|BILIRUBIN DIRECT|United Healthcare|UNITED HEALTHCARE OTHER|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID SUPERIOR|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|United Healthcare|UNITED HEALTHCARE|192.25||||43.14||| 82248|EAP|0300|BILIRUBIN DIRECT|Tricare|TRICARE EAST REGION|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|United Medicare Advantage|UHC MEDICARE GOLD MA|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|MEDICAID|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|United Healthcare|UNITED HEALTHCARE|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicare|WELLCARE CHOICE MA|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|NON CONTRACTED|COMMERCIAL OTHER 1|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Cigna|CIGNA|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|UTMB|UTMB CORRECTIONAL MANAGED CARE|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicare|MEDICARE PART B ONLY IP|192.25||||||| 82248|EAP|0300|BILIRUBIN DIRECT|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|192.25||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicare|HEALTHSPRING MA|192.25||||192.25||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|124.50||||||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicare|BCBS MEDICARE PPO MA|||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||27.96||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Aenta Medicare Advantage|AETNA MEDICARE MA|||||27.96||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Blue Cross PPO Specialty|BCBSTX PPO|124.50||||27.96||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Medicare|MEDICARE ACUTE|124.50||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicare|HEALTHSPRING MA|||||27.96||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Access Direct Platinum|HEALTHFIRST TPA UMR|||||27.96||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicaid|MEDICAID AMERIGROUP|||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Cigna|CIGNA|||||27.96||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Humana Medicare Advantage|HUMANA MA|124.50||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|124.50||||||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Healthcare|UNITED HEALTHCARE OTHER|||||27.96||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Medicaid|MEDICAID|||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Medicare Advantage|UHC MEDICARE GOLD MA|124.50||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Blue Cross HMO Specialty|BCBSTX HMO|124.50||||||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||27.96||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Veterans Affairs|VETERANS ADMINISTRATION|124.50||||27.96||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|124.50||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|124.50||||76.23||| 82271|EAP|0300|OCCULT BLOOD, GASTRIC|Managed Medicaid|MEDICAID SUPERIOR|||||27.96||| 82271|EAP|0300|OCCULT BLOOD, GASTRIC|Medicare|MEDICARE ACUTE|124.50||||||| 82306|EAP|0300|VITAMIN D,25 OH|Medicare|MEDICARE ACUTE|1,040.75||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Tricare|TRICARE EAST REGION|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|United Healthcare|UNITED HEALTHCARE|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Workers Compensation|WORKERS COMPENSATION OTHER|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Blue Cross PPO Specialty|BCBSTX PPO|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Blue Cross HMO Specialty|BCBSTX HMO|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|NON CONTRACTED|COMMERCIAL OTHER 1|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,040.75||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Cigna|CIGNA|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Humana Medicare Advantage|HUMANA MA|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicaid|MEDICAID SUPERIOR|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicaid|MEDICAID AMERIGROUP|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicare|BCBS MEDICARE PPO MA|||||1,040.75||| 82306|EAP|0300|VITAMIN D,25 OH|Medicaid|MEDICAID|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicare|HEALTHSPRING MA|||||233.52||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||233.52||| 82308|EAP|0301|CALCITONIN|Medicare|MEDICARE ACUTE|10.26||||||| 82310|EAP|0300|CALCIUM SERUM|Humana Medicare Advantage|HUMANA MA|||||197.50||| 82310|EAP|0300|CALCIUM SERUM|Blue Cross PPO Specialty|BCBSTX PPO|||||120.92||| 82310|EAP|0300|CALCIUM SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||120.92||| 82310|EAP|0300|CALCIUM SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||44.34||| 82310|EAP|0300|CALCIUM SERUM|Managed Medicare|HEALTHSPRING MA|||||44.34||| 82310|EAP|0300|CALCIUM SERUM|Managed Medicare|BCBS MEDICARE PPO MA|||||197.50||| 82310|EAP|0300|CALCIUM SERUM|Medicare|MEDICARE ACUTE|||||197.50||| 82310|EAP|0300|CALCIUM SERUM|United Healthcare|UNITED HEALTHCARE|||||44.34||| 82310|EAP|0300|CALCIUM SERUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||120.92||| 82330|EAP|0301|CALCIUM, IONIZED|Medicare|MEDICARE ACUTE|523.50||||||| 82330|EAP|0301|CALCIUM, IONIZED|NON CONTRACTED|COMMERCIAL OTHER 1|523.50||||||| 82330|EAP|0301|CALCIUM, IONIZED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||117.42||| 82330|EAP|0301|CALCIUM, IONIZED|Managed Medicare|BCBS MEDICARE PPO MA|||||523.50||| 82340|EAP|0301|CALCIUM 24HR URINE|Managed Medicare|HEALTHSPRING MA|||||51.84||| 82370|EAP|0300|CALCIUM,TOTAL X-RAY DIFFR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.87||| 82375|EAP|0301|CARBON MONOXIDE CARBOXYHE|Workers Compensation|WORKERS COMPENSATION OTHER|||||472.25||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Aetna|AETNA PPO|||||163.02||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Medicare|MEDICARE ACUTE|726.50||||163.02||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Blue Cross PPO Specialty|BCBSTX PPO|||||163.02||| 82384|EAP|0301|CATECHOLAMINES|Medicare|MEDICARE ACUTE|||||217.02||| 82384|EAP|0301|CATECHLOAMINES FRACTIONAT|Humana Medicare Advantage|HUMANA MA|||||217.02||| 82390|EAP|0301|CERULOPLASMIN|Humana Medicare Advantage|HUMANA MA|||||92.28||| 82397|EAP|0300|INSULIN-LIKE GROWTH FACTO|Medicare|MEDICARE ACUTE|814.75||||||| 82397|EAP|0300|INSULIN-LIKE GROWTH FACTO|Cigna|CIGNA|||||182.70||| 82465|EAP|0300|CHOLESTEROL|UTMB|UTMB CORRECTIONAL MANAGED CARE|167.25||||||| 82465|EAP|0300|CHOLESTEROL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||37.44||| 82465|EAP|0300|CHOLESTEROL|Medicare|MEDICARE ACUTE|||||37.44||| 82525|EAP|0300|COPPER SERUM|Medicare|MEDICARE ACUTE|475.50||||106.62||| 82525|EAP|0300|COPPER SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||106.62||| 82525|EAP|0300|COPPER SERUM|Blue Cross PPO Specialty|BCBSTX PPO|||||106.62||| 82533|EAP|0300|CORTISOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|624.75||||140.10||| 82533|EAP|0300|CORTISOL|Blue Cross PPO Specialty|BCBSTX PPO|||||140.10||| 82533|EAP|0300|CORTISOL|Medicare|MEDICARE ACUTE|||||140.10||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicare|BCBS MEDICARE PPO MA|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Medicaid|MEDICAID HMO|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicare|HEALTHSPRING MA|249.75||||||| 82550|EAP|0301|CK (CREATINE KINASE)|United Healthcare|UNITED HEALTHCARE|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|UTMB|UTMB CORRECTIONAL MANAGED CARE|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|NON CONTRACTED|COMMERCIAL OTHER 1|||||152.87||| 82550|EAP|0301|CK (CREATINE KINASE)|United Medicare Advantage|UHC MEDICARE GOLD MA|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|United Healthcare|UNITED HEALTHCARE|||||55.98||| 82550|EAP|0301|CK (CREATINE KINASE)|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Medicare|MEDICARE ACUTE|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Veterans Affairs|VETERANS ADMINISTRATION|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|NON CONTRACTED|COMMERCIAL OTHER 2|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Tricare|TRICARE EAST REGION|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||55.98||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicaid|MEDICAID SUPERIOR|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Humana Medicare Advantage|HUMANA MA|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicaid|MEDICAID AMERIGROUP|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||152.87||| 82550|EAP|0301|CK (CREATINE KINASE)|Blue Cross HMO Specialty|BCBSTX HMO|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Aenta Medicare Advantage|AETNA MEDICARE MA|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Blue Cross PPO Specialty|BCBSTX PPO|249.75||||249.75||| 82552|EAP|0301|CK ISOENZYMES|Blue Cross PPO Specialty|BCBSTX PPO|||||115.14||| 82552|EAP|0301|CK ISOENZYMES|Medicare|MEDICARE ACUTE|513.25||||||| 82553|EAP|0301|CKMB|Managed Medicare|HEALTHSPRING MA|235.75||||||| 82553|EAP|0301|CKMB|Medicaid|MEDICAID HMO|||||235.75||| 82553|EAP|0301|CKMB|Medicaid|MEDICAID|||||235.75||| 82553|EAP|0301|CKMB|Managed Medicare|BCBS MEDICARE PPO MA|||||235.75||| 82553|EAP|0301|CKMB|Medicare|MEDICARE ACUTE|235.75||||235.75||| 82553|EAP|0301|CKMB|NON CONTRACTED|COMMERCIAL OTHER 1|||||144.31||| 82553|EAP|0301|CKMB|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||52.86||| 82553|EAP|0301|CKMB|United Healthcare|UNITED HEALTHCARE|||||235.75||| 82553|EAP|0301|CKMB|Tricare|TRICARE EAST REGION|||||235.75||| 82553|EAP|0301|CKMB|United Medicare Advantage|UHC MEDICARE GOLD MA|235.75||||235.75||| 82553|EAP|0301|CKMB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||235.75||| 82553|EAP|0301|CKMB|NON CONTRACTED|COMMERCIAL OTHER 2|||||235.75||| 82553|EAP|0301|CKMB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||235.75||| 82553|EAP|0301|CKMB|Veterans Affairs|VETERANS ADMINISTRATION|235.75||||235.75||| 82553|EAP|0301|CKMB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|235.75||||235.75||| 82553|EAP|0301|CKMB|Managed Medicaid|MEDICAID SUPERIOR|||||235.75||| 82553|EAP|0301|CKMB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|235.75||||235.75||| 82553|EAP|0301|CKMB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||235.75||| 82553|EAP|0301|CKMB|UTMB|UTMB CORRECTIONAL MANAGED CARE|235.75||||235.75||| 82553|EAP|0301|CKMB|Aenta Medicare Advantage|AETNA MEDICARE MA|235.75||||235.75||| 82553|EAP|0301|CKMB|Humana Medicare Advantage|HUMANA MA|235.75||||235.75||| 82553|EAP|0301|CKMB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||235.75||| 82553|EAP|0301|CKMB|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||235.75||| 82553|EAP|0301|CKMB|Blue Cross PPO Specialty|BCBSTX PPO|||||235.75||| 82553|EAP|0301|CKMB|Cigna|CIGNA|||||235.75||| 82553|EAP|0301|CKMB|Managed Medicaid|MEDICAID AMERIGROUP|||||235.75||| 82565|EAP|0300|CREATININE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||44.04||| 82565|EAP|0300|CREATININE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.04||| 82565|EAP|0300|CREATININE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||44.04||| 82565|EAP|0300|CREATININE|Blue Cross PPO Specialty|BCBSTX PPO|196.25||||44.04||| 82565|EAP|0300|CREATININE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||44.04||| 82565|EAP|0300|CREATININE|Humana Medicare Advantage|HUMANA MA|44.04||||44.04||| 82565|EAP|0300|CREATININE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|196.25||||44.04||| 82565|EAP|0300|CREATININE|Managed Medicaid|MEDICAID SUPERIOR|||||196.25||| 82565|EAP|0300|CREATININE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||44.04||| 82565|EAP|0300|CREATININE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||44.04||| 82565|EAP|0300|CREATININE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||44.04||| 82565|EAP|0300|CREATININE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||44.04||| 82565|EAP|0300|CREATININE|United Medicare Advantage|UHC MEDICARE GOLD MA|196.25||||44.04||| 82565|EAP|0300|CREATININE|Blue Cross HMO Specialty|BCBSTX HMO|196.25||||44.04||| 82565|EAP|0300|CREATININE|Tricare|TRICARE EAST REGION|||||44.04||| 82565|EAP|0300|CREATININE|PHCS|HUMANA INSURANCE|||||44.04||| 82565|EAP|0300|CREATININE|Medicare|MEDICARE ACUTE|196.25||||44.04||| 82565|EAP|0300|CREATININE|NON CONTRACTED|COMMERCIAL OTHER 1|196.25||||44.04||| 82565|EAP|0300|CREATININE|Managed Medicare|BCBS MEDICARE PPO MA|||||196.25||| 82565|EAP|0300|CREATININE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||44.04||| 82565|EAP|0300|CREATININE|Managed Medicaid|MEDICAID AMERIGROUP|||||44.04||| 82565|EAP|0300|CREATININE|Medicaid|MEDICAID|||||196.25||| 82565|EAP|0300|CREATININE|Managed Medicare|HEALTHSPRING MA|||||44.04||| 82565|EAP|0300|CREATININE|United Healthcare|UNITED HEALTHCARE|||||44.04||| 82565|EAP|0300|CREATININE|Veterans Affairs|VETERANS ADMINISTRATION|||||44.04||| 82565|EAP|0300|CREATININE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||44.04||| 82565|EAP|0300|CREATININE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||44.04||| 82565|EAP|0300|CREATININE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|196.25||||44.04||| 82570|EAP|0300|CREATININE URINE, RANDOM|Medicaid|MEDICAID|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.98||| 82570|EAP|0300|CREATININE URINE, RANDOM|NON CONTRACTED|COMMERCIAL OTHER 1|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Healthcare|UNITED HEALTHCARE|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Medicare|MEDICARE ACUTE|44.46||||44.46||| 82570|EAP|0300|24 HOUR URINE CREATININE|PHCS|HUMANA INSURANCE|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Workers Compensation|WORKERS COMPENSATION OTHER|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||44.46||| 82570|EAP|0300|24 HOUR URINE CREATININE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Veterans Affairs|VETERANS ADMINISTRATION|||||44.46||| 82570|EAP|0300|24 HOUR URINE CREATININE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicaid|MEDICAID SUPERIOR|1.98||||1.98||| 82570|EAP|0300|CREATININE URINE, RANDOM|Tricare|TRICARE EAST REGION|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicare|HEALTHSPRING MA|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Cigna|CIGNA|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Healthcare|GEHA|||||44.46||| 82570|EAP|0300|24 HOUR URINE CREATININE|Managed Medicaid|MEDICAID SUPERIOR|1.98||||44.46||| 82570|EAP|0300|24 HOUR URINE CREATININE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Humana Medicare Advantage|HUMANA MA|||||44.46||| 82570|EAP|0300|24 HOUR URINE CREATININE|Managed Medicaid|MEDICAID AMERIGROUP|1.98||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicaid|MEDICAID AMERIGROUP|1.98||||1.98||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.46||| 82570|EAP|0300|24 HOUR URINE CREATININE|Blue Cross PPO Specialty|BCBSTX PPO|1.98||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Blue Cross PPO Specialty|BCBSTX PPO|1.98||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||44.46||| 82570|EAP|0300|24 HOUR URINE CREATININE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|Blue Cross HMO Specialty|BCBSTX HMO|||||44.46||| 82570|EAP|0300|CREATININE URINE, RANDOM|ChampVA|CHAMPVA CENTER|||||44.46||| 82575|EAP|0300|CREATININE CLEARANCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|Humana Medicare Advantage|HUMANA MA|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|Managed Medicaid|MEDICAID SUPERIOR|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|Managed Medicaid|MEDICAID AMERIGROUP|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|Blue Cross PPO Specialty|BCBSTX PPO|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|NON CONTRACTED|COMMERCIAL OTHER 1|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|Veterans Affairs|VETERANS ADMINISTRATION|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|Medicare|MEDICARE ACUTE|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|PHCS|HUMANA INSURANCE|||||81.18||| 82575|EAP|0300|CREATININE CLEARANCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||81.18||| 82595|EAP|0301|CRYOGLOBULIN QUANTITATIVE|Medicare|MEDICARE ACUTE|247.75||||||| 82607|EAP|0301|VITAMIN B-12|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|577.50||||129.54||| 82607|EAP|0301|VITAMIN B-12|Cigna|CIGNA|||||129.54||| 82607|EAP|0301|VITAMIN B-12|United Medicare Advantage|UHC MEDICARE GOLD MA|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|577.50||||129.54||| 82607|EAP|0301|VITAMIN B-12|Managed Medicaid|MEDICAID AMERIGROUP|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Managed Medicaid|MEDICAID SUPERIOR|577.50||||129.54||| 82607|EAP|0301|VITAMIN B-12|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Humana Medicare Advantage|HUMANA MA|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Aenta Medicare Advantage|AETNA MEDICARE MA|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Blue Cross HMO Specialty|BCBSTX HMO|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||129.54||| 82607|EAP|0301|VITAMIN B-12|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Blue Cross PPO Specialty|BCBSTX PPO|577.50||||129.54||| 82607|EAP|0301|VITAMIN B-12|Tricare|TRICARE EAST REGION|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Managed Medicare|HEALTHSPRING MA|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|577.50||||||| 82607|EAP|0301|VITAMIN B-12|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||129.54||| 82607|EAP|0301|VITAMIN B-12|United Healthcare|UNITED HEALTHCARE|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Medicaid|MEDICAID|||||129.54||| 82607|EAP|0301|VITAMIN B-12|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Medicare|MEDICARE PART B ONLY IP|577.50||||||| 82607|EAP|0301|VITAMIN B-12|NON CONTRACTED|COMMERCIAL OTHER 1|||||129.54||| 82607|EAP|0301|VITAMIN B-12|Medicare|MEDICARE ACUTE|577.50||||129.54||| 82627|EAP|0301|DHEA-SULFATE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||191.10||| 82627|EAP|0301|DHEA-SULFATE|Blue Cross PPO Specialty|BCBSTX PPO|||||191.10||| 82627|EAP|0301|DHEA-SULFATE|Managed Medicaid|MEDICAID AMERIGROUP|||||191.10||| 82627|EAP|0301|DHEA-SULFATE|Managed Medicaid|MEDICAID SUPERIOR|||||191.10||| 82627|EAP|0301|DHEA-SULFATE|United Healthcare|UNITED HEALTHCARE|||||191.10||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXVI|Cigna|CIGNA|||||330.84||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Cigna|CIGNA|||||810.63||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||292.75||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Managed Medicare|BCBS MEDICARE PPO MA|||||1,328.50||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Medicare|MEDICARE ACUTE|1,328.50||||292.75||| 82668|EAP|0300|ERYTHROPOIETIN|Humana Medicare Advantage|HUMANA MA|720.50||||161.58||| 82668|EAP|0300|ERYTHROPOIETIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||161.58||| 82670|EAP|0301|ESTRADIOL|NON CONTRACTED|COMMERCIAL OTHER 1|1,070.50||||240.12||| 82670|EAP|0301|ESTRADIOL|United Healthcare|UNITED HEALTHCARE|||||240.12||| 82670|EAP|0301|ESTRADIOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||240.12||| 82670|EAP|0301|ESTRADIOL|Blue Cross PPO Specialty|BCBSTX PPO|||||240.12||| 82670|EAP|0301|ESTRADIOL|Aetna|AETNA PPO|||||240.12||| 82670|EAP|0301|ESTRADIOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||240.12||| 82670|EAP|0301|ESTRADIOL|Managed Medicaid|MEDICAID AMERIGROUP|||||240.12||| 82670|EAP|0301|ESTRADIOL|Managed Medicaid|MEDICAID SUPERIOR|||||240.12||| 82670|EAP|0301|ESTRADIOL|United Healthcare|TML GROUP BENEFITS|||||240.12||| 82671|EAP|0300|ESTROGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||274.50||| 82728|EAP|0301|FERRITIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||117.06||| 82728|EAP|0301|FERRITIN|Medicaid|MEDICAID|521.50||||||| 82728|EAP|0301|FERRITIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||117.06||| 82728|EAP|0301|FERRITIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|521.50||||||| 82728|EAP|0301|FERRITIN|Medicaid|MEDICAID HMO|||||117.06||| 82728|EAP|0301|FERRITIN|Tricare|TRICARE EAST REGION|521.50||||319.28||| 82728|EAP|0301|FERRITIN|Managed Medicare|HEALTHSPRING MA|521.50||||319.28||| 82728|EAP|0301|FERRITIN|Medicare|MEDICARE ACUTE|521.50||||117.06||| 82728|EAP|0301|FERRITIN|United Healthcare|GEHA|||||117.06||| 82728|EAP|0301|FERRITIN|PHCS|HUMANA INSURANCE|||||117.06||| 82728|EAP|0301|FERRITIN|United Healthcare|UNITED HEALTHCARE|||||117.06||| 82728|EAP|0301|FERRITIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|521.50||||117.06||| 82728|EAP|0301|FERRITIN|Medicare|MEDICARE PART B ONLY IP|521.50||||||| 82728|EAP|0301|FERRITIN|Managed Medicaid|MEDICAID SUPERIOR|521.50||||117.06||| 82728|EAP|0301|FERRITIN|United Medicare Advantage|UHC MEDICARE GOLD MA|521.50||||117.06||| 82728|EAP|0301|FERRITIN|Workers Compensation|WORKERS COMPENSATION OTHER|521.50||||||| 82728|EAP|0301|FERRITIN|Veterans Affairs|VETERANS ADMINISTRATION|||||117.06||| 82728|EAP|0301|FERRITIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|521.50||||117.06||| 82728|EAP|0301|FERRITIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|521.50||||||| 82728|EAP|0301|FERRITIN|Managed Medicaid|MEDICAID AMERIGROUP|||||117.06||| 82728|EAP|0301|FERRITIN|United Healthcare|UNITED HEALTHCARE OTHER|||||117.06||| 82728|EAP|0301|FERRITIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|521.50||||117.06||| 82728|EAP|0301|FERRITIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||521.50||| 82728|EAP|0301|FERRITIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|521.50||||117.06||| 82728|EAP|0301|FERRITIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||117.06||| 82728|EAP|0301|FERRITIN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||117.06||| 82728|EAP|0301|FERRITIN|Aetna|AETNA PPO|||||117.06||| 82728|EAP|0301|FERRITIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|521.50||||117.06||| 82728|EAP|0301|FERRITIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||117.06||| 82728|EAP|0301|FERRITIN|Blue Cross PPO Specialty|BCBSTX PPO|521.50||||117.06||| 82728|EAP|0301|FERRITIN|Cigna|CIGNA|||||117.06||| 82728|EAP|0301|FERRITIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||117.06||| 82728|EAP|0301|FERRITIN|United Healthcare|TML GROUP BENEFITS|||||117.06||| 82728|EAP|0301|FERRITIN|Humana Medicare Advantage|HUMANA MA|521.50||||117.06||| 82731|EAP|0300|FETAL FIBRONECTIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,901.50||| 82731|EAP|0300|FETAL FIBRONECTIN|Managed Medicaid|MEDICAID AMERIGROUP|||||1,901.50||| 82731|EAP|0300|FETAL FIBRONECTIN|Blue Cross PPO Specialty|BCBSTX PPO|||||1,901.50||| 82731|EAP|0300|FETAL FIBRONECTIN|Aetna|AETNA OTHER|||||1,901.50||| 82731|EAP|0300|FETAL FIBRONECTIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,901.50||| 82731|EAP|0300|FETAL FIBRONECTIN|Managed Medicaid|MEDICAID SUPERIOR|||||1,901.50||| 82731|EAP|0300|FETAL FIBRONECTIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,901.50||| 82746|EAP|0300|FOLIC ACID|Medicare|MEDICARE PART B ONLY IP|563.25||||||| 82746|EAP|0300|FOLIC ACID|Tricare|TRICARE EAST REGION|||||126.36||| 82746|EAP|0300|FOLIC ACID|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||126.36||| 82746|EAP|0300|FOLIC ACID|Medicare|MEDICARE ACUTE|563.25||||126.36||| 82746|EAP|0300|FOLIC ACID|Medicaid|MEDICAID|||||126.36||| 82746|EAP|0300|FOLIC ACID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|563.25||||||| 82746|EAP|0300|FOLIC ACID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|563.25||||126.36||| 82746|EAP|0300|FOLIC ACID|United Medicare Advantage|UHC MEDICARE GOLD MA|563.25||||126.36||| 82746|EAP|0300|FOLIC ACID|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||126.36||| 82746|EAP|0300|FOLIC ACID|Managed Medicare|HEALTHSPRING MA|||||126.36||| 82746|EAP|0300|FOLIC ACID|NON CONTRACTED|COMMERCIAL OTHER 1|||||126.36||| 82746|EAP|0300|FOLIC ACID|United Healthcare|UNITED HEALTHCARE|||||126.36||| 82746|EAP|0300|FOLIC ACID|Managed Medicaid|MEDICAID AMERIGROUP|||||126.36||| 82746|EAP|0300|FOLIC ACID|Cigna|CIGNA|||||126.36||| 82746|EAP|0300|FOLIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||126.36||| 82746|EAP|0300|FOLIC ACID|Humana Medicare Advantage|HUMANA MA|||||126.36||| 82746|EAP|0300|FOLIC ACID|Managed Medicaid|MEDICAID SUPERIOR|563.25||||126.36||| 82746|EAP|0300|FOLIC ACID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|563.25||||126.36||| 82746|EAP|0300|FOLIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|563.25||||126.36||| 82746|EAP|0300|FOLIC ACID|Aenta Medicare Advantage|AETNA MEDICARE MA|||||126.36||| 82746|EAP|0300|FOLIC ACID|Blue Cross HMO Specialty|BCBSTX HMO|||||126.36||| 82746|EAP|0300|FOLIC ACID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||126.36||| 82746|EAP|0300|FOLIC ACID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||126.36||| 82746|EAP|0300|FOLIC ACID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||126.36||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|662.25||||||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|Medicare|MEDICARE ACUTE|||||662.25||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|NON CONTRACTED|COMMERCIAL OTHER 1|||||662.25||| 82784|EAP|0301|IMMUNOGLOBULINS IGG/IGA/I|Medicare|MEDICARE ACUTE|||||79.92||| 82784|EAP|0300|IMMUNOGLOBULIN A|Managed Medicare|HEALTHSPRING MA|||||79.92||| 82784|EAP|0300|IMMUNOGLOBULIN G|Managed Medicare|HEALTHSPRING MA|||||79.92||| 82784|EAP|0300|IMMUNOGLOBULIN G|Medicare|MEDICARE ACUTE|||||79.92||| 82784|EAP|0300|IMMUNOGLOBULIN A|Medicare|MEDICARE ACUTE|||||79.92||| 82784|EAP|0301|IMMUNOGLOBULIN M|Managed Medicare|HEALTHSPRING MA|||||79.92||| 82784|EAP|0300|IMMUNOGLOBULIN A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||79.92||| 82784|EAP|0301|IMMUNOGLOBULIN M|Medicare|MEDICARE ACUTE|||||79.92||| 82785|EAP|0301|IMMUNOGLOBULIN E|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.31||| 82785|EAP|0301|IMMUNOGLOBULIN E|Managed Medicaid|MEDICAID AMERIGROUP|||||141.54||| 82785|EAP|0301|IMMUNOGLOBULIN E|Tricare|TRICARE EAST REGION|6.31||||||| 82785|EAP|0301|IMMUNOGLOBULIN E|Humana Medicare Advantage|HUMANA MA|6.31||||141.54||| 82785|EAP|0301|IMMUNOGLOBULIN E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||141.54||| 82785|EAP|0301|IMMUNOGLOBULIN E|Blue Cross PPO Specialty|BCBSTX PPO|6.31||||141.54||| 82785|EAP|0301|IMMUNOGLOBULIN E|Managed Medicaid|MEDICAID SUPERIOR|||||141.54||| 82785|EAP|0301|IMMUNOGLOBULIN E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.31||| 82785|EAP|0301|IMMUNOGLOBULIN E|Medicare|MEDICARE ACUTE|6.31||||6.31||| 82785|EAP|0301|IMMUNOGLOBULIN E|Medicaid|MEDICAID|||||141.54||| 82787|EAP|0300|IGG SUBCLASS II|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.25||||||| 82787|EAP|0300|IGG SUBCLASS IV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.25||||||| 82787|EAP|0300|IGG SUBCLASS III|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.25||||||| 82787|EAP|0300|IGG SUBCLASS I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.25||||||| 82787|EAP|0300|IGG SUBCLASS II|Blue Cross HMO Specialty|BCBSTX HMO|110.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicare|HEALTHSPRING MA|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Medicaid|MEDICAID|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Medicare|MEDICARE PART B ONLY IP|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|UTMB|UTMB CORRECTIONAL MANAGED CARE|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|NON CONTRACTED|COMMERCIAL OTHER 1|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Tricare|TRICARE EAST REGION|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicare|WELLCARE CHOICE MA|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|United Healthcare|UNITED HEALTHCARE|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|741.25||||741.25||| 82803|EAP|0300|CORD BLOOD GAS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|741.25||||370.75||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Workers Compensation|WORKERS COMPENSATION OTHER|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicaid|MEDICAID SUPERIOR|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Blue Cross PPO Specialty|BCBSTX OTHER|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Humana Medicare Advantage|HUMANA MA|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|741.25||||741.25||| 82803|EAP|0300|CORD BLOOD GAS|Managed Medicaid|MEDICAID SUPERIOR|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicaid|MEDICAID AMERIGROUP|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|United Medicare Advantage|UHC MEDICARE GOLD MA|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Medicaid|MEDICAID HMO|||||741.25||| 82803|EAP|0300|CORD BLOOD GAS|Blue Cross PPO Specialty|BCBSTX PPO|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|United Healthcare|UNITED HEALTHCARE OTHER|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Blue Cross PPO Specialty|BCBSTX PPO|741.25||||741.25||| 82803|EAP|0300|CORD BLOOD GAS|UTMB|UTMB CORRECTIONAL MANAGED CARE|741.25||||741.25||| 82803|EAP|0300|CORD BLOOD GAS|Aetna|AETNA PPO|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Medicare|MEDICARE ACUTE|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Aenta Medicare Advantage|AETNA MEDICARE MA|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Blue Cross HMO Specialty|BCBSTX HMO|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Veterans Affairs|VETERANS ADMINISTRATION|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||741.25||| 82941|EAP|0301|GASTRIN|Blue Cross PPO Specialty|BCBSTX PPO|||||151.56||| 82945|EAP|0301|GLUCOSE CSF|Managed Medicaid|MEDICAID SUPERIOR|||||150.25||| 82947|EAP|0300|GLUCOSE|Managed Medicare|HEALTHSPRING MA|||||33.72||| 82947|EAP|0300|GLUCOSE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||33.72||| 82947|EAP|0300|GLUCOSE|Medicare|MEDICARE ACUTE|150.25||||33.72||| 82947|EAP|0300|GLUCOSE|NON CONTRACTED|COMMERCIAL OTHER 1|||||33.72||| 82947|EAP|0300|GLUCOSE|Tricare|TRICARE EAST REGION|||||33.72||| 82947|EAP|0300|GLUCOSE|United Healthcare|UNITED HEALTHCARE|||||33.72||| 82947|EAP|0300|GLUCOSE|PHCS|HUMANA INSURANCE|||||33.72||| 82947|EAP|0300|GLUCOSE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||33.72||| 82947|EAP|0300|GLUCOSE|Medicaid|MEDICAID HMO|||||33.72||| 82947|EAP|0300|GLUCOSE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||33.72||| 82947|EAP|0300|GLUCOSE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||33.72||| 82947|EAP|0300|GLUCOSE|Managed Medicare|BCBS MEDICARE PPO MA|||||33.72||| 82947|EAP|0300|GLUCOSE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||33.72||| 82947|EAP|0300|GLUCOSE|Medicaid|MEDICAID|150.25||||33.72||| 82947|EAP|0300|GLUCOSE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||33.72||| 82947|EAP|0300|GLUCOSE|Aetna|AETNA PPO|||||33.72||| 82947|EAP|0300|GLUCOSE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||33.72||| 82947|EAP|0300|GLUCOSE|Blue Cross HMO Specialty|BCBSTX HMO|||||33.72||| 82947|EAP|0300|GLUCOSE|Humana Medicare Advantage|HUMANA MA|150.25||||||| 82947|EAP|0300|GLUCOSE|Managed Medicaid|MEDICAID SUPERIOR|||||33.72||| 82947|EAP|0300|GLUCOSE|Managed Medicaid|MEDICAID AMERIGROUP|||||33.72||| 82947|EAP|0300|GLUCOSE|Cigna|CIGNA|||||33.72||| 82947|EAP|0300|GLUCOSE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||33.72||| 82947|EAP|0300|GLUCOSE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||33.72||| 82947|EAP|0300|GLUCOSE|Blue Cross PPO Specialty|BCBSTX PPO|150.25||||33.72||| 82950|EAP|0300|GLUCOSE 2 HR PP|Managed Medicaid|MEDICAID SUPERIOR|||||1.82||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||110.64||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||110.64||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||110.64||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Blue Cross PPO Specialty|BCBSTX PPO|||||110.64||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Cigna|CIGNA|||||110.64||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Managed Medicaid|MEDICAID SUPERIOR|||||110.64||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Aetna|AETNA PPO|||||110.64||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Managed Medicaid|MEDICAID AMERIGROUP|||||110.64||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||110.64||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||110.64||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Cigna|CIGNA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Humana Medicare Advantage|HUMANA MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicaid|MEDICAID SUPERIOR|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicaid|MEDICAID AMERIGROUP|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross PPO Specialty|BCBSTX PPO|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross HMO Specialty|BCBSTX HMO|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross PPO Specialty|BCBSTX OTHER|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Aetna|AETNA PPO|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Healthcare|UNITED HEALTHCARE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|NON CONTRACTED|COMMERCIAL OTHER 1|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Veterans Affairs|VETERANS ADMINISTRATION|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Workers Compensation|WORKERS COMPENSATION OTHER|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|UTMB|UTMB CORRECTIONAL MANAGED CARE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Aenta Medicare Advantage|AETNA MEDICARE MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Medicare Advantage|UHC MEDICARE GOLD MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Healthcare|UNITED HEALTHCARE OTHER|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Healthcare|UNITED HEALTHCARE|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicare|MEDICARE ACUTE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Tricare|TRICARE EAST REGION|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicare|MEDICARE PART B ONLY IP|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|NON CONTRACTED|COMMERCIAL OTHER 2|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicare|HEALTHSPRING MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicare|WELLCARE CHOICE MA|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|Medicaid|MEDICAID HMO|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicare|BCBS MEDICARE PPO MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicaid|MEDICAID|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicaid|SUPERIOR HEALTHPLAN CHIP|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicaid|COUNTY INDIGENT HEALTH OTHER|89.75||||||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Medicare|MEDICARE ACUTE|275.75||||61.86||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||61.86||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Blue Cross PPO Specialty|BCBSTX PPO|||||61.86||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|275.75||||||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||61.86||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Managed Medicaid|MEDICAID SUPERIOR|||||61.86||| 82985|EAP|0300|FRUCTOSAMINE GLYCATED PRO|Cigna|CIGNA|||||129.54||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Managed Medicare|HEALTHSPRING MA|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Medicaid|MEDICAID|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Tricare|TRICARE EAST REGION|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|United Healthcare|UNITED HEALTHCARE|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|NON CONTRACTED|COMMERCIAL OTHER 1|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|United Healthcare|TML GROUP BENEFITS|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Tricare|TRICARE FOR LIFE|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Medicare|MEDICARE ACUTE|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Blue Cross PPO Specialty|BCBSTX PPO|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Aetna|AETNA PPO|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|ChampVA|CHAMPVA CENTER|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Managed Medicaid|MEDICAID SUPERIOR|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Managed Medicaid|MEDICAID AMERIGROUP|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Cigna|CIGNA|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|NON CONTRACTED|COMMERCIAL OTHER 2|||||159.72||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||159.72||| 83002|EAP|0300|LUTENINIZING HORMONE|Managed Medicaid|MEDICAID SUPERIOR|||||159.18||| 83002|EAP|0300|LUTENINIZING HORMONE|Blue Cross PPO Specialty|BCBSTX PPO|||||159.18||| 83002|EAP|0300|LUTENINIZING HORMONE|Medicare|MEDICARE ACUTE|||||159.18||| 83002|EAP|0300|LUTENINIZING HORMONE|United Healthcare|UNITED HEALTHCARE|||||159.18||| 83002|EAP|0300|LUTENINIZING HORMONE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||159.18||| 83002|EAP|0300|LUTENINIZING HORMONE|Managed Medicaid|MEDICAID AMERIGROUP|||||159.18||| 83002|EAP|0300|LUTENINIZING HORMONE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||159.18||| 83002|EAP|0300|LUTENINIZING HORMONE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||159.18||| 83003|EAP|0301|GROWTH HORMONE|Blue Cross PPO Specialty|BCBSTX PPO|||||143.28||| 83003|EAP|0301|GROWTH HORMONE|Managed Medicaid|MEDICAID SUPERIOR|||||143.28||| 83003|EAP|0301|GROWTH HORMONE|Cigna|CIGNA|||||143.28||| 83010|EAP|0301|HAPTOGLOBIN|Medicare|MEDICARE ACUTE|4.82||||||| 83010|EAP|0301|HAPTOGLOBIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.82||||||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Managed Medicaid|MEDICAID SUPERIOR|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Managed Medicaid|MEDICAID AMERIGROUP|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Cigna|CIGNA|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Blue Cross PPO Specialty|BCBSTX PPO|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Blue Cross HMO Specialty|BCBSTX HMO|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Aetna|AETNA PPO|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Medicaid|MEDICAID HMO|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Medicare|MEDICARE ACUTE|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|United Healthcare|TML GROUP BENEFITS|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|NON CONTRACTED|COMMERCIAL OTHER 1|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Tricare|TRICARE EAST REGION|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Medicaid|MEDICAID|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|United Healthcare|UNITED HEALTHCARE|||||110.64||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Access Direct Platinum|HEALTHFIRST TPA UMR|||||110.64||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Workers Compensation|WORKERS COMPENSATION OTHER|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Blue Cross HMO Specialty|BCBSTX HMO|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Aetna|AETNA PPO|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Blue Cross PPO Specialty|BCBSTX OTHER|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Medicare Advantage|UHC MEDICARE GOLD MA|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Aenta Medicare Advantage|AETNA MEDICARE MA|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Cigna|CIGNA|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|MEDICAID HMO|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Cigna|CIGNA|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Veterans Affairs|VETERANS ADMINISTRATION|371.75||||||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Blue Cross PPO Specialty|BCBSTX PPO|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicaid|MEDICAID SUPERIOR|227.58||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Humana Medicare Advantage|HUMANA MA|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicaid|MEDICAID AMERIGROUP|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|MEDICAID|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Tricare|TRICARE EAST REGION|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicare|MEDICARE ACUTE|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|UNITED HEALTHCARE OTHER|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|UTMB|UTMB CORRECTIONAL MANAGED CARE|371.75||||||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|UNITED HEALTHCARE|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|NON CONTRACTED|COMMERCIAL OTHER 1|371.75||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|UNITED HEALTHCARE|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|PHCS|HUMANA INSURANCE|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|TML GROUP BENEFITS|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicare|WELLCARE CHOICE MA|371.75||||||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicare|BCBS MEDICARE PPO MA|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||83.40||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicare|HEALTHSPRING MA|||||83.40||| 83090|EAP|0301|HOMOCYSTEINE|Medicare|MEDICARE ACUTE|||||144.96||| 83090|EAP|0301|HOMOCYSTEINE|Blue Cross PPO Specialty|BCBSTX PPO|||||144.96||| 83090|EAP|0301|HOMOCYSTEINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||144.96||| 83090|EAP|0301|HOMOCYSTEINE|Managed Medicaid|MEDICAID SUPERIOR|||||144.96||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Medicaid|MEDICAID|10,698.73|5816.37|12356.37|5816.37|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Managed Medicaid|MEDICAID AMERIGROUP|22,954.53|12356.37|12356.37|5816.37|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Managed Medicaid|MEDICAID SUPERIOR|15,898.11|8357.64|12356.37|5816.37|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|30,791.45|2989.39|2989.39|69.94|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11,279.25|2250.69|2989.39|69.94|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|17,582.50|69.94|2989.39|69.94|||| 83497|EAP|0301|HIAA-5 SCREENING URINE|Blue Cross PPO Specialty|BCBSTX PPO|||||39.96||| 83498|EAP|0301|17 ALPHA HYDROXYPROGESTER|United Healthcare|UNITED HEALTHCARE|||||233.46||| 83498|EAP|0301|17 ALPHA HYDROXYPROGESTER|Managed Medicaid|MEDICAID SUPERIOR|||||233.46||| 83498|EAP|0301|17 ALPHA HYDROXYPROGESTER|Managed Medicaid|MEDICAID AMERIGROUP|||||233.46||| 83498|EAP|0301|17 ALPHA HYDROXYPROGESTER|Blue Cross PPO Specialty|BCBSTX PPO|||||233.46||| 83498|EAP|0301|17 ALPHA HYDROXYPROGESTER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||233.46||| 83516|EAP|0301|ANTI TISSUE TRANSGLUTAMIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.95||| 83516|EAP|0301|ANTI TISSUE TRANSGLUTAMIN|Blue Cross PPO Specialty|BCBSTX PPO|||||0.95||| 83516|EAP|0301|TISSUE TRANSGLUTAMINASE I|Blue Cross PPO Specialty|BCBSTX PPO|||||99.12||| 83516|EAP|0300|MYELOPEROXIDASE|Blue Cross PPO Specialty|BCBSTX PPO|||||95.20||| 83516|EAP|0300|TISSUE TRANSGLUTAMINASE I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||99.12||| 83516|EAP|0301|TISSUE TRANSGLUTAMINASE I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||99.12||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||103.56||| 83516|EAP|0300|MYELOPEROXIDASE|United Healthcare|UNITED HEALTHCARE|||||95.20||| 83516|EAP|0302|GLIADIN ANTIBODIES IGG|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.18||||||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|United Healthcare|UNITED HEALTHCARE OTHER|||||3.80||| 83516|EAP|0300|GLIADIN ANTIBODY IGA|Tricare|TRICARE EAST REGION|||||99.12||| 83520|EAP|0300|TRYPTASE|Managed Medicaid|MEDICAID AMERIGROUP|||||111.24||| 83520|EAP|0301|IMMUNOASSY NOT OTHERWISE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||111.24||| 83520|EAP|0300|FECAL ELASTASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||109.32||| 83520|EAP|0301|IMMUNOASSY NOT OTHERWISE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||111.24||| 83520|EAP|0301|IMMUNOASSY NOT OTHERWISE|Blue Cross HMO Specialty|BCBSTX HMO|||||111.24||| 83520|EAP|0301|IMMUNOASSY NOT OTHERWISE|Blue Cross PPO Specialty|BCBSTX PPO|||||111.24||| 83525|EAP|0301|INSULIN LEVEL|Blue Cross PPO Specialty|BCBSTX PPO|||||98.28||| 83540|EAP|0301|IRON|NON CONTRACTED|COMMERCIAL OTHER 1|||||55.68||| 83540|EAP|0301|IRON|Medicare|MEDICARE ACUTE|||||55.68||| 83540|EAP|0301|IRON|United Healthcare|UNITED HEALTHCARE|||||55.68||| 83540|EAP|0301|IRON|Tricare|TRICARE EAST REGION|||||55.68||| 83540|EAP|0301|IRON|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||55.68||| 83540|EAP|0301|IRON|Managed Medicare|HEALTHSPRING MA|||||55.68||| 83540|EAP|0301|IRON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||55.68||| 83540|EAP|0301|IRON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||55.68||| 83540|EAP|0301|IRON|Blue Cross PPO Specialty|BCBSTX PPO|||||55.68||| 83540|EAP|0301|IRON|Humana Medicare Advantage|HUMANA MA|||||55.68||| 83540|EAP|0301|IRON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||151.84||| 83540|EAP|0301|IRON|Cigna|CIGNA|||||55.68||| 83540|EAP|0301|IRON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||55.68||| 83540|EAP|0301|IRON|United Medicare Advantage|UHC MEDICARE GOLD MA|||||55.68||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|335.25||||335.25||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Blue Cross PPO Specialty|BCBSTX PPO|335.25||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicaid|MEDICAID SUPERIOR|335.25||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|335.25||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicaid|MEDICAID AMERIGROUP|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Medicare Advantage|UHC MEDICARE GOLD MA|335.25||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|335.25||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||205.19||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Veterans Affairs|VETERANS ADMINISTRATION|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|NON CONTRACTED|COMMERCIAL OTHER 1|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicare|MEDICARE ACUTE|335.25||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Healthcare|UNITED HEALTHCARE|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Healthcare|GEHA|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Cigna|CIGNA|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Healthcare|UNITED HEALTHCARE OTHER|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|PHCS|HUMANA INSURANCE|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicare|MEDICARE PART B ONLY IP|335.25||||||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Humana Medicare Advantage|HUMANA MA|335.25||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicaid|MEDICAID|335.25||||||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicaid|MEDICAID HMO|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicare|HEALTHSPRING MA|||||205.19||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||75.12||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|335.25||||||| 83605|EAP|0301|LACTIC ACID|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||409.25||| 83605|EAP|0301|LACTIC ACID|Medicaid|MEDICAID HMO|||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicare|BCBS MEDICARE PPO MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicare|HEALTHSPRING MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||409.25||| 83605|EAP|0301|LACTIC ACID|UTMB|UTMB CORRECTIONAL MANAGED CARE|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|NON CONTRACTED|COMMERCIAL OTHER 1|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Medicare|MEDICARE PART B ONLY IP|409.25||||||| 83605|EAP|0301|LACTIC ACID|Medicare|MEDICARE ACUTE|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|United Healthcare|UNITED HEALTHCARE OTHER|409.25||||||| 83605|EAP|0301|LACTIC ACID|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||409.25||| 83605|EAP|0301|LACTIC ACID|United Healthcare|UNITED HEALTHCARE|||||409.25||| 83605|EAP|0301|LACTIC ACID|Tricare|TRICARE EAST REGION|||||409.25||| 83605|EAP|0301|LACTIC ACID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|United Medicare Advantage|UHC MEDICARE GOLD MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|United Medicare Advantage|AARP UHC WEST COMPLETE MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|409.25||||||| 83605|EAP|0301|LACTIC ACID|Medicaid|MEDICAID|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Humana Medicare Advantage|HUMANA MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Cigna|CIGNA|||||409.25||| 83605|EAP|0301|LACTIC ACID|ChampVA|CHAMPVA CENTER|409.25||||||| 83605|EAP|0301|LACTIC ACID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicaid|MEDICAID SUPERIOR|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicaid|MEDICAID AMERIGROUP|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Veterans Affairs|VETERANS ADMINISTRATION|||||409.25||| 83605|EAP|0301|LACTIC ACID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Aenta Medicare Advantage|AETNA MEDICARE MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Blue Cross HMO Specialty|BCBSTX HMO|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Aetna|AETNA PPO|409.25||||409.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross PPO Specialty|BCBSTX PPO|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Aetna|AETNA PPO|231.25||||51.84||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|231.25||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Cigna|CIGNA|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Humana Medicare Advantage|HUMANA MA|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID SUPERIOR|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID AMERIGROUP|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Veterans Affairs|VETERANS ADMINISTRATION|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||51.84||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|UHC MEDICARE GOLD MA|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||51.84||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|UTMB|UTMB CORRECTIONAL MANAGED CARE|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicare|MEDICARE ACUTE|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Healthcare|UNITED HEALTHCARE OTHER|231.25||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|MEDICAID HMO|||||51.84||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicare|HEALTHSPRING MA|231.25||||141.55||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|MEDICAID|||||141.55||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Healthcare|UNITED HEALTHCARE|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|NON CONTRACTED|COMMERCIAL OTHER 1|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Tricare|TRICARE EAST REGION|||||231.25||| 83630|EAP|0300|LACTOFERRIN (STOOL)|Humana Medicare Advantage|HUMANA MA|||||168.66||| 83630|EAP|0300|LACTOFERRIN (STOOL)|Blue Cross PPO Specialty|BCBSTX PPO|||||168.66||| 83655|EAP|0301|LEAD|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||104.04||| 83655|EAP|0301|LEAD|Medicaid|MEDICAID|||||104.04||| 83655|EAP|0301|LEAD|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||104.04||| 83655|EAP|0301|LEAD|NON CONTRACTED|COMMERCIAL OTHER 1|||||104.04||| 83655|EAP|0301|LEAD|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||104.04||| 83655|EAP|0301|LEAD|United Healthcare|UNITED HEALTHCARE|||||104.04||| 83655|EAP|0301|LEAD|Tricare|TRICARE EAST REGION|||||104.04||| 83655|EAP|0301|LEAD|Access Direct Platinum|HEALTHFIRST TPA UMR|||||104.04||| 83655|EAP|0301|LEAD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||104.04||| 83655|EAP|0301|LEAD|Blue Cross PPO Specialty|BCBSTX PPO|||||104.04||| 83655|EAP|0301|LEAD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||104.04||| 83655|EAP|0301|LEAD|Managed Medicaid|MEDICAID AMERIGROUP|||||104.04||| 83655|EAP|0301|LEAD|Managed Medicaid|MEDICAID SUPERIOR|||||104.04||| 83655|EAP|0301|LEAD|Cigna|CIGNA|||||104.04||| 83690|EAP|0301|LIPASE|United Medicare Advantage|UHC MEDICARE GOLD MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|Workers Compensation|WORKERS COMPENSATION OTHER|||||264.25||| 83690|EAP|0301|LIPASE|Veterans Affairs|VETERANS ADMINISTRATION|264.25||||264.25||| 83690|EAP|0301|LIPASE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|264.25||||264.25||| 83690|EAP|0301|LIPASE|Cigna|CIGNA|264.25||||264.25||| 83690|EAP|0301|LIPASE|ChampVA|CHAMPVA CENTER|264.25||||||| 83690|EAP|0301|LIPASE|Cigna|CIGNA|||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicaid|MEDICAID SUPERIOR|264.25||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicaid|MEDICAID AMERIGROUP|264.25||||264.25||| 83690|EAP|0301|LIPASE|Humana Medicare Advantage|HUMANA MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|264.25||||264.25||| 83690|EAP|0301|LIPASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|264.25||||264.25||| 83690|EAP|0301|LIPASE|Blue Cross PPO Specialty|BCBSTX OTHER|||||264.25||| 83690|EAP|0301|LIPASE|Aenta Medicare Advantage|AETNA MEDICARE MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|Aetna|AETNA PPO|264.25||||264.25||| 83690|EAP|0301|LIPASE|Blue Cross HMO Specialty|BCBSTX HMO|264.25||||264.25||| 83690|EAP|0301|LIPASE|Access Direct Platinum|HEALTHFIRST TPA UMR|264.25||||264.25||| 83690|EAP|0301|LIPASE|Blue Cross PPO Specialty|BCBSTX PPO|264.25||||264.25||| 83690|EAP|0301|LIPASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|264.25||||264.25||| 83690|EAP|0301|LIPASE|Aetna|AETNA OTHER|||||264.25||| 83690|EAP|0301|LIPASE|NON CONTRACTED|COMMERCIAL OTHER 1|264.25||||264.25||| 83690|EAP|0301|LIPASE|NON CONTRACTED|COMMERCIAL OTHER 2|||||264.25||| 83690|EAP|0301|LIPASE|Medicare|MEDICARE PART B ONLY IP|264.25||||||| 83690|EAP|0301|LIPASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|264.25||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|264.25||||264.25||| 83690|EAP|0301|LIPASE|Medicare|MEDICARE ACUTE|264.25||||264.25||| 83690|EAP|0301|LIPASE|United Healthcare|UNITED HEALTHCARE OTHER|264.25||||264.25||| 83690|EAP|0301|LIPASE|Tricare|TRICARE EAST REGION|||||264.25||| 83690|EAP|0301|LIPASE|PHCS|MULTIPLAN PHCS|||||264.25||| 83690|EAP|0301|LIPASE|United Healthcare|UNITED HEALTHCARE|264.25||||264.25||| 83690|EAP|0301|LIPASE|UTMB|UTMB CORRECTIONAL MANAGED CARE|264.25||||264.25||| 83690|EAP|0301|LIPASE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||264.25||| 83690|EAP|0301|LIPASE|PHCS|HUMANA INSURANCE|||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicare|BCBS MEDICARE PPO MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||264.25||| 83690|EAP|0301|LIPASE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|MEDICAID|264.25||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|MEDICAID HMO|||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicare|WELLCARE CHOICE MA|264.25||||||| 83690|EAP|0301|LIPASE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicare|HEALTHSPRING MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||264.25||| 83690|EAP|0301|LIPASE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|MEDICAID TEXAS CHILDRENS|||||264.25||| 83718|EAP|0301|HDL CHOLESTEROL|UTMB|UTMB CORRECTIONAL MANAGED CARE|313.75||||||| 83718|EAP|0301|HDL CHOLESTEROL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||70.38||| 83721|EAP|0300|LDL, DIRECT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.81||| 83735|EAP|0301|MAGNESIUM|Medicaid|MEDICAID TEXAS CHILDRENS|||||2.57||| 83735|EAP|0301|MAGNESIUM|Medicaid|MEDICAID HMO|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.57||||||| 83735|EAP|0301|MAGNESIUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicare|HEALTHSPRING MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicare|BCBS MEDICARE PPO MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicare|WELLCARE CHOICE MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Medicaid|MEDICAID|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.57||| 83735|EAP|0301|MAGNESIUM|NON CONTRACTED|COMMERCIAL OTHER 1|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Medicare|MEDICARE PART B ONLY IP|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|PHCS|HUMANA INSURANCE|||||2.57||| 83735|EAP|0301|MAGNESIUM|United Healthcare|UNITED HEALTHCARE|||||2.57||| 83735|EAP|0301|MAGNESIUM|United Healthcare|TML GROUP BENEFITS|||||2.57||| 83735|EAP|0301|MAGNESIUM|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||2.57||| 83735|EAP|0301|MAGNESIUM|United Healthcare|UNITED HEALTHCARE|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Tricare|TRICARE FOR LIFE|||||2.57||| 83735|EAP|0301|MAGNESIUM|Tricare|TRICARE EAST REGION|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Veterans Affairs|VETERANS ADMINISTRATION|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|United Healthcare|UNITED HEALTHCARE OTHER|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Medicare|MEDICARE ACUTE|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.57||| 83735|EAP|0301|MAGNESIUM 24 HR URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.57||||57.60||| 83735|EAP|0301|MAGNESIUM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||2.57||| 83735|EAP|0301|MAGNESIUM|United Medicare Advantage|UHC MEDICARE GOLD MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.57||| 83735|EAP|0301|MAGNESIUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicaid|MEDICAID SUPERIOR|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Cigna|CIGNA|||||2.57||| 83735|EAP|0301|MAGNESIUM|Humana Medicare Advantage|HUMANA MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Aenta Medicare Advantage|AETNA MEDICARE MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicaid|MEDICAID AMERIGROUP|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Blue Cross HMO Specialty|BCBSTX HMO|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Blue Cross PPO Specialty|BCBSTX PPO|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.57||| 83735|EAP|0301|MAGNESIUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Aetna|AETNA PPO|2.57||||57.60||| 83735|EAP|0301|MAGNESIUM|Aetna|AETNA OTHER|||||2.57||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||228.42||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Blue Cross PPO Specialty|BCBSTX PPO|||||228.42||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Managed Medicaid|MEDICAID SUPERIOR|||||228.42||| 83825|EAP|0301|MERCURY QUANATATIVE|Medicare|MEDICARE ACUTE|||||111.48||| 83835|EAP|0301|PLASMA METANEPHRINES|Medicare|MEDICARE ACUTE|||||1.40||| 83835|EAP|0301|METANEPHRINES FRACTIONATE|Medicare|MEDICARE ACUTE|||||145.56||| 83874|EAP|0301|MYOGLOBIN SERUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.11||| 83880|EAP|0300|PRO-BNP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||291.72||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Veterans Affairs|VETERANS ADMINISTRATION|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||801.24||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Medicare Advantage|UHC MEDICARE GOLD MA|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Managed Medicaid|MEDICAID SUPERIOR|1,310.75||||1,310.75||| 83880|EAP|0300|PRO-BNP|Humana Medicare Advantage|HUMANA MA|||||291.72||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Humana Medicare Advantage|HUMANA MA|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Managed Medicaid|MEDICAID AMERIGROUP|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Aenta Medicare Advantage|AETNA MEDICARE MA|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Blue Cross HMO Specialty|BCBSTX HMO|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,310.75||| 83880|EAP|0300|PRO-BNP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||291.72||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Blue Cross PPO Specialty|BCBSTX PPO|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Cigna|CIGNA|||||1,310.75||| 83880|EAP|0300|PRO-BNP|Blue Cross PPO Specialty|BCBSTX PPO|||||291.72||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Managed Medicare|HEALTHSPRING MA|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Medicaid|MEDICAID|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Managed Medicare|WELLCARE CHOICE MA|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|NON CONTRACTED|COMMERCIAL OTHER 1|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Medicare|MEDICARE PART B ONLY IP|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Medicare|MEDICARE ACUTE|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|PHCS|HUMANA INSURANCE|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Healthcare|UNITED HEALTHCARE OTHER|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Managed Medicare|BCBS MEDICARE PPO MA|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Healthcare|UNITED HEALTHCARE|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Healthcare|UNITED HEALTHCARE|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Tricare|TRICARE EAST REGION|1,310.75||||1,310.75||| 83880|EAP|0300|PRO-BNP|Medicare|MEDICARE ACUTE|||||291.72||| 83883|EAP|0300|FREE LIGHT CHAINS/SERUM|Medicare|MEDICARE ACUTE|||||291.63||| 83883|EAP|0300|FREE LIGHT CHAINS/SERUM|Managed Medicare|HEALTHSPRING MA|||||115.50||| 83883|EAP|0300|FREE LIGHT CHAINS/SERUM|Humana Medicare Advantage|HUMANA MA|||||115.50||| 83921|EAP|0300|METHYLMALONIC ACID|United Medicare Advantage|UHC MEDICARE GOLD MA|630.75||||141.48||| 83921|EAP|0300|METHYLMALONIC ACID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|630.75||||||| 83921|EAP|0300|METHYLMALONIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|630.75||||||| 83921|EAP|0300|METHYLMALONIC ACID|Humana Medicare Advantage|HUMANA MA|||||630.75||| 83921|EAP|0300|METHYLMALONIC ACID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|630.75||||||| 83921|EAP|0300|METHYLMALONIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|630.75||||630.75||| 83921|EAP|0300|METHYLMALONIC ACID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|630.75||||||| 83921|EAP|0300|METHYLMALONIC ACID|Medicare|MEDICARE ACUTE|630.75||||141.48||| 83921|EAP|0300|METHYLMALONIC ACID|Medicare|MEDICARE PART B ONLY IP|630.75||||||| 83930|EAP|0301|OSMOLALITY SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||188.75||| 83930|EAP|0301|OSMOLALITY SERUM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||188.75||| 83935|EAP|0301|OSMOLALITY URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||42.30||| 83970|EAP|0301|PTH INTACT|PHCS|HUMANA INSURANCE|||||354.72||| 83970|EAP|0301|PTH INTACT|NON CONTRACTED|COMMERCIAL OTHER 1|||||354.72||| 83970|EAP|0301|PTH INTACT|Medicare|MEDICARE ACUTE|13.39||||354.72||| 83970|EAP|0301|PTH INTACT|Managed Medicare|HEALTHSPRING MA|||||354.72||| 83970|EAP|0301|PTH INTACT|Managed Medicare|BCBS MEDICARE PPO MA|||||13.39||| 83970|EAP|0301|PTH INTACT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||354.72||| 83970|EAP|0301|PTH INTACT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||354.72||| 83970|EAP|0301|PTH INTACT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||354.72||| 83970|EAP|0301|PTH INTACT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||354.72||| 83970|EAP|0301|PTH INTACT|Cigna|CIGNA|||||13.39||| 83970|EAP|0301|PTH INTACT|Humana Medicare Advantage|HUMANA MA|13.39||||354.72||| 83970|EAP|0301|PTH INTACT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||354.72||| 83970|EAP|0301|PTH INTACT|Blue Cross PPO Specialty|BCBSTX PPO|13.39||||354.72||| 83993|EAP|0300|CALPROTECTIN, FECAL|Cigna|CIGNA|||||1.60||| 840|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W MCC|Medicare|MEDICARE ACUTE|44,925.32|22898.19|22898.19|22898.19|||| 84075|EAP|0300|ALKALINE PHOSPHATASE|Managed Medicaid|MEDICAID SUPERIOR|||||44.46||| 84075|EAP|0300|ALKALINE PHOSPHATASE|Managed Medicare|HEALTHSPRING MA|||||44.46||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Managed Medicare|HEALTHSPRING MA|||||75.18||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Managed Medicaid|MEDICAID SUPERIOR|||||205.22||| 841|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|19,490.25|12701.83|12701.83|12701.83|||| 84100|EAP|0300|PHOSPHORUS BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||40.74||| 84100|EAP|0300|PHOSPHORUS BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Aetna|AETNA PPO|||||40.74||| 84100|EAP|0300|PHOSPHORUS BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||40.74||| 84100|EAP|0300|PHOSPHORUS BLOOD|Cigna|CIGNA|||||111.37||| 84100|EAP|0300|PHOSPHORUS BLOOD|Humana Medicare Advantage|HUMANA MA|1.82||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||40.74||| 84100|EAP|0300|PHOSPHORUS BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|1.82||||40.74||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicaid|MEDICAID SUPERIOR|1.82||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicare|HEALTHSPRING MA|||||40.74||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicare|BCBS MEDICARE PPO MA|||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|Medicare|MEDICARE ACUTE|1.82||||40.74||| 84100|EAP|0300|PHOSPHORUS BLOOD|PHCS|HUMANA INSURANCE|||||40.74||| 84100|EAP|0300|PHOSPHORUS BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||40.74||| 84132|EAP|0300|POTASSIUM BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||39.48||| 84132|EAP|0300|POTASSIUM BLOOD|Medicare|MEDICARE ACUTE|175.75||||39.48||| 84132|EAP|0300|POTASSIUM BLOOD|Medicaid|MEDICAID|||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|175.75||||||| 84132|EAP|0300|POTASSIUM BLOOD|Humana Medicare Advantage|HUMANA MA|||||39.48||| 84132|EAP|0300|POTASSIUM BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||39.48||| 84132|EAP|0300|POTASSIUM BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|175.75||||39.48||| 84132|EAP|0300|POTASSIUM BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|175.75||||39.48||| 84132|EAP|0300|POTASSIUM BLOOD|United Healthcare|UNITED HEALTHCARE|175.75||||39.48||| 84133|EAP|0300|POTASSIUM URINE,RANDOM|Blue Cross PPO Specialty|BCBSTX PPO|||||36.96||| 84133|EAP|0300|POTASSIUM/URINE 24HR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||36.96||| 84134|EAP|0300|PREALBUMIN|Medicare|MEDICARE ACUTE|323.25||||72.54||| 84134|EAP|0300|PREALBUMIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||72.54||| 84134|EAP|0300|PREALBUMIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||72.54||| 84134|EAP|0300|PREALBUMIN|Humana Medicare Advantage|HUMANA MA|||||72.54||| 84134|EAP|0300|PREALBUMIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||72.54||| 84134|EAP|0300|PREALBUMIN|Blue Cross PPO Specialty|BCBSTX PPO|||||72.54||| 84134|EAP|0300|PREALBUMIN|Aetna|AETNA PPO|||||72.54||| 84144|EAP|0300|PROGESTERONE|Blue Cross HMO Specialty|BCBSTX HMO|||||179.28||| 84144|EAP|0300|PROGESTERONE|Blue Cross PPO Specialty|BCBSTX PPO|||||179.28||| 84144|EAP|0300|PROGESTERONE|Cigna|CIGNA|||||489.39||| 84144|EAP|0300|PROGESTERONE|Managed Medicaid|MEDICAID SUPERIOR|||||179.28||| 84144|EAP|0300|PROGESTERONE|Medicaid|MEDICAID|||||179.28||| 84144|EAP|0300|PROGESTERONE|United Healthcare|UNITED HEALTHCARE|||||179.28||| 84144|EAP|0300|PROGESTERONE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||179.28||| 84145|EAP|0300|PROCALCITONIN|Medicare|MEDICARE ACUTE|921.50||||921.50||| 84145|EAP|0300|PROCALCITONIN|Managed Medicare|BCBS MEDICARE PPO MA|921.50||||||| 84145|EAP|0300|PROCALCITONIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||921.50||| 84145|EAP|0300|PROCALCITONIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Humana Medicare Advantage|HUMANA MA|921.50||||921.50||| 84145|EAP|0300|PROCALCITONIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Blue Cross PPO Specialty|BCBSTX PPO|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Aenta Medicare Advantage|AETNA MEDICARE MA|921.50||||||| 84146|EAP|0300|PROLACTIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||166.56||| 84146|EAP|0300|PROLACTIN|Blue Cross PPO Specialty|BCBSTX PPO|||||166.56||| 84146|EAP|0300|PROLACTIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||166.56||| 84146|EAP|0300|PROLACTIN|Aetna|AETNA PPO|||||166.56||| 84146|EAP|0300|PROLACTIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||166.56||| 84146|EAP|0300|PROLACTIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||166.56||| 84146|EAP|0300|PROLACTIN|Cigna|CIGNA|||||166.56||| 84146|EAP|0300|PROLACTIN|ChampVA|CHAMPVA CENTER|||||166.56||| 84146|EAP|0300|PROLACTIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||166.56||| 84146|EAP|0300|PROLACTIN|Managed Medicaid|MEDICAID SUPERIOR|||||166.56||| 84146|EAP|0300|PROLACTIN|Managed Medicaid|MEDICAID AMERIGROUP|||||166.56||| 84146|EAP|0300|PROLACTIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||166.56||| 84146|EAP|0300|PROLACTIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||166.56||| 84146|EAP|0300|PROLACTIN|Medicaid|MEDICAID|||||166.56||| 84146|EAP|0300|PROLACTIN|Managed Medicare|HEALTHSPRING MA|||||166.56||| 84146|EAP|0300|PROLACTIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||166.56||| 84146|EAP|0300|PROLACTIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||166.56||| 84146|EAP|0300|PROLACTIN|United Healthcare|TML GROUP BENEFITS|||||166.56||| 84146|EAP|0300|PROLACTIN|Medicare|MEDICARE ACUTE|||||166.56||| 84146|EAP|0300|PROLACTIN|Tricare|TRICARE FOR LIFE|||||166.56||| 84146|EAP|0300|PROLACTIN|Tricare|TRICARE EAST REGION|||||166.56||| 84146|EAP|0300|PROLACTIN|United Healthcare|UNITED HEALTHCARE|||||166.56||| 84146|EAP|0300|PROLACTIN|NON CONTRACTED|COMMERCIAL OTHER 2|||||166.56||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Medicare|MEDICARE ACUTE|704.50||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicare|HEALTHSPRING MA|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicare|BCBS MEDICARE PPO MA|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|NON CONTRACTED|COMMERCIAL OTHER 1|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Cigna|CIGNA|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Humana Medicare Advantage|HUMANA MA|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross HMO Specialty|BCBSTX HMO|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||158.04||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||158.04||| 84154|EAP|0300|PSA FREE|Medicare|MEDICARE ACUTE|704.50||||||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||31.50||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Blue Cross PPO Specialty|BCBSTX PPO|||||31.50||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Blue Cross PPO Specialty|BCBSTX PPO|||||1.92||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Cigna|CIGNA|||||31.50||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Humana Medicare Advantage|HUMANA MA|140.50||||31.50||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Veterans Affairs|VETERANS ADMINISTRATION|||||1.92||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||31.50||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Blue Cross HMO Specialty|BCBSTX HMO|||||31.50||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||31.50||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.86||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||31.50||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Managed Medicare|HEALTHSPRING MA|||||31.50||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|||||31.50||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|140.50||||||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|PHCS|HUMANA INSURANCE|||||31.50||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Medicare|MEDICARE ACUTE|140.50||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Medicare|MEDICARE ACUTE|31.50||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|NON CONTRACTED|COMMERCIAL OTHER 1|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|NON CONTRACTED|COMMERCIAL OTHER 1|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Medicare|MEDICARE ACUTE|31.50||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Medicaid|MEDICAID HMO|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||140.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Managed Medicare|HEALTHSPRING MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Workers Compensation|WORKERS COMPENSATION OTHER|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Veterans Affairs|VETERANS ADMINISTRATION|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Veterans Affairs|VETERANS ADMINISTRATION|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Managed Medicaid|MEDICAID SUPERIOR|140.50||||140.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Managed Medicaid|MEDICAID SUPERIOR|140.50||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Managed Medicaid|MEDICAID AMERIGROUP|140.50||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Medicaid|MEDICAID|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Humana Medicare Advantage|HUMANA MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Managed Medicaid|MEDICAID AMERIGROUP|140.50||||140.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|PHCS|HUMANA INSURANCE|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Blue Cross HMO Specialty|BCBSTX HMO|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Aetna|AETNA PPO|||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Humana Medicare Advantage|HUMANA MA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Cigna|CIGNA|||||31.50||| 84156|EAP|0300|TOTAL PROTEIN URINE|Blue Cross PPO Specialty|BCBSTX PPO|140.50||||31.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Blue Cross PPO Specialty|BCBSTX PPO|140.50||||31.50||| 84157|EAP|0300|PROTEIN, CSF|Managed Medicaid|MEDICAID SUPERIOR|||||140.50||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Managed Medicare|HEALTHSPRING MA|||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|NON CONTRACTED|COMMERCIAL OTHER 1|||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Medicare|MEDICARE ACUTE|411.50||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|United Medicare Advantage|UHC MEDICARE GOLD MA|||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Cigna|CIGNA|||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Humana Medicare Advantage|HUMANA MA|411.50||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|411.50||||||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Blue Cross PPO Specialty|BCBSTX PPO|||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||92.28||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||251.89||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Blue Cross HMO Specialty|BCBSTX HMO|||||92.28||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Humana Medicare Advantage|HUMANA MA|||||153.24||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||153.24||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Blue Cross PPO Specialty|BCBSTX PPO|||||153.24||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Veterans Affairs|VETERANS ADMINISTRATION|||||153.24||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|United Medicare Advantage|UHC MEDICARE GOLD MA|||||153.24||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||153.24||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Medicare|MEDICARE ACUTE|||||153.24||| 842|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC|Veterans Affairs|VETERANS ADMINISTRATION|10,651.14|7567.34|7567.34|7567.34|||| 84207|EAP|0300|VITAMIN B-6 (PYRIDOXINE)|Medicare|MEDICARE ACUTE|1,076.50||||241.44||| 84244|EAP|0300|RENIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||189.06||| 84244|EAP|0300|RENIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.43||||||| 84244|EAP|0300|RENIN|Blue Cross PPO Specialty|BCBSTX PPO|||||189.06||| 84244|EAP|0300|RENIN|Managed Medicaid|MEDICAID AMERIGROUP|||||189.06||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.17||||||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|NON CONTRACTED|COMMERCIAL OTHER 1|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Medicare|MEDICARE ACUTE|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Healthcare|UNITED HEALTHCARE|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Cigna|CIGNA|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Humana Medicare Advantage|HUMANA MA|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicaid|MEDICAID SUPERIOR|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicaid|MEDICAID AMERIGROUP|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross HMO Specialty|BCBSTX HMO|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross PPO Specialty|BCBSTX PPO|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Aetna|AETNA PPO|||||186.78||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Aenta Medicare Advantage|AETNA MEDICARE MA|||||186.78||| 84295|EAP|0300|SODIUM SERUM|United Healthcare|UNITED HEALTHCARE|||||41.34||| 84295|EAP|0300|SODIUM SERUM|Medicare|MEDICARE ACUTE|||||184.25||| 84300|EAP|0300|SODIUM URINE|Blue Cross PPO Specialty|BCBSTX PPO|||||41.76||| 84300|EAP|0300|SODIUM URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||41.76||| 84300|EAP|0300|SODIUM URINE|Humana Medicare Advantage|HUMANA MA|186.25||||||| 84300|EAP|0300|SODIUM 24HR URINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||41.76||| 84300|EAP|0300|SODIUM 24HR URINE|PHCS|HUMANA INSURANCE|||||41.76||| 84300|EAP|0300|SODIUM URINE|Medicare|MEDICARE ACUTE|186.25||||||| 84300|EAP|0300|SODIUM URINE|Medicare|MEDICARE PART B ONLY IP|186.25||||||| 84305|EAP|0300|SOMATOMEDIN C|Blue Cross PPO Specialty|BCBSTX PPO|||||182.70||| 84376|EAP|0300|REDUCING SUBSTANCE STOOL|Blue Cross PPO Specialty|BCBSTX PPO|||||83.63||| 84403|EAP|0300|TESTOSTERONE TOTAL|Medicare|MEDICARE ACUTE|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|989.25||||||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicaid|MEDICAID SUPERIOR|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicaid|MEDICAID AMERIGROUP|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Cigna|CIGNA|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Humana Medicare Advantage|HUMANA MA|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Aetna|AETNA PPO|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Healthcare|UNITED HEALTHCARE|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||221.88||| 84403|EAP|0300|TESTOSTERONE TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|||||221.88||| 84425|EAP|0300|THIAMINE (B1)|Blue Cross PPO Specialty|BCBSTX PPO|||||58.38||| 84425|EAP|0300|THIAMINE (B1)|Managed Medicaid|MEDICAID SUPERIOR|||||58.38||| 84425|EAP|0300|THIAMINE (B1)|Medicare|MEDICARE ACUTE|201.75||||58.38||| 84432|EAP|0300|THYROGLOBULIN|Medicare|MEDICARE ACUTE|||||135.66||| 84432|EAP|0300|THYROGLOBULIN|United Healthcare|UNITED HEALTHCARE OTHER|||||135.66||| 84432|EAP|0300|THYROGLOBULIN|Cigna|CIGNA|||||135.66||| 84432|EAP|0300|THYROGLOBULIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||135.66||| 84432|EAP|0300|THYROGLOBULIN|Blue Cross PPO Specialty|BCBSTX PPO|||||135.66||| 84432|EAP|0300|THYROGLOBULIN|Managed Medicaid|MEDICAID AMERIGROUP|||||135.66||| 84432|EAP|0300|THYROGLOBULIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||135.66||| 84436|EAP|0300|T4 THYROXINE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||59.04||| 84436|EAP|0300|T4 THYROXINE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.63||| 84436|EAP|0300|T4 THYROXINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||59.04||| 84436|EAP|0300|T4 THYROXINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||59.04||| 84436|EAP|0300|T4 THYROXINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||59.04||| 84436|EAP|0300|T4 THYROXINE|Blue Cross PPO Specialty|BCBSTX PPO|||||59.04||| 84436|EAP|0300|T4 THYROXINE|Cigna|CIGNA|||||161.02||| 84436|EAP|0300|T4 THYROXINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||59.04||| 84436|EAP|0300|T4 THYROXINE|Medicare|MEDICARE ACUTE|2.63||||59.04||| 84439|EAP|0300|T4 FREE|Managed Medicare|HEALTHSPRING MA|345.50||||77.52||| 84439|EAP|0300|T4 FREE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||77.52||| 84439|EAP|0300|T4 FREE|Managed Medicare|BCBS MEDICARE PPO MA|||||77.52||| 84439|EAP|0300|T4 FREE|United Healthcare|UNITED HEALTHCARE|||||77.52||| 84439|EAP|0300|T4 FREE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||77.52||| 84439|EAP|0300|T4 FREE|Medicare|MEDICARE ACUTE|345.50||||77.52||| 84439|EAP|0300|T4 FREE|Managed Medicaid|MEDICAID AMERIGROUP|||||77.52||| 84439|EAP|0300|T4 FREE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||77.52||| 84439|EAP|0300|T4 FREE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||77.52||| 84439|EAP|0300|T4 FREE|Blue Cross HMO Specialty|BCBSTX HMO|||||77.52||| 84439|EAP|0300|T4 FREE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||77.52||| 84439|EAP|0300|T4 FREE|Aetna|AETNA PPO|||||77.52||| 84439|EAP|0300|T4 FREE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||77.52||| 84439|EAP|0300|T4 FREE|Aetna|AETNA OTHER|||||77.52||| 84439|EAP|0300|T4 FREE|Aenta Medicare Advantage|AETNA MEDICARE MA|345.50||||77.52||| 84439|EAP|0300|T4 FREE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||77.52||| 84439|EAP|0300|T4 FREE|Blue Cross PPO Specialty|BCBSTX OTHER|||||77.52||| 84439|EAP|0300|T4 FREE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||77.52||| 84439|EAP|0300|T4 FREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||77.52||| 84439|EAP|0300|T4 FREE|Humana Medicare Advantage|HUMANA MA|||||77.52||| 84439|EAP|0300|T4 FREE|Blue Cross PPO Specialty|BCBSTX PPO|||||77.52||| 84439|EAP|0300|T4 FREE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||77.52||| 84439|EAP|0300|T4 FREE|United Medicare Advantage|UHC MEDICARE GOLD MA|345.50||||77.52||| 84439|EAP|0300|T4 FREE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|345.50||||77.52||| 84439|EAP|0300|T4 FREE|Cigna|CIGNA|||||77.52||| 84439|EAP|0300|T4 FREE|United Healthcare|TML GROUP BENEFITS|||||77.52||| 84439|EAP|0300|T4 FREE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||77.52||| 84439|EAP|0300|T4 FREE|Tricare|TRICARE EAST REGION|||||77.52||| 84439|EAP|0300|T4 FREE|United Healthcare|UNITED HEALTHCARE OTHER|||||77.52||| 84439|EAP|0300|T4 FREE|Workers Compensation|WORKERS COMPENSATION OTHER|||||77.52||| 84439|EAP|0300|T4 FREE|NON CONTRACTED|COMMERCIAL OTHER 1|||||77.52||| 84439|EAP|0300|T4 FREE|Managed Medicaid|MEDICAID SUPERIOR|77.52||||77.52||| 84439|EAP|0300|T4 FREE|Medicaid|MEDICAID|||||77.52||| 84439|EAP|0300|T4 FREE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||77.52||| 84439|EAP|0300|T4 FREE|Medicaid|MEDICAID HMO|||||77.52||| 84442|EAP|0300|THYROXINE BINDING GLOBULI|Blue Cross PPO Specialty|BCBSTX PPO|||||127.14||| 84442|EAP|0300|THYROXINE BINDING GLOBULI|Managed Medicare|HEALTHSPRING MA|566.50||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|UTMB|UTMB CORRECTIONAL MANAGED CARE|643.75||||394.06||| 84443|EAP|0300|THYROID STIMULATING HORMO|NON CONTRACTED|COMMERCIAL OTHER 1|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|UNITED HEALTHCARE|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|UNITED HEALTHCARE OTHER|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicare|MEDICARE PART B ONLY IP|643.75||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Tricare|TRICARE EAST REGION|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MEDICAID HMO|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|WELLCARE CHOICE MA|643.75||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|TML GROUP BENEFITS|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MEDICAID|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicare|MEDICARE ACUTE|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|COUNTY INDIGENT HEALTH OTHER|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC MEDICARE GOLD MA|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Veterans Affairs|VETERANS ADMINISTRATION|643.75||||643.75||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|643.75||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID AMERIGROUP|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|PHCS|HUMANA INSURANCE|||||643.75||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|BCBS MEDICARE PPO MA|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|HEALTHSPRING MA|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|643.75||||643.75||| 84443|EAP|0300|THYROID STIMULATING HORMO|Cigna|CIGNA|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Humana Medicare Advantage|HUMANA MA|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID SUPERIOR|394.06||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|ChampVA|CHAMPVA CENTER|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|NON CONTRACTED|COMMERCIAL OTHER 2|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Workers Compensation|WORKERS COMPENSATION OTHER|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross HMO Specialty|BCBSTX HMO|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross PPO Specialty|BCBSTX OTHER|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aetna|AETNA PPO|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA UMR|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aetna|AETNA OTHER|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||394.06||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross PPO Specialty|BCBSTX PPO|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Tricare|TRICARE FOR LIFE|||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aenta Medicare Advantage|AETNA MEDICARE MA|643.75||||144.36||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||144.36||| 84446|EAP|0301|VITAMIN E|Medicare|MEDICARE ACUTE|5.43||||||| 84450|EAP|0301|AST (SGOT)|Medicare|MEDICARE ACUTE|||||44.46||| 84450|EAP|0301|AST (SGOT)|Blue Cross PPO Specialty|BCBSTX PPO|||||44.46||| 84450|EAP|0301|AST (SGOT)|Managed Medicaid|MEDICAID AMERIGROUP|||||44.46||| 84450|EAP|0301|AST (SGOT)|Managed Medicaid|MEDICAID SUPERIOR|||||44.46||| 84450|EAP|0301|AST (SGOT)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||44.46||| 84450|EAP|0301|AST (SGOT)|Managed Medicare|HEALTHSPRING MA|||||44.46||| 84460|EAP|0301|ALT (SGPT)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||45.48||| 84460|EAP|0301|ALT (SGPT)|Blue Cross PPO Specialty|BCBSTX PPO|||||45.48||| 84460|EAP|0301|ALT (SGPT)|Managed Medicaid|MEDICAID AMERIGROUP|||||45.48||| 84460|EAP|0301|ALT (SGPT)|Managed Medicare|HEALTHSPRING MA|||||45.48||| 84460|EAP|0301|ALT (SGPT)|Medicare|MEDICARE ACUTE|||||45.48||| 84460|EAP|0301|ALT (SGPT)|Managed Medicaid|MEDICAID SUPERIOR|||||45.48||| 84466|EAP|0301|TRANSFERRIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||79.08||| 84466|EAP|0301|TRANSFERRIN|Blue Cross PPO Specialty|BCBSTX PPO|||||79.08||| 84466|EAP|0301|TRANSFERRIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||79.08||| 84466|EAP|0301|TRANSFERRIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||79.08||| 84466|EAP|0301|TRANSFERRIN|Managed Medicaid|MEDICAID SUPERIOR|||||352.50||| 84466|EAP|0301|TRANSFERRIN|Humana Medicare Advantage|HUMANA MA|||||79.08||| 84466|EAP|0301|TRANSFERRIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||79.08||| 84466|EAP|0301|TRANSFERRIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||79.08||| 84466|EAP|0301|TRANSFERRIN|Medicare|MEDICARE ACUTE|||||79.08||| 84466|EAP|0301|TRANSFERRIN|Tricare|TRICARE EAST REGION|||||79.08||| 84466|EAP|0301|TRANSFERRIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||79.08||| 84478|EAP|0300|TRIGLYCERIDES|UTMB|UTMB CORRECTIONAL MANAGED CARE|220.50||||||| 84478|EAP|0300|TRIGLYCERIDES|Medicare|MEDICARE ACUTE|220.50||||220.50||| 84478|EAP|0300|TRIGLYCERIDES|Veterans Affairs|VETERANS ADMINISTRATION|220.50||||||| 84478|EAP|0300|TRIGLYCERIDES|Aenta Medicare Advantage|AETNA MEDICARE MA|||||220.50||| 84478|EAP|0300|TRIGLYCERIDES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|220.50||||49.44||| 84478|EAP|0300|TRIGLYCERIDES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|220.50||||||| 84479|EAP|0300|T3 UPTAKE|United Medicare Advantage|UHC MEDICARE GOLD MA|247.75||||||| 84479|EAP|0300|T3 UPTAKE|Managed Medicare|HEALTHSPRING MA|247.75||||||| 84479|EAP|0300|T3 UPTAKE|Cigna|CIGNA|||||247.75||| 84479|EAP|0300|T3 UPTAKE|Medicare|MEDICARE ACUTE|247.75||||55.62||| 84480|EAP|0301|TOTAL T3|Medicare|MEDICARE ACUTE|||||121.86||| 84480|EAP|0301|TOTAL T3|Cigna|CIGNA|||||121.86||| 84480|EAP|0301|TOTAL T3|Managed Medicaid|MEDICAID AMERIGROUP|||||121.86||| 84480|EAP|0301|TOTAL T3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||121.86||| 84480|EAP|0301|TOTAL T3|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||332.43||| 84481|EAP|0300|T3, FREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||145.56||| 84481|EAP|0300|T3, FREE|Blue Cross PPO Specialty|BCBSTX PPO|||||145.56||| 84481|EAP|0300|T3, FREE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||145.56||| 84481|EAP|0300|T3, FREE|Humana Medicare Advantage|HUMANA MA|||||145.56||| 84481|EAP|0300|T3, FREE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||145.56||| 84481|EAP|0300|T3, FREE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||145.56||| 84481|EAP|0300|T3, FREE|Managed Medicare|HEALTHSPRING MA|||||145.56||| 84481|EAP|0300|T3, FREE|Medicare|MEDICARE ACUTE|||||145.56||| 84484|EAP|0301|TROPONIN I|NON CONTRACTED|COMMERCIAL OTHER 2|||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|UNITED HEALTHCARE|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Medicare|MEDICARE PART B ONLY IP|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Medicare|MEDICARE ACUTE|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|UTMB|UTMB CORRECTIONAL MANAGED CARE|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|UNITED HEALTHCARE OTHER|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|UNITED HEALTHCARE|||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|TML GROUP BENEFITS|||||377.25||| 84484|EAP|0301|TROPONIN I|PHCS|HUMANA INSURANCE|||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||377.25||| 84484|EAP|0301|TROPONIN I|Tricare|TRICARE EAST REGION|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||377.25||| 84484|EAP|0301|TROPONIN I|Medicaid|COUNTY INDIGENT HEALTH OTHER|377.25||||||| 84484|EAP|0301|TROPONIN I|Managed Medicare|HEALTHSPRING MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Medicaid|MEDICAID HMO|||||377.25||| 84484|EAP|0301|TROPONIN I|Medicaid|MEDICAID|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicare|BCBS MEDICARE PPO MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|United Medicare Advantage|AARP UHC WEST COMPLETE MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Tricare|TRICARE FOR LIFE|||||377.25||| 84484|EAP|0301|TROPONIN I|United Medicare Advantage|UHC MEDICARE GOLD MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicare|WELLCARE CHOICE MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Workers Compensation|WORKERS COMPENSATION OTHER|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Veterans Affairs|VETERANS ADMINISTRATION|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicaid|MEDICAID AMERIGROUP|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Cigna|CIGNA|||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicaid|MEDICAID SUPERIOR|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Humana Medicare Advantage|HUMANA MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Aenta Medicare Advantage|AETNA MEDICARE MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Aetna|AETNA PPO|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|NON CONTRACTED|COMMERCIAL OTHER 1|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Aetna|AETNA OTHER|||||377.25||| 84484|EAP|0301|TROPONIN I|Blue Cross PPO Specialty|BCBSTX OTHER|||||377.25||| 84484|EAP|0301|TROPONIN I|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Access Direct Platinum|HEALTHFIRST TPA UMR|||||377.25||| 84484|EAP|0301|TROPONIN I|Blue Cross HMO Specialty|BCBSTX HMO|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Blue Cross PPO Specialty|BCBSTX PPO|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|377.25||||377.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Aenta Medicare Advantage|AETNA MEDICARE MA|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Access Direct Platinum|HEALTHFIRST TPA UMR|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Blue Cross PPO Specialty|BCBSTX PPO|151.25||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicaid|MEDICAID AMERIGROUP|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Humana Medicare Advantage|HUMANA MA|33.90||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|151.25||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicaid|MEDICAID SUPERIOR|||||151.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Veterans Affairs|VETERANS ADMINISTRATION|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Medicare Advantage|UHC MEDICARE GOLD MA|151.25||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Medicaid|MEDICAID|||||151.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Blue Cross HMO Specialty|BCBSTX HMO|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicare|HEALTHSPRING MA|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicare|BCBS MEDICARE PPO MA|||||151.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Medicare|MEDICARE ACUTE|151.25||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Healthcare|UNITED HEALTHCARE|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Tricare|TRICARE EAST REGION|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||33.90||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|NON CONTRACTED|COMMERCIAL OTHER 1|151.25||||33.90||| 84550|EAP|0300|URIC ACID BLOOD|NON CONTRACTED|COMMERCIAL OTHER 1|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|United Healthcare|UNITED HEALTHCARE|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|PHCS|HUMANA INSURANCE|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Medicare|MEDICARE PART B ONLY IP|173.25||||||| 84550|EAP|0300|URIC ACID BLOOD|Medicaid|MEDICAID|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||173.25||| 84550|EAP|0300|URIC ACID BLOOD|Medicaid|MEDICAID HMO|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicare|BCBS MEDICARE PPO MA|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|173.25||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicaid|MEDICAID AMERIGROUP|173.25||||173.25||| 84550|EAP|0300|URIC ACID BLOOD|Medicare|MEDICARE ACUTE|173.25||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Cigna|CIGNA|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Humana Medicare Advantage|HUMANA MA|173.25||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicare|HEALTHSPRING MA|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Veterans Affairs|VETERANS ADMINISTRATION|173.25||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicaid|MEDICAID SUPERIOR|173.25||||106.04||| 84550|EAP|0300|URIC ACID BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|173.25||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Aetna|AETNA PPO|||||38.82||| 84550|EAP|0300|URIC ACID BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||38.82||| 84590|EAP|0301|VITAMIN A (RETINOL)|Medicare|MEDICARE ACUTE|444.25||||||| 84591|EAP|0301|NIACIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||99.66||| 84597|EAP|0301|VITAMIN K|Medicare|MEDICARE ACUTE|260.50||||58.38||| 84630|EAP|0300|ZINC SERUM|Managed Medicaid|MEDICAID SUPERIOR|||||97.86||| 84681|EAP|0300|C-PEPTIDE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||178.80||| 84681|EAP|0300|C-PEPTIDE|UTMB|UTMB CORRECTIONAL MANAGED CARE|797.25||||||| 84681|EAP|0300|C-PEPTIDE|Tricare|TRICARE EAST REGION|||||178.80||| 84681|EAP|0300|C-PEPTIDE|Managed Medicare|BCBS MEDICARE PPO MA|||||178.80||| 84681|EAP|0300|C-PEPTIDE|Humana Medicare Advantage|HUMANA MA|797.25||||||| 84702|EAP|0300|HCG QUANTITATIVE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.35||||||| 84702|EAP|0300|HCG QUANTITATIVE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Managed Medicaid|MEDICAID AMERIGROUP|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Cigna|CIGNA|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Cigna|CIGNA|||||205.03||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross PPO Specialty|BCBSTX PPO|3.35||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross HMO Specialty|BCBSTX HMO|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Cigna|CIGNA|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|Access Direct Platinum|HEALTHFIRST TPA UMR|3.35||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross PPO Specialty|BCBSTX OTHER|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|NON CONTRACTED|COMMERCIAL OTHER 1|3.35||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Managed Medicaid|MEDICAID SUPERIOR|3.35||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|United Healthcare|UNITED HEALTHCARE|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|Medicare|MEDICARE ACUTE|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Tricare|TRICARE EAST REGION|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|United Healthcare|UNITED HEALTHCARE|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||75.06||| 84702|EAP|0300|HCG QUANTITATIVE|Medicaid|MEDICAID HMO|||||205.03||| 84702|EAP|0300|HCG QUANTITATIVE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|Medicaid|MEDICAID|||||3.35||| 84703|EAP|0300|PREGNANCY TEST SERUM|Managed Medicare|HEALTHSPRING MA|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Medicaid|MEDICAID HMO|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||64.56||| 84703|EAP|0300|PREGNANCY TEST SERUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||64.56||| 84703|EAP|0300|PREGNANCY TEST SERUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.88||||||| 84703|EAP|0300|PREGNANCY TEST SERUM|Tricare|TRICARE EAST REGION|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|United Healthcare|UNITED HEALTHCARE|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||64.56||| 84703|EAP|0300|PREGNANCY TEST SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.88||||176.28||| 84703|EAP|0300|PREGNANCY TEST SERUM|Blue Cross HMO Specialty|BCBSTX HMO|||||176.28||| 84703|EAP|0300|PREGNANCY TEST SERUM|Aetna|AETNA PPO|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Blue Cross PPO Specialty|BCBSTX PPO|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|PHCS|HUMANA INSURANCE|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||64.56||| 84703|EAP|0300|PREGNANCY TEST SERUM|Medicaid|MEDICAID|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Managed Medicaid|MEDICAID SUPERIOR|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|||||64.56||| 84703|EAP|0300|PREGNANCY TEST SERUM|Managed Medicaid|MEDICAID AMERIGROUP|||||64.56||| 84703|EAP|0300|PREGNANCY TEST SERUM|United Healthcare|UNITED HEALTHCARE|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Cigna|CIGNA|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|ChampVA|CHAMPVA CENTER|2.88||||||| 84703|EAP|0300|PREGNANCY TEST SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Medicare|MEDICARE ACUTE|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.88||||2.88||| 84999|EAP|0301|STOOL OSMOLALITY|Cigna|CIGNA|||||42.30||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|NON CONTRACTED|COMMERCIAL OTHER 2|||||73.33||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|NON CONTRACTED|COMMERCIAL OTHER 1|64.50||||47.04||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Healthcare|UNITED HEALTHCARE OTHER|64.50||||68.92||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|PHCS|HUMANA INSURANCE|||||73.33||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|UTMB|UTMB CORRECTIONAL MANAGED CARE|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicare|MEDICARE PART B ONLY IP|73.33||||||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicare|MEDICARE ACUTE|73.33||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Tricare|TRICARE EAST REGION|73.33||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Healthcare|UNITED HEALTHCARE|||||73.33||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicare|HEALTHSPRING MA|73.33||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|MEDICAID HMO|73.33||||68.92||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|COUNTY INDIGENT HEALTH OTHER|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicare|BCBS MEDICARE PPO MA|73.33||||68.92||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|MEDICAID|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Workers Compensation|WORKERS COMPENSATION OTHER|||||68.92||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Medicare Advantage|UHC MEDICARE GOLD MA|73.33||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicare|WELLCARE CHOICE MA|73.33||||||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||29.58||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|73.33||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|73.33||||73.33||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Veterans Affairs|VETERANS ADMINISTRATION|73.33||||73.33||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||47.04||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross PPO Specialty|BCBSTX PPO|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|73.33||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Aetna|AETNA OTHER|||||73.33||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||29.58||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross HMO Specialty|BCBSTX HMO|73.33||||73.33||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Aetna|AETNA PPO|73.33||||47.04||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Healthcare|UNITED HEALTHCARE|73.33||||29.58||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|73.33||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross PPO Specialty|BCBSTX OTHER|||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Aenta Medicare Advantage|AETNA MEDICARE MA|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Access Direct Platinum|HEALTHFIRST TPA UMR|64.50||||||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|64.50||||47.04||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Cigna|CIGNA|68.92||||29.58||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|73.33||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicaid|MEDICAID AMERIGROUP|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Cigna|CIGNA|||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicaid|MEDICAID SUPERIOR|64.50||||29.58||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Humana Medicare Advantage|HUMANA MA|73.33||||64.50||| 85014|EAP|0300|HEMATOCRIT|Cigna|CIGNA|90.75||||20.34||| 85014|EAP|0300|HEMATOCRIT|Humana Medicare Advantage|HUMANA MA|103.18||||20.34||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID SUPERIOR|90.75||||20.34||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.18||||90.75||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||61.76||| 85014|EAP|0300|HEMATOCRIT|Aetna|AETNA PPO|90.75||||||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID AMERIGROUP|103.18||||20.34||| 85014|EAP|0300|HEMATOCRIT|Access Direct Platinum|HEALTHFIRST TPA UMR|||||20.34||| 85014|EAP|0300|HEMATOCRIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||20.34||| 85014|EAP|0300|HEMATOCRIT|Blue Cross PPO Specialty|BCBSTX PPO|90.75||||20.34||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC MEDICARE GOLD MA|103.18||||90.75||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|96.97||||90.75||| 85014|EAP|0300|HEMATOCRIT|Veterans Affairs|VETERANS ADMINISTRATION|103.18||||||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.18||||||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|HEALTHSPRING MA|||||20.34||| 85014|EAP|0300|HEMATOCRIT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||20.34||| 85014|EAP|0300|HEMATOCRIT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||20.34||| 85014|EAP|0300|HEMATOCRIT|Medicaid|MEDICAID|96.97||||20.34||| 85014|EAP|0300|HEMATOCRIT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||90.75||| 85014|EAP|0300|HEMATOCRIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|90.75||||90.75||| 85014|EAP|0300|HEMATOCRIT|NON CONTRACTED|COMMERCIAL OTHER 1|90.75||||90.75||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE|||||20.34||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||20.34||| 85014|EAP|0300|HEMATOCRIT|Medicare|MEDICARE ACUTE|90.75||||20.34||| 85014|EAP|0300|HEMATOCRIT|Tricare|TRICARE EAST REGION|||||55.55||| 85018|EAP|0300|HEMOGLOBIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|90.75||||90.75||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|UNITED HEALTHCARE|||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Tricare|TRICARE EAST REGION|||||90.75||| 85018|EAP|0300|HEMOGLOBIN|NON CONTRACTED|COMMERCIAL OTHER 1|90.75||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|MEDICAID|96.97||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|HEALTHSPRING MA|||||20.34||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|103.18||||||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.18||||||| 85018|EAP|0300|HEMOGLOBIN|Medicare|MEDICARE ACUTE|90.75||||20.34||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|96.97||||90.75||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC MEDICARE GOLD MA|103.18||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Veterans Affairs|VETERANS ADMINISTRATION|103.18||||||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||55.55||| 85018|EAP|0300|HEMOGLOBIN|Aetna|AETNA PPO|90.75||||||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross PPO Specialty|BCBSTX PPO|90.75||||20.34||| 85018|EAP|0300|HEMOGLOBIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||61.76||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID SUPERIOR|90.75||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Cigna|CIGNA|90.75||||||| 85018|EAP|0300|HEMOGLOBIN|Humana Medicare Advantage|HUMANA MA|103.18||||20.34||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.18||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID AMERIGROUP|103.18||||103.18||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Cigna|CIGNA|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Humana Medicare Advantage|HUMANA MA|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Cigna|CIGNA|297.75||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|ChampVA|CHAMPVA CENTER|297.75||||||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicaid|MEDICAID SUPERIOR|297.75||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross PPO Specialty|BCBSTX OTHER|||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|338.52||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|297.75||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Access Direct Platinum|HEALTHFIRST TPA UMR|297.75||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross PPO Specialty|BCBSTX PPO|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross HMO Specialty|BCBSTX HMO|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|338.52||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Aetna|AETNA PPO|338.52||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Workers Compensation|WORKERS COMPENSATION OTHER|318.14||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|297.75||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Medicare Advantage|AARP UHC WEST COMPLETE MA|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|318.14||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Veterans Affairs|VETERANS ADMINISTRATION|338.52||||338.52||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicare|HEALTHSPRING MA|338.52||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Aetna|AETNA OTHER|318.14||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Aenta Medicare Advantage|AETNA MEDICARE MA|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicare|BCBS MEDICARE PPO MA|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|MEDICAID TEXAS CHILDRENS|||||338.52||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|COUNTY INDIGENT HEALTH OTHER|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|MEDICAID HMO|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|MEDICAID|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicare|WELLCARE CHOICE MA|338.52||||338.52||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Medicare Advantage|UHC MEDICARE GOLD MA|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||338.52||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|MOLINA HEALTHCARE OF TEXAS|338.52||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|PHCS|MULTIPLAN PHCS|||||338.52||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicaid|MEDICAID AMERIGROUP|297.75||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Cigna|CIGNA|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Tricare|TRICARE EAST REGION|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Tricare|TRICARE FOR LIFE|||||172.38||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|NON CONTRACTED|COMMERCIAL OTHER 1|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicare|MEDICARE PART B ONLY IP|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicare|MEDICARE ACUTE|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|GEHA|||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|TML GROUP BENEFITS|||||0.47||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|UNITED HEALTHCARE OTHER|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|UNITED HEALTHCARE|297.75||||172.38||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|UNITED HEALTHCARE|297.75||||318.14||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|UMR UNITED MEDICAL RESOURCES|338.52||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|UTMB|UTMB CORRECTIONAL MANAGED CARE|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|NON CONTRACTED|COMMERCIAL OTHER 2|||||338.52||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|PHCS|HUMANA INSURANCE|||||297.75||| 85027|EAP|0300|CBC/NO DIFF|Cigna|CIGNA|247.75||||55.62||| 85027|EAP|0300|CBC/NO DIFF|NON CONTRACTED|COMMERCIAL OTHER 2|||||281.68||| 85027|EAP|0300|CBC/NO DIFF|Medicare|MEDICARE PART B ONLY IP|281.68||||||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|UNITED HEALTHCARE OTHER|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|UNITED HEALTHCARE|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Tricare|TRICARE EAST REGION|281.68||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Medicare|MEDICARE ACUTE|281.68||||247.75||| 85027|EAP|0300|CBC/NO DIFF|NON CONTRACTED|COMMERCIAL OTHER 1|247.75||||264.72||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicare|BCBS MEDICARE PPO MA|281.68||||264.72||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicare|HEALTHSPRING MA|281.68||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|MEDICAID HMO|281.68||||281.68||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|MEDICAID|264.72||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||55.62||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|COUNTY INDIGENT HEALTH OTHER|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicare|WELLCARE CHOICE MA|281.68||||||| 85027|EAP|0300|CBC/NO DIFF|Workers Compensation|WORKERS COMPENSATION OTHER|||||264.72||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|281.68||||247.75||| 85027|EAP|0300|CBC/NO DIFF|United Medicare Advantage|AARP UHC WEST COMPLETE MA|281.68||||281.68||| 85027|EAP|0300|CBC/NO DIFF|United Medicare Advantage|UHC MEDICARE GOLD MA|281.68||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Veterans Affairs|VETERANS ADMINISTRATION|281.68||||281.68||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|UNITED HEALTHCARE|281.68||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|281.68||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross HMO Specialty|BCBSTX HMO|281.68||||281.68||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross PPO Specialty|BCBSTX OTHER|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|UTMB|UTMB CORRECTIONAL MANAGED CARE|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|281.68||||151.69||| 85027|EAP|0300|CBC/NO DIFF|Aetna|AETNA PPO|281.68||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Aetna|AETNA OTHER|||||281.68||| 85027|EAP|0300|CBC/NO DIFF|Aenta Medicare Advantage|AETNA MEDICARE MA|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross PPO Specialty|BCBSTX PPO|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicaid|MEDICAID AMERIGROUP|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|281.68||||281.68||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicaid|MEDICAID UNITED HEALTHCARE|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Cigna|CIGNA|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicaid|MEDICAID SUPERIOR|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Humana Medicare Advantage|HUMANA MA|281.68||||247.75||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicaid|MEDICAID SUPERIOR|164.50||||||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicaid|MEDICAID AMERIGROUP|164.50||||112.00||| 85044|EAP|0305|RETICULOCYTE COUNT|Humana Medicare Advantage|HUMANA MA|175.77||||187.03||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||36.96||| 85044|EAP|0305|RETICULOCYTE COUNT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||36.96||| 85044|EAP|0305|RETICULOCYTE COUNT|Blue Cross PPO Specialty|BCBSTX PPO|164.50||||36.96||| 85044|EAP|0305|RETICULOCYTE COUNT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||112.00||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|187.03||||||| 85044|EAP|0305|RETICULOCYTE COUNT|United Medicare Advantage|UHC MEDICARE GOLD MA|164.50||||36.96||| 85044|EAP|0305|RETICULOCYTE COUNT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|175.77||||36.96||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicare|HEALTHSPRING MA|||||164.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|164.50||||||| 85044|EAP|0305|RETICULOCYTE COUNT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||36.96||| 85044|EAP|0305|RETICULOCYTE COUNT|NON CONTRACTED|COMMERCIAL OTHER 1|||||164.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Medicare|MEDICARE PART B ONLY IP|187.03||||||| 85044|EAP|0305|RETICULOCYTE COUNT|Medicare|MEDICARE ACUTE|187.03||||164.50||| 85049|EAP|0305|PLATELET COUNT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.71||| 85210|EAP|0305|FACTOR II ASSAY|Managed Medicaid|MEDICAID SUPERIOR|||||111.60||| 85240|EAP|0305|FACTOR VIII ASSAY|United Healthcare|UNITED HEALTHCARE|||||55.14||| 85240|EAP|0305|FACTOR VIII ASSAY|Blue Cross PPO Specialty|BCBSTX PPO|||||55.14||| 85246|EAP|0305|F8, VWF, FACTOR ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|313.50||||||| 85246|EAP|0305|F8, VWF, FACTOR ANTIGEN|United Healthcare|UNITED HEALTHCARE|||||70.32||| 85300|EAP|0305|ANTITHROMBIN III ACTIVITY|NON CONTRACTED|COMMERCIAL OTHER 1|||||101.88||| 85300|EAP|0305|ANTITHROMBIN III ACTIVITY|Medicare|MEDICARE ACUTE|454.25||||101.88||| 85300|EAP|0305|ANTITHROMBIN III ACTIVITY|Humana Medicare Advantage|HUMANA MA|||||101.88||| 85300|EAP|0305|ANTITHROMBIN III ACTIVITY|Managed Medicaid|MEDICAID SUPERIOR|||||101.88||| 85300|EAP|0305|ANTITHROMBIN III ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|||||101.88||| 85301|EAP|0300|ANTITHROMBIN III ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||92.94||| 85301|EAP|0300|ANTITHROMBIN III ANTIGEN|Humana Medicare Advantage|HUMANA MA|||||92.94||| 85306|EAP|0300|PROTEIN C ACTIVITY|NON CONTRACTED|COMMERCIAL OTHER 1|||||118.86||| 85306|EAP|0305|PROTEIN S ACTIVITY/TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||99.66||| 85306|EAP|0305|PROTEIN S ACTIVITY/TOTAL|Medicare|MEDICARE ACUTE|505.08||||99.66||| 85306|EAP|0300|PROTEIN C ACTIVITY|Medicare|MEDICARE ACUTE|529.50||||118.86||| 85306|EAP|0305|PROTEIN S ACTIVITY/TOTAL|Humana Medicare Advantage|HUMANA MA|||||99.66||| 85306|EAP|0305|PROTEIN S ACTIVITY/TOTAL|Managed Medicaid|MEDICAID SUPERIOR|||||99.66||| 85306|EAP|0300|PROTEIN C ACTIVITY|Humana Medicare Advantage|HUMANA MA|||||118.86||| 85306|EAP|0300|PROTEIN C ACTIVITY|Managed Medicaid|MEDICAID SUPERIOR|||||118.86||| 85306|EAP|0305|PROTEIN S ACTIVITY/TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|||||99.66||| 85306|EAP|0300|PROTEIN C ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|||||118.86||| 85307|EAP|0305|PROTEIN C RESISTANCE|Blue Cross PPO Specialty|BCBSTX PPO|||||118.62||| 85335|EAP|0305|FACTOR VIII INHIBITOR|Blue Cross PPO Specialty|BCBSTX PPO|||||110.64||| 85379|EAP|0305|D-DIMER|Managed Medicare|BCBS MEDICARE PPO MA|||||2.73||| 85379|EAP|0305|D-DIMER|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||310.38||| 85379|EAP|0305|D-DIMER|Medicaid|MEDICAID HMO|||||310.38||| 85379|EAP|0305|D-DIMER|Managed Medicare|WELLCARE CHOICE MA|||||310.38||| 85379|EAP|0305|D-DIMER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.73||| 85379|EAP|0305|D-DIMER|Managed Medicare|HEALTHSPRING MA|310.38||||310.38||| 85379|EAP|0305|D-DIMER|NON CONTRACTED|COMMERCIAL OTHER 2|||||310.38||| 85379|EAP|0305|D-DIMER|NON CONTRACTED|COMMERCIAL OTHER 1|||||310.38||| 85379|EAP|0305|D-DIMER|Tricare|TRICARE FOR LIFE|||||2.73||| 85379|EAP|0305|D-DIMER|United Healthcare|TML GROUP BENEFITS|||||2.73||| 85379|EAP|0305|D-DIMER|United Healthcare|UNITED HEALTHCARE|||||2.73||| 85379|EAP|0305|D-DIMER|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||61.26||| 85379|EAP|0305|D-DIMER|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.73||||2.73||| 85379|EAP|0305|D-DIMER|United Healthcare|UNITED HEALTHCARE OTHER|||||310.38||| 85379|EAP|0305|D-DIMER|Medicare|MEDICARE ACUTE|310.38||||2.73||| 85379|EAP|0305|D-DIMER|United Medicare Advantage|AARP UHC WEST COMPLETE MA|310.38||||310.38||| 85379|EAP|0305|D-DIMER|Tricare|TRICARE EAST REGION|310.38||||310.38||| 85379|EAP|0305|D-DIMER|Workers Compensation|WORKERS COMPENSATION OTHER|310.38||||||| 85379|EAP|0305|D-DIMER|United Medicare Advantage|UHC MEDICARE GOLD MA|310.38||||310.38||| 85379|EAP|0305|D-DIMER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|310.38||||2.73||| 85379|EAP|0305|D-DIMER|Veterans Affairs|VETERANS ADMINISTRATION|310.38||||310.38||| 85379|EAP|0305|D-DIMER|Medicaid|MEDICAID|||||2.73||| 85379|EAP|0305|D-DIMER|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|310.38||||||| 85379|EAP|0305|D-DIMER|Managed Medicaid|MEDICAID AMERIGROUP|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Cigna|CIGNA|||||310.38||| 85379|EAP|0305|D-DIMER|Cigna|CIGNA|||||2.73||| 85379|EAP|0305|D-DIMER|Humana Medicare Advantage|HUMANA MA|310.38||||2.73||| 85379|EAP|0305|D-DIMER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|310.38||||291.69||| 85379|EAP|0305|D-DIMER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|310.38||||2.73||| 85379|EAP|0305|D-DIMER|Managed Medicaid|MEDICAID SUPERIOR|||||291.69||| 85379|EAP|0305|D-DIMER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|310.38||||310.38||| 85379|EAP|0305|D-DIMER|Aenta Medicare Advantage|AETNA MEDICARE MA|||||291.69||| 85379|EAP|0305|D-DIMER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||291.69||| 85379|EAP|0305|D-DIMER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.73||| 85379|EAP|0305|D-DIMER|Blue Cross PPO Specialty|BCBSTX PPO|310.38||||310.38||| 85379|EAP|0305|D-DIMER|Blue Cross HMO Specialty|BCBSTX HMO|310.38||||310.38||| 85379|EAP|0305|D-DIMER|Aetna|AETNA PPO|||||2.73||| 85384|EAP|0300|FIBRINOGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||369.79||| 85384|EAP|0300|FIBRINOGEN|Blue Cross PPO Specialty|BCBSTX PPO|325.25||||369.79||| 85384|EAP|0300|FIBRINOGEN|Aetna|AETNA PPO|325.25||||73.02||| 85384|EAP|0300|FIBRINOGEN|Managed Medicaid|MEDICAID SUPERIOR|369.79||||199.14||| 85384|EAP|0300|FIBRINOGEN|Humana Medicare Advantage|HUMANA MA|369.79||||||| 85384|EAP|0300|FIBRINOGEN|Managed Medicaid|MEDICAID AMERIGROUP|369.79||||199.14||| 85384|EAP|0300|FIBRINOGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||325.25||| 85384|EAP|0300|FIBRINOGEN|Veterans Affairs|VETERANS ADMINISTRATION|369.79||||||| 85384|EAP|0300|FIBRINOGEN|United Healthcare|UNITED HEALTHCARE|||||73.02||| 85384|EAP|0300|FIBRINOGEN|Medicare|MEDICARE ACUTE|325.25||||73.02||| 85384|EAP|0300|FIBRINOGEN|Medicaid|MEDICAID TEXAS CHILDRENS|||||369.79||| 85384|EAP|0300|FIBRINOGEN|Medicaid|MEDICAID HMO|||||73.02||| 85384|EAP|0300|FIBRINOGEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||325.25||| 85384|EAP|0300|FIBRINOGEN|Medicaid|MEDICAID|||||73.02||| 85461|EAP|0300|FETAL SCREEN|Medicaid|MEDICAID HMO|278.83||||||| 85461|EAP|0300|FETAL SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|278.83||||278.83||| 85461|EAP|0300|FETAL SCREEN|Managed Medicaid|MEDICAID SUPERIOR|278.83||||||| 85461|EAP|0300|FETAL SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|278.83||||||| 85461|EAP|0300|FETAL SCREEN|Aetna|AETNA PPO|278.83||||||| 85597|EAP|0300|PLATELET NEUTRALIZATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||124.74||| 85597|EAP|0300|PLATELET NEUTRALIZATION|Humana Medicare Advantage|HUMANA MA|||||124.74||| 85597|EAP|0300|PLATELET NEUTRALIZATION|Managed Medicaid|MEDICAID SUPERIOR|||||124.74||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|NON CONTRACTED|COMMERCIAL OTHER 2|||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|NON CONTRACTED|COMMERCIAL OTHER 1|160.81||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Healthcare|TML GROUP BENEFITS|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Healthcare|UNITED HEALTHCARE|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Tricare|TRICARE EAST REGION|||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|PHCS|HUMANA INSURANCE|||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Healthcare|UNITED HEALTHCARE OTHER|150.50||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicare|MEDICARE ACUTE|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|UTMB|UTMB CORRECTIONAL MANAGED CARE|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicare|MEDICARE PART B ONLY IP|171.11||||160.81||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|MEDICAID TEXAS CHILDRENS|||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|MEDICAID|150.50||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicare|BCBS MEDICARE PPO MA|171.11||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicare|WELLCARE CHOICE MA|||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Aenta Medicare Advantage|AETNA MEDICARE MA|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Blue Cross PPO Specialty|BCBSTX OTHER|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Blue Cross HMO Specialty|BCBSTX HMO|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|MEDICAID HMO|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicare|HEALTHSPRING MA|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Aetna|AETNA PPO|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Aetna|AETNA OTHER|||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Access Direct Platinum|HEALTHFIRST TPA UMR|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Blue Cross PPO Specialty|BCBSTX PPO|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicaid|MEDICAID AMERIGROUP|150.50||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Cigna|CIGNA|160.81||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Cigna|CIGNA|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|ChampVA|CHAMPVA CENTER|150.50||||||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicaid|MEDICAID SUPERIOR|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Humana Medicare Advantage|HUMANA MA|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Workers Compensation|WORKERS COMPENSATION OTHER|||||160.81||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||33.72||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Medicare Advantage|UHC MEDICARE GOLD MA|171.11||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|171.11||||171.11||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Veterans Affairs|VETERANS ADMINISTRATION|171.11||||171.11||| 85613|EAP|0305|RUSSELL VIPER VENOM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||60.12||| 85613|EAP|0305|RUSSELL VIPER VENOM|Managed Medicaid|MEDICAID SUPERIOR|||||60.12||| 85613|EAP|0305|RUSSELL VIPER VENOM|Humana Medicare Advantage|HUMANA MA|||||60.12||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Medicaid|MEDICAID|||||117.39||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicare|HEALTHSPRING MA|103.25||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||63.24||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Healthcare|UNITED HEALTHCARE|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Healthcare|GEHA|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Healthcare|UNITED HEALTHCARE OTHER|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|UTMB|UTMB CORRECTIONAL MANAGED CARE|117.39||||103.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Medicare|MEDICARE ACUTE|103.25||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Aenta Medicare Advantage|AETNA MEDICARE MA|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Blue Cross HMO Specialty|BCBSTX HMO|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.32||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Blue Cross PPO Specialty|BCBSTX PPO|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Aetna|AETNA PPO|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicaid|MEDICAID SUPERIOR|103.25||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicaid|MEDICAID AMERIGROUP|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Cigna|CIGNA|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Humana Medicare Advantage|HUMANA MA|103.25||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|117.39||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Medicare Advantage|UHC MEDICARE GOLD MA|117.39||||23.22||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||23.22||| 85660|EAP|0305|SICKLE CELL SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Cigna|CIGNA|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Managed Medicaid|MEDICAID SUPERIOR|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Aetna|AETNA PPO|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Tricare|TRICARE EAST REGION|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|United Healthcare|UNITED HEALTHCARE|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Medicaid|MEDICAID HMO|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||47.40||| 85660|EAP|0305|SICKLE CELL SCREEN|Medicaid|MEDICAID|||||47.40||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58,225.94|15216.82|15216.82|15216.82|||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Workers Compensation|WORKERS COMPENSATION OTHER|||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Veterans Affairs|VETERANS ADMINISTRATION|261.50||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Medicare Advantage|UHC MEDICARE GOLD MA|261.50||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|245.75||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|261.50||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Aenta Medicare Advantage|AETNA MEDICARE MA|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||51.60||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Blue Cross HMO Specialty|BCBSTX HMO|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Aetna|AETNA OTHER|||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Blue Cross PPO Specialty|BCBSTX PPO|245.75||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Aetna|AETNA PPO|245.75||||245.75||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|261.50||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicaid|MEDICAID SUPERIOR|261.50||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicaid|MEDICAID AMERIGROUP|2.30||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Cigna|CIGNA|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Humana Medicare Advantage|HUMANA MA|261.50||||2.30||| 85730|EAP|0305|PTT MIXING STUDY|Managed Medicaid|MEDICAID SUPERIOR|261.50||||55.62||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|MEDICAID HMO|||||245.75||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|261.50||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicare|HEALTHSPRING MA|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicare|WELLCARE CHOICE MA|||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|MEDICAID|2.30||||261.50||| 85730|EAP|0305|PTT MIXING STUDY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|245.75||||55.62||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicare|BCBS MEDICARE PPO MA|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|261.50||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|NON CONTRACTED|COMMERCIAL OTHER 2|||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|NON CONTRACTED|COMMERCIAL OTHER 1|245.75||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicare|MEDICARE PART B ONLY IP|261.50||||245.75||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|PHCS|HUMANA INSURANCE|||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||245.75||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Tricare|TRICARE EAST REGION|261.50||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Healthcare|UNITED HEALTHCARE OTHER|2.30||||261.50||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicare|MEDICARE ACUTE|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Healthcare|TML GROUP BENEFITS|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Healthcare|UNITED HEALTHCARE|||||2.30||| 85732|EAP|0300|LUPUS ANTICOAGULANT|NON CONTRACTED|COMMERCIAL OTHER 1|||||55.62||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicaid|MEDICAID SUPERIOR|||||55.62||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Blue Cross PPO Specialty|BCBSTX PPO|||||55.62||| 85732|EAP|0300|LUPUS ANTICOAGULANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||55.62||| 86003|EAP|0300|ALLERGEN SPECIFIC IGE|Blue Cross PPO Specialty|BCBSTX PPO|||||40.38||| 86003|EAP|0300|ALLERGEN SPECIFIC IGE|Managed Medicaid|MEDICAID AMERIGROUP|||||40.38||| 86003|EAP|0300|ALLERGEN SPECIFIC IGE|Humana Medicare Advantage|HUMANA MA|||||40.38||| 86003|EAP|0300|ALLERGEN SPECIFIC IGE|Managed Medicaid|MEDICAID SUPERIOR|||||40.38||| 86003|EAP|0300|ALLERGEN SPECIFIC IGE|Medicaid|MEDICAID|||||40.38||| 86003|EAP|0300|ALLERGEN SPECIFIC IGE|Medicare|MEDICARE ACUTE|||||40.38||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Medicare|MEDICARE ACUTE|463.25||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Healthcare|UNITED HEALTHCARE|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Healthcare|UNITED HEALTHCARE OTHER|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicare|HEALTHSPRING MA|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Workers Compensation|WORKERS COMPENSATION OTHER|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|463.25||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Veterans Affairs|VETERANS ADMINISTRATION|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicaid|MEDICAID AMERIGROUP|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|463.25||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Cigna|CIGNA|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicaid|MEDICAID SUPERIOR|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Humana Medicare Advantage|HUMANA MA|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Blue Cross HMO Specialty|BCBSTX HMO|||||103.92||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Blue Cross PPO Specialty|BCBSTX PPO|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Blue Cross PPO Specialty|BCBSTX PPO|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Managed Medicaid|MEDICAID SUPERIOR|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|463.25||||||| 86039|EAP|0302|ANATITER (PATTERN)|Cigna|CIGNA|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Humana Medicare Advantage|HUMANA MA|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Veterans Affairs|VETERANS ADMINISTRATION|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|Medicare|MEDICARE ACUTE|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|United Healthcare|UNITED HEALTHCARE|||||103.92||| 86039|EAP|0302|ANATITER (PATTERN)|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.92||| 86140|EAP|0302|C-REACTIVE PROTEIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.98||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|NON CONTRACTED|COMMERCIAL OTHER 1|1.98||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Tricare|TRICARE EAST REGION|1.98||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicare|MEDICARE PART B ONLY IP|1.98||||||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Healthcare|GEHA|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicare|MEDICARE ACUTE|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicare|HEALTHSPRING MA|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicare|BCBS MEDICARE PPO MA|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Medicare Advantage|UHC MEDICARE GOLD MA|1.98||||121.23||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Veterans Affairs|VETERANS ADMINISTRATION|||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Healthcare|UNITED HEALTHCARE|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Workers Compensation|WORKERS COMPENSATION OTHER|1.98||||||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.98||||||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID SUPERIOR|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Cigna|CIGNA|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID AMERIGROUP|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Humana Medicare Advantage|HUMANA MA|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.98||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Aenta Medicare Advantage|AETNA MEDICARE MA|1.98||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross HMO Specialty|BCBSTX HMO|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Aetna|AETNA PPO|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross PPO Specialty|BCBSTX OTHER|||||44.46||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross PPO Specialty|BCBSTX PPO|1.98||||44.46||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||496.25||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||496.25||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Blue Cross PPO Specialty|BCBSTX PPO|||||111.24||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|496.25||||496.25||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||496.25||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||111.24||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||111.24||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Medicare|MEDICARE ACUTE|496.25||||496.25||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|United Healthcare|UNITED HEALTHCARE OTHER|||||303.75||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|NON CONTRACTED|COMMERCIAL OTHER 1|||||66.30||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||66.30||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Humana Medicare Advantage|HUMANA MA|||||66.30||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Managed Medicaid|MEDICAID SUPERIOR|||||66.30||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Blue Cross PPO Specialty|BCBSTX PPO|||||66.30||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Blue Cross PPO Specialty|BCBSTX PPO|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Blue Cross PPO Specialty|BCBSTX PPO|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Managed Medicaid|MEDICAID SUPERIOR|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Managed Medicaid|MEDICAID SUPERIOR|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Humana Medicare Advantage|HUMANA MA|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Humana Medicare Advantage|HUMANA MA|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Humana Medicare Advantage|HUMANA MA|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Managed Medicaid|MEDICAID SUPERIOR|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|NON CONTRACTED|COMMERCIAL OTHER 1|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|NON CONTRACTED|COMMERCIAL OTHER 1|||||67.50||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|NON CONTRACTED|COMMERCIAL OTHER 1|||||67.50||| 86160|EAP|0302|COMPLEMENT C4|Managed Medicare|HEALTHSPRING MA|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Managed Medicare|HEALTHSPRING MA|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Medicare|MEDICARE ACUTE|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Workers Compensation|WORKERS COMPENSATION OTHER|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|Veterans Affairs|VETERANS ADMINISTRATION|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|Medicare|MEDICARE ACUTE|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Veterans Affairs|VETERANS ADMINISTRATION|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|Workers Compensation|WORKERS COMPENSATION OTHER|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Cigna|CIGNA|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|Managed Medicaid|MEDICAID AMERIGROUP|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|Humana Medicare Advantage|HUMANA MA|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|Cigna|CIGNA|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Managed Medicaid|MEDICAID AMERIGROUP|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Humana Medicare Advantage|HUMANA MA|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.20||| 86160|EAP|0302|COMPLEMENT C4|Blue Cross PPO Specialty|BCBSTX PPO|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Blue Cross PPO Specialty|BCBSTX PPO|||||103.20||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.20||| 86161|EAP|0300|C1 ESTERASE INHIBITOR/QNT|Managed Medicaid|MEDICAID AMERIGROUP|||||103.20||| 86162|EAP|0302|COMPLEMENT TOTAL (CH50)|Medicare|MEDICARE ACUTE|||||161.46||| 86162|EAP|0302|COMPLEMENT TOTAL (CH50)|Managed Medicaid|MEDICAID AMERIGROUP|||||161.46||| 86162|EAP|0302|COMPLEMENT TOTAL (CH50)|Cigna|CIGNA|||||161.46||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||111.24||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Humana Medicare Advantage|HUMANA MA|||||111.24||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||111.24||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|United Healthcare|UNITED HEALTHCARE|||||111.24||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|United Healthcare|UNITED HEALTHCARE|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Medicare|MEDICARE ACUTE|526.50||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Managed Medicare|HEALTHSPRING MA|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|United Medicare Advantage|UHC MEDICARE GOLD MA|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Cigna|CIGNA|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Managed Medicaid|MEDICAID AMERIGROUP|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Humana Medicare Advantage|HUMANA MA|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|526.50||||||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Blue Cross PPO Specialty|BCBSTX PPO|||||118.08||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||118.08||| 86235|EAP|0300|RNP ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||147.90||| 86235|EAP|0302|ANTITHYMIC NUCLEAR ANTIGE|Blue Cross HMO Specialty|BCBSTX HMO|||||103.02||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||154.14||| 86235|EAP|0300|SMITH ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||147.90||| 86235|EAP|0300|RNP ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||147.90||| 86235|EAP|0300|CENTROMERE B ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||99.12||| 86235|EAP|0302|SCLERODERMA ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||154.14||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||154.14||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||154.14||| 86235|EAP|0300|JO-1 ANTIBODY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||154.14||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||154.14||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||154.14||| 86235|EAP|0302|SCLERODERMA ANTIBODY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||154.14||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||154.14||| 86235|EAP|0302|SCLERODERMA ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||154.14||| 86235|EAP|0300|SMITH-RNP ANTIBODIES|Managed Medicare|HEALTHSPRING MA|||||154.14||| 86235|EAP|0300|CENTROMERE B ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||99.12||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|Medicare|MEDICARE ACUTE|||||154.14||| 86235|EAP|0302|SCLERODERMA ANTIBODY|Medicare|MEDICARE ACUTE|||||154.14||| 86235|EAP|0300|JO-1 ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||154.14||| 86235|EAP|0300|RNP ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||147.90||| 86235|EAP|0302|SCLERODERMA ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||154.14||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|Medicare|MEDICARE ACUTE|||||154.14||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||154.14||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||154.14||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|United Healthcare|UNITED HEALTHCARE|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Medicare|MEDICARE ACUTE|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Veterans Affairs|VETERANS ADMINISTRATION|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Workers Compensation|WORKERS COMPENSATION OTHER|||||103.56||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Humana Medicare Advantage|HUMANA MA|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Blue Cross PPO Specialty|BCBSTX PPO|||||103.56||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Blue Cross HMO Specialty|BCBSTX HMO|||||103.56||| 86256|EAP|0310|ENDOMYSIAL IGA ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.56||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Medicare|MEDICARE ACUTE|97,565.50|8713.01|22061.49|8713.01|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|63,097.40|8724.73|22061.49|8713.01|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|54,136.45|15799.19|22061.49|8713.01|||| 863|DRG||POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|30,965.23|22061.49|22061.49|8713.01|||| 86301|EAP|0302|CA 19-9|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||178.86||| 86301|EAP|0302|CA 19-9|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||178.86||| 86301|EAP|0302|CA 19-9|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||178.86||| 86301|EAP|0302|CA 19-9|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||178.86||| 86301|EAP|0302|CA 19-9|Medicare|MEDICARE ACUTE|||||178.86||| 86304|EAP|0302|CA 125|NON CONTRACTED|COMMERCIAL OTHER 1|797.25||||||| 86304|EAP|0302|CA 125|Tricare|TRICARE EAST REGION|||||178.86||| 86304|EAP|0302|CA 125|Medicare|MEDICARE ACUTE|||||178.86||| 86304|EAP|0302|CA 125|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||797.25||| 86304|EAP|0302|CA 125|Managed Medicaid|MEDICAID AMERIGROUP|||||178.86||| 86304|EAP|0302|CA 125|Humana Medicare Advantage|HUMANA MA|||||178.86||| 86304|EAP|0302|CA 125|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||178.86||| 86304|EAP|0302|CA 125|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||178.86||| 86304|EAP|0302|CA 125|Blue Cross PPO Specialty|BCBSTX PPO|797.25||||178.86||| 86304|EAP|0302|CA 125|Aetna|AETNA PPO|||||178.86||| 86304|EAP|0302|CA 125|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||178.86||| 86304|EAP|0302|CA 125|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||178.86||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||239.18||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Blue Cross PPO Specialty|BCBSTX PPO|||||390.75||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Managed Medicaid|MEDICAID AMERIGROUP|||||87.60||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Managed Medicaid|MEDICAID SUPERIOR|||||390.75||| 86331|EAP|0300|PNEUMINITIS ANTIBODY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||103.02||| 86331|EAP|0300|PNEUMINITIS ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||103.02||| 86334|EAP|0300|IMMUNOFIXATION,SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.82||| 86334|EAP|0300|IMMUNOFIXATION,SERUM|Humana Medicare Advantage|HUMANA MA|||||1.82||| 86334|EAP|0300|IMMUNOFIXATION,SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.82||| 86334|EAP|0300|IMMUNOFIXATION,SERUM|Medicare|MEDICARE ACUTE|||||1.82||| 86334|EAP|0300|IMMUNOFIXATION,SERUM|Managed Medicare|HEALTHSPRING MA|||||1.82||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Managed Medicare|HEALTHSPRING MA|||||252.24||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||252.24||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|PHCS|HUMANA INSURANCE|||||252.24||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Medicare|MEDICARE ACUTE|||||252.24||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||252.24||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Blue Cross PPO Specialty|BCBSTX PPO|||||252.24||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Humana Medicare Advantage|HUMANA MA|||||252.24||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Veterans Affairs|VETERANS ADMINISTRATION|||||252.24||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||252.24||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||252.24||| 86336|EAP|0300|INHIBIN A|Managed Medicaid|MEDICAID AMERIGROUP|||||0.85||| 86336|EAP|0300|INHIBIN A|NON CONTRACTED|COMMERCIAL OTHER 1|4.96||||||| 86337|EAP|0302|INSULIN ANTIBODIES|Tricare|TRICARE EAST REGION|||||148.68||| 86340|EAP|0302|INTRINSIC FACTOR ANTIBODY|Medicare|MEDICARE ACUTE|||||129.54||| 86341|EAP|0300|ISLET CELL ANTIBODY|Tricare|TRICARE EAST REGION|||||148.68||| 86359|EAP|0300|T CELLS,TOTAL COUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.11||| 86359|EAP|0300|T CELLS,TOTAL COUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,166.50||||||| 86360|EAP|0302|ABSOLUTE CD4&CD8 COUNT IN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||403.80||| 86360|EAP|0302|ABSOLUTE CD4&CD8 COUNT IN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,360.75||||||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Medicare|MEDICARE PART B ONLY IP|65,650.26|7950.16|8466.37|6334.5|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Medicare|MEDICARE ACUTE|42,891.06|7939.18|8466.37|6334.5|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|United Healthcare|UNITED HEALTHCARE OTHER|36,847.25|8466.37|8466.37|6334.5|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Managed Medicaid|MEDICAID SUPERIOR|13,605.25|6334.5|8466.37|6334.5|||| 86430|EAP|0300|RA QUAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||46.45||| 86430|EAP|0300|RA QUAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||46.45||| 86430|EAP|0300|RA QUAL|Blue Cross PPO Specialty|BCBSTX PPO|||||46.45||| 86430|EAP|0300|RA QUAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||46.45||| 86430|EAP|0300|RA QUAL|Managed Medicaid|MEDICAID SUPERIOR|||||46.45||| 86430|EAP|0300|RA QUAL|Managed Medicaid|MEDICAID AMERIGROUP|||||46.45||| 86430|EAP|0300|RA QUAL|Humana Medicare Advantage|HUMANA MA|||||46.45||| 86430|EAP|0300|RA QUAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.45||| 86430|EAP|0300|RA QUAL|United Healthcare|UNITED HEALTHCARE OTHER|||||46.45||| 86430|EAP|0300|RA QUAL|United Healthcare|UNITED HEALTHCARE|||||46.45||| 86430|EAP|0300|RA QUAL|Medicare|MEDICARE ACUTE|||||46.45||| 86430|EAP|0300|RA QUAL|Managed Medicare|HEALTHSPRING MA|||||46.45||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Managed Medicare|HEALTHSPRING MA|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|NON CONTRACTED|COMMERCIAL OTHER 1|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Medicare|MEDICARE ACUTE|217.25||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|United Healthcare|UNITED HEALTHCARE|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Humana Medicare Advantage|HUMANA MA|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Cigna|CIGNA|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Managed Medicaid|MEDICAID SUPERIOR|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Blue Cross HMO Specialty|BCBSTX HMO|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Blue Cross PPO Specialty|BCBSTX PPO|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||48.78||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Veterans Affairs|VETERANS ADMINISTRATION|||||48.78||| 86480|EAP|0300|QUANTIFERON TB GOLD|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Blue Cross PPO Specialty|BCBSTX PPO|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Managed Medicaid|MEDICAID SUPERIOR|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Humana Medicare Advantage|HUMANA MA|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Medicare|MEDICARE ACUTE|||||5.23||| 86480|EAP|0300|QUANTIFERON TB GOLD|Tricare|TRICARE EAST REGION|||||5.23||| 86592|EAP|0300|RPR|Medicaid|MEDICAID HMO|163.25||||36.66||| 86592|EAP|0300|RPR|Medicaid|MEDICAID|163.25||||36.66||| 86592|EAP|0300|RPR|Medicaid|MOLINA HEALTHCARE OF TEXAS|163.25||||36.66||| 86592|EAP|0300|RPR|NON CONTRACTED|COMMERCIAL OTHER 1|163.25||||36.66||| 86592|EAP|0300|RPR|United Healthcare|UNITED HEALTHCARE|163.25||||36.66||| 86592|EAP|0300|RPR|United Healthcare|TML GROUP BENEFITS|||||36.66||| 86592|EAP|0300|RPR|Tricare|TRICARE EAST REGION|163.25||||36.66||| 86592|EAP|0300|RPR|Medicare|MEDICARE ACUTE|163.25||||36.66||| 86592|EAP|0300|RPR|United Healthcare|UMR UNITED MEDICAL RESOURCES|163.25||||36.66||| 86592|EAP|0300|RPR|United Healthcare|UNITED HEALTHCARE|||||36.66||| 86592|EAP|0300|RPR|Managed Medicaid|MEDICAID AMERIGROUP|163.25||||36.66||| 86592|EAP|0300|RPR|Cigna|CIGNA|163.25||||||| 86592|EAP|0300|RPR|Cigna|CIGNA|99.96||||36.66||| 86592|EAP|0300|RPR|PHCS|HUMANA INSURANCE|||||36.66||| 86592|EAP|0300|RPR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||163.25||| 86592|EAP|0300|RPR|Cigna|CIGNA|||||36.66||| 86592|EAP|0300|RPR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|163.25||||36.66||| 86592|EAP|0300|RPR|Managed Medicaid|MEDICAID SUPERIOR|163.25||||36.66||| 86592|EAP|0300|RPR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||36.66||| 86592|EAP|0300|RPR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||36.66||| 86592|EAP|0300|RPR|Humana Medicare Advantage|HUMANA MA|||||36.66||| 86592|EAP|0300|RPR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|163.25||||36.66||| 86592|EAP|0300|RPR|Blue Cross HMO Specialty|BCBSTX HMO|163.25||||36.66||| 86592|EAP|0300|RPR|Aetna|AETNA PPO|163.25||||36.66||| 86592|EAP|0300|RPR|Access Direct Platinum|HEALTHFIRST TPA UMR|163.25||||36.66||| 86592|EAP|0300|RPR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||36.66||| 86592|EAP|0300|RPR|Blue Cross PPO Specialty|BCBSTX PPO|163.25||||36.66||| 86592|EAP|0300|RPR|Aetna|AETNA OTHER|||||99.96||| 86592|EAP|0300|RPR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|163.25||||36.66||| 86592|EAP|0300|RPR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||36.66||| 866|DRG||VIRAL ILLNESS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|20,758.20|5106.17|5106.17|5106.17|||| 86606|EAP|0300|PNEUMONIA PANEL|United Healthcare|UNITED HEALTHCARE|||||70.26||| 86606|EAP|0300|ASPERGILLUS|Medicare|MEDICARE ACUTE|||||70.26||| 86606|EAP|0300|PNEUMONIA PANEL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||70.26||| 86606|EAP|0300|ASPERGILLUS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|313.50||||70.26||| 86606|EAP|0300|ASPERGILLUS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||70.26||| 86606|EAP|0300|ASPERGILLUS|Blue Cross PPO Specialty|BCBSTX PPO|||||70.26||| 86606|EAP|0300|ASPERGILLUS|Blue Cross HMO Specialty|BCBSTX HMO|||||70.26||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Blue Cross PPO Specialty|BCBSTX PPO|||||70.26||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||70.26||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Managed Medicaid|MEDICAID AMERIGROUP|||||70.26||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Managed Medicaid|MEDICAID AMERIGROUP|||||70.26||| 86612|EAP|0300|BLASTOMYCES|Medicare|MEDICARE ACUTE|||||69.06||| 86612|EAP|0300|BLASTOMYCES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.02||||69.06||| 86612|EAP|0300|BLASTOMYCES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||69.06||| 86612|EAP|0300|BLASTOMYCES|Blue Cross PPO Specialty|BCBSTX PPO|||||69.06||| 86612|EAP|0300|BLASTOMYCES|Blue Cross HMO Specialty|BCBSTX HMO|||||69.06||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|Tricare|TRICARE EAST REGION|652.75||||||| 86622|EAP|0302|BRUCELLA ABORTUS ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||70.26||| 86635|EAP|0300|COCCIDIOIDES|Medicare|MEDICARE ACUTE|||||69.06||| 86635|EAP|0300|COCCIDIOIDES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|382.50||||69.06||| 86635|EAP|0300|COCCIDIOIDES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||69.06||| 86635|EAP|0300|COCCIDIOIDES|Blue Cross PPO Specialty|BCBSTX PPO|||||69.06||| 86644|EAP|0300|CYTOMEGALOVIRUS IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||337.61||| 86644|EAP|0300|CYTOMEGALOVIRUS IGG|Managed Medicaid|MEDICAID SUPERIOR|551.50||||||| 86645|EAP|0300|CYTOMEGALOVIRUS IGM ANTIB|Managed Medicaid|MEDICAID SUPERIOR|313.50||||||| 86645|EAP|0300|CYTOMEGALOVIRUS IGM ANTIB|Blue Cross PPO Specialty|BCBSTX PPO|||||313.50||| 86663|EAP|0300|EPSTEIN BARR,EARLY ANTIGE|Blue Cross PPO Specialty|BCBSTX PPO|211.75||||211.75||| 86664|EAP|0302|EBV NUCLEAR ANTIGEN AB IG|Blue Cross PPO Specialty|BCBSTX PPO|5.86||||131.46||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|Blue Cross PPO Specialty|BCBSTX PPO|6.95||||155.88||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Medicaid|MEDICAID HMO|||||551.50||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Medicaid|MEDICAID|||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|NON CONTRACTED|COMMERCIAL OTHER 1|||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Medicare|MEDICARE ACUTE|||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Tricare|TRICARE EAST REGION|||||551.50||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Managed Medicaid|MEDICAID SUPERIOR|551.50||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Managed Medicaid|MEDICAID AMERIGROUP|||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Blue Cross HMO Specialty|BCBSTX HMO|||||123.72||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Blue Cross PPO Specialty|BCBSTX PPO|||||123.72||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Blue Cross HMO Specialty|BCBSTX HMO|||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Blue Cross PPO Specialty|BCBSTX PPO|||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Managed Medicaid|MEDICAID SUPERIOR|505.25||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Managed Medicaid|MEDICAID AMERIGROUP|||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|NON CONTRACTED|COMMERCIAL OTHER 1|||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Tricare|TRICARE EAST REGION|||||505.25||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Medicare|MEDICARE ACUTE|||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Medicaid|MEDICAID HMO|||||505.25||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Medicaid|MEDICAID|||||113.34||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||113.34||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Medicaid|MEDICAID|||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Medicaid|MEDICAID HMO|||||741.50||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|NON CONTRACTED|COMMERCIAL OTHER 1|||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Medicare|MEDICARE ACUTE|||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Tricare|TRICARE EAST REGION|||||741.50||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Managed Medicaid|MEDICAID SUPERIOR|741.50||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Managed Medicaid|MEDICAID AMERIGROUP|||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Blue Cross PPO Specialty|BCBSTX PPO|||||166.32||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Blue Cross HMO Specialty|BCBSTX HMO|||||166.32||| 86698|EAP|0300|HISTOPLASMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||140.52||| 86698|EAP|0300|HISTOPLASMA|Blue Cross PPO Specialty|BCBSTX PPO|||||140.52||| 86698|EAP|0300|HISTOPLASMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||140.52||| 86698|EAP|0300|HISTOPLASMA|Medicare|MEDICARE ACUTE|||||140.52||| 867|DRG||OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|60,336.35|15333.42|15333.42|15333.42|||| 86701|EAP|0300|HIV 1 ANTIBODY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.66||| 86701|EAP|0300|HIV 1 ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|2.19||||||| 86701|EAP|0300|HIV 1 ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||0.66||| 86702|EAP|0300|HIV 2 ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||1.00||| 86702|EAP|0300|HIV 2 ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|3.34||||||| 86702|EAP|0300|HIV 2 ANTIBODY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.00||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|525.50||||525.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Healthcare|UNITED HEALTHCARE|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicare|MEDICARE ACUTE|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Healthcare|UNITED HEALTHCARE|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Tricare|TRICARE EAST REGION|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|NON CONTRACTED|COMMERCIAL OTHER 1|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicaid|MEDICAID HMO|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicaid|MEDICAID|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicare|HEALTHSPRING MA|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Workers Compensation|WORKERS COMPENSATION OTHER|||||525.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Workers Compensation|UT EMPLOYEE INJURY|||||525.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicare|WELLCARE CHOICE MA|525.50||||||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Healthcare|TML GROUP BENEFITS|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|PHCS|HUMANA INSURANCE|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST TPA UMR|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Blue Cross HMO Specialty|BCBSTX HMO|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Aetna|AETNA OTHER|||||321.70||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Aetna|AETNA PPO|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Cigna|CIGNA|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Cigna|CIGNA|117.90||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Cigna|CIGNA|525.50||||||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Humana Medicare Advantage|HUMANA MA|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicaid|MEDICAID SUPERIOR|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|525.50||||117.90||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|525.50||||117.90||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Managed Medicaid|MEDICAID SUPERIOR|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|4.62||||||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|4.62||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4.62||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|4.62||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Workers Compensation|WORKERS COMPENSATION OTHER|||||4.62||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Workers Compensation|UT EMPLOYEE INJURY|||||4.62||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Workers Compensation|WORKERS COMPENSATION OTHER|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Veterans Affairs|VETERANS ADMINISTRATION|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Medicaid|MEDICAID|4.62||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.62||||4.62||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|United Healthcare|UNITED HEALTHCARE|||||103.56||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Medicare|MEDICARE ACUTE|4.62||||103.56||| 86704|EAP|0300|HEPATITIS B CORE TOTAL|Medicare|MEDICARE ACUTE|4.62||||103.56||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|UTMB|UTMB CORRECTIONAL MANAGED CARE|450.75||||||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Medicare|MEDICARE ACUTE|||||101.16||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||101.16||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||101.16||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Workers Compensation|WORKERS COMPENSATION OTHER|||||411.50||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Veterans Affairs|VETERANS ADMINISTRATION|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicaid|MEDICAID SUPERIOR|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Humana Medicare Advantage|HUMANA MA|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicaid|MEDICAID AMERIGROUP|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Access Direct Platinum|HEALTHFIRST TPA UMR|||||411.50||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Workers Compensation|UT EMPLOYEE INJURY|||||411.50||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Aenta Medicare Advantage|AETNA MEDICARE MA|411.50||||||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Blue Cross PPO Specialty|BCBSTX PPO|411.50||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Blue Cross HMO Specialty|BCBSTX HMO|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Medicaid|MEDICAID|411.50||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicare|HEALTHSPRING MA|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|UTMB|UTMB CORRECTIONAL MANAGED CARE|411.50||||411.50||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|NON CONTRACTED|COMMERCIAL OTHER 1|||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Medicare|MEDICARE ACUTE|411.50||||92.28||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Healthcare|UNITED HEALTHCARE|||||92.28||| 86708|EAP|0300|HEPATITIS A TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||474.75||| 86708|EAP|0300|HEPATITIS A TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||106.50||| 86708|EAP|0300|HEPATITIS A TOTAL|Medicare|MEDICARE ACUTE|474.75||||106.50||| 86708|EAP|0300|HEPATITIS A TOTAL|United Healthcare|UNITED HEALTHCARE|||||106.50||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|NON CONTRACTED|COMMERCIAL OTHER 1|||||49.75||| 86708|EAP|0300|HEPATITIS A TOTAL|Medicaid|MEDICAID|474.75||||106.50||| 86708|EAP|0300|HEPATITIS A TOTAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||106.50||| 86708|EAP|0300|HEPATITIS A TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|474.75||||||| 86708|EAP|0300|HEPATITIS A TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||106.50||| 86708|EAP|0300|HEPATITIS A TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|474.75||||106.50||| 86708|EAP|0300|HEPATITIS A TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||106.50||| 86708|EAP|0300|HEPATITIS A TOTAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Humana Medicare Advantage|HUMANA MA|||||49.75||| 86708|EAP|0300|HEPATITIS A TOTAL|Managed Medicaid|MEDICAID SUPERIOR|||||106.50||| 86708|EAP|0300|HEPATITIS A TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||106.50||| 86708|EAP|0300|HEPATITIS A TOTAL|Workers Compensation|WORKERS COMPENSATION OTHER|||||474.75||| 86708|EAP|0300|HEPATITIS A TOTAL|Workers Compensation|UT EMPLOYEE INJURY|||||474.75||| 86708|EAP|0300|HEPATITIS A TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||106.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Humana Medicare Advantage|HUMANA MA|||||96.72||| 86709|EAP|0302|HEPATITIS A AB IGM|Medicare|MEDICARE ACUTE|||||96.72||| 86735|EAP|0302|MUMPS IGG|Tricare|TRICARE EAST REGION|||||500.25||| 86735|EAP|0302|MUMPS IGG|United Healthcare|UNITED HEALTHCARE|||||112.14||| 86735|EAP|0302|MUMPS IGG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||112.14||| 86735|EAP|0302|MUMPS IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||112.14||| 86735|EAP|0302|MUMPS IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||112.14||| 86735|EAP|0302|MUMPS IGG|Managed Medicaid|MEDICAID SUPERIOR|||||399.70||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|Humana Medicare Advantage|HUMANA MA|||||227.65||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|Blue Cross PPO Specialty|BCBSTX PPO|||||227.65||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|Medicare|MEDICARE ACUTE|||||227.65||| 86747|EAP|0302|PARVOVIRUS ANTIBODY B19 I|Blue Cross PPO Specialty|BCBSTX PPO|||||5.76||| 86747|EAP|0302|PARVOVIRUS ANTIBODY B19 I|Managed Medicaid|MEDICAID SUPERIOR|5.76||||129.18||| 86762|EAP|0302|RUBELLA IGG|Medicaid|MEDICAID|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|Medicaid|MOLINA HEALTHCARE OF TEXAS|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|Medicaid|MEDICAID HMO|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|Tricare|TRICARE EAST REGION|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|Medicare|MEDICARE ACUTE|||||123.72||| 86762|EAP|0302|RUBELLA IGG|United Healthcare|UNITED HEALTHCARE|||||123.72||| 86762|EAP|0302|RUBELLA IGG|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||123.72||| 86762|EAP|0302|RUBELLA IGG|United Healthcare|TML GROUP BENEFITS|||||123.72||| 86762|EAP|0302|RUBELLA IGG|NON CONTRACTED|COMMERCIAL OTHER 1|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||123.72||| 86762|EAP|0302|RUBELLA IGG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||123.72||| 86762|EAP|0302|RUBELLA IGG|Managed Medicaid|MEDICAID SUPERIOR|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|Managed Medicaid|MEDICAID AMERIGROUP|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||123.72||| 86762|EAP|0302|RUBELLA IGG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||123.72||| 86762|EAP|0302|RUBELLA IGG|Cigna|CIGNA|||||123.72||| 86762|EAP|0302|RUBELLA IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||123.72||| 86762|EAP|0302|RUBELLA IGG|Blue Cross PPO Specialty|BCBSTX PPO|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||123.72||| 86762|EAP|0302|RUBELLA IGG|Aetna|AETNA PPO|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|551.50||||123.72||| 86762|EAP|0302|RUBELLA IGG|Aetna|AETNA OTHER|||||551.50||| 86762|EAP|0302|RUBELLA IGG|Access Direct Platinum|HEALTHFIRST TPA UMR|551.50||||123.72||| 86765|EAP|0300|RUBEOLA IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||110.76||| 86765|EAP|0300|RUBEOLA IGG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||110.76||| 86765|EAP|0300|RUBEOLA IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||110.76||| 86765|EAP|0300|RUBEOLA IGG|Managed Medicaid|MEDICAID SUPERIOR|||||110.76||| 86765|EAP|0300|RUBEOLA IGG|United Healthcare|UNITED HEALTHCARE|||||110.76||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Medicare|MEDICARE ACUTE|84.26||||||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|United Medicare Advantage|UHC MEDICARE GOLD MA|84.26||||||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|84.26||||||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Blue Cross PPO Specialty|BCBSTX PPO|84.26||||||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Aetna|AETNA PPO|||||84.26||| 86777|EAP|0302|TOXOPLASMA IGG ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||337.61||| 86777|EAP|0302|TOXOPLASMA IGG ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|||||123.72||| 86777|EAP|0302|TOXOPLASMA IGG ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|551.50||||||| 86778|EAP|0302|TOXOPLASMA IGM ANTIBODIES|Managed Medicaid|MEDICAID SUPERIOR|4.89||||||| 86778|EAP|0302|TOXOPLASMA IGM ANTIBODIES|Managed Medicaid|MEDICAID AMERIGROUP|||||109.74||| 86778|EAP|0302|TOXOPLASMA IGM ANTIBODIES|Blue Cross PPO Specialty|BCBSTX PPO|||||299.37||| 86780|EAP|0300|FTA ABS|Blue Cross PPO Specialty|BCBSTX PPO|||||76.62||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Medicaid|MEDICAID|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|NON CONTRACTED|COMMERCIAL OTHER 1|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|United Healthcare|UNITED HEALTHCARE|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Medicare|MEDICARE ACUTE|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|United Healthcare|TML GROUP BENEFITS|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Managed Medicaid|MEDICAID AMERIGROUP|||||70.26||| 86787|EAP|0300|VARICELLA ZOSTER, IGM AB|Managed Medicaid|MEDICAID SUPERIOR|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Managed Medicaid|MEDICAID SUPERIOR|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Cigna|CIGNA|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Access Direct Platinum|HEALTHFIRST TPA UMR|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Blue Cross PPO Specialty|BCBSTX PPO|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Blue Cross HMO Specialty|BCBSTX HMO|||||70.26||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Aetna|AETNA PPO|||||70.26||| 86787|EAP|0300|VARICELLA ZOSTER, IGM AB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||70.26||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|||||136.68||| 86803|EAP|0302|HEPATITIS C ANTIBODY|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.47||||5.47||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Healthcare|TML GROUP BENEFITS|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Medicare|MEDICARE ACUTE|5.47||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Medicaid|MEDICAID HMO|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Medicaid|MEDICAID|5.47||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.47||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Workers Compensation|UT EMPLOYEE INJURY|||||5.47||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Veterans Affairs|VETERANS ADMINISTRATION|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Tricare|TRICARE EAST REGION|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Aenta Medicare Advantage|AETNA MEDICARE MA|5.47||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|5.47||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Aetna|AETNA PPO|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.47||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Cigna|CIGNA|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||122.64||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||122.64||| 86812|EAP|0302|HLA - B-27|Humana Medicare Advantage|HUMANA MA|||||221.76||| 86850|EAP|0302|ANTIBODY SCREEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|349.42||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Medicaid|MEDICAID|349.42||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicare|HEALTHSPRING MA|349.42||||349.42||| 86850|EAP|0302|ANTIBODY SCREEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|Tricare|TRICARE EAST REGION|347.34||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|PHCS|HUMANA INSURANCE|||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|United Healthcare|UNITED HEALTHCARE|345.25||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|United Healthcare|UNITED HEALTHCARE|||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|United Healthcare|TML GROUP BENEFITS|||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|United Healthcare|UMR UNITED MEDICAL RESOURCES|349.42||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Medicare|MEDICARE ACUTE|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|Veterans Affairs|VETERANS ADMINISTRATION|349.42||||||| 86850|EAP|0302|ANTIBODY SCREEN|United Medicare Advantage|UHC MEDICARE GOLD MA|349.42||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|349.42||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|347.34||||349.42||| 86850|EAP|0302|ANTIBODY SCREEN|NON CONTRACTED|COMMERCIAL OTHER 1|347.34||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|349.42||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST TPA UMR|345.25||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|345.25||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|347.34||||||| 86850|EAP|0302|ANTIBODY SCREEN|Aenta Medicare Advantage|AETNA MEDICARE MA|345.25||||||| 86850|EAP|0302|ANTIBODY SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|345.25||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Medicaid|MEDICAID HMO|349.42||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Blue Cross HMO Specialty|BCBSTX HMO|345.25||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Aetna|AETNA OTHER|347.34||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|Aetna|AETNA PPO|349.42||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Cigna|CIGNA|345.25||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Cigna|CIGNA|349.42||||||| 86850|EAP|0302|ANTIBODY SCREEN|Cigna|CIGNA|||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Humana Medicare Advantage|HUMANA MA|349.42||||349.42||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|349.42||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|349.42||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|345.25||||78.96||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicaid|MEDICAID SUPERIOR|345.25||||78.96||| 86860|EAP|0300|ELUTION, BLOOD BANK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|580.25||||||| 86860|EAP|0300|ELUTION, BLOOD BANK|Blue Cross PPO Specialty|BCBSTX PPO|587.26||||||| 86860|EAP|0300|ELUTION, BLOOD BANK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|587.26||||580.25||| 86870|EAP|0302|ANTIBODY ID RBC AB/@PANEL|United Healthcare|UNITED HEALTHCARE|||||580.25||| 86870|EAP|0302|ANTIBODY ID RBC AB/@PANEL|Medicare|MEDICARE ACUTE|580.25||||||| 86870|EAP|0302|ANTIBODY ID RBC AB/@PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|587.26||||580.25||| 86870|EAP|0302|ANTIBODY ID RBC AB/@PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||587.26||| 86870|EAP|0302|ANTIBODY ID RBC AB/@PANEL|Blue Cross PPO Specialty|BCBSTX PPO|580.25||||1.49||| 86870|EAP|0302|ANTIBODY ID RBC AB/@PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|580.25||||||| 86880|EAP|0302|DIRECT COOMBS|Cigna|CIGNA|182.43||||||| 86880|EAP|0302|DIRECT COOMBS|Managed Medicaid|MEDICAID AMERIGROUP|182.43||||||| 86880|EAP|0302|DIRECT COOMBS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|181.34||||||| 86880|EAP|0302|DIRECT COOMBS|Managed Medicaid|MEDICAID SUPERIOR|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|182.43||||||| 86880|EAP|0302|DIRECT COOMBS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Aetna|AETNA PPO|182.43||||||| 86880|EAP|0302|DIRECT COOMBS|Blue Cross PPO Specialty|BCBSTX PPO|182.43||||||| 86880|EAP|0302|DIRECT COOMBS|Medicaid|MEDICAID|182.43||||||| 86880|EAP|0302|DIRECT COOMBS|Medicaid|SUPERIOR HEALTHPLAN CHIP|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Medicaid|MEDICAID HMO|182.43||||||| 86880|EAP|0302|DIRECT COOMBS|Medicare|MEDICARE ACUTE|181.34||||||| 86880|EAP|0302|DIRECT COOMBS|United Healthcare|UNITED HEALTHCARE|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Tricare|TRICARE EAST REGION|181.34||||||| 86885|EAP|0300|DIRECT COOMBS,POLYCLONAL|United Healthcare|UNITED HEALTHCARE|||||180.25||| 86885|EAP|0300|DIRECT COOMBS,C3|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||182.43||| 86885|EAP|0300|DIRECT COOMBS,C3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|182.43||||180.25||| 86885|EAP|0300|DIRECT COOMBS,POLYCLONAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.25||||||| 86885|EAP|0300|DIRECT COOMBS,C3|Blue Cross PPO Specialty|BCBSTX PPO|||||46.25||| 86885|EAP|0300|DIRECT COOMBS,C3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.25||||||| 86886|EAP|0300|ANTI-D TITER|United Healthcare|UNITED HEALTHCARE|||||1.98||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|182.43||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicaid|MEDICAID AMERIGROUP|182.43||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicaid|MEDICAID SUPERIOR|180.25||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Cigna|CIGNA|182.43||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Cigna|CIGNA|180.25||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Humana Medicare Advantage|HUMANA MA|182.43||||182.43||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Cigna|CIGNA|||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.25||||41.16||| 86900|EAP|0300|BLOOD TYPING ABO DISCREPA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.25||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|180.25||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Access Direct Platinum|HEALTHFIRST TPA UMR|180.25||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross PPO Specialty|BCBSTX OTHER|||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross HMO Specialty|BCBSTX HMO|180.25||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Aetna|AETNA OTHER|181.34||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross PPO Specialty|BCBSTX PPO|180.25||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Aetna|AETNA PPO|182.43||||41.16||| 86900|EAP|0300|BLOOD TYPING ABO DISCREPA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|182.43||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Medicare Advantage|UHC MEDICARE GOLD MA|182.43||||181.34||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Aenta Medicare Advantage|AETNA MEDICARE MA|180.25||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|181.34||||182.43||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Veterans Affairs|VETERANS ADMINISTRATION|182.43||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|182.43||||110.71||| 86900|EAP|0300|BLOOD TYPING, ABO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||182.43||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|182.43||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|MOLINA HEALTHCARE OF TEXAS|182.43||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|MEDICAID TEXAS CHILDRENS|||||182.43||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|MEDICAID|182.43||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|181.34||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicare|HEALTHSPRING MA|182.43||||182.43||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|MEDICAID HMO|182.43||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|UTMB|UTMB CORRECTIONAL MANAGED CARE|180.25||||181.34||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicare|MEDICARE ACUTE|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|PHCS|HUMANA INSURANCE|||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Healthcare|UNITED HEALTHCARE|180.25||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Healthcare|UNITED HEALTHCARE|||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Healthcare|TML GROUP BENEFITS|||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|NON CONTRACTED|COMMERCIAL OTHER 1|181.34||||41.16||| 86900|EAP|0300|BLOOD TYPING ABO DISCREPA|Medicare|MEDICARE ACUTE|182.43||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Healthcare|UMR UNITED MEDICAL RESOURCES|182.43||||41.16||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Tricare|TRICARE EAST REGION|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|UTMB|UTMB CORRECTIONAL MANAGED CARE|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|NON CONTRACTED|COMMERCIAL OTHER 1|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Healthcare|TML GROUP BENEFITS|||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Healthcare|UNITED HEALTHCARE|180.25||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Healthcare|UMR UNITED MEDICAL RESOURCES|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|PHCS|HUMANA INSURANCE|||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicare|MEDICARE ACUTE|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|181.34||||||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|MEDICAID TEXAS CHILDRENS|||||182.43||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|MEDICAID|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|MOLINA HEALTHCARE OF TEXAS|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicare|HEALTHSPRING MA|182.43||||182.43||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Veterans Affairs|VETERANS ADMINISTRATION|182.43||||||| 86901|EAP|0300|BLOOD TYPING, RHD|United Medicare Advantage|AARP UHC WEST COMPLETE MA|181.34||||182.43||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Medicare Advantage|UHC MEDICARE GOLD MA|182.43||||181.34||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|182.43||||110.71||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|MEDICAID HMO|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|181.34||||182.43||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Tricare|TRICARE EAST REGION|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Aenta Medicare Advantage|AETNA MEDICARE MA|180.25||||||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Aetna|AETNA PPO|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Aetna|AETNA OTHER|181.34||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross HMO Specialty|BCBSTX HMO|180.25||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross PPO Specialty|BCBSTX PPO|180.25||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Access Direct Platinum|HEALTHFIRST TPA UMR|180.25||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|180.25||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross PPO Specialty|BCBSTX OTHER|||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Cigna|CIGNA|182.43||||||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Cigna|CIGNA|180.25||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Healthcare|UNITED HEALTHCARE|||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Cigna|CIGNA|||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Humana Medicare Advantage|HUMANA MA|182.43||||182.43||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|182.43||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicaid|MEDICAID AMERIGROUP|180.25||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicaid|MEDICAID SUPERIOR|180.25||||41.16||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.25||||41.16||| 86902|EAP|0302|ANTIGEN SCREEN-ONE ANTIGE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,048.26||||349.42||| 86902|EAP|0302|ANTIGEN SCREEN-ONE ANTIGE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||349.42||| 86902|EAP|0302|ANTIGEN SCREEN-EIGHT ANTI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|349.42||||709.50||| 86905|EAP|0302|ANTIGEN SCREEN GROUP 2|Blue Cross PPO Specialty|BCBSTX PPO|345.25||||||| 86905|EAP|0300|SINGLE PATIENT ANTIGEN TY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||345.25||| 86905|EAP|0302|ANTIGEN SCREEN GROUP I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||345.25||| 86905|EAP|0302|ANTIGEN SCREEN GROUP I|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||349.42||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|Medicaid|MEDICAID|580.25||||587.26||| 86922|EAP|0300|CROSSMATCH PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|||||364.63||| 86922|EAP|0300|CROSSMATCH PANEL|Medicare|MEDICARE ACUTE|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicare|HEALTHSPRING MA|||||587.26||| 86922|EAP|0300|CROSSMATCH PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|587.26||||583.76||| 86922|EAP|0300|CROSSMATCH PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|583.76||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|583.76||||587.26||| 86922|EAP|0300|CROSSMATCH PANEL|Veterans Affairs|VETERANS ADMINISTRATION|587.26||||||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicaid|MEDICAID SUPERIOR|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicaid|MEDICAID AMERIGROUP|580.25||||587.26||| 86922|EAP|0300|CROSSMATCH PANEL|Humana Medicare Advantage|HUMANA MA|587.26||||587.26||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|587.26||||368.13||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|587.26||||583.76||| 86922|EAP|0300|CROSSMATCH PANEL|Blue Cross PPO Specialty|BCBSTX PPO|580.25||||583.76||| 86922|EAP|0300|CROSSMATCH PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Aetna|AETNA PPO|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.49||| 86945|EAP|0300|IRRADIATION OF BLOOD PROD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||345.25||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|UTMB|UTMB CORRECTIONAL MANAGED CARE|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Medicare|MEDICARE ACUTE|254.61||||56.40||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|United Medicare Advantage|UHC MEDICARE GOLD MA|254.61||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||254.61||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Cigna|CIGNA|||||254.61||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Managed Medicaid|MEDICAID AMERIGROUP|246.50||||254.61||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Humana Medicare Advantage|HUMANA MA|246.50||||246.50||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Managed Medicaid|MEDICAID SUPERIOR|254.61||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Blue Cross PPO Specialty|BCBSTX PPO|246.50||||||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|395.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|401.75||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross PPO Specialty|BCBSTX OTHER|||||88.74||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross PPO Specialty|BCBSTX PPO|408.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Aetna|AETNA PPO|408.25||||248.50||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|408.25||||||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicaid|MEDICAID AMERIGROUP|395.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Cigna|CIGNA|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Humana Medicare Advantage|HUMANA MA|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|395.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicaid|MEDICAID SUPERIOR|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Veterans Affairs|VETERANS ADMINISTRATION|||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Medicare Advantage|UHC MEDICARE GOLD MA|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|395.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Medicare Advantage|AARP UHC WEST COMPLETE MA|408.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicare|BCBS MEDICARE PPO MA|408.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross HMO Specialty|BCBSTX HMO|401.75||||88.74||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid|MEDICAID HMO|408.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicare|WELLCARE CHOICE MA|||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicare|HEALTHSPRING MA|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Aenta Medicare Advantage|AETNA MEDICARE MA|395.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid|MEDICAID|408.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|UTMB|UTMB CORRECTIONAL MANAGED CARE|395.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Tricare|TRICARE EAST REGION|408.25||||401.75||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|NON CONTRACTED|COMMERCIAL OTHER 1|401.75||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicare|MEDICARE PART B ONLY IP|408.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicare|MEDICARE ACUTE|408.25||||401.75||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Healthcare|UNITED HEALTHCARE OTHER|395.25||||408.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Healthcare|UNITED HEALTHCARE|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Healthcare|UNITED HEALTHCARE|||||408.25||| 87046|EAP|0306|CULTURE, STOOL|NON CONTRACTED|COMMERCIAL OTHER 1|||||373.13||| 87046|EAP|0306|CULTURE, STOOL|Medicare|MEDICARE ACUTE|373.13||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Managed Medicare|HEALTHSPRING MA|373.13||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Veterans Affairs|VETERANS ADMINISTRATION|373.13||||||| 87046|EAP|0306|CULTURE, STOOL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||81.06||| 87046|EAP|0306|CULTURE, STOOL|United Medicare Advantage|UHC MEDICARE GOLD MA|373.13||||81.06||| 87046|EAP|0306|CULTURE, STOOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|373.13||||221.16||| 87046|EAP|0300|STOOL ADDL PATHOGENS|Medicare|MEDICARE ACUTE|||||81.06||| 87046|EAP|0306|CULTURE, STOOL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|361.25||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Managed Medicaid|MEDICAID AMERIGROUP|||||361.25||| 87046|EAP|0306|CULTURE, STOOL|Humana Medicare Advantage|HUMANA MA|367.19||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Managed Medicaid|MEDICAID SUPERIOR|||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Blue Cross PPO Specialty|BCBSTX PPO|||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Aetna|AETNA PPO|||||81.06||| 87046|EAP|0306|CULTURE, STOOL|Blue Cross HMO Specialty|BCBSTX HMO|373.13||||||| 87046|EAP|0306|CULTURE, STOOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||81.06||| 87070|EAP|0300|CULTURE,WOUND|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.30||||335.43||| 87070|EAP|0306|CULTURE THROAT/NOSE|Blue Cross PPO Specialty|BCBSTX PPO|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.30||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Blue Cross PPO Specialty|BCBSTX OTHER|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Aenta Medicare Advantage|AETNA MEDICARE MA|3.30||||||| 87070|EAP|0306|CULTURE THROAT/NOSE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.30||| 87070|EAP|0300|CULTURE, GENITAL|Blue Cross HMO Specialty|BCBSTX HMO|3.30||||74.04||| 87070|EAP|0306|CULTURE THROAT/NOSE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Blue Cross HMO Specialty|BCBSTX HMO|||||335.43||| 87070|EAP|0306|CULTURE THROAT/NOSE|Aetna|AETNA PPO|||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Blue Cross PPO Specialty|BCBSTX PPO|340.86||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Blue Cross PPO Specialty|BCBSTX PPO|3.30||||3.30||| 87070|EAP|0300|CULTURE, GENITAL|Blue Cross PPO Specialty|BCBSTX PPO|3.30||||74.04||| 87070|EAP|0300|CULTURE, GENITAL|Managed Medicaid|MEDICAID AMERIGROUP|170.50||||74.04||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicaid|MEDICAID SUPERIOR|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|340.86||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.30||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.30||| 87070|EAP|0300|CULTURE,BODY FLUID|Cigna|CIGNA|||||176.11||| 87070|EAP|0300|CULTURE,BODY FLUID|Managed Medicaid|MEDICAID AMERIGROUP|335.43||||176.11||| 87070|EAP|0300|CULTURE, MRSA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|335.43||||74.04||| 87070|EAP|0306|CULTURE THROAT/NOSE|Humana Medicare Advantage|HUMANA MA|340.86||||335.43||| 87070|EAP|0300|CULTURE,WOUND|Humana Medicare Advantage|HUMANA MA|3.30||||340.86||| 87070|EAP|0300|CULTURE,RESPIRATORY|Humana Medicare Advantage|HUMANA MA|3.30||||3.30||| 87070|EAP|0300|CULTURE,BODY FLUID|Humana Medicare Advantage|HUMANA MA|170.50||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|335.43||||340.86||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicaid|MEDICAID AMERIGROUP|335.43||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|340.86||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|340.86||||3.30||| 87070|EAP|0300|CULTURE,WOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|340.86||||340.86||| 87070|EAP|0300|CULTURE,WOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|176.11||||340.86||| 87070|EAP|0300|CULTURE,WOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.30||||335.43||| 87070|EAP|0300|CULTURE,RESPIRATORY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.30||||3.30||| 87070|EAP|0300|CULTURE,BODY FLUID|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.30||||176.11||| 87070|EAP|0300|CULTURE, GENITAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.30||||74.04||| 87070|EAP|0306|CULTURE THROAT/NOSE|United Medicare Advantage|UHC MEDICARE GOLD MA|3.30||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Veterans Affairs|VETERANS ADMINISTRATION|||||340.86||| 87070|EAP|0300|CULTURE, GENITAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||74.04||| 87070|EAP|0306|CULTURE THROAT/NOSE|Cigna|CIGNA|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Managed Medicare|HEALTHSPRING MA|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicare|BCBS MEDICARE PPO MA|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Medicaid|MEDICAID HMO|||||340.86||| 87070|EAP|0300|CULTURE,WOUND|Medicaid|MEDICAID|334.40||||340.86||| 87070|EAP|0306|CULTURE THROAT/NOSE|Managed Medicaid|MEDICAID AMERIGROUP|340.86||||3.30||| 87070|EAP|0300|CULTURE, GENITAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||74.04||| 87070|EAP|0306|CULTURE THROAT/NOSE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Medicaid|MEDICAID HMO|||||3.30||| 87070|EAP|0300|CULTURE, GENITAL|Managed Medicaid|MEDICAID SUPERIOR|176.11||||74.04||| 87070|EAP|0306|CULTURE THROAT/NOSE|Medicaid|MEDICAID|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicare|HEALTHSPRING MA|3.30||||340.86||| 87070|EAP|0300|CULTURE, GENITAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||74.04||| 87070|EAP|0306|CULTURE THROAT/NOSE|Managed Medicaid|MEDICAID SUPERIOR|335.43||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Medicaid|MEDICAID HMO|||||340.86||| 87070|EAP|0306|CULTURE THROAT/NOSE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|340.86||||||| 87070|EAP|0306|CULTURE THROAT/NOSE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||340.86||| 87070|EAP|0300|CULTURE,BODY FLUID|UTMB|UTMB CORRECTIONAL MANAGED CARE|170.50||||||| 87070|EAP|0306|CULTURE THROAT/NOSE|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.30||||335.43||| 87070|EAP|0300|CULTURE,WOUND|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|NON CONTRACTED|COMMERCIAL OTHER 2|||||335.43||| 87070|EAP|0300|CULTURE,RESPIRATORY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|NON CONTRACTED|COMMERCIAL OTHER 1|||||335.43||| 87070|EAP|0300|CULTURE,WOUND|United Healthcare|UNITED HEALTHCARE|||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Medicare|MEDICARE ACUTE|176.11||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Medicare|MEDICARE ACUTE|3.30||||340.86||| 87070|EAP|0300|CULTURE,WOUND|United Healthcare|UNITED HEALTHCARE|||||340.86||| 87070|EAP|0306|CULTURE THROAT/NOSE|PHCS|HUMANA INSURANCE|||||3.30||| 87070|EAP|0300|CULTURE, GENITAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|340.86||||74.04||| 87070|EAP|0306|CULTURE THROAT/NOSE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||335.43||| 87070|EAP|0306|CULTURE THROAT/NOSE|United Healthcare|UNITED HEALTHCARE OTHER|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Medicare|MEDICARE PART B ONLY IP|340.86||||||| 87070|EAP|0300|CULTURE,BODY FLUID|Medicare|MEDICARE ACUTE|323.75||||173.31||| 87070|EAP|0300|CULTURE,WOUND|Tricare|TRICARE EAST REGION|340.86||||340.86||| 87070|EAP|0300|CULTURE,RESPIRATORY|Tricare|TRICARE EAST REGION|340.86||||340.86||| 87070|EAP|0306|CULTURE THROAT/NOSE|Tricare|TRICARE EAST REGION|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Medicare|MEDICARE ACUTE|340.86||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Tricare|TRICARE FOR LIFE|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|United Healthcare|GEHA|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|United Healthcare|UNITED HEALTHCARE|||||340.86||| 87070|EAP|0306|CULTURE THROAT/NOSE|United Healthcare|UNITED HEALTHCARE|||||335.43||| 87070|EAP|0300|CULTURE,WOUND|Medicare|MEDICARE ACUTE|340.86||||340.86||| 87075|EAP|0300|ANAEROBIC CULTURE|NON CONTRACTED|COMMERCIAL OTHER 1|||||362.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Medicare|MEDICARE PART B ONLY IP|374.42||||||| 87075|EAP|0300|ANAEROBIC CULTURE|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||81.30||| 87075|EAP|0300|ANAEROBIC CULTURE|Medicare|MEDICARE ACUTE|374.42||||81.30||| 87075|EAP|0300|ANAEROBIC CULTURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|374.42||||||| 87075|EAP|0300|ANAEROBIC CULTURE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|362.50||||227.86||| 87075|EAP|0300|ANAEROBIC CULTURE|Humana Medicare Advantage|HUMANA MA|362.50||||374.42||| 87075|EAP|0300|ANAEROBIC CULTURE|Managed Medicaid|MEDICAID AMERIGROUP|362.50||||||| 87075|EAP|0300|ANAEROBIC CULTURE|Managed Medicaid|MEDICAID SUPERIOR|362.50||||||| 87075|EAP|0300|ANAEROBIC CULTURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|362.50||||||| 87075|EAP|0300|ANAEROBIC CULTURE|Blue Cross PPO Specialty|BCBSTX PPO|362.50||||||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Aenta Medicare Advantage|AETNA MEDICARE MA|3.10||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Blue Cross HMO Specialty|BCBSTX HMO|315.10||||320.20||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Aetna|AETNA OTHER|||||320.20||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Aetna|AETNA PPO|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Blue Cross PPO Specialty|BCBSTX PPO|3.10||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicaid|MEDICAID SUPERIOR|320.20||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|315.10||||189.71||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|320.20||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicaid|MEDICAID AMERIGROUP|3.10||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Humana Medicare Advantage|HUMANA MA|3.10||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|ChampVA|CHAMPVA CENTER|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.10||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Cigna|CIGNA|||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Veterans Affairs|VETERANS ADMINISTRATION|||||320.20||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Medicare Advantage|UHC MEDICARE GOLD MA|320.20||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.10||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|320.20||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicare|WELLCARE CHOICE MA|320.20||||||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|MEDICAID HMO|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|MEDICAID|320.20||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|320.20||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicare|HEALTHSPRING MA|||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicare|BCBS MEDICARE PPO MA|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.10||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Tricare|TRICARE EAST REGION|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Healthcare|UNITED HEALTHCARE|||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Healthcare|UNITED HEALTHCARE OTHER|||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Healthcare|TML GROUP BENEFITS|||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicare|MEDICARE ACUTE|320.20||||69.42||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Healthcare|UNITED HEALTHCARE|||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicare|MEDICARE PART B ONLY IP|320.20||||||| 87081|EAP|0306|CULTURE BETA STREP GRP A|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.57||| 87081|EAP|0300|CULTURE, GC|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|PHCS|HUMANA INSURANCE|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Medicare|MEDICARE ACUTE|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Tricare|TRICARE EAST REGION|||||0.57||| 87081|EAP|0300|CULTURE, GC|Tricare|TRICARE EAST REGION|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.57||| 87081|EAP|0300|CULTURE, GC|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.57||| 87081|EAP|0300|CULTURE, GC|Medicaid|MEDICAID|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Medicaid|MEDICAID|262.61||||0.57||| 87081|EAP|0300|CULTURE, GC|Medicaid|MEDICAID HMO|||||0.57||| 87081|EAP|0300|CULTURE, GC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.57||| 87081|EAP|0300|CULTURE, GC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.57||| 87081|EAP|0300|CULTURE, GC|Cigna|CIGNA|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Managed Medicaid|MEDICAID AMERIGROUP|254.25||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|United Healthcare|UNITED HEALTHCARE|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Cigna|CIGNA|||||0.57||| 87081|EAP|0300|CULTURE, GC|Managed Medicaid|MEDICAID AMERIGROUP|||||0.57||| 87081|EAP|0300|CULTURE, GC|Managed Medicaid|MEDICAID SUPERIOR|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Managed Medicaid|MEDICAID SUPERIOR|254.25||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.57||| 87081|EAP|0300|CULTURE, GC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|262.61||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Blue Cross PPO Specialty|BCBSTX PPO|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.57||| 87081|EAP|0300|CULTURE, GC|Blue Cross HMO Specialty|BCBSTX HMO|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Aetna|AETNA OTHER|||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Blue Cross HMO Specialty|BCBSTX HMO|||||0.57||| 87081|EAP|0300|CULTURE, GC|Blue Cross PPO Specialty|BCBSTX PPO|254.25||||0.57||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Aetna|AETNA PPO|||||0.57||| 87081|EAP|0300|CULTURE, GC|Aetna|AETNA PPO|||||0.57||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross PPO Specialty|BCBSTX PPO|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|319.94||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Access Direct Platinum|HEALTHFIRST TPA UMR|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Aenta Medicare Advantage|AETNA MEDICARE MA|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross PPO Specialty|BCBSTX OTHER|||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross HMO Specialty|BCBSTX HMO|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Aetna|AETNA OTHER|309.75||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|Aetna|AETNA PPO|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicaid|MEDICAID SUPERIOR|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Cigna|CIGNA|319.94||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Cigna|CIGNA|||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|ChampVA|CHAMPVA CENTER|||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|309.75||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|Humana Medicare Advantage|HUMANA MA|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicaid|MEDICAID AMERIGROUP|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Workers Compensation|WORKERS COMPENSATION OTHER|||||69.42||| 87086|EAP|0300|DEFINITIVE IDENT ANAEROBE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|310.25||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Medicare Advantage|UHC MEDICARE GOLD MA|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|309.75||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|319.94||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Veterans Affairs|VETERANS ADMINISTRATION|||||319.94||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicare|WELLCARE CHOICE MA|319.94||||||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|319.94||||189.59||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|MOLINA HEALTHCARE OF TEXAS|319.94||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|MEDICAID HMO|||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|MEDICAID|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicare|HEALTHSPRING MA|319.94||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|NON CONTRACTED|COMMERCIAL OTHER 1|309.75||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Healthcare|UNITED HEALTHCARE|||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Healthcare|UNITED HEALTHCARE OTHER|309.75||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Healthcare|UNITED HEALTHCARE|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicare|MEDICARE ACUTE|309.75||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|Tricare|TRICARE EAST REGION|||||69.42||| 87086|EAP|0300|CULTURE URINE COL. CT.|UTMB|UTMB CORRECTIONAL MANAGED CARE|309.75||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Healthcare|UMR UNITED MEDICAL RESOURCES|319.94||||189.59||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Healthcare|TML GROUP BENEFITS|||||189.59||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicare|MEDICARE PART B ONLY IP|309.75||||||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54,833.54|14633.9|14633.9|1925.71|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Medicare|MEDICARE ACUTE|43,780.75|14368.5|14633.9|1925.71|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicare|HEALTHSPRING MA|34,022.25|14369.38|14633.9|1925.71|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Humana Medicare Advantage|HUMANA MA|48,326.95|10844.96|14633.9|1925.71|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|27,320.03|1925.71|14633.9|1925.71|||| 87101|EAP|0300|CULTURE,FUNGUS,HAIR,SKIN,|Medicare|MEDICARE ACUTE|295.50||||||| 87116|EAP|0306|CULTURE AFB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||92.88||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||64.56||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Medicare|MEDICARE ACUTE|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Aenta Medicare Advantage|AETNA MEDICARE MA|||||64.56||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||64.56||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Blue Cross PPO Specialty|BCBSTX PPO|||||63.53||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Access Direct Platinum|HEALTHFIRST TPA UMR|||||64.56||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||64.56||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Humana Medicare Advantage|HUMANA MA|||||62.50||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|United Medicare Advantage|UHC MEDICARE GOLD MA|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.82||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Veterans Affairs|VETERANS ADMINISTRATION|||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Cigna|CIGNA|||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Managed Medicaid|MEDICAID AMERIGROUP|1.82||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Humana Medicare Advantage|HUMANA MA|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Managed Medicaid|MEDICAID SUPERIOR|1.82||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Aenta Medicare Advantage|AETNA MEDICARE MA|1.82||||||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.82||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Blue Cross HMO Specialty|BCBSTX HMO|||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Aetna|AETNA PPO|||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||111.40||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Blue Cross PPO Specialty|BCBSTX PPO|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Medicare|MEDICARE ACUTE|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|United Healthcare|UNITED HEALTHCARE|||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Medicare|MEDICARE PART B ONLY IP|1.82||||||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Tricare|TRICARE EAST REGION|||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||111.40||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Medicaid|MEDICAID HMO|||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Medicaid|MEDICAID|1.82||||1.82||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Managed Medicare|HEALTHSPRING MA|||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Managed Medicare|BCBS MEDICARE PPO MA|||||40.80||| 87185|EAP|0300|BETA LACTAMASE ENZYME DET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||40.80||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicaid|MEDICAID|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicare|WELLCARE CHOICE MA|3.31||||||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicare|HEALTHSPRING MA|||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicare|BCBS MEDICARE PPO MA|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Healthcare|UNITED HEALTHCARE OTHER|||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Healthcare|UNITED HEALTHCARE|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicare|MEDICARE PART B ONLY IP|3.31||||||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicare|MEDICARE ACUTE|3.31||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Healthcare|TML GROUP BENEFITS|||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Healthcare|UNITED HEALTHCARE|||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Aenta Medicare Advantage|AETNA MEDICARE MA|3.31||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Blue Cross PPO Specialty|BCBSTX PPO|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Tricare|TRICARE EAST REGION|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Aetna|AETNA OTHER|||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Blue Cross HMO Specialty|BCBSTX HMO|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Aetna|AETNA PPO|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.31||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicaid|MEDICAID SUPERIOR|3.31||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicaid|MEDICAID AMERIGROUP|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicaid|MEDICAID HMO|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Cigna|CIGNA|||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Cigna|CIGNA|||||202.64||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Humana Medicare Advantage|HUMANA MA|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|ChampVA|CHAMPVA CENTER|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Workers Compensation|WORKERS COMPENSATION OTHER|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Veterans Affairs|VETERANS ADMINISTRATION|||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Medicare Advantage|UHC MEDICARE GOLD MA|3.31||||74.28||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.31||||74.28||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Humana Medicare Advantage|HUMANA MA|78,177.62|9114.785|21069.41|4719.34|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|39,270.61|21069.41|21069.41|4719.34|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|36,103.83|4826.615|21069.41|4719.34|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|71,472.60|9016.06|21069.41|4719.34|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|37,481.60|6402.46|21069.41|4719.34|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|22,535.25|4719.34|21069.41|4719.34|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|25,650.52|9121.7|21069.41|4719.34|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|31,773.36|8061.7|21069.41|4719.34|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Medicare|MEDICARE ACUTE|47,403.10|9200.06|21069.41|4719.34|||| 87205|EAP|0306|GRAM STAIN|Medicaid|MEDICAID|163.25||||36.66||| 87205|EAP|0306|GRAM STAIN|Managed Medicare|BCBS MEDICARE PPO MA|||||36.66||| 87205|EAP|0306|GRAM STAIN|Medicaid|MEDICAID HMO|||||36.66||| 87205|EAP|0306|GRAM STAIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||36.66||| 87205|EAP|0306|GRAM STAIN|Managed Medicare|HEALTHSPRING MA|163.25||||99.96||| 87205|EAP|0306|GRAM STAIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||36.66||| 87205|EAP|0306|GRAM STAIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||99.96||| 87205|EAP|0306|GRAM STAIN|Medicare|MEDICARE PART B ONLY IP|163.25||||||| 87205|EAP|0306|GRAM STAIN|Medicare|MEDICARE ACUTE|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|Tricare|TRICARE EAST REGION|163.25||||99.96||| 87205|EAP|0306|GRAM STAIN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||36.66||| 87205|EAP|0306|GRAM STAIN|United Healthcare|GEHA|||||36.66||| 87205|EAP|0306|GRAM STAIN|United Healthcare|UNITED HEALTHCARE|||||163.25||| 87205|EAP|0306|GRAM STAIN|Veterans Affairs|VETERANS ADMINISTRATION|||||163.25||| 87205|EAP|0306|GRAM STAIN|United Medicare Advantage|UHC MEDICARE GOLD MA|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|163.25||||36.66||| 87205|EAP|0306|GRAM STAIN|Aenta Medicare Advantage|AETNA MEDICARE MA|163.25||||||| 87205|EAP|0306|GRAM STAIN|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|163.25||||||| 87205|EAP|0306|GRAM STAIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||36.66||| 87205|EAP|0306|GRAM STAIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||36.66||| 87205|EAP|0306|GRAM STAIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||36.66||| 87205|EAP|0306|GRAM STAIN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||36.66||| 87205|EAP|0306|GRAM STAIN|Blue Cross HMO Specialty|BCBSTX HMO|163.25||||36.66||| 87205|EAP|0306|GRAM STAIN|Blue Cross PPO Specialty|BCBSTX PPO|163.25||||36.66||| 87205|EAP|0306|GRAM STAIN|Aetna|AETNA PPO|||||36.66||| 87205|EAP|0306|GRAM STAIN|Managed Medicaid|MEDICAID AMERIGROUP|163.25||||36.66||| 87205|EAP|0306|GRAM STAIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||163.25||| 87205|EAP|0306|GRAM STAIN|Cigna|CIGNA|||||163.25||| 87205|EAP|0306|GRAM STAIN|Cigna|CIGNA|||||99.96||| 87205|EAP|0306|GRAM STAIN|Humana Medicare Advantage|HUMANA MA|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|Managed Medicaid|MEDICAID SUPERIOR|163.25||||36.66||| 87205|EAP|0306|GRAM STAIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|163.25||||99.96||| 87209|EAP|0300|TRICHROME STAIN|Humana Medicare Advantage|HUMANA MA|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||64.56||| 87209|EAP|0300|TRICHROME STAIN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||64.56||| 87209|EAP|0300|TRICHROME STAIN|Blue Cross PPO Specialty|BCBSTX PPO|||||63.53||| 87209|EAP|0300|TRICHROME STAIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||64.56||| 87209|EAP|0300|TRICHROME STAIN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||64.56||| 87209|EAP|0300|TRICHROME STAIN|Medicare|MEDICARE ACUTE|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||64.56||| 87210|EAP|0306|WET MOUNT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||36.66||| 87210|EAP|0306|WET MOUNT|Medicaid|MEDICAID|||||99.96||| 87210|EAP|0306|WET MOUNT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||36.66||| 87210|EAP|0306|WET MOUNT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||163.25||| 87210|EAP|0306|WET MOUNT|Tricare|TRICARE EAST REGION|||||36.66||| 87210|EAP|0306|WET MOUNT|NON CONTRACTED|COMMERCIAL OTHER 1|||||36.66||| 87210|EAP|0306|WET MOUNT|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||36.66||| 87210|EAP|0306|WET MOUNT|United Healthcare|UNITED HEALTHCARE OTHER|||||163.25||| 87210|EAP|0306|WET MOUNT|United Healthcare|UNITED HEALTHCARE|||||36.66||| 87210|EAP|0306|WET MOUNT|Medicaid|MEDICAID HMO|||||99.96||| 87210|EAP|0306|WET MOUNT|Medicare|MEDICARE ACUTE|||||36.66||| 87210|EAP|0306|WET MOUNT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||36.66||| 87210|EAP|0306|WET MOUNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||36.66||| 87210|EAP|0306|WET MOUNT|Blue Cross HMO Specialty|BCBSTX HMO|||||36.66||| 87210|EAP|0306|WET MOUNT|Blue Cross PPO Specialty|BCBSTX PPO|163.25||||36.66||| 87210|EAP|0306|WET MOUNT|Managed Medicaid|MEDICAID SUPERIOR|||||36.66||| 87210|EAP|0306|WET MOUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||36.66||| 87210|EAP|0306|WET MOUNT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||36.66||| 87210|EAP|0306|WET MOUNT|Managed Medicaid|MEDICAID AMERIGROUP|||||36.66||| 87210|EAP|0306|WET MOUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||36.66||| 87252|EAP|0300|CULTURE VIRAL/RESPIRATORY|Managed Medicaid|MEDICAID AMERIGROUP|897.25||||||| 87252|EAP|0300|CULTURE VIRAL/RESPIRATORY|Medicare|MEDICARE ACUTE|897.25||||||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Tricare|TRICARE EAST REGION|||||223.98||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||223.98||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Blue Cross PPO Specialty|BCBSTX PPO|||||223.98||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Managed Medicaid|MEDICAID SUPERIOR|||||223.98||| 87299|EAP|0300|TRICHOMONAS DFA ANTIGEN (|Blue Cross PPO Specialty|BCBSTX PPO|||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Managed Medicare|HEALTHSPRING MA|474.87||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Medicare|MEDICARE ACUTE|474.87||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|United Medicare Advantage|UHC MEDICARE GOLD MA|467.31||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Veterans Affairs|VETERANS ADMINISTRATION|474.87||||||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|NON CONTRACTED|COMMERCIAL OTHER 1|||||474.87||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|474.87||||467.31||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|United Medicare Advantage|AARP UHC WEST COMPLETE MA|459.75||||281.42||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Managed Medicaid|MEDICAID UNITED HEALTHCARE|459.75||||||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|467.31||||||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Humana Medicare Advantage|HUMANA MA|474.87||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|474.87||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Aenta Medicare Advantage|AETNA MEDICARE MA|||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Blue Cross PPO Specialty|BCBSTX PPO|||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Aetna|AETNA PPO|||||103.08||| 87324|EAP|0306|CLOSTRIDIUM DIFFICILE TOX|Blue Cross HMO Specialty|BCBSTX HMO|474.87||||103.08||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.08||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||103.08||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||103.08||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Humana Medicare Advantage|HUMANA MA|||||103.08||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|||||103.08||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||103.08||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||276.92||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|450.75||||103.08||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Veterans Affairs|VETERANS ADMINISTRATION|465.58||||||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Medicare|MEDICARE ACUTE|||||103.08||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Managed Medicare|HEALTHSPRING MA|||||103.08||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Managed Medicare|HEALTHSPRING MA|||||101.28||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Medicare|MEDICARE ACUTE|||||101.28||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Veterans Affairs|VETERANS ADMINISTRATION|457.57||||||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||101.28||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||272.14||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.43||||101.28||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Humana Medicare Advantage|HUMANA MA|||||101.28||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Managed Medicaid|MEDICAID SUPERIOR|||||101.28||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Blue Cross PPO Specialty|BCBSTX PPO|||||101.28||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||101.28||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||101.28||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.08||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Blue Cross PPO Specialty|BCBSTX PPO|||||103.08||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Medicare|MEDICARE ACUTE|474.87||||103.08||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicaid|MOLINA HEALTHCARE OF TEXAS|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicare|HEALTHSPRING MA|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicaid|MEDICAID HMO|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||395.75||| 87340|EAP|0302|HEPATITIS B SURFACE AG|PHCS|HUMANA INSURANCE|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Healthcare|UNITED HEALTHCARE|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Healthcare|UNITED HEALTHCARE|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Healthcare|UMR UNITED MEDICAL RESOURCES|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Healthcare|TML GROUP BENEFITS|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Tricare|TRICARE EAST REGION|395.75||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|NON CONTRACTED|COMMERCIAL OTHER 1|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Workers Compensation|WORKERS COMPENSATION OTHER|||||242.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Workers Compensation|UT EMPLOYEE INJURY|||||395.75||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|395.75||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Veterans Affairs|VETERANS ADMINISTRATION|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Cigna|CIGNA|408.77||||||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicare|MEDICARE ACUTE|395.75||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicaid|MEDICAID|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID AMERIGROUP|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Cigna|CIGNA|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID SUPERIOR|395.75||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Cigna|CIGNA|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Humana Medicare Advantage|HUMANA MA|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|395.75||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST TPA UMR|395.75||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Aenta Medicare Advantage|AETNA MEDICARE MA|395.75||||||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Aetna|AETNA OTHER|408.77||||395.75||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Blue Cross HMO Specialty|BCBSTX HMO|395.75||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Blue Cross PPO Specialty|BCBSTX PPO|408.77||||88.74||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Aetna|AETNA PPO|408.77||||88.74||| 87425|EAP|0300|ROTAVIRUS ANTIGEN DETECTI|Medicare|MEDICARE ACUTE|||||103.08||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Humana Medicare Advantage|HUMANA MA|178.25||||||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicaid|MEDICAID|1,315.25||||301.62||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Medicaid|MEDICAID|||||1,338.82||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicaid|MEDICAID HMO|||||1,315.25||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||13.19||| 87491|EAP|0300|CHLAMYDIA BY TMA|Managed Medicare|HEALTHSPRING MA|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,315.25||||||| 87491|EAP|0300|CHLAMYDIA BY TMA|NON CONTRACTED|COMMERCIAL OTHER 1|||||301.62||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|United Healthcare|UNITED HEALTHCARE OTHER|||||1,315.25||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|PHCS|HUMANA INSURANCE|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Healthcare|UNITED HEALTHCARE OTHER|||||1,315.25||| 87491|EAP|0300|CHLAMYDIA BY TMA|Tricare|TRICARE EAST REGION|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||301.62||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.19||| 87491|EAP|0300|CHLAMYDIA BY TMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Healthcare|UNITED HEALTHCARE|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicare|MEDICARE ACUTE|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Aetna|AETNA PPO|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Blue Cross PPO Specialty|BCBSTX OTHER|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Blue Cross HMO Specialty|BCBSTX HMO|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Aetna|AETNA OTHER|||||808.44||| 87491|EAP|0300|CHLAMYDIA BY TMA|Blue Cross PPO Specialty|BCBSTX PPO|1,315.25||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Humana Medicare Advantage|HUMANA MA|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Cigna|CIGNA|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Managed Medicaid|MEDICAID AMERIGROUP|1,315.25||||301.62||| 87491|EAP|0300|CHLAMYDIA BY TMA|Managed Medicaid|MEDICAID SUPERIOR|808.44||||301.62||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Managed Medicaid|MEDICAID SUPERIOR|||||1,362.39||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Managed Medicaid|MEDICAID AMERIGROUP|||||13.19||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Humana Medicare Advantage|HUMANA MA|1,025.92||||||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|993.25||||||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Blue Cross PPO Specialty|BCBSTX PPO|||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||662.21||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|993.25||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Medicare|MEDICARE ACUTE|1,009.59||||298.50||| 87497|EAP|0300|CYTOMEGALO VIRUS,PCR QT|Blue Cross PPO Specialty|BCBSTX PPO|1,066.50||||||| 87497|EAP|0300|CYTOMEGALO VIRUS,PCR QT|Managed Medicaid|MEDICAID SUPERIOR|||||243.84||| 87502|EAP|0300|FLU A/B AG|Medicaid|MEDICAID|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||23.35||| 87502|EAP|0300|FLU A/B AG|Medicaid|MEDICAID HMO|||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicare|HEALTHSPRING MA|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||23.35||| 87502|EAP|0300|FLU A/B AG|NON CONTRACTED|COMMERCIAL OTHER 2|||||2,373.41||| 87502|EAP|0300|FLU A/B AG|NON CONTRACTED|COMMERCIAL OTHER 1|||||23.35||| 87502|EAP|0300|FLU A/B AG|Medicare|MEDICARE ACUTE|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|United Healthcare|UNITED HEALTHCARE|||||23.35||| 87502|EAP|0300|FLU A/B AG|PHCS|HUMANA INSURANCE|||||23.35||| 87502|EAP|0300|FLU A/B AG|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||23.35||| 87502|EAP|0300|FLU A/B AG|Tricare|TRICARE FOR LIFE|||||23.35||| 87502|EAP|0300|FLU A/B AG|Tricare|TRICARE EAST REGION|||||23.35||| 87502|EAP|0300|FLU A/B AG|Medicare|MEDICARE PART B ONLY IP|||||23.35||| 87502|EAP|0300|FLU A/B AG|United Medicare Advantage|UHC MEDICARE GOLD MA|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|United Healthcare|UNITED HEALTHCARE OTHER|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||23.35||| 87502|EAP|0300|FLU A/B AG|UTMB|UTMB CORRECTIONAL MANAGED CARE|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Veterans Affairs|VETERANS ADMINISTRATION|||||23.35||| 87502|EAP|0300|FLU A/B AG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||23.35||| 87502|EAP|0300|FLU A/B AG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Humana Medicare Advantage|HUMANA MA|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicaid|MEDICAID AMERIGROUP|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Cigna|CIGNA|||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicaid|MEDICAID SUPERIOR|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Aenta Medicare Advantage|AETNA MEDICARE MA|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Blue Cross PPO Specialty|BCBSTX PPO|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Blue Cross HMO Specialty|BCBSTX HMO|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Blue Cross PPO Specialty|BCBSTX OTHER|||||23.35||| 87502|EAP|0300|FLU A/B AG|Aetna|AETNA PPO|||||23.35||| 87502|EAP|0300|FLU A/B AG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|23.35||||2,373.41||| 87502|EAP|0300|FLU A/B AG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||23.35||| 87502|EAP|0300|FLU A/B AG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||23.35||| 87517|EAP|0306|HEPATITIS B PCR,QUANT|Blue Cross PPO Specialty|BCBSTX PPO|||||243.84||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Medicare|MEDICARE ACUTE|||||301.62||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||301.62||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||301.62||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Humana Medicare Advantage|HUMANA MA|||||301.62||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||301.62||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Blue Cross PPO Specialty|BCBSTX PPO|||||301.62||| 87536|EAP|0302|HIV 1 RNA, PCR, QUANT|Managed Medicaid|MEDICAID AMERIGROUP|||||731.28||| 87536|EAP|0302|HIV 1 RNA, PCR, QUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,506.75||||||| 87591|EAP|0300|GC BY TMA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||301.62||| 87591|EAP|0300|GC BY TMA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||301.62||| 87591|EAP|0300|GC BY TMA|Medicaid|MEDICAID|1,315.25||||301.62||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Medicaid|MEDICAID|||||1,338.82||| 87591|EAP|0300|GC BY TMA|Managed Medicare|HEALTHSPRING MA|||||301.62||| 87591|EAP|0300|GC BY TMA|Medicaid|MEDICAID HMO|||||1,315.25||| 87591|EAP|0300|GC BY TMA|NON CONTRACTED|COMMERCIAL OTHER 1|||||301.62||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|United Healthcare|UNITED HEALTHCARE OTHER|||||1,315.25||| 87591|EAP|0300|GC BY TMA|Medicare|MEDICARE ACUTE|||||301.62||| 87591|EAP|0300|GC BY TMA|United Healthcare|UNITED HEALTHCARE|||||301.62||| 87591|EAP|0300|GC BY TMA|PHCS|HUMANA INSURANCE|||||301.62||| 87591|EAP|0300|GC BY TMA|Tricare|TRICARE EAST REGION|||||301.62||| 87591|EAP|0300|GC BY TMA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||301.62||| 87591|EAP|0300|GC BY TMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||301.62||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.19||| 87591|EAP|0300|GC BY TMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||301.62||| 87591|EAP|0300|GC BY TMA|Aetna|AETNA PPO|||||301.62||| 87591|EAP|0300|GC BY TMA|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,315.25||||||| 87591|EAP|0300|GC BY TMA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||301.62||| 87591|EAP|0300|GC BY TMA|Blue Cross HMO Specialty|BCBSTX HMO|||||301.62||| 87591|EAP|0300|GC BY TMA|Aetna|AETNA OTHER|||||808.44||| 87591|EAP|0300|GC/URINE/AMPLIFIED PROBE|Blue Cross PPO Specialty|BCBSTX PPO|1,315.25||||301.62||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||13.19||| 87591|EAP|0300|GC BY TMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||301.62||| 87591|EAP|0300|GC BY TMA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||301.62||| 87591|EAP|0300|GC BY TMA|Blue Cross PPO Specialty|BCBSTX PPO|1,315.25||||301.62||| 87591|EAP|0300|GC BY TMA|Blue Cross PPO Specialty|BCBSTX OTHER|||||301.62||| 87591|EAP|0300|GC BY TMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||301.62||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Managed Medicaid|MEDICAID SUPERIOR|||||1,362.39||| 87591|EAP|0300|GC BY TMA|Humana Medicare Advantage|HUMANA MA|||||301.62||| 87591|EAP|0300|GC BY TMA|Cigna|CIGNA|||||301.62||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Managed Medicaid|MEDICAID AMERIGROUP|||||13.19||| 87591|EAP|0300|GC BY TMA|Managed Medicaid|MEDICAID SUPERIOR|808.44||||301.62||| 87591|EAP|0300|GC BY TMA|Managed Medicaid|MEDICAID AMERIGROUP|1,315.25||||301.62||| 87591|EAP|0300|GC BY TMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||301.62||| 87651|EAP|0300|TRICHOMONAS,URINE,MALE|Managed Medicaid|MEDICAID AMERIGROUP|||||2.87||| 87798|EAP|0306|ENTEROVIRUS PCR (CSF)|Blue Cross PPO Specialty|BCBSTX PPO|1,315.25||||||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Managed Medicaid|MEDICAID SUPERIOR|||||368.10||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Blue Cross PPO Specialty|BCBSTX PPO|4.43||||||| 87804|EAP|0306|FLU A&B SCREEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||103.08||| 87804|EAP|0306|FLU A&B SCREEN|Medicaid|MEDICAID|||||103.08||| 87804|EAP|0306|FLU A&B SCREEN|Medicaid|MEDICAID HMO|||||103.08||| 87804|EAP|0306|FLU A&B SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.08||| 87804|EAP|0306|FLU A&B SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|||||103.08||| 87804|EAP|0306|FLU A&B SCREEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||103.08||| 87804|EAP|0306|FLU A&B SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|||||103.08||| 87804|EAP|0306|FLU A&B SCREEN|Managed Medicaid|MEDICAID SUPERIOR|||||103.08||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||103.08||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Managed Medicaid|MEDICAID SUPERIOR|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Humana Medicare Advantage|HUMANA MA|474.87||||||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Managed Medicaid|MEDICAID AMERIGROUP|467.31||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Cigna|CIGNA|||||474.87||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.08||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Blue Cross HMO Specialty|BCBSTX HMO|||||474.87||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Blue Cross PPO Specialty|BCBSTX PPO|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||474.87||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicare|MEDICARE ACUTE|459.75||||||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|United Healthcare|UNITED HEALTHCARE|||||474.87||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Tricare|TRICARE EAST REGION|||||474.87||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|NON CONTRACTED|COMMERCIAL OTHER 1|||||467.31||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicaid|MEDICAID|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicaid|MEDICAID HMO|||||467.31||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||459.75||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Medicaid|MEDICAID|||||231.70||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Medicaid|MEDICAID HMO|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|United Healthcare|UNITED HEALTHCARE OTHER|||||353.75||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Tricare|TRICARE EAST REGION|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Blue Cross HMO Specialty|BCBSTX HMO|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Aetna|AETNA PPO|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Blue Cross PPO Specialty|BCBSTX PPO|353.75||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Cigna|CIGNA|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Managed Medicaid|MEDICAID AMERIGROUP|||||0.98||| 87810|EAP|0300|CHYLMD TRACH ASSAY W/OPTI|Managed Medicaid|MEDICAID SUPERIOR|||||0.98||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|474.87||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Cigna|CIGNA|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Humana Medicare Advantage|HUMANA MA|474.87||||467.31||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|467.31||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|459.75||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Blue Cross PPO Specialty|BCBSTX PPO|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||281.42||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Blue Cross HMO Specialty|BCBSTX HMO|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Blue Cross PPO Specialty|BCBSTX OTHER|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Aetna|AETNA PPO|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicaid|MEDICAID SUPERIOR|467.31||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|UTMB|UTMB CORRECTIONAL MANAGED CARE|459.75||||467.31||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|NON CONTRACTED|COMMERCIAL OTHER 2|||||467.31||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|NON CONTRACTED|COMMERCIAL OTHER 1|||||467.31||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|PHCS|HUMANA INSURANCE|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicaid|MEDICAID AMERIGROUP|467.31||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|United Healthcare|UNITED HEALTHCARE OTHER|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicare|MEDICARE ACUTE|474.87||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Tricare|TRICARE EAST REGION|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|United Medicare Advantage|UHC MEDICARE GOLD MA|459.75||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Tricare|TRICARE FOR LIFE|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|United Healthcare|UNITED HEALTHCARE|||||467.31||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|MEDICAID|459.75||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|MEDICAID HMO|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicare|HEALTHSPRING MA|||||459.75||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|Humana Medicare Advantage|HUMANA MA|459.75||||||| 87902|EAP|0306|HEPATITIS C VIRAL GENOTYP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||243.84||| 87902|EAP|0306|HEPATITIS C VIRAL GENOTYP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||243.84||| 87999|EAP|0306||Workers Compensation|WORKERS COMPENSATION OTHER|||||69.42||| 881|DRG||DEPRESSIVE NEUROSES|Humana Medicare Advantage|HUMANA MA|43,789.50|7618.95|7618.95|7618.95|||| 88112|EAP|0310|NON-GYN THIN PREP|Managed Medicaid|MEDICAID SUPERIOR|906.50||||||| 88161|EAP|0300|CYTO PREP SCREENING|Medicare|MEDICARE ACUTE|283.77||||246.75||| 88161|EAP|0300|CYTO PREP SCREENING|United Medicare Advantage|UHC MEDICARE GOLD MA|320.78||||246.75||| 88161|EAP|0300|CYTO PREP SCREENING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||283.77||| 88161|EAP|0300|CYTO PREP SCREENING|Veterans Affairs|VETERANS ADMINISTRATION|320.78||||320.78||| 88161|EAP|0300|CYTO PREP SCREENING|Blue Cross PPO Specialty|BCBSTX PPO|||||246.75||| 88161|EAP|0300|CYTO PREP SCREENING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||320.78||| 88161|EAP|0300|CYTO PREP SCREENING|Managed Medicaid|MEDICAID SUPERIOR|||||320.78||| 88161|EAP|0300|CYTO PREP SCREENING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|320.78||||246.75||| 88161|EAP|0300|CYTO PREP SCREENING|Humana Medicare Advantage|HUMANA MA|246.75||||||| 88161|EAP|0300|CYTO PREP SCREENING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||246.75||| 88184|EAP|0310|FLOW CYTOMETRY/SURF/CYTOP|Blue Cross PPO Specialty|BCBSTX PPO|||||0.99||| 88184|EAP|0310|FLOW CYTOMETRY/SURF/CYTOP|Medicare|MEDICARE ACUTE|||||0.99||| 88185|EAP|0300|FLOW CYTOMETRY/EACH MARKE|Medicare|MEDICARE ACUTE|||||29.70||| 88185|EAP|0300|FLOW CYTOMETRY/EACH MARKE|Blue Cross PPO Specialty|BCBSTX PPO|||||29.70||| 88187|EAP|0310|PI LINKED ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||60.36||| 88187|EAP|0310|PI LINKED ANTIGEN|Medicare|MEDICARE ACUTE|||||60.36||| 88230|EAP|0312|TISSUE CULT FOR CHROMSOME|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,001.16||| 88262|EAP|0310|CHROMOSOME ANAY/CT 15-20|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,071.18||| 88291|EAP|0312|CYTOGENETICS & MOLECULAR|NON CONTRACTED|COMMERCIAL OTHER 1|||||66.75||| 88300|EAP|0310|LEVEL I (GROSS ONLY)|Medicare|MEDICARE ACUTE|563.23||||||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|433.25||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|563.23||||||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Managed Medicaid|MEDICAID AMERIGROUP|563.23||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|563.23||||||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Managed Medicaid|MEDICAID SUPERIOR|433.25||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Medicaid|MEDICAID HMO|563.23||||||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Medicaid|MEDICAID|563.23||||||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Medicare|MEDICARE ACUTE|563.23||||433.25||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|PHCS|HUMANA INSURANCE|||||207.30||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Medicare|MEDICARE ACUTE|1,178.45||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Medicaid|MEDICAID|||||1,178.45||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicaid|MEDICAID SUPERIOR|906.50||||1,178.45||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicaid|MEDICAID AMERIGROUP|906.50||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||556.90||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Humana Medicare Advantage|HUMANA MA|1,042.48||||556.90||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|906.50||||||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|906.50||||||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,178.45||||1,042.48||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|906.50||||||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|906.50||||1,042.48||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|United Medicare Advantage|UHC MEDICARE GOLD MA|1,178.45||||1,178.45||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|906.50||||1,178.45||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Veterans Affairs|VETERANS ADMINISTRATION|1,178.45||||||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,178.45||||207.30||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Blue Cross PPO Specialty|BCBSTX PPO|1,042.48||||||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicaid|MEDICAID SUPERIOR|906.50||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicaid|MEDICAID AMERIGROUP|||||1,178.45||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Humana Medicare Advantage|HUMANA MA|1,178.45||||692.88||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||207.30||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Medicaid|MEDICAID|1,178.45||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||207.30||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicare|BCBS MEDICARE PPO MA|906.50||||||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Tricare|TRICARE EAST REGION|||||207.30||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|United Healthcare|UNITED HEALTHCARE|||||1,178.45||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Medicare|MEDICARE PART B ONLY IP|906.50||||||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Medicare|MEDICARE ACUTE|1,178.45||||906.50||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Medicare|MEDICARE ACUTE|1,852.83||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Tricare|TRICARE EAST REGION|||||1,425.25||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Medicaid|MOLINA HEALTHCARE OF TEXAS|1,852.83||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Medicaid|MEDICAID|1,639.04||||1,425.25||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Medicaid|MEDICAID HMO|1,852.83||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,425.25||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Managed Medicaid|MEDICAID AMERIGROUP|1,425.25||||1,852.83||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,852.83||||1,852.83||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Humana Medicare Advantage|HUMANA MA|1,425.25||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,425.25||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Managed Medicaid|MEDICAID SUPERIOR|1,852.83||||1,639.04||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Aenta Medicare Advantage|AETNA MEDICARE MA|1,852.83||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,425.25||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|United Medicare Advantage|UHC MEDICARE GOLD MA|1,852.83||||||| 88309|EAP|0310|LEVEL VI (GROSS & MICRO)|Managed Medicaid|MEDICAID SUPERIOR|1,852.83||||||| 88309|EAP|0310|LEVEL VI (GROSS & MICRO)|Managed Medicaid|MEDICAID AMERIGROUP|||||1,852.83||| 88311|EAP|0310|BONE DECALCIFICATION|Medicare|MEDICARE ACUTE|343.53||||343.53||| 88311|EAP|0310|BONE DECALCIFICATION|United Medicare Advantage|UHC MEDICARE GOLD MA|343.53||||||| 88311|EAP|0310|BONE DECALCIFICATION|Veterans Affairs|VETERANS ADMINISTRATION|343.53||||||| 88311|EAP|0310|BONE DECALCIFICATION|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|343.53||||||| 88311|EAP|0310|BONE DECALCIFICATION|United Medicare Advantage|AARP UHC WEST COMPLETE MA|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|343.53||||||| 88311|EAP|0310|BONE DECALCIFICATION|Aenta Medicare Advantage|AETNA MEDICARE MA|343.53||||||| 88311|EAP|0310|BONE DECALCIFICATION|Blue Cross PPO Specialty|BCBSTX PPO|343.53||||||| 88311|EAP|0310|BONE DECALCIFICATION|Humana Medicare Advantage|HUMANA MA|303.89||||||| 88313|EAP|0310|SPECIAL STAINS GROUP II(I|Medicare|MEDICARE ACUTE|||||433.25||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Humana Medicare Advantage|HUMANA MA|906.50||||||| 884|DRG||ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY|Medicare|MEDICARE ACUTE|21,235.50|11819.74|11819.74|11819.74|||| 885|DRG||PSYCHOSES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27,970.50|13949.98|14782.4|10177.29|||| 885|DRG||PSYCHOSES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|30,121.73|14782.4|14782.4|10177.29|||| 885|DRG||PSYCHOSES|Medicare|MEDICARE ACUTE|32,082.50|10177.29|14782.4|10177.29|||| 89|DRG||CONCUSSION W CC|Medicare|MEDICARE ACUTE|33,991.54|8851.82|8851.82|8851.82|||| 89051|EAP|0300|WBC & DIFFERENTIAL CSF|Managed Medicaid|MEDICAID SUPERIOR|||||2.11||| 89051|EAP|0300|WBC & DIFFERENTIAL CSF|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.11||||||| 89051|EAP|0300|WBC & DIFFERENTIAL CSF|Medicare|MEDICARE ACUTE|2.11||||47.34||| 89055|EAP|0300|FECAL LEUCOCYTE|Managed Medicare|HEALTHSPRING MA|185.60||||36.66||| 89055|EAP|0300|FECAL LEUCOCYTE|Medicare|MEDICARE ACUTE|185.60||||36.66||| 89055|EAP|0300|FECAL LEUCOCYTE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||36.66||| 89055|EAP|0300|FECAL LEUCOCYTE|United Medicare Advantage|UHC MEDICARE GOLD MA|185.60||||163.25||| 89055|EAP|0300|FECAL LEUCOCYTE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|185.60||||163.25||| 89055|EAP|0300|FECAL LEUCOCYTE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||36.66||| 89055|EAP|0300|FECAL LEUCOCYTE|Veterans Affairs|VETERANS ADMINISTRATION|185.60||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||36.66||| 89055|EAP|0300|FECAL LEUCOCYTE|Blue Cross HMO Specialty|BCBSTX HMO|185.60||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Blue Cross PPO Specialty|BCBSTX PPO|||||36.66||| 89055|EAP|0300|FECAL LEUCOCYTE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||36.66||| 89055|EAP|0300|FECAL LEUCOCYTE|Humana Medicare Advantage|HUMANA MA|174.43||||36.66||| 89055|EAP|0300|FECAL LEUCOCYTE|Managed Medicaid|MEDICAID AMERIGROUP|||||163.25||| 89055|EAP|0300|FECAL LEUCOCYTE|Cigna|CIGNA|||||36.66||| 89060|EAP|0300|CRYSTAL ID, BODY FLIUD EX|Cigna|CIGNA|||||2.74||| 89060|EAP|0300|CRYSTAL ID, BODY FLIUD EX|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.74||||||| 89060|EAP|0300|CRYSTAL ID, BODY FLIUD EX|Medicare|MEDICARE ACUTE|||||61.44||| 894|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19,752.08|19752.075|19752.075|19752.075|||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|Blue Cross PPO Specialty|BCBSTX PPO|17,859.53||||||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35,277.38||||||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|Medicare|MEDICARE ACUTE|86,324.75|13424.54|64813.62|11577.32|||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|44,326.55|11577.32|64813.62|11577.32|||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|14,437.50|13425.42|64813.62|11577.32|||| 896|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|64,813.62|64813.62|64813.62|11577.32|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|13,379.35||||||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15,632.50||||||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Cigna|CIGNA|13,648.33|47.25|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Cigna|CIGNA|13,603.88|47.25|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Humana Medicare Advantage|HUMANA MA|14,523.90|7781.61|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15,708.78|11041.1|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18,156.78|10447.27|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17,946.60|7496.38|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Aetna|AETNA PPO|18,642.55|10495.76|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UMR|12,166.90|7496.38|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|United Healthcare|UNITED HEALTHCARE|16,080.70|8210.6|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|United Healthcare|UNITED HEALTHCARE|32,090.75|8210.6|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|138.13|138.13|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|165.90|7643.71|11041.1|47.25|||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Medicare|MEDICARE ACUTE|19,686.55|7643.71|11041.1|47.25|||| 90371|ERX|0636|HEP B IMMUNE GLOB 110 UNI|Blue Cross PPO Specialty|BCBSTX PPO|456.40||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicaid|MEDICAID SUPERIOR|||||371.13||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicaid|MEDICAID AMERIGROUP|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Medicaid|SUPERIOR HEALTHPLAN CHIP|3.28||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||414.25||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Tricare|TRICARE EAST REGION|171.43||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|NON CONTRACTED|COMMERCIAL OTHER 1|||||414.25||| 90471|EAP|0940|ADMIN OF VACCINE INITIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.28||| 90471|EAP|0940|ADMIN OF VACCINE INITIAL|Medicare|MEDICARE ACUTE|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|United Healthcare|UNITED HEALTHCARE OTHER|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|United Healthcare|UNITED HEALTHCARE|||||414.25||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|United Healthcare|UNITED HEALTHCARE|3.28||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Workers Compensation|WORKERS COMPENSATION OTHER|3.28||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||414.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||414.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Veterans Affairs|VETERANS ADMINISTRATION|||||414.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Medicare|MEDICARE ACUTE|3.28||||414.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.28||||||| 90471|EAP|0940|ADMIN OF VACCINE INITIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||405.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Blue Cross HMO Specialty|BCBSTX HMO|||||414.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||414.25||| 90471|EAP|0940|ADMIN OF VACCINE INITIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||414.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|14.85||||||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Aetna|AETNA PPO|3.28||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Aetna|AETNA OTHER|||||414.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Aetna|AETNA PPO|||||371.13||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Blue Cross PPO Specialty|BCBSTX PPO|3.28||||414.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Cigna|CIGNA|||||414.25||| 90471|EAP|0940|ADMIN OF VACCINE INITIAL|Humana Medicare Advantage|HUMANA MA|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Blue Cross PPO Specialty|BCBSTX PPO|3.28||||||| 90471|EAP|0940|ADMIN OF VACCINE INITIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Humana Medicare Advantage|HUMANA MA|||||414.25||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Cigna|CIGNA|3.28||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicare|BCBS MEDICARE PPO MA|||||414.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||371.13||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Medicaid|MEDICAID|3.28||||||| 90471|EAP|0940|ADMIN OF VACCINE INITIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||405.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicare|HEALTHSPRING MA|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Managed Medicaid|MEDICAID SUPERIOR|3.28||||||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Medicaid|MEDICAID HMO|3.28||||||| 90471|EAP|0940|ADMIN OF VACCINE INITIAL|Managed Medicaid|MEDICAID SUPERIOR|||||405.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Medicaid|MEDICAID|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Managed Medicaid|MEDICAID AMERIGROUP|3.28||||||| 90472|EAP|0940|ADMIN OF VACCINE EA ADDED|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||469.50||| 90472|EAP|0940|ADMIN OF VACCINE EA ADDED|Medicare|MEDICARE ACUTE|||||371.75||| 906|DRG||HAND PROCEDURES FOR INJURIES|Workers Compensation|WORKERS COMPENSATION OTHER|23,219.09|19392.29|19392.29|19392.29|||| 90658|ERX|0250|INFLUENZA VACCINE 09-10 0|Medicare|MEDICARE ACUTE|||||152.25||| 90675|ERX|0636|RABIES VACCINE,PCEC 2.5 U|Blue Cross PPO Specialty|BCBSTX PPO|||||1,688.87||| 90686|ERX|0250|INFLUENZA VACCINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|100.35||||||| 90686|ERX|0250|INFLUENZA VACCINE|United Medicare Advantage|UHC MEDICARE GOLD MA|100.35||||||| 90686|ERX|0250|INFLUENZA VACCINE|Medicare|MEDICARE ACUTE|100.35||||100.35||| 90686|ERX|0250|INFLUENZA VACCINE|Veterans Affairs|VETERANS ADMINISTRATION|||||100.35||| 90700|ERX|0636|TET-DIPH-PERTUS(ACEL)(PED|Managed Medicaid|MEDICAID SUPERIOR|||||142.05||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Managed Medicare|HEALTHSPRING MA|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Medicaid|MEDICAID|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Medicare|MEDICARE ACUTE|195.84||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Workers Compensation|WORKERS COMPENSATION OTHER|195.84||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Aetna|AETNA PPO|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Managed Medicaid|MEDICAID SUPERIOR|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Managed Medicaid|MEDICAID AMERIGROUP|195.84||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Aetna|AETNA OTHER|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|NON CONTRACTED|COMMERCIAL OTHER 1|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Cigna|CIGNA|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Blue Cross HMO Specialty|BCBSTX HMO|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|195.84||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Veterans Affairs|VETERANS ADMINISTRATION|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Blue Cross PPO Specialty|BCBSTX PPO|195.84||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|United Healthcare|UNITED HEALTHCARE OTHER|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Humana Medicare Advantage|HUMANA MA|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Managed Medicare|BCBS MEDICARE PPO MA|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|United Healthcare|UNITED HEALTHCARE|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||195.84||| 90714|ERX|0250|TETANUS-DIPTHE TOX (ADULT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||195.84||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Medicare|MEDICARE ACUTE|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Blue Cross PPO Specialty|BCBSTX PPO|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Cigna|CIGNA|||||238.05||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Humana Medicare Advantage|HUMANA MA|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Blue Cross PPO Specialty|BCBSTX PPO|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Medicaid|COUNTY INDIGENT HEALTH OTHER|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicaid|MEDICAID UNITED HEALTHCARE|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|UTMB|UTMB CORRECTIONAL MANAGED CARE|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicare|HEALTHSPRING MA|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Blue Cross HMO Specialty|BCBSTX HMO|||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicare|BCBS MEDICARE PPO MA|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|United Medicare Advantage|UHC MEDICARE GOLD MA|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Medicare|MEDICARE ACUTE|397.75||||397.75||| 909|DRG||OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC|Medicare|MEDICARE ACUTE|40,536.93|11035.88|11035.88|11035.88|||| 914|DRG||TRAUMATIC INJURY W/O MCC|Medicare|MEDICARE ACUTE|29,496.97|8033.14|8033.14|8033.14|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Medicare|MEDICARE ACUTE|29,550.80|7864.74|11761.45|6905.76|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|383.33|6905.76|11761.45|6905.76|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|32,119.85|11761.45|11761.45|6905.76|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|27,872.38|15552.79|21344.84|4846.63|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|21,892.75|4846.63|21344.84|4846.63|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|208,796.81|21344.84|21344.84|4846.63|||| 92|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W CC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|52,099.56|8572.87|8572.87|8572.87|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Blue Cross PPO Specialty|BCBSTX PPO|7,580.25|6243.29|6243.29|6243.29|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|33,634.50|3311.13|3311.13|3311.13|||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Medicaid|MEDICAID HMO|195.98||||||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Managed Medicaid|MEDICAID SUPERIOR|150.75||||195.98||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|United Healthcare|UNITED HEALTHCARE|150.75||||||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Blue Cross PPO Specialty|BCBSTX PPO|195.98||||195.98||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Managed Medicaid|MEDICAID AMERIGROUP|195.98||||195.98||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Medicaid|SUPERIOR HEALTHPLAN CHIP|150.75||||||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Medicaid|MEDICAID|150.75||||173.37||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|173.37||||||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|195.98||||||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Cigna|CIGNA|195.98||||||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|150.75||||||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Tricare|TRICARE EAST REGION|173.37||||||| 92586|EAP|0471|NEONATAL HEARING SCREEN A|Aetna|AETNA PPO|195.98||||||| 92950|EAP|0450|CPR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,170.98||||||| 92950|EAP|0450|CPR|Managed Medicare|WELLCARE CHOICE MA|||||1,170.98||| 92950|EAP|0450|CPR|Medicaid|MEDICAID HMO|||||1,035.87||| 92950|EAP|0450|CPR|Humana Medicare Advantage|HUMANA MA|||||900.75||| 92950|EAP|0450|CPR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||900.75||| 92950|EAP|0450|CPR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||900.75||| 92950|EAP|0450|CPR|Medicare|MEDICARE ACUTE|||||1,170.98||| 92950|EAP|0450|CPR|Blue Cross PPO Specialty|BCBSTX PPO|||||900.75||| 92950|EAP|0450|CPR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,170.98||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|Medicare|MEDICARE ACUTE|||||1,291.50||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,678.95||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,678.95||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicaid|MEDICAID AMERIGROUP|6.64||||6.64||| 93005|EAP|0730|EKG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.64||||638.75||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|MEDICAID|763.60||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|863.20||||6.64||| 93005|EAP|0730|EKG|Medicaid|MEDICAID|763.60||||638.75||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Veterans Affairs|VETERANS ADMINISTRATION|863.20||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicare|BCBS MEDICARE PPO MA|863.20||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicare|WELLCARE CHOICE MA|863.20||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicare|HEALTHSPRING MA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|UNITED HEALTHCARE|||||763.60||| 93005|EAP|0730|EKG|Medicare|MEDICARE ACUTE|6.64||||638.75||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|NON CONTRACTED|COMMERCIAL OTHER 1|6.64||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|TML GROUP BENEFITS|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|UNITED HEALTHCARE|863.20||||763.60||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|UNITED HEALTHCARE OTHER|6.64||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.64||||6.64||| 93005|EAP|0730|EKG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.64||||638.75||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicare|MEDICARE ACUTE|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Tricare|TRICARE EAST REGION|863.20||||763.60||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|NON CONTRACTED|COMMERCIAL OTHER 2|||||863.20||| 93005|EAP|0730|EKG|Blue Cross PPO Specialty|BCBSTX PPO|6.64||||638.75||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|PHCS|HUMANA INSURANCE|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicare|MEDICARE PART B ONLY IP|6.64||||763.60||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Aetna|AETNA OTHER|||||763.60||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|863.20||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|MEDICAID HMO|||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|863.20||||763.60||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross HMO Specialty|BCBSTX HMO|6.64||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Aenta Medicare Advantage|AETNA MEDICARE MA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross PPO Specialty|BCBSTX OTHER|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|863.20||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Cigna|CIGNA|863.20||||763.60||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|763.60||||863.20||| 93005|EAP|0730|EKG|Humana Medicare Advantage|HUMANA MA|863.20||||638.75||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|ChampVA|CHAMPVA CENTER|||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Medicare Advantage|UHC MEDICARE GOLD MA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Workers Compensation|WORKERS COMPENSATION OTHER|863.20||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross PPO Specialty|BCBSTX PPO|6.64||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|863.20||||863.20||| 93005|EAP|0730|EKG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|863.20||||638.75||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Aetna|AETNA PPO|863.20||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicaid|MEDICAID SUPERIOR|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.64||||6.64||| 93005|EAP|0730|EKG|Aenta Medicare Advantage|AETNA MEDICARE MA|6.64||||638.75||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Humana Medicare Advantage|HUMANA MA|863.20||||863.20||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Cigna|CIGNA|763.60||||6.64||| 93015|EAP|0460|CARDIO STRESS TEST|Medicare|MEDICARE ACUTE|4.42||||||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross HMO Specialty|BCBSTX HMO|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Aetna|AETNA PPO|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Aetna|BOON CHAPMAN|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Cigna|CIGNA|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Aetna|AETNA OTHER|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross PPO Specialty|BCBSTX PPO|13.57||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Humana Medicare Advantage|HUMANA MA|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,560.55||| 93017|EAP|0482|STRESS TEST TRACING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Managed Medicaid|MEDICAID AMERIGROUP|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|United Healthcare|GOLDEN RULE|||||1,560.55||| 93017|EAP|0482|STRESS TEST TRACING|Veterans Affairs|VETERANS ADMINISTRATION|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|United Healthcare|GEHA|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Managed Medicare|HEALTHSPRING MA|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|Medicaid|MEDICAID|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Tricare|TRICARE FOR LIFE|||||1,560.55||| 93017|EAP|0482|STRESS TEST TRACING|PHCS|HUMANA INSURANCE|||||1,560.55||| 93017|EAP|0482|STRESS TEST TRACING|Managed Medicaid|MEDICAID SUPERIOR|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Managed Medicare|BCBS MEDICARE PPO MA|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|NON CONTRACTED|COMMERCIAL OTHER 2|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|PHCS|MULTIPLAN PHCS|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Medicare|MEDICARE ACUTE|13.57||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|United Healthcare|UNITED HEALTHCARE OTHER|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|United Healthcare|UNITED HEALTHCARE|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|NON CONTRACTED|COMMERCIAL OTHER 1|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|United Healthcare|TML GROUP BENEFITS|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Access Direct Platinum|HEALTHFIRST TPA UMR|||||13.57||| 93017|EAP|0482|STRESS TEST TRACING|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|United Healthcare|UNITED HEALTHCARE|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|ChampVA|CHAMPVA CENTER|||||1,560.55||| 93017|EAP|0482|STRESS TEST TRACING|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,764.10||| 93017|EAP|0482|STRESS TEST TRACING|Tricare|TRICARE EAST REGION|||||13.57||| 93303|EAP|0483|ECHO TTE 2D CONGENTIAL CO|Medicare|MEDICARE ACUTE|||||1,791.41||| 93303|EAP|0483|ECHO TTE 2D CONGENTIAL CO|Managed Medicare|HEALTHSPRING MA|||||1,628.75||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5,305.32||||5,557.63||| 93306|EAP|0483||Aetna|AETNA PPO|||||3,044.43||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross HMO Specialty|BCBSTX HMO|||||5,557.63||| 93306|EAP|0483||United Healthcare|UMR UNITED MEDICAL RESOURCES|||||27.68||| 93306|EAP|0483||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,906.22||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aetna|AETNA OTHER|||||5,557.63||| 93306|EAP|0483||Veterans Affairs|VETERANS ADMINISTRATION|5,557.63||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC MEDICARE GOLD MA|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Veterans Affairs|VETERANS ADMINISTRATION|5,557.63||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|50.53||||5,557.63||| 93306|EAP|0483||Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.68||||27.68||| 93306|EAP|0483||Medicare|MEDICARE ACUTE|27.68||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID AMERIGROUP|50.53||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5,557.63||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5,305.32||| 93306|EAP|0483||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5,557.63||||50.53||| 93306|EAP|0483||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID SUPERIOR|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|HEALTHSPRING MA|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|WELLCARE CHOICE MA|5,557.63||||||| 93306|EAP|0483||Managed Medicaid|MEDICAID AMERIGROUP|50.53||||3,044.43||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|MEDICAID|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|BCBS MEDICARE PPO MA|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|MEDICAID HMO|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|NON CONTRACTED|COMMERCIAL OTHER 1|||||50.53||| 93306|EAP|0483||United Healthcare|UNITED HEALTHCARE|||||2,906.22||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|UNITED HEALTHCARE OTHER|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|PHCS|HUMANA INSURANCE|||||50.53||| 93306|EAP|0483||NON CONTRACTED|COMMERCIAL OTHER 1|||||2,906.22||| 93306|EAP|0483||PHCS|HUMANA INSURANCE|||||3,044.43||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|UTMB|UTMB CORRECTIONAL MANAGED CARE|50.53||||||| 93306|EAP|0483||Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|AARP|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|UNITED HEALTHCARE|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicare|MEDICARE PART B ONLY IP|50.53||||5,557.63||| 93306|EAP|0483||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|50.53||||3,044.43||| 93306|EAP|0483||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Tricare|TRICARE EAST REGION|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicare|MEDICARE ACUTE|5,305.32||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Tricare|TRICARE FOR LIFE|||||5,305.32||| 93306|EAP|0483||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,044.43||| 93306|EAP|0483||Access Direct Platinum|HEALTHFIRST TPA UMR|||||27.68||| 93306|EAP|0483||United Healthcare|UNITED HEALTHCARE|||||3,044.43||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|NON CONTRACTED|COMMERCIAL OTHER 2|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||50.53||| 93306|EAP|0483||United Healthcare|UNITED HEALTHCARE OTHER|||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|50.53||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aetna|AETNA PPO|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|ChampVA|CHAMPVA CENTER|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross PPO Specialty|BCBSTX OTHER|||||5,557.63||| 93306|EAP|0483||Blue Cross PPO Specialty|BCBSTX OTHER|||||3,044.43||| 93306|EAP|0483||Humana Medicare Advantage|HUMANA MA|2,906.22||||3,044.43||| 93306|EAP|0483||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,557.63||||2,906.22||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5,557.63||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Humana Medicare Advantage|HUMANA MA|5,557.63||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Cigna|CIGNA|||||50.53||| 93306|EAP|0483||Cigna|CIGNA|||||27.68||| 93306|EAP|0483||Blue Cross PPO Specialty|BCBSTX PPO|27.68||||3,044.43||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross PPO Specialty|BCBSTX PPO|50.53||||50.53||| 93306|EAP|0483||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|50.53||||27.68||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aenta Medicare Advantage|AETNA MEDICARE MA|5,557.63||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Cigna|CIGNA|||||5,557.63||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aetna|BOON CHAPMAN|||||5,557.63||| 93306|EAP|0483||Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||27.68||| 93306|EAP|0483||Aetna|BOON CHAPMAN|||||3,044.43||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5,557.63||| 93306|EAP|0483||Aetna|AETNA OTHER|||||3,044.43||| 93306|EAP|0483||Blue Cross HMO Specialty|BCBSTX HMO|||||3,044.43||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Blue Cross HMO Specialty|BCBSTX HMO|||||1,515.62||| 93308|EAP|0483|ECHO LTD OR F/U|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,280.25||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|United Healthcare|UNITED HEALTHCARE|||||1,339.81||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicare|BCBS MEDICARE PPO MA|||||1,222.13||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicare|HEALTHSPRING MA|||||1,280.25||| 93308|EAP|0483|ECHO LTD OR F/U|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,280.25||| 93308|EAP|0483|ECHO LTD OR F/U|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,280.25||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,222.13||| 93308|EAP|0483|ECHO LTD OR F/U|Blue Cross PPO Specialty|BCBSTX OTHER|||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,222.13||| 93308|EAP|0483|ECHO LTD OR F/U|Blue Cross HMO Specialty|BCBSTX HMO|||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Blue Cross PPO Specialty|BCBSTX PPO|||||1,280.25||| 93308|EAP|0483|ECHO LTD OR F/U|Veterans Affairs|VETERANS ADMINISTRATION|||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Humana Medicare Advantage|HUMANA MA|||||1,280.25||| 93308|EAP|0483|ECHO LTD OR F/U|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,280.25||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,280.25||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,515.62||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|NON CONTRACTED|COMMERCIAL OTHER 1|||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U|Managed Medicaid|MEDICAID AMERIGROUP|||||1,222.13||| 93308|EAP|0483|ECHO LTD OR F/U|Tricare|TRICARE EAST REGION|||||11.64||| 93308|EAP|0483|ECHO LTD OR F/U W/CONTRAS|Blue Cross PPO Specialty|BCBSTX PPO|||||1,339.81||| 93308|EAP|0483|ECHO LTD OR F/U|Medicare|MEDICARE ACUTE|||||1,280.25||| 93308|EAP|0483|ECHO LTD OR F/U|United Healthcare|UNITED HEALTHCARE|||||1,222.13||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|PHCS|HUMANA INSURANCE|||||3,044.43||| 93351|EAP|0483|ECHO STRESS|PHCS|HUMANA INSURANCE|||||1,742.89||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Humana Medicare Advantage|HUMANA MA|||||27.68||| 93351|EAP|0483|ECHO STRESS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Blue Cross PPO Specialty|BCBSTX OTHER|||||3,044.43||| 93351|EAP|0483|ECHO STRESS|Blue Cross PPO Specialty|BCBSTX PPO|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Cigna|CIGNA|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Cigna|CIGNA|||||3,044.43||| 93351|EAP|0483|ECHO STRESS|Cigna|CIGNA|||||16.60||| 93351|EAP|0483|ECHO STRESS|Humana Medicare Advantage|HUMANA MA|||||16.60||| 93351|EAP|0483|ECHO STRESS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,825.78||| 93351|EAP|0483|ECHO STRESS|ChampVA|CHAMPVA CENTER|||||16.60||| 93351|EAP|0483|ECHO STRESS|Medicare|MEDICARE ACUTE|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||3,044.43||| 93351|EAP|0483|ECHO STRESS|Blue Cross PPO Specialty|BCBSTX OTHER|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||16.60||| 93351|EAP|0483|ECHO STRESS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||16.60||| 93351|EAP|0483|ECHO STRESS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.60||| 93351|EAP|0483|ECHO STRESS|Blue Cross HMO Specialty|BCBSTX HMO|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.68||| 93351|EAP|0483|ECHO STRESS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||16.60||| 93351|EAP|0483|ECHO STRESS|Managed Medicaid|MEDICAID SUPERIOR|||||16.60||| 93351|EAP|0483|ECHO STRESS|Aetna|BOON CHAPMAN|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Aetna|AETNA PPO|||||16.60||| 93351|EAP|0483|ECHO STRESS|Aetna|AETNA OTHER|||||16.60||| 93351|EAP|0483|ECHO STRESS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Aetna|AETNA OTHER|||||16.60||| 93351|EAP|0483|ECHO STRESS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,044.43||| 93351|EAP|0483|ECHO STRESS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||16.60||| 93351|EAP|0483|ECHO STRESS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,044.43||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Managed Medicaid|MEDICAID SUPERIOR|||||27.68||| 93351|EAP|0483|ECHO STRESS|Aetna|AETNA PPO|||||16.60||| 93351|EAP|0483|ECHO STRESS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||16.60||| 93351|EAP|0483|ECHO STRESS|Managed Medicare|BCBS MEDICARE PPO MA|||||16.60||| 93351|EAP|0483|ECHO STRESS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,825.78||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 1|||||27.68||| 93351|EAP|0483|ECHO STRESS|Managed Medicaid|MEDICAID AMERIGROUP|||||16.60||| 93351|EAP|0483|ECHO STRESS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||16.60||| 93351|EAP|0483|ECHO STRESS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||16.60||| 93351|EAP|0483|ECHO STRESS|NON CONTRACTED|COMMERCIAL OTHER 1|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|Managed Medicare|HEALTHSPRING MA|||||3,044.43||| 93351|EAP|0483|ECHO STRESS|Managed Medicare|HEALTHSPRING MA|||||16.60||| 93351|EAP|0483|ECHO STRESS|PHCS|MULTIPLAN PHCS|||||16.60||| 93351|EAP|0483|ECHO STRESS|United Healthcare|GEHA|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|United Healthcare|UNITED HEALTHCARE|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|United Healthcare|UNITED HEALTHCARE|||||3,044.43||| 93351|EAP|0483|ECHO STRESS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,825.78||| 93351|EAP|0483|ECHO STRESS|United Healthcare|GOLDEN RULE|||||1,825.78||| 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|United Healthcare|UNITED HEALTHCARE OTHER|||||16.60||| 93351|EAP|0483|ECHO STRESS|United Healthcare|UNITED HEALTHCARE|||||16.60||| 93351|EAP|0483|ECHO STRESS|Tricare|TRICARE EAST REGION|||||16.60||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|United Healthcare|GOLDEN RULE|||||27.68||| 93351|EAP|0483|ECHO STRESS W/CONTRAST|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||3,044.43||| 934|DRG||FULL THICKNESS BURN W/O SKIN GRAFT OR INHAL INJ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44,631.89|12071.95|12071.95|12071.95|||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Medicare Advantage|UHC MEDICARE GOLD MA|2,061.98||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Blue Cross HMO Specialty|BCBSTX HMO|||||1,968.37||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Healthcare|UNITED HEALTHCARE|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,061.98||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Healthcare|UNITED HEALTHCARE OTHER|||||1,968.37||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Tricare|TRICARE EAST REGION|||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Medicare|MEDICARE ACUTE|1,874.75||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,968.37||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicaid|MEDICAID AMERIGROUP|||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|PHCS|HUMANA INSURANCE|||||1,968.37||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1,968.37||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2,061.98||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Veterans Affairs|VETERANS ADMINISTRATION|||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Humana Medicare Advantage|HUMANA MA|1,874.75||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicare|HEALTHSPRING MA|||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicare|BCBS MEDICARE PPO MA|||||1,968.37||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|NON CONTRACTED|COMMERCIAL OTHER 2|||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Aetna|AETNA OTHER|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Aetna|AETNA PPO|||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,968.37||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Cigna|CIGNA|||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Blue Cross PPO Specialty|BCBSTX PPO|||||2,061.98||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,874.75||| 93922|EAP|0921|ABI LOWER EXTREMITY|Cigna|CIGNA|||||805.68||| 93922|EAP|0921|ABI LOWER EXTREMITY|Humana Medicare Advantage|HUMANA MA|||||712.72||| 93922|EAP|0921|ABI LOWER EXTREMITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||712.72||| 93922|EAP|0921|ABI LOWER EXTREMITY|Blue Cross HMO Specialty|BCBSTX HMO|||||619.75||| 93922|EAP|0921|ABI LOWER EXTREMITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||805.68||| 93922|EAP|0921|ABI LOWER EXTREMITY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||712.72||| 93922|EAP|0921|ABI LOWER EXTREMITY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||805.68||| 93922|EAP|0921|ABI LOWER EXTREMITY|Aetna|AETNA OTHER|||||619.75||| 93922|EAP|0921|ABI LOWER EXTREMITY|United Healthcare|UNITED HEALTHCARE|||||712.72||| 93922|EAP|0921|ABI LOWER EXTREMITY|Managed Medicaid|MEDICAID AMERIGROUP|||||805.68||| 93922|EAP|0921|ABI LOWER EXTREMITY|Managed Medicare|HEALTHSPRING MA|||||805.68||| 93922|EAP|0921|ABI LOWER EXTREMITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||805.68||| 93922|EAP|0921|ABI LOWER EXTREMITY|Blue Cross PPO Specialty|BCBSTX PPO|||||805.68||| 93922|EAP|0921|ABI LOWER EXTREMITY|Managed Medicare|BCBS MEDICARE PPO MA|||||619.75||| 93922|EAP|0921|ABI LOWER EXTREMITY|United Healthcare|UNITED HEALTHCARE|||||805.68||| 93922|EAP|0921|ABI LOWER EXTREMITY|Medicare|MEDICARE ACUTE|||||619.75||| 93922|EAP|0921|ABI LOWER EXTREMITY|NON CONTRACTED|COMMERCIAL OTHER 1|||||619.75||| 93922|EAP|0921|ABI LOWER EXTREMITY|United Healthcare|UNITED HEALTHCARE OTHER|||||619.75||| 93922|EAP|0921|ABI LOWER EXTREMITY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||619.75||| 93924|EAP|0921|ABI REST/STRESS|NON CONTRACTED|COMMERCIAL OTHER 1|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|Medicare|MEDICARE ACUTE|||||1,372.80||| 93924|EAP|0921|ABI REST/STRESS|United Healthcare|UNITED HEALTHCARE|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|PHCS|HUMANA INSURANCE|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|Managed Medicare|HEALTHSPRING MA|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,372.80||| 93924|EAP|0921|ABI REST/STRESS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,214.40||| 93924|EAP|0921|ABI REST/STRESS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|Managed Medicare|BCBS MEDICARE PPO MA|||||1,214.40||| 93924|EAP|0921|ABI REST/STRESS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,214.40||| 93924|EAP|0921|ABI REST/STRESS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,372.80||| 93924|EAP|0921|ABI REST/STRESS|United Healthcare|UNITED HEALTHCARE OTHER|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,372.80||| 93924|EAP|0921|ABI REST/STRESS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,372.80||| 93924|EAP|0921|ABI REST/STRESS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,372.80||| 93924|EAP|0921|ABI REST/STRESS|Blue Cross HMO Specialty|BCBSTX HMO|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|Blue Cross PPO Specialty|BCBSTX PPO|||||1,214.40||| 93924|EAP|0921|ABI REST/STRESS|Aetna|ZZZZZ AETNA|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|Medicaid|MEDICAID|||||1,372.80||| 93924|EAP|0921|ABI REST/STRESS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,372.80||| 93924|EAP|0921|ABI REST/STRESS|Humana Medicare Advantage|HUMANA MA|||||10.56||| 93924|EAP|0921|ABI REST/STRESS|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,372.80||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Humana Medicare Advantage|HUMANA MA|||||2,067.13||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Blue Cross PPO Specialty|BCBSTX OTHER|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Cigna|CIGNA|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Aetna|AETNA PPO|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Blue Cross HMO Specialty|BCBSTX HMO|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Blue Cross PPO Specialty|BCBSTX PPO|2,336.75||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Aetna|AETNA OTHER|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Aetna|ZZZZZ AETNA|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Veterans Affairs|VETERANS ADMINISTRATION|||||2,067.13||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|PHCS|HUMANA INSURANCE|||||2,067.13||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Managed Medicare|BCBS MEDICARE PPO MA|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Managed Medicaid|MEDICAID AMERIGROUP|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Medicare|MEDICARE ACUTE|2,067.13||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|United Healthcare|UNITED HEALTHCARE OTHER|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|United Healthcare|UNITED HEALTHCARE|||||2,336.75||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|Managed Medicare|HEALTHSPRING MA|||||1,797.50||| 93925|EAP|0921|.UPLEX BIL LOWER EXT ART|United Healthcare|UNITED HEALTHCARE|||||2,067.13||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Medicare|MEDICARE ACUTE|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Tricare|TRICARE EAST REGION|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|United Healthcare|UNITED HEALTHCARE OTHER|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Medicare|MEDICARE ACUTE|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Humana Medicare Advantage|HUMANA MA|1,481.03||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Aetna|AETNA PPO|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Managed Medicare|HEALTHSPRING MA|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Blue Cross HMO Specialty|BCBSTX HMO|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Cigna|CIGNA|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Blue Cross PPO Specialty|BCBSTX PPO|1,481.03||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,481.03||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Cigna|CIGNA|||||1,310.14||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Humana Medicare Advantage|HUMANA MA|1,481.03||||1,310.14||| 93930|EAP|0921|DUPLEX BIL UPPER EXT ART|Humana Medicare Advantage|HUMANA MA|||||1,797.50||| 93930|EAP|0921|DUPLEX BIL UPPER EXT ART|Medicare|MEDICARE ACUTE|||||1,797.50||| 93930|EAP|0921|DUPLEX BIL UPPER EXT ART|Blue Cross PPO Specialty|BCBSTX PPO|1,797.50||||1,797.50||| 93931|EAP|0921|DUPLEX EXT.LT.UPPER ARTER|Humana Medicare Advantage|HUMANA MA|||||1,481.03||| 93931|EAP|0921|DUPLEX EXT. RT. UPPER ART|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,139.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Cigna|CIGNA|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,070.29||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Blue Cross HMO Specialty|BCBSTX HMO|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Aetna|AETNA PPO|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,070.29||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicare|HEALTHSPRING MA|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2,070.29||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicare|BCBS MEDICARE PPO MA|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Tricare|TRICARE EAST REGION|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|NON CONTRACTED|COMMERCIAL OTHER 1|2,340.33||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Medicare|MEDICARE ACUTE|2,340.33||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Healthcare|UNITED HEALTHCARE OTHER|||||2,070.29||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Healthcare|UNITED HEALTHCARE|||||2,070.29||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Healthcare|UNITED HEALTHCARE|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Healthcare|GOLDEN RULE|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Medicare Advantage|UHC MEDICARE GOLD MA|1,800.25||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Veterans Affairs|VETERANS ADMINISTRATION|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Blue Cross PPO Specialty|BCBSTX PPO|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Humana Medicare Advantage|HUMANA MA|||||2,070.29||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Blue Cross PPO Specialty|BCBSTX OTHER|||||2,070.29||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2,340.33||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Cigna|CIGNA|||||2,070.29||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,370.52||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,549.28||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Aetna|AETNA PPO|||||1,549.28||| 93971|EAP|0921|DUPLEX UPPER EXT RT VEINS|Blue Cross HMO Specialty|BCBSTX HMO|1,191.75||||1,549.28||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|Blue Cross HMO Specialty|BCBSTX HMO|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Blue Cross HMO Specialty|BCBSTX HMO|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Aetna|AETNA PPO|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Blue Cross PPO Specialty|BCBSTX PPO|1,549.28||||1,549.28||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|Blue Cross PPO Specialty|BCBSTX PPO|1,549.28||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Humana Medicare Advantage|HUMANA MA|||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|Humana Medicare Advantage|HUMANA MA|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Humana Medicare Advantage|HUMANA MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Cigna|CIGNA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Cigna|CIGNA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Blue Cross PPO Specialty|BCBSTX PPO|1,549.28||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,549.28||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,549.28||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Veterans Affairs|VETERANS ADMINISTRATION|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,549.28||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Tricare|TRICARE EAST REGION|||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT RT VEINS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Cigna|CIGNA|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|NON CONTRACTED|COMMERCIAL OTHER 1|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|NON CONTRACTED|COMMERCIAL OTHER 1|1,549.28||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Tricare|TRICARE EAST REGION|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|United Healthcare|UNITED HEALTHCARE|||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|PHCS|HUMANA INSURANCE|||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|Medicare|MEDICARE ACUTE|1,191.75||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Medicare|MEDICARE ACUTE|1,191.75||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Blue Cross HMO Specialty|BCBSTX HMO|1,191.75||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|United Healthcare|UNITED HEALTHCARE OTHER|||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Medicare|MEDICARE ACUTE|1,549.28||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|United Healthcare|UNITED HEALTHCARE OTHER|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Tricare|TRICARE FOR LIFE|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|NON CONTRACTED|COMMERCIAL OTHER 2|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|United Healthcare|UNITED HEALTHCARE|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Tricare|TRICARE FOR LIFE|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|United Healthcare|UNITED HEALTHCARE|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT RT VEINS|Managed Medicaid|MEDICAID SUPERIOR|1,191.75||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,549.28||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT RT VEINS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|United Healthcare|UNITED HEALTHCARE|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicaid|MEDICAID AMERIGROUP|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicare|HEALTHSPRING MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Medicaid|MEDICAID|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Managed Medicare|HEALTHSPRING MA|||||1,549.28||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicare|BCBS MEDICARE PPO MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,370.52||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Managed Medicaid|MEDICAID SUPERIOR|1,191.75||||1,549.28||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||804.70||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||711.85||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Medicaid|MEDICAID|6.19||||||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Managed Medicare|HEALTHSPRING MA|||||804.70||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.19||||||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Managed Medicaid|MEDICAID AMERIGROUP|||||804.70||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Medicare|MEDICARE ACUTE|||||804.70||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||804.70||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Cigna|CIGNA|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Humana Medicare Advantage|HUMANA MA|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|United Healthcare|UNITED HEALTHCARE|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|NON CONTRACTED|COMMERCIAL OTHER 1|||||711.85||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Blue Cross PPO Specialty|BCBSTX PPO|||||804.70||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Blue Cross PPO Specialty|BCBSTX PPO|||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Humana Medicare Advantage|HUMANA MA|||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,768.98||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Blue Cross HMO Specialty|BCBSTX HMO|||||1,768.98||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,768.98||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,768.98||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Managed Medicare|HEALTHSPRING MA|||||1,360.75||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|Medicare|MEDICARE ACUTE|||||1,043.50||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|United Healthcare|UNITED HEALTHCARE|||||1,356.55||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,356.55||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|Humana Medicare Advantage|HUMANA MA|||||1,043.50||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,200.03||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|Managed Medicare|HEALTHSPRING MA|||||1,356.55||| 93979|EAP|0402|US DUP SCAN AORTA IVC ILI|Cigna|CIGNA|||||594.10||| 93979|EAP|0402|US DUP SCAN AORTA IVC ILI|Managed Medicare|HEALTHSPRING MA|||||594.10||| 93979|EAP|0402|US DUP SCAN AORTA IVC ILI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.57||| 93979|EAP|0402|US DUP SCAN AORTA IVC ILI|Medicare|MEDICARE ACUTE|||||525.55||| 94002|EAP|0410|VENT ASSIST & MGMNT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||504.75||| 94002|EAP|0410|VENT MANAGEMENT INIT DAY|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||24.56||| 94002|EAP|0410|VENT MANAGEMENT INIT DAY|Medicare|MEDICARE ACUTE|||||24.56||| 94002|EAP|0410|VENT ASSIST & MGMNT|Medicare|MEDICARE ACUTE|||||504.75||| 94002|EAP|0410|VENT ASSIST & MGMNT|Medicaid|MEDICAID HMO|||||504.75||| 94002|EAP|0410|VENT MANAGEMENT INIT DAY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||24.56||| 94002|EAP|0410|VENT ASSIST & MGMNT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||504.75||| 94002|EAP|0410|VENT MANAGEMENT INIT DAY|Cigna|CIGNA|||||24.56||| 94002|EAP|0410|VENT MANAGEMENT INIT DAY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||24.56||| 94002|EAP|0410|VENT ASSIST & MGMNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||504.75||| 94002|EAP|0410|VENT MANAGEMENT INIT DAY|Blue Cross PPO Specialty|BCBSTX PPO|||||24.56||| 94002|EAP|0410|VENT ASSIST & MGMNT|Humana Medicare Advantage|HUMANA MA|24.56||||504.75||| 94010|EAP|0270|METERED DOSE INHALER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|115.25||||||| 94010|EAP|0460|PULMONARY FUNCTION BEFORE|Blue Cross PPO Specialty|BCBSTX PPO|||||2,391.50||| 94010|EAP|0270|METERED DOSE INHALER|Blue Cross PPO Specialty|BCBSTX PPO|115.25||||||| 94010|EAP|0270|METERED DOSE INHALER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|115.25||||115.25||| 94010|EAP|0270|METERED DOSE INHALER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|115.25||||||| 94010|EAP|0270|METERED DOSE INHALER|UTMB|UTMB CORRECTIONAL MANAGED CARE|115.25||||||| 94010|EAP|0270|METERED DOSE INHALER|United Medicare Advantage|UHC MEDICARE GOLD MA|115.25||||115.25||| 94010|EAP|0270|METERED DOSE INHALER|Workers Compensation|WORKERS COMPENSATION OTHER|115.25||||||| 94010|EAP|0270|METERED DOSE INHALER|United Medicare Advantage|AARP UHC WEST COMPLETE MA|115.25||||115.25||| 94010|EAP|0270|METERED DOSE INHALER|Humana Medicare Advantage|HUMANA MA|115.25||||115.25||| 94010|EAP|0270|METERED DOSE INHALER|Medicare|MEDICARE ACUTE|115.25||||115.25||| 94010|EAP|0270|METERED DOSE INHALER|Tricare|TRICARE EAST REGION|115.25||||||| 94010|EAP|0270|METERED DOSE INHALER|Managed Medicaid|MEDICAID AMERIGROUP|115.25||||||| 94010|EAP|0270|METERED DOSE INHALER|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|115.25||||||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Managed Medicaid|MEDICAID SUPERIOR|||||1,883.70||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Medicaid|MEDICAID HMO|||||1,883.70||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Medicaid|MEDICAID|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Medicare|MEDICARE ACUTE|1,883.70||||1,666.35||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|NON CONTRACTED|COMMERCIAL OTHER 1|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|United Healthcare|UNITED HEALTHCARE|||||1,883.70||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|United Healthcare|UNITED HEALTHCARE|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,883.70||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||1,883.70||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Humana Medicare Advantage|HUMANA MA|14.49||||1,883.70||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,666.35||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Blue Cross PPO Specialty|BCBSTX PPO|||||1,666.35||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Cigna|CIGNA|||||1,883.70||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||14.49||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Blue Cross PPO Specialty|BCBSTX PPO|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Aenta Medicare Advantage|AETNA MEDICARE MA|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|261.63||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Aetna|AETNA OTHER|||||261.63||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|261.63||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Blue Cross HMO Specialty|BCBSTX HMO|261.63||||261.63||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Humana Medicare Advantage|HUMANA MA|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Veterans Affairs|VETERANS ADMINISTRATION|261.63||||261.63||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|United Medicare Advantage|UHC MEDICARE GOLD MA|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Blue Cross PPO Specialty|BCBSTX OTHER|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|261.63||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicare|MEDICARE PART B ONLY IP|261.63||||||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Tricare|TRICARE EAST REGION|261.63||||261.63||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|NON CONTRACTED|COMMERCIAL OTHER 1|||||231.44||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|201.25||||261.63||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Cigna|CIGNA|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicare|MEDICARE ACUTE|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|UTMB|UTMB CORRECTIONAL MANAGED CARE|201.25||||261.63||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|United Healthcare|UNITED HEALTHCARE|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|United Healthcare|UNITED HEALTHCARE|201.25||||||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicaid|MEDICAID AMERIGROUP|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicaid|MEDICAID SUPERIOR|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||261.63||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicaid|COUNTY INDIGENT HEALTH OTHER|201.25||||||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicaid|MEDICAID HMO|||||231.44||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicare|WELLCARE CHOICE MA|261.63||||||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicare|BCBS MEDICARE PPO MA|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicaid|MEDICAID|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicare|HEALTHSPRING MA|201.25||||201.25||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.01||||5.01||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.01||||||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Medicaid|MEDICAID|5.01||||5.01||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.01||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Medicare|MEDICARE PART B ONLY IP|5.01||||||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Medicare|MEDICARE ACUTE|5.01||||5.01||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Managed Medicare|HEALTHSPRING MA|||||5.01||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.01||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|United Medicare Advantage|UHC MEDICARE GOLD MA|5.01||||5.01||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.01||||||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.01||| 94660|EAP|0410|CONTIN POS AIRWAY PRESSUR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.01||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Veterans Affairs|VETERANS ADMINISTRATION|||||5.01||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Humana Medicare Advantage|HUMANA MA|5.01||||5.01||| 94660|EAP|0410|CONTIN POS AIRWAY PRESSUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.01||||||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Blue Cross PPO Specialty|BCBSTX PPO|5.01||||||| 94660|EAP|0410|NON-INVASIVE VENTILATOR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.01||||||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,039.38||||1,568.75||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,568.75||| 94664|EAP|0410|SPUTUM INDUCTION|Humana Medicare Advantage|HUMANA MA|2,039.38||||1,568.75||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Humana Medicare Advantage|HUMANA MA|2,039.38||||1,568.75||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,568.75||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Blue Cross PPO Specialty|BCBSTX PPO|||||1,568.75||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,039.38||||1,568.75||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Managed Medicaid|MEDICAID SUPERIOR|||||1,804.07||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Managed Medicaid|MEDICAID AMERIGROUP|||||1,568.75||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2,039.38||||||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Medicare|MEDICARE ACUTE|1,568.75||||1,804.07||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,568.75||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,568.75||||1,568.75||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|416.33||||368.29||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Humana Medicare Advantage|HUMANA MA|254.48||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|320.25||||||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||254.48||| 94680|EAP|0460|BREATHING EXER EA TRMT|Managed Medicare|HEALTHSPRING MA|416.33||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Managed Medicaid|MEDICAID AMERIGROUP|320.25||||416.33||| 94680|EAP|0460|BREATHING EXER EA TRMT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|416.33||||368.29||| 94680|EAP|0460|BREATHING EXER EA TRMT|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|416.33||||||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Managed Medicaid|MEDICAID SUPERIOR|2.58||||320.25||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|254.48||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Medicare|MEDICARE ACUTE|416.33||||416.33||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Healthcare|UNITED HEALTHCARE|416.33||||368.29||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Workers Compensation|WORKERS COMPENSATION OTHER|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Tricare|TRICARE EAST REGION|||||320.25||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|320.25||||320.25||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|320.25||||254.48||| 94680|EAP|0460|BREATHING EXER EA TRMT|NON CONTRACTED|COMMERCIAL OTHER 1|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Medicare Advantage|UHC MEDICARE GOLD MA|416.33||||416.33||| 94680|EAP|0460|BREATHING EXER EA TRMT|Veterans Affairs|VETERANS ADMINISTRATION|416.33||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Workers Compensation|WORKERS COMPENSATION OTHER|368.29||||368.29||| 94680|EAP|0460|BREATHING EXER EA TRMT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Managed Medicaid|MEDICAID SUPERIOR|368.29||||416.33||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|416.33||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Blue Cross PPO Specialty|BCBSTX PPO|416.33||||416.33||| 94680|EAP|0460|BREATHING EXER EA TRMT|Humana Medicare Advantage|HUMANA MA|416.33||||416.33||| 94680|EAP|0460|BREATHING EXER EA TRMT|Cigna|CIGNA|416.33||||||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|416.33||||320.25||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Blue Cross HMO Specialty|BCBSTX HMO|320.25||||254.48||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|254.48||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Aetna|AETNA PPO|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Aenta Medicare Advantage|AETNA MEDICARE MA|416.33||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Blue Cross HMO Specialty|BCBSTX HMO|320.25||||||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Blue Cross PPO Specialty|BCBSTX PPO|254.48||||254.48||| 94680|EAP|0460|BREATHING EXER EA TRMT|Cigna|CIGNA|320.25||||||| 94680|EAP|0410|INCENTIVE SPIROMETRY TREA|Medicare|MEDICARE ACUTE|287.37||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||416.33||| 94729|EAP|0460|DIFFUSION CAPACITY|Humana Medicare Advantage|HUMANA MA|||||1,112.80||| 94729|EAP|0460|DIFFUSION CAPACITY|Medicare|MEDICARE ACUTE|||||1,112.80||| 94729|EAP|0460|DIFFUSION CAPACITY|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||1,112.80||| 94760|EAP|0460|OXIMETER EA USE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|746.53||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|746.53||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Managed Medicaid|MEDICAID AMERIGROUP|574.25||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Medicaid|MEDICAID|574.25||||746.53||| 94760|EAP|0460|OXIMETER EA USE|Medicaid|MEDICAID HMO|||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Managed Medicare|WELLCARE CHOICE MA|746.53||||746.53||| 94760|EAP|0460|OXIMETER EA USE|Managed Medicare|HEALTHSPRING MA|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Managed Medicaid|MEDICAID SUPERIOR|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Managed Medicare|BCBS MEDICARE PPO MA|||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Medicare|MEDICARE PART B ONLY IP|574.25||||660.39||| 94760|EAP|0460|OXIMETER EA USE|Medicare|MEDICARE ACUTE|574.25||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|NON CONTRACTED|COMMERCIAL OTHER 2|||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Tricare|TRICARE EAST REGION|746.53||||746.53||| 94760|EAP|0460|OXIMETER EA USE|PHCS|HUMANA INSURANCE|||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Medicare|MEDICARE ACUTE|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|United Healthcare|UNITED HEALTHCARE|||||746.53||| 94760|EAP|0460|OXIMETER EA USE|United Healthcare|UNITED HEALTHCARE|746.53||||660.39||| 94760|EAP|0460|OXIMETER EA USE|NON CONTRACTED|COMMERCIAL OTHER 1|574.25||||746.53||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|574.25||||746.53||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|United Medicare Advantage|UHC MEDICARE GOLD MA|574.25||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|574.25||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Tricare|TRICARE EAST REGION|574.25||||746.53||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Medicare|MEDICARE PART B ONLY IP|660.39||||660.39||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Managed Medicaid|MEDICAID SUPERIOR|60.75||||574.25||| 94760|EAP|0460|OXIMETER EA USE|UTMB|UTMB CORRECTIONAL MANAGED CARE|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Veterans Affairs|VETERANS ADMINISTRATION|746.53||||574.25||| 94760|EAP|0460|OXIMETER EA USE|United Healthcare|UNITED HEALTHCARE OTHER|||||746.53||| 94760|EAP|0460|OXIMETER EA USE|United Medicare Advantage|UHC MEDICARE GOLD MA|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Workers Compensation|WORKERS COMPENSATION OTHER|||||746.53||| 94760|EAP|0460|OXIMETER EA USE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|746.53||||746.53||| 94760|EAP|0460|OXIMETER EA USE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||746.53||| 94760|EAP|0460|OXIMETER EA USE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|746.53||||746.53||| 94760|EAP|0460|OXIMETER EA USE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|746.53||||574.25||| 94760|EAP|0460|OXIMETER EA USE|United Healthcare|TML GROUP BENEFITS|||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Aenta Medicare Advantage|AETNA MEDICARE MA|574.25||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Aetna|AETNA PPO|||||660.39||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Blue Cross HMO Specialty|BCBSTX HMO|574.25||||660.39||| 94760|EAP|0460|OXIMETER EA USE|Blue Cross HMO Specialty|BCBSTX HMO|574.25||||660.39||| 94760|EAP|0460|OXIMETER EA USE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Aetna|AETNA OTHER|||||746.53||| 94760|EAP|0460|OXIMETER EA USE|Blue Cross PPO Specialty|BCBSTX PPO|574.25||||746.53||| 94760|EAP|0460|OXIMETER EA USE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|746.53||||746.53||| 94760|EAP|0460|OXIMETER EA USE|Blue Cross PPO Specialty|BCBSTX OTHER|||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|746.53||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Humana Medicare Advantage|HUMANA MA|746.53||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Cigna|CIGNA|||||660.39||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Humana Medicare Advantage|HUMANA MA|60.75||||574.25||| 94760|EAP|0460|OXIMETER EA USE|Cigna|CIGNA|||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Blue Cross PPO Specialty|BCBSTX PPO|574.25||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Aenta Medicare Advantage|AETNA MEDICARE MA|60.75||||574.25||| 94761|EAP|0410|PULSE OXIMETRY|Medicare|MEDICARE ACUTE|||||248.75||| 94799|EAP|0410|RT ASSIST EA 24HR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|741.65||||||| 94799|EAP|0410|RT ASSIST EA 24HR|Cigna|CIGNA|||||570.50||| 94799|EAP|0410|RT ASSIST EA 24HR|Humana Medicare Advantage|HUMANA MA|656.08||||570.50||| 94799|EAP|0410|RT ASSIST EA 24HR|Blue Cross PPO Specialty|BCBSTX PPO|570.50||||741.65||| 94799|EAP|0410|RT ASSIST EA 24HR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|570.50||||||| 94799|EAP|0410|RT ASSIST EA 24HR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||741.65||| 94799|EAP|0410|RT ASSIST EA 24HR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|570.50||||||| 94799|EAP|0410|RT ASSIST EA 24HR|Blue Cross HMO Specialty|BCBSTX HMO|570.50||||570.50||| 94799|EAP|0410|RT ASSIST EA 24HR|United Medicare Advantage|UHC MEDICARE GOLD MA|570.50||||741.65||| 94799|EAP|0410|RT ASSIST EA 24HR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|656.08||||741.65||| 94799|EAP|0410|RT ASSIST EA 24HR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|741.65||||570.50||| 94799|EAP|0410|RT ASSIST EA 24HR|Veterans Affairs|VETERANS ADMINISTRATION|||||570.50||| 94799|EAP|0410|RT ASSIST EA 24HR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||741.65||| 94799|EAP|0410|RT ASSIST EA 24HR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|741.65||||570.50||| 94799|EAP|0410|RT ASSIST EA 24HR|Managed Medicaid|MEDICAID AMERIGROUP|570.50||||||| 94799|EAP|0410|RT ASSIST EA 24HR|Managed Medicare|WELLCARE CHOICE MA|||||741.65||| 94799|EAP|0410|RT ASSIST EA 24HR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|570.50||||||| 94799|EAP|0410|RT ASSIST EA 24HR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||741.65||| 94799|EAP|0410|RT ASSIST EA 24HR|NON CONTRACTED|COMMERCIAL OTHER 1|||||741.65||| 94799|EAP|0410|RT ASSIST EA 24HR|Medicaid|MEDICAID HMO|||||656.08||| 94799|EAP|0410|RT ASSIST EA 24HR|Medicare|MEDICARE ACUTE|570.50||||570.50||| 94799|EAP|0410|RT ASSIST EA 24HR|United Healthcare|UNITED HEALTHCARE|||||570.50||| 94799|EAP|0410|RT ASSIST EA 24HR|Managed Medicare|HEALTHSPRING MA|570.50||||741.65||| 94799|EAP|0410|RT ASSIST EA 24HR|Managed Medicaid|MEDICAID SUPERIOR|570.50||||570.50||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Medicaid|MEDICAID|12,551.50|7086.99|11268.31|7086.99|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|35,159.24|7493.68|11268.31|7086.99|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Medicare|MEDICARE ACUTE|23,551.59|7357.89|11268.31|7086.99|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|27,443.91|11268.31|11268.31|7086.99|||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||11.25||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Managed Medicaid|MEDICAID SUPERIOR|||||11.25||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Aetna|AETNA PPO|||||11.25||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicare|MEDICARE ACUTE|0.11||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicaid|MEDICAID|0.11||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.11||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.11||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.11||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Humana Medicare Advantage|HUMANA MA|0.11||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Cigna|CIGNA|0.11||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Healthcare|UNITED HEALTHCARE|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID SUPERIOR|0.11||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.11||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross PPO Specialty|BCBSTX PPO|0.11||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.11||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross HMO Specialty|BCBSTX HMO|0.11||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.11||||||| 9500133|ERX|0250|GUAIFEN-CODEINE 100-10MG/|Aenta Medicare Advantage|AETNA MEDICARE MA|8.75||||||| 9500133|ERX|0250|GUAIFEN-CODEINE 100-10MG/|Medicare|MEDICARE ACUTE|8.75||||||| 9500133|ERX|0250|GUAIFEN-CODEINE 100-10MG/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.75||||||| 9500174|ERX|0250|GLYCERIN SUPP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9500174|ERX|0250|GLYCERIN SUPP|Medicare|MEDICARE ACUTE|2.50||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.50||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.50||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Humana Medicare Advantage|HUMANA MA|||||8.50||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Cigna|CIGNA|8.50||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Blue Cross PPO Specialty|BCBSTX PPO|||||8.50||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Medicare|MEDICARE ACUTE|8.50||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.50||||||| 9500281|ERX|0250|HYDROCORTISONE 20MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|4.50||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||818.50||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Humana Medicare Advantage|HUMANA MA|818.50||||||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|818.50||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Medicaid|MEDICAID|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Medicare|MEDICARE ACUTE|27.25||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|NON CONTRACTED|COMMERCIAL OTHER 1|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|MEDICAID AMERIGROUP|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|MEDICAID SUPERIOR|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Blue Cross PPO Specialty|BCBSTX PPO|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||27.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicaid|MEDICAID SUPERIOR|0.05||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Healthcare|UNITED HEALTHCARE|||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Healthcare|UNITED HEALTHCARE|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicare|BCBS MEDICARE PPO MA|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicare|MEDICARE PART B ONLY IP|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|MEDICAID|0.05||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||0.05||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Blue Cross PPO Specialty|BCBSTX PPO|42.50||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Managed Medicaid|MEDICAID SUPERIOR|42.50||||||| 9500422|ERX|0250|NYSTATIN OINT, 15 GM|Medicare|MEDICARE ACUTE|35.50||||||| 9500422|ERX|0250|NYSTATIN OINT, 15 GM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|35.50||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicare|MEDICARE ACUTE|34.25||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|MEDICAID SUPERIOR|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Workers Compensation|WORKERS COMPENSATION OTHER|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Blue Cross HMO Specialty|BCBSTX HMO|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.50||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.50||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Cigna|CIGNA|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|MEDICAID AMERIGROUP|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Healthcare|UNITED HEALTHCARE OTHER|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Blue Cross PPO Specialty|BCBSTX PPO|9.50||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Medicare Advantage|AARP UHC WEST COMPLETE MA|9.50||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Medicare Advantage|UHC MEDICARE GOLD MA|9.50||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.50||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|9.50||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicare|MEDICARE ACUTE|9.50||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Humana Medicare Advantage|HUMANA MA|||||9.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|44.50||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Healthcare|UNITED HEALTHCARE|44.50||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|UTMB|UTMB CORRECTIONAL MANAGED CARE|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.50||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Medicare Advantage|UHC MEDICARE GOLD MA|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicaid|MEDICAID AMERIGROUP|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Cigna|CIGNA|||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Blue Cross PPO Specialty|BCBSTX PPO|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Medicare|MEDICARE ACUTE|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Veterans Affairs|VETERANS ADMINISTRATION|44.50||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Managed Medicaid|MEDICAID AMERIGROUP|42.50||||||| 9500489|ERX|0250|HYDROCORTISONE 1% CREAM,|Cigna|CIGNA|42.50||||||| 9500596|ERX|0250|PETROLATUM, WHITE, 30 GM|Managed Medicaid|MEDICAID SUPERIOR|15.75||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||14.50||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.50||||14.50||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Medicare|MEDICARE ACUTE|14.50||||14.50||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Medicaid|MEDICAID|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Managed Medicare|BCBS MEDICARE PPO MA|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Managed Medicare|HEALTHSPRING MA|14.50||||14.50||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|United Medicare Advantage|UHC MEDICARE GOLD MA|14.50||||14.50||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Medicare|MEDICARE PART B ONLY IP|14.50||||14.50||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Blue Cross HMO Specialty|BCBSTX HMO|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Managed Medicaid|MEDICAID SUPERIOR|14.50||||14.50||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.50||||14.50||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Blue Cross PPO Specialty|BCBSTX PPO|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Humana Medicare Advantage|HUMANA MA|14.50||||14.50||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Aenta Medicare Advantage|AETNA MEDICARE MA|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Managed Medicaid|MEDICAID AMERIGROUP|||||14.50||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|Managed Medicaid|MEDICAID SUPERIOR|52.50||||||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|52.50||||||| 9500653|ERX|0250|NYSTATIN-TRIAMCINOLONE 1|Medicare|MEDICARE ACUTE|52.50||||||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.38||| 9500679|ERX|0250|MICONAZOLE 2% CREAM, 30 G|Humana Medicare Advantage|HUMANA MA|0.38||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Blue Cross HMO Specialty|BCBSTX HMO|||||45.25||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.50||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Medicare|MEDICARE ACUTE|1.50||||||| 9500695|ERX|0250|LIDOCAINE 5% OINT, 35 GM|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Medicare|MEDICARE ACUTE|||||2.75||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicaid|MEDICAID|9.50||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicare|HEALTHSPRING MA|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicare|BCBS MEDICARE PPO MA|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicare|MEDICARE ACUTE|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicare|MEDICARE PART B ONLY IP|9.50||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Medicare Advantage|UHC MEDICARE GOLD MA|9.50||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Veterans Affairs|VETERANS ADMINISTRATION|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Blue Cross PPO Specialty|BCBSTX PPO|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Humana Medicare Advantage|HUMANA MA|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Healthcare|UNITED HEALTHCARE|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Tricare|TRICARE EAST REGION|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|NON CONTRACTED|COMMERCIAL OTHER 1|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Medicare Advantage|AARP UHC WEST COMPLETE MA|9.50||||9.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|41.75||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Humana Medicare Advantage|HUMANA MA|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Medicare|MEDICARE ACUTE|41.75||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41.75||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|41.75||||41.75||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||24.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|United Healthcare|UNITED HEALTHCARE|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicare|HEALTHSPRING MA|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||24.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||24.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||24.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||24.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Humana Medicare Advantage|HUMANA MA|||||24.50||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.75||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||36.75||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Medicare|MEDICARE ACUTE|36.75||||36.75||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||36.75||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Managed Medicare|HEALTHSPRING MA|0.30||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Humana Medicare Advantage|HUMANA MA|||||0.30||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.07||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Managed Medicare|HEALTHSPRING MA|0.07||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Humana Medicare Advantage|HUMANA MA|0.07||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Medicare|MEDICARE ACUTE|0.07||||0.07||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.07||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Medicare|MEDICARE ACUTE|0.07||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.07||||||| 9501073|ERX|0250|DIGOXIN 250MCG TABLET|Humana Medicare Advantage|HUMANA MA|0.07||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|8.80||||||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Tricare|TRICARE EAST REGION|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 Healthcare|UNITED HEALTHCARE|||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Medicaid|MEDICAID|||||8.80||| 9501180|ERX|0250|ONDANSETRON 4MG TABLET|Medicare|MEDICARE ACUTE|8.80||||||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|United Healthcare|UNITED HEALTHCARE|||||819.75||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||819.75||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|ChampVA|CHAMPVA CENTER|819.75||||||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||819.75||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|819.75||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Veterans Affairs|VETERANS ADMINISTRATION|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.16||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Humana Medicare Advantage|HUMANA MA|5.16||||5.16||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Medicare|MEDICARE PART B ONLY IP|5.16||||5.16||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Medicare|MEDICARE ACUTE|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.16||||5.16||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|NON CONTRACTED|COMMERCIAL OTHER 1|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|United Medicare Advantage|UHC MEDICARE GOLD MA|5.16||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|47.75||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Medicare|MEDICARE ACUTE|47.75||||||| 9501263|ERX|0250|DEMECLOCYCLINE 150MG TABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|116.25||||||| 9501263|ERX|0250|DEMECLOCYCLINE 150MG TABL|Medicare|MEDICARE PART B ONLY IP|116.25||||||| 9501263|ERX|0250|DEMECLOCYCLINE 150MG TABL|Medicare|MEDICARE ACUTE|116.25||||||| 9501263|ERX|0250|DEMECLOCYCLINE 150MG TABL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|116.25||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Healthcare|UNITED HEALTHCARE|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Healthcare|GOLDEN RULE|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicare|MEDICARE ACUTE|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|MEDICAID HMO|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicare|MEDICARE PART B ONLY IP|8.80||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|8.80||||||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|MEDICAID|||||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|Tricare|TRICARE EAST REGION|||||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|Workers Compensation|UT EMPLOYEE INJURY|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicare|HEALTHSPRING MA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||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 Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Managed Medicaid|MEDICAID AMERIGROUP|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Humana Medicare Advantage|HUMANA MA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Cigna|CIGNA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.80||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|52.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||52.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|52.25||||||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||52.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Medicare|MEDICARE ACUTE|||||52.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|52.25||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|UTMB|UTMB CORRECTIONAL MANAGED CARE|271.40||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Tricare|TRICARE EAST REGION|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|United Medicare Advantage|AARP UHC WEST COMPLETE MA|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|United Medicare Advantage|UHC MEDICARE GOLD MA|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicare|MEDICARE ACUTE|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Workers Compensation|WORKERS COMPENSATION OTHER|271.40||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|271.40||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross PPO Specialty|BCBSTX PPO|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|271.40||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|MEDICAID AMERIGROUP|271.40||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Humana Medicare Advantage|HUMANA MA|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|271.40||||||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Medicare|MEDICARE ACUTE|||||35.50||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||252.25||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|252.25||||252.25||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||69.50||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Medicaid|MEDICAID HMO|||||69.50||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Medicare|MEDICARE ACUTE|69.50||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||69.50||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|69.50||||||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Humana Medicare Advantage|HUMANA MA|103.75||||103.75||| 9501537|ERX|0250|ACYCLOVIR 800MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.75||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Humana Medicare Advantage|HUMANA MA|0.34||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.34||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.34||||||| 9501545|ERX|0250|BUPROPION SR 100MG TABLET|Medicare|MEDICARE ACUTE|0.34||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|28.75||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Humana Medicare Advantage|HUMANA MA|||||28.75||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|28.75||||||| 9501594|ERX|0250|OLANZAPINE 2.5MG TABLET|Medicare|MEDICARE ACUTE|83.50||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||34.25||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34.25||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|34.25||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicare|WELLCARE CHOICE MA|||||34.25||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|34.25||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Medicare|MEDICARE ACUTE|34.25||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Aetna|AETNA PPO|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||2.50||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Cigna|CIGNA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|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|Blue Cross PPO Specialty|BCBSTX PPO|||||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|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9501719|ERX|0250|SITAGLIPTIN 50MG TABLET|Managed Medicare|HEALTHSPRING MA|62.25||||||| 9501719|ERX|0250|SITAGLIPTIN 50MG TABLET|Medicare|MEDICARE ACUTE|62.25||||||| 9501719|ERX|0250|SITAGLIPTIN 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|62.25||||||| 9501719|ERX|0250|SITAGLIPTIN 50MG TABLET|Humana Medicare Advantage|HUMANA MA|62.25||||62.25||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Medicare|MEDICARE ACUTE|2.50||||||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.50||| 9501750|ERX|0250|PREDNISONE 5MG TABLET|Medicare|MEDICARE ACUTE|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|HEALTHSPRING MA|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicaid|MEDICAID|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Humana Medicare Advantage|HUMANA MA|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|6.50||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|6.50||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|6.50||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6.50||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.50||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.50||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|6.50||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Medicare|MEDICARE ACUTE|6.50||||6.50||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicare|MEDICARE ACUTE|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Humana Medicare Advantage|HUMANA MA|40.25||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||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 MEDICARE GOLD MA|||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Healthcare|UNITED HEALTHCARE|||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Medicare|MEDICARE ACUTE|2.75||||2.75||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Medicare|MEDICARE ACUTE|4.50||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|4.50||||||| 9501875|ERX|0250|HYDRALAZINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|4.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Medicaid|MEDICAID|0.09||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.09||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Tricare|TRICARE EAST REGION|0.09||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.75||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.75||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||7.75||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||7.75||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|Medicare|MEDICARE PART B ONLY IP|7.75||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Managed Medicare|HEALTHSPRING MA|7.75||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.75||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7.75||||7.75||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||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||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Medicare|MEDICARE ACUTE|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|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicaid|MEDICAID AMERIGROUP|||||25.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Medicare|MEDICARE ACUTE|||||25.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||25.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||25.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.25||||||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Blue Cross PPO Specialty|BCBSTX PPO|||||25.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||25.25||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|United Healthcare|UNITED HEALTHCARE OTHER|||||6.75||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|6.75||||||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Managed Medicaid|MEDICAID AMERIGROUP|6.75||||6.75||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|4.75||||||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||4.75||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Cigna|CIGNA|||||4.75||| 9502089|ERX|0250|PROPRANOLOL 10MG TABLET|Medicare|MEDICARE ACUTE|4.75||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.50||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Medicare|MEDICARE ACUTE|||||5.50||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7.75||||||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|Cigna|CIGNA|||||7.75||| 9502105|ERX|0250|PROPRANOLOL 40MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7.75||||||| 9502121|ERX|0250|METOCLOPRAMIDE 5MG TABLET|Medicare|MEDICARE ACUTE|7.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicaid|MEDICAID SUPERIOR|2.50||||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 Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Aetna|AETNA PPO|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicaid|MEDICAID|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicaid|MEDICAID HMO|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Medicaid|MEDICAID|||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Tricare|TRICARE EAST REGION|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||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 Medicaid|MEDICAID CIGNA HEALTHSPRING|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 PPO Specialty|BCBSTX PPO|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35.25||||||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||35.25||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Medicare|MEDICARE ACUTE|||||35.25||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|||||7.75||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Managed Medicaid|MEDICAID AMERIGROUP|||||7.75||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|||||7.75||| 9502261|ERX|0250|EYE WASH, 120ML|Medicare|MEDICARE ACUTE|||||44.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|9.50||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|9.50||||9.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.50||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.50||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||9.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.50||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||9.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Medicare|MEDICARE ACUTE|9.50||||9.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Medicare|MEDICARE ACUTE|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Blue Cross PPO Specialty|BCBSTX PPO|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.04||||0.04||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.04||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.04||||0.04||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicaid|MEDICAID AMERIGROUP|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Humana Medicare Advantage|HUMANA MA|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.04||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicaid|MEDICAID SUPERIOR|0.04||||0.04||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.04||||0.04||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicaid|MEDICAID|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicaid|MEDICAID HMO|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicare|MEDICARE ACUTE|0.04||||0.04||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Medicare|MEDICARE ACUTE|33.50||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Humana Medicare Advantage|HUMANA MA|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicaid|MEDICAID AMERIGROUP|36.75||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicaid|MEDICAID SUPERIOR|36.75||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Cigna|CIGNA|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross HMO Specialty|BCBSTX HMO|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross PPO Specialty|BCBSTX PPO|36.75||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Aetna|AETNA PPO|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Aetna|AETNA OTHER|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36.75||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|36.75||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|36.75||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Healthcare|UNITED HEALTHCARE|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Tricare|TRICARE EAST REGION|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|36.75||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|NON CONTRACTED|COMMERCIAL OTHER 1|36.75||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|36.75||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|MEDICAID HMO|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicaid|MEDICAID|36.75||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|BCBS MEDICARE PPO MA|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Managed Medicare|HEALTHSPRING MA|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Medicare|MEDICARE ACUTE|36.75||||36.75||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Medicaid|MEDICAID|100.70||||||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Medicare|MEDICARE ACUTE|||||31.64||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|31.64||||||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Blue Cross PPO Specialty|BCBSTX PPO|31.64||||||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|31.64||||||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Managed Medicaid|MEDICAID SUPERIOR|169.75||||||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Managed Medicaid|MEDICAID AMERIGROUP|100.70||||||| 9502451|ERX|0250|LIDOCAINE-EPI 2% SDV 20ML|Cigna|CIGNA|31.64||||||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.86||||0.86||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.86||| 9502469|ERX|0250|OLANZAPINE 5MG TABLET|Medicare|MEDICARE ACUTE|0.86||||0.86||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Healthcare|UNITED HEALTHCARE|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Healthcare|UNITED HEALTHCARE|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|36.25||||||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Tricare|TRICARE EAST REGION|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|36.25||||||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|36.25||||||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicare|MEDICARE PART B ONLY IP|36.25||||||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|BCBS MEDICARE PPO MA|36.25||||||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|MEDICAID|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|HEALTHSPRING MA|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicare|MEDICARE ACUTE|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Veterans Affairs|VETERANS ADMINISTRATION|36.25||||||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|WORKERS COMPENSATION OTHER|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Healthcare|UNITED HEALTHCARE OTHER|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Blue Cross HMO Specialty|BCBSTX HMO|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Blue Cross PPO Specialty|BCBSTX PPO|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Humana Medicare Advantage|HUMANA MA|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicaid|MEDICAID AMERIGROUP|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicaid|MEDICAID SUPERIOR|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Cigna|CIGNA|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Cigna|CIGNA|36.25||||36.25||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|222.75||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Blue Cross PPO Specialty|BCBSTX PPO|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Managed Medicaid|MEDICAID AMERIGROUP|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Managed Medicaid|MEDICAID SUPERIOR|244.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicare|BCBS MEDICARE PPO MA|||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Medicaid|MEDICAID|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Healthcare|UNITED HEALTHCARE|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Healthcare|UNITED HEALTHCARE|||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Tricare|TRICARE EAST REGION|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Workers Compensation|WORKERS COMPENSATION OTHER|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicaid|MEDICAID AMERIGROUP|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicaid|MEDICAID SUPERIOR|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Medicare|MEDICARE ACUTE|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Humana Medicare Advantage|HUMANA MA|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Cigna|CIGNA|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Cigna|CIGNA|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Cigna|CIGNA|||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Blue Cross HMO Specialty|BCBSTX HMO|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Aetna|AETNA PPO|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Aetna|AETNA OTHER|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|165.25||||165.25||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Blue Cross HMO Specialty|BCBSTX HMO|||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Cigna|CIGNA|||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.15||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicare|BCBS MEDICARE PPO MA|||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicare|HEALTHSPRING MA|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicare|WELLCARE CHOICE MA|||||0.15||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Medicare|MEDICARE PART B ONLY IP|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Tricare|TRICARE EAST REGION|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||0.15||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Veterans Affairs|VETERANS ADMINISTRATION|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Blue Cross HMO Specialty|BCBSTX HMO|0.15||||0.15||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Aenta Medicare Advantage|AETNA MEDICARE MA|0.15||||0.15||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|135.75||||||| 9502709|ERX|0636||Aetna|AETNA PPO|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Managed Medicaid|MEDICAID AMERIGROUP|135.75||||135.75||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Managed Medicaid|MEDICAID SUPERIOR|135.75||||||| 9502709|ERX|0636||Blue Cross PPO Specialty|BCBSTX PPO|135.75||||||| 9502709|ERX|0636||Cigna|CIGNA|135.75||||||| 9502709|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|135.75||||||| 9502709|ERX|0636||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|135.75||||||| 9502709|ERX|0636||United Healthcare|UNITED HEALTHCARE|135.75||||||| 9502709|ERX|0636||Medicare|MEDICARE ACUTE|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|135.75||||||| 9502709|ERX|0636||Managed Medicaid|MEDICAID UNITED HEALTHCARE|135.75||||||| 9502709|ERX|0636||Managed Medicaid|MEDICAID SUPERIOR|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Medicaid|MEDICAID HMO|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Medicare|MEDICARE ACUTE|135.75||||||| 9502709|ERX|0636||Medicaid|MEDICAID|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Medicaid|MEDICAID|135.75||||||| 9502709|ERX|0636||Managed Medicaid|MEDICAID AMERIGROUP|135.75||||||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Medicaid|MEDICAID HMO|1.01||||||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Medicaid|MEDICAID|1.01||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.01||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Managed Medicare|BCBS MEDICARE PPO MA|||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Managed Medicaid|MEDICAID SUPERIOR|1.01||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Managed Medicaid|MEDICAID AMERIGROUP|1.01||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Cigna|CIGNA|||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Blue Cross PPO Specialty|BCBSTX PPO|1.01||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Medicare|MEDICARE ACUTE|||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.01||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.01||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|68.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Healthcare|UNITED HEALTHCARE|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicaid|MEDICAID|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicare|MEDICARE ACUTE|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Humana Medicare Advantage|HUMANA MA|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Cigna|CIGNA|||||69.75||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Managed Medicaid|MEDICAID SUPERIOR|26.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Managed Medicaid|MEDICAID AMERIGROUP|26.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Cigna|CIGNA|26.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Blue Cross PPO Specialty|BCBSTX PPO|26.25||||||| 9502816|ERX|0250|SIMVASTATIN 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||12.75||| 9502816|ERX|0250|SIMVASTATIN 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9502816|ERX|0250|SIMVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9502816|ERX|0250|SIMVASTATIN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9502816|ERX|0250|SIMVASTATIN 10MG TABLET|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Medicare|MEDICARE ACUTE|37.75||||||| 9502949|ERX|0250|PIPERACILLIN-TAZOBACTAM 2|Medicaid|MEDICAID HMO|||||148.50||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.08||| 9502964|ERX|0250|PIPERACILLIN-TAZOBACTAM 3|Medicare|MEDICARE ACUTE|2.08||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Medicare|MEDICARE ACUTE|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Medicare|MEDICARE PART B ONLY IP|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|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.50||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||2.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Medicaid|MEDICAID|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicare|HEALTHSPRING MA|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Tricare|TRICARE EAST REGION|24.50||||||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||12.50||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.50||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||12.50||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Medicare|MEDICARE PART B ONLY IP|11.50||||||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Medicare|MEDICARE ACUTE|11.50||||||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Humana Medicare Advantage|HUMANA MA|11.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Veterans Affairs|VETERANS ADMINISTRATION|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross PPO Specialty|BCBSTX PPO|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Humana Medicare Advantage|HUMANA MA|4.25||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Healthcare|UNITED HEALTHCARE|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicare|MEDICARE ACUTE|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicare|HEALTHSPRING MA|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|MEDICAID HMO|||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicaid|MEDICAID|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Healthcare|TML GROUP BENEFITS|||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Healthcare|UNITED HEALTHCARE|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.25||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Tricare|TRICARE EAST REGION|||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicaid|MEDICAID SUPERIOR|5.25||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross HMO Specialty|BCBSTX HMO|||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Aetna|AETNA PPO|||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Veterans Affairs|VETERANS ADMINISTRATION|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Workers Compensation|WORKERS COMPENSATION OTHER|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicaid|MEDICAID AMERIGROUP|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicaid|MEDICAID SUPERIOR|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Humana Medicare Advantage|HUMANA MA|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Aenta Medicare Advantage|AETNA MEDICARE MA|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Cigna|CIGNA|||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross HMO Specialty|BCBSTX HMO|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|UNITED HEALTHCARE|||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|UNITED HEALTHCARE|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|NON CONTRACTED|COMMERCIAL OTHER 1|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Medicare Advantage|UHC MEDICARE GOLD MA|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|MEDICAID|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|BCBS MEDICARE PPO MA|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|HEALTHSPRING MA|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|WELLCARE CHOICE MA|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicare|MEDICARE PART B ONLY IP|0.09||||0.09||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Cigna|CIGNA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Aetna|AETNA PPO|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9503178|ERX|0250|CEFOXITIN 1 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||130.25||| 9503178|ERX|0250|CEFOXITIN 1 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|130.25||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Managed Medicaid|MEDICAID SUPERIOR|0.38||||||| 9503244|ERX|0250|CEFOXITIN 2 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||2.36||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Managed Medicare|HEALTHSPRING MA|0.86||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Medicare|MEDICARE PART B ONLY IP|0.86||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Medicare|MEDICARE ACUTE|0.86||||0.86||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.86||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.86||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.86||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||82.75||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|82.75||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|82.75||||||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||82.75||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||82.75||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Medicare|MEDICARE ACUTE|82.75||||82.75||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Medicaid|MEDICAID|||||82.75||| 9503467|ERX|0250|QUETIAPINE 200MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|82.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicare|MEDICARE ACUTE|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Healthcare|UNITED HEALTHCARE|||||25.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Cigna|CIGNA|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.75||||25.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.75||||||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||682.50||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|NON CONTRACTED|COMMERCIAL OTHER 1|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicaid|MEDICAID|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicare|HEALTHSPRING MA|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicare|MEDICARE PART B ONLY IP|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Blue Cross HMO Specialty|BCBSTX HMO|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Aenta Medicare Advantage|AETNA MEDICARE MA|0.05||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Humana Medicare Advantage|HUMANA MA|16.75||||||| 9503806|ERX|0250|DILTIAZEM 120MG TABLET|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Medicare|MEDICARE ACUTE|0.13||||||| 9503855|ERX|0250|ACEBUTOLOL 200MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.15||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Medicare|MEDICARE ACUTE|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.05||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||0.05||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9503871|ERX|0250|LEVOTHYROXINE 50MCG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||5.25||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicare|HEALTHSPRING MA|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Tricare|TRICARE EAST REGION|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.25||||5.25||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicare|BCBS MEDICARE PPO MA|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.25||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.25||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Aetna|AETNA PPO|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Veterans Affairs|VETERANS ADMINISTRATION|6.50||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Blue Cross PPO Specialty|BCBSTX PPO|6.50||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Humana Medicare Advantage|HUMANA MA|6.50||||6.50||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.50||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Medicare|MEDICARE ACUTE|6.50||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.50||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.50||||6.50||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Medicare|MEDICARE ACUTE|6.50||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Humana Medicare Advantage|HUMANA MA|6.50||||6.50||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.50||| 9503962|ERX|0250|NITROGLYCERIN 0.2MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|0.20||||||| 9503970|ERX|0250|NITROGLYCERIN 0.4MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||0.23||| 9503970|ERX|0250|NITROGLYCERIN 0.4MG PATCH|Medicare|MEDICARE ACUTE|0.23||||0.23||| 9504044|ERX|0250|K IODIDE-IODINE 50MG/ML,3|United Healthcare|UNITED HEALTHCARE|||||0.18||| 9504044|ERX|0250|K IODIDE-IODINE 50MG/ML,3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.18||| 9504044|ERX|0250|K IODIDE-IODINE 50MG/ML,3|Blue Cross PPO Specialty|BCBSTX PPO|||||0.18||| 9504044|ERX|0250|K IODIDE-IODINE 50MG/ML,3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.18||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Humana Medicare Advantage|HUMANA MA|0.21||||0.21||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Medicare|MEDICARE ACUTE|0.21||||0.21||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.21||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.21||||||| 9504127|ERX|0250|ERTAPENEM 1 G VIAL|Managed Medicare|HEALTHSPRING MA|581.25||||||| 9504127|ERX|0250|ERTAPENEM 1 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||581.25||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.50||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.50||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||16.50||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.50||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Medicare|MEDICARE ACUTE|16.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicare|MEDICARE PART B ONLY IP|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicare|BCBS MEDICARE PPO MA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Workers Compensation|WORKERS COMPENSATION OTHER|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Tricare|TRICARE EAST REGION|||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Cigna|CIGNA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.50||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Humana Medicare Advantage|HUMANA MA|0.53||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|0.53||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.53||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.53||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Cigna|CIGNA|0.53||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Medicare|MEDICARE ACUTE|0.53||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.53||||||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Healthcare|UNITED HEALTHCARE|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Tricare|TRICARE EAST REGION|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|17.50||||||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|||||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|Workers Compensation|WORKERS COMPENSATION OTHER|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|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|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 AMERIGROUP|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|17.50||||17.50||| 9504234|ERX|0250|MORPHINE 10MG/1ML|Cigna|CIGNA|||||17.50||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|||||57.75||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|||||57.75||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|57.75||||57.75||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Medicaid|MEDICAID|||||57.75||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Medicare|MEDICARE ACUTE|57.75||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||57.75||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||57.75||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||57.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Healthcare|UNITED HEALTHCARE|||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.75||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Tricare|TRICARE EAST REGION|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.75||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|16.75||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||16.75||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.22||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.22||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|Medicare|MEDICARE ACUTE|0.22||||0.22||| 9504291|ERX|0250|PHENYTOIN 250MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||28.50||| 9504291|ERX|0250|PHENYTOIN 250MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||28.50||| 9504291|ERX|0250|PHENYTOIN 250MG/5ML|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicare|MEDICARE ACUTE|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicare|HEALTHSPRING MA|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Cigna|CIGNA|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||81.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Aetna|AETNA PPO|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross PPO Specialty|BCBSTX PPO|29.50||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Humana Medicare Advantage|HUMANA MA|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicaid|MEDICAID SUPERIOR|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicare|BCBS MEDICARE PPO MA|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Medicare|MEDICARE ACUTE|29.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicare|BCBS MEDICARE PPO MA|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicare|MEDICARE ACUTE|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicare|HEALTHSPRING MA|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Tricare|TRICARE EAST REGION|||||34.50||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||34.50||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|34.50||||34.50||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Veterans Affairs|VETERANS ADMINISTRATION|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicaid|MEDICAID AMERIGROUP|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Managed Medicaid|MEDICAID SUPERIOR|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Cigna|CIGNA|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Blue Cross PPO Specialty|BCBSTX PPO|34.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Humana Medicare Advantage|HUMANA MA|34.50||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Blue Cross PPO Specialty|BCBSTX PPO|35.50||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|35.50||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35.50||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicaid|MEDICAID SUPERIOR|35.50||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicaid|MEDICAID AMERIGROUP|35.50||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Cigna|CIGNA|||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|35.50||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Healthcare|UNITED HEALTHCARE|35.50||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Humana Medicare Advantage|HUMANA MA|35.50||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|35.50||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Tricare|TRICARE EAST REGION|||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|35.50||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|35.50||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Medicaid|MEDICAID|35.50||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Medicare|MEDICARE ACUTE|35.50||||35.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|35.50||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicare|MEDICARE ACUTE|33.50||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||33.50||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|33.50||||33.50||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Workers Compensation|WORKERS COMPENSATION OTHER|33.50||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Humana Medicare Advantage|HUMANA MA|33.50||||33.50||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.50||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Managed Medicaid|MEDICAID SUPERIOR|33.50||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Cigna|CIGNA|33.50||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||33.50||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Blue Cross PPO Specialty|BCBSTX PPO|33.50||||33.50||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||37.50||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Aenta Medicare Advantage|AETNA MEDICARE MA|37.50||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Managed Medicaid|MEDICAID SUPERIOR|37.50||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Managed Medicaid|MEDICAID AMERIGROUP|37.50||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Blue Cross PPO Specialty|BCBSTX PPO|37.50||||37.50||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Cigna|CIGNA|37.50||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|United Medicare Advantage|UHC MEDICARE GOLD MA|37.50||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Tricare|TRICARE EAST REGION|37.50||||||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Medicare|MEDICARE ACUTE|37.50||||||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Medicare Advantage|UHC MEDICARE GOLD MA|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Healthcare|UNITED HEALTHCARE|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicare|MEDICARE ACUTE|64.75||||||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|NON CONTRACTED|COMMERCIAL OTHER 1|64.75||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicaid|MEDICAID AMERIGROUP|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicaid|MEDICAID SUPERIOR|64.75||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross PPO Specialty|BCBSTX PPO|64.75||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Access Direct Platinum|HEALTHFIRST TPA UMR|64.75||||||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||64.75||| 9504549|ERX|0250|MEASLES,MUMPS&RUBELLA VAC|Blue Cross PPO Specialty|BCBSTX PPO|569.25||||||| 9504549|ERX|0250|MEASLES,MUMPS&RUBELLA VAC|Managed Medicaid|MEDICAID AMERIGROUP|569.25||||||| 9504549|ERX|0250|MEASLES,MUMPS&RUBELLA VAC|Managed Medicaid|MEDICAID SUPERIOR|569.25||||||| 9504549|ERX|0250|MEASLES,MUMPS&RUBELLA VAC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|569.25||||||| 9504549|ERX|0250|MEASLES,MUMPS&RUBELLA VAC|United Healthcare|UMR UNITED MEDICAL RESOURCES|569.25||||||| 9504549|ERX|0250|MEASLES,MUMPS&RUBELLA VAC|United Healthcare|UNITED HEALTHCARE|569.25||||||| 9504549|ERX|0250|MEASLES,MUMPS&RUBELLA VAC|Medicaid|MEDICAID HMO|569.25||||||| 9504549|ERX|0250|MEASLES,MUMPS&RUBELLA VAC|Medicaid|MEDICAID|569.25||||||| 9504556|ERX|0250|DEX 25%-WATER,ABBOJECT 10|Medicare|MEDICARE ACUTE|||||39.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Humana Medicare Advantage|HUMANA MA|99.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|99.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|||||99.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||99.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|99.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|99.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|99.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||99.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Tricare|TRICARE EAST REGION|||||99.75||| 9504630|ERX|0250|KETAMINE 500MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|99.75||||||| 9504630|ERX|0250|KETAMINE 500MG/10ML|Medicare|MEDICARE ACUTE|99.75||||99.75||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Tricare|TRICARE EAST REGION|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Veterans Affairs|VETERANS ADMINISTRATION|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Blue Cross PPO Specialty|BCBSTX PPO|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|4.48||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Humana Medicare Advantage|HUMANA MA|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID SUPERIOR|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Cigna|CIGNA|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicare|HEALTHSPRING MA|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicare|MEDICARE PART B ONLY IP|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicare|MEDICARE ACUTE|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicaid|MEDICAID|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Healthcare|UNITED HEALTHCARE OTHER|||||4.48||| 9504663|ERX|0250|DOBUTAMINE 250MG/20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||46.75||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.79||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicaid|MEDICAID|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicaid|MEDICAID HMO|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Healthcare|UNITED HEALTHCARE|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Tricare|TRICARE EAST REGION|||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Aetna|AETNA PPO|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicare|HEALTHSPRING MA|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Cigna|CIGNA|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Cigna|CIGNA|||||12.50||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicaid|MEDICAID SUPERIOR|31.25||||31.25||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicaid|MEDICAID AMERIGROUP|||||31.25||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||31.25||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Blue Cross PPO Specialty|BCBSTX PPO|||||31.25||| 9504713|ERX|0250|LIDOCAINE/EPI 2%MDV 20ML|Medicare|MEDICARE ACUTE|31.25||||||| 9504739|ERX|0250|ACETYLCYSTEINE 20%, 30ML|Medicare|MEDICARE ACUTE|72.75||||72.75||| 9504739|ERX|0250|ACETYLCYSTEINE 20%, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|72.75||||||| 9504739|ERX|0250|ACETYLCYSTEINE 20%, 30ML|Blue Cross HMO Specialty|BCBSTX HMO|||||72.75||| 9504739|ERX|0250|ACETYLCYSTEINE 20%, 30ML|Managed Medicaid|MEDICAID SUPERIOR|||||72.75||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Humana Medicare Advantage|HUMANA MA|113.25||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|113.25||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Managed Medicaid|MEDICAID SUPERIOR|113.25||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||113.25||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|113.25||||113.25||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|113.25||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|113.25||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|113.25||||||| 9504754|ERX|0250|SUFENTANIL 100MCG/2ML|Medicare|MEDICARE ACUTE|113.25||||113.25||| 9504770|ERX|0250|MANNITOL 25% 12.5 G/50ML|Blue Cross PPO Specialty|BCBSTX PPO|||||14.75||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Managed Medicare|HEALTHSPRING MA|429.75||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Medicare|MEDICARE PART B ONLY IP|429.75||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Medicare|MEDICARE ACUTE|429.75||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||429.75||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|429.75||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Humana Medicare Advantage|HUMANA MA|429.75||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Blue Cross PPO Specialty|BCBSTX PPO|429.75||||||| 9504838|ERX|0250|LIDOCAINE 1%MDV 50ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||20.25||| 9504838|ERX|0250|LIDOCAINE 1%MDV 50ML|Blue Cross PPO Specialty|BCBSTX PPO|||||20.25||| 9504838|ERX|0250|LIDOCAINE 1%MDV 50ML|Managed Medicaid|MEDICAID AMERIGROUP|||||20.25||| 9504838|ERX|0250|LIDOCAINE 1%MDV 50ML|United Healthcare|UNITED HEALTHCARE OTHER|||||20.25||| 9504838|ERX|0250|LIDOCAINE 1%MDV 50ML|United Healthcare|UNITED HEALTHCARE|||||20.25||| 9504838|ERX|0250|LIDOCAINE 1%MDV 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||20.25||| 9504838|ERX|0250|LIDOCAINE 1%MDV 50ML|Managed Medicare|HEALTHSPRING MA|||||20.25||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Managed Medicaid|MEDICAID SUPERIOR|27.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Blue Cross PPO Specialty|BCBSTX PPO|||||27.50||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Managed Medicare|HEALTHSPRING MA|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|United Healthcare|UNITED HEALTHCARE|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Tricare|TRICARE EAST REGION|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Managed Medicaid|MEDICAID AMERIGROUP|0.15||||0.15||| 9504903|ERX|0250|LIDOCAINE 1%PF 2ML|Cigna|CIGNA|||||0.15||| 9504911|ERX|0250||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.50||||||| 9504911|ERX|0250||Blue Cross PPO Specialty|BCBSTX PPO|||||12.50||| 9504911|ERX|0250||Medicare|MEDICARE ACUTE|||||12.50||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Medicare|MEDICARE ACUTE|||||12.50||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Blue Cross PPO Specialty|BCBSTX PPO|||||12.50||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Humana Medicare Advantage|HUMANA MA|59.25||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|59.25||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicaid|MEDICAID SUPERIOR|59.25||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Cigna|CIGNA|||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Blue Cross PPO Specialty|BCBSTX PPO|59.25||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Aenta Medicare Advantage|AETNA MEDICARE MA|||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59.25||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicare|MEDICARE ACUTE|59.25||||59.25||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Medicare|MEDICARE ACUTE|||||44.75||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Veterans Affairs|VETERANS ADMINISTRATION|||||44.75||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Blue Cross PPO Specialty|BCBSTX PPO|||||44.75||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Humana Medicare Advantage|HUMANA MA|46.25||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Cigna|CIGNA|||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.25||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Medicare|MEDICARE ACUTE|46.25||||46.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicaid|MEDICAID HMO|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicare|WELLCARE CHOICE MA|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicare|MEDICARE ACUTE|144.50||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|UTMB|UTMB CORRECTIONAL MANAGED CARE|144.50||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Medicare Advantage|UHC MEDICARE GOLD MA|144.50||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Blue Cross PPO Specialty|BCBSTX PPO|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Humana Medicare Advantage|HUMANA MA|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||144.50||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Healthcare|UNITED HEALTHCARE OTHER|||||47.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||47.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||47.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Medicare|MEDICARE ACUTE|47.25||||47.25||| 9505033|ERX|0250|CEFTAZIDIME 1 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||111.25||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicaid|MEDICAID|12.50||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicare|HEALTHSPRING MA|||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Healthcare|UNITED HEALTHCARE|12.50||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Healthcare|UNITED HEALTHCARE OTHER|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|MEDICAID|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|MEDICAID HMO|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|12.50||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicare|WELLCARE CHOICE MA|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicare|MEDICARE PART B ONLY IP|12.50||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicare|HEALTHSPRING MA|12.50||||12.50||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Medicaid|MEDICAID|12.50||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Managed Medicare|HEALTHSPRING MA|||||12.50||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.50||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Cigna|CIGNA|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Humana Medicare Advantage|HUMANA MA|140.75||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|140.75||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Managed Medicaid|MEDICAID SUPERIOR|140.75||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|140.75||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Blue Cross HMO Specialty|BCBSTX HMO|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Blue Cross PPO Specialty|BCBSTX PPO|140.75||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|United Healthcare|UNITED HEALTHCARE|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Medicare|MEDICARE PART B ONLY IP|140.75||||||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Managed Medicare|HEALTHSPRING MA|||||140.75||| 9505140|ERX|0258|WATER FOR IRRIGATION 500M|Medicare|MEDICARE ACUTE|140.75||||140.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicare|MEDICARE ACUTE|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicare|BCBS MEDICARE PPO MA|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Tricare|TRICARE EAST REGION|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicare|MEDICARE PART B ONLY IP|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Humana Medicare Advantage|HUMANA MA|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Cigna|CIGNA|||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|109.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicaid|MEDICAID AMERIGROUP|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicaid|MEDICAID SUPERIOR|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Cigna|CIGNA|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Aetna|AETNA PPO|35.25||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Blue Cross PPO Specialty|BCBSTX PPO|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Humana Medicare Advantage|HUMANA MA|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|UTMB|UTMB CORRECTIONAL MANAGED CARE|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Medicare Advantage|AARP UHC WEST COMPLETE MA|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|HEALTHSPRING MA|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|35.25||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|35.25||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicare|MEDICARE ACUTE|||||35.25||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Medicare|MEDICARE ACUTE|0.41||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicare|WELLCARE CHOICE MA|||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Medicaid|MEDICAID HMO|||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.41||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.41||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.41||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|NON CONTRACTED|COMMERCIAL OTHER 1|0.41||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.41||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Veterans Affairs|VETERANS ADMINISTRATION|||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Blue Cross PPO Specialty|BCBSTX PPO|0.41||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Humana Medicare Advantage|HUMANA MA|0.41||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.41||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Humana Medicare Advantage|HUMANA MA|12.50||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Medicaid|MEDICAID|12.50||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Medicare|MEDICARE ACUTE|12.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||24.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicare|HEALTHSPRING MA|24.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Humana Medicare Advantage|HUMANA MA|||||24.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Aetna|AETNA OTHER|||||94.75||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Blue Cross PPO Specialty|BCBSTX PPO|94.75||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Managed Medicaid|MEDICAID SUPERIOR|94.75||||94.75||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Managed Medicaid|MEDICAID AMERIGROUP|94.75||||94.75||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||94.75||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Medicaid|MEDICAID HMO|94.75||||||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||94.75||| 9505249|ERX|0258|MAG SULF 20 GM/500ML WATE|Medicaid|MEDICAID|94.75||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Healthcare|UNITED HEALTHCARE|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|PHCS|HUMANA INSURANCE|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Tricare|TRICARE EAST REGION|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicare|HEALTHSPRING MA|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicare|MEDICARE PART B ONLY IP|114.50||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Medicare|MEDICARE ACUTE|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Cigna|CIGNA|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Humana Medicare Advantage|HUMANA MA|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicaid|MEDICAID SUPERIOR|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Managed Medicaid|MEDICAID AMERIGROUP|114.50||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross PPO Specialty|BCBSTX PPO|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross HMO Specialty|BCBSTX HMO|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|114.50||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross HMO Specialty|BCBSTX HMO|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross PPO Specialty|BCBSTX PPO|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|199.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Humana Medicare Advantage|HUMANA MA|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicaid|MEDICAID AMERIGROUP|199.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Veterans Affairs|VETERANS ADMINISTRATION|||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicare|HEALTHSPRING MA|||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Managed Medicare|BCBS MEDICARE PPO MA|199.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Medicare|MEDICARE ACUTE|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|199.75||||199.75||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|24.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Medicaid|MEDICAID|24.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Managed Medicare|HEALTHSPRING MA|24.50||||||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Humana Medicare Advantage|HUMANA MA|||||24.50||| 9505298|ERX|0250|CARVEDILOL 6.25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||24.50||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|206.75||||206.75||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|United Medicare Advantage|AARP UHC WEST COMPLETE MA|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Blue Cross HMO Specialty|BCBSTX HMO|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Blue Cross PPO Specialty|BCBSTX PPO|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicaid|MEDICAID AMERIGROUP|||||206.75||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicaid|MEDICAID UNITED HEALTHCARE|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicare|BCBS MEDICARE PPO MA|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Medicare|MEDICARE ACUTE|206.75||||206.75||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Medicare|MEDICARE ACUTE|239.50||||||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||239.50||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Managed Medicaid|MEDICAID AMERIGROUP|||||239.50||| 9505322|ERX|0258|DEX 5%-LR KCL 20 MEQ 1000|Blue Cross PPO Specialty|BCBSTX PPO|||||239.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Humana Medicare Advantage|HUMANA MA|||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||24.50||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Healthcare|UNITED HEALTHCARE|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.25||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|18.25||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Tricare|TRICARE EAST REGION|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Humana Medicare Advantage|HUMANA MA|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID SUPERIOR|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Cigna|CIGNA|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||18.25||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||24.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Medicaid|MEDICAID|24.50||||24.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Managed Medicare|HEALTHSPRING MA|||||24.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||24.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||24.50||| 9505470|ERX|0250|CARVEDILOL 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||24.50||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||162.50||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||162.50||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Medicare|MEDICARE ACUTE|162.50||||162.50||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Humana Medicare Advantage|HUMANA MA|||||162.50||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||162.50||| 9505561|ERX|0258|DOPAMINE 800MG/500ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.22||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicaid|MEDICAID HMO|||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|103.25||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|103.25||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicaid|MEDICAID SUPERIOR|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|195.75||||195.75||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|195.75||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Humana Medicare Advantage|HUMANA MA|195.75||||195.75||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|195.75||||195.75||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicaid|MEDICAID SUPERIOR|||||195.75||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Blue Cross PPO Specialty|BCBSTX PPO|195.75||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicare|MEDICARE ACUTE|195.75||||195.75||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|195.75||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicare|HEALTHSPRING MA|||||195.75||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|United Healthcare|UNITED HEALTHCARE|||||174.75||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Medicare|MEDICARE ACUTE|174.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|||||174.75||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|132.75||||132.75||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Managed Medicaid|MEDICAID SUPERIOR|132.75||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Medicare|MEDICARE ACUTE|198.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|198.50||||||| 9505801|ERX|0258|LIDOCAINE 0.4% IN D5W 500|Medicare|MEDICARE ACUTE|||||162.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|165.25||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Aetna|AETNA PPO|165.25||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Blue Cross PPO Specialty|BCBSTX PPO|165.25||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Cigna|CIGNA|165.25||||||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|165.25||||||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Humana Medicare Advantage|HUMANA MA|165.25||||||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicaid|MEDICAID AMERIGROUP|||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|165.25||||||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicaid|MEDICAID SUPERIOR|165.25||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|165.25||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|165.25||||||| 9505835|ERX|0258|LACTATED RINGERS 500ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|165.25||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Medicaid|MEDICAID|||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Managed Medicare|WELLCARE CHOICE MA|||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|United Healthcare|UNITED HEALTHCARE|165.25||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|NON CONTRACTED|COMMERCIAL OTHER 1|165.25||||||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Tricare|TRICARE EAST REGION|165.25||||165.25||| 9505835|ERX|0258|LACTATED RINGERS 500ML|Medicare|MEDICARE ACUTE|165.25||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|27.50||||27.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Medicare|MEDICARE ACUTE|27.50||||27.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|27.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Medicare Advantage|UHC MEDICARE GOLD MA|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Humana Medicare Advantage|HUMANA MA|209.50||||209.50||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicaid|MEDICAID AMERIGROUP|||||209.50||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||209.50||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicaid|MEDICAID SUPERIOR|||||209.50||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Blue Cross PPO Specialty|BCBSTX PPO|||||209.50||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicaid|MEDICAID|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicare|MEDICARE ACUTE|209.50||||209.50||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|Medicare|MEDICARE ACUTE|162.25||||||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|162.25||||||| 9505975|ERX|0258|DEX 5%-1/2NS KCL 10 MEQ 1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||162.25||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Humana Medicare Advantage|HUMANA MA|163.50||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Cigna|CIGNA|||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicare|MEDICARE ACUTE|163.50||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicare|HEALTHSPRING MA|||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|163.50||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||163.50||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|United Healthcare|UNITED HEALTHCARE|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Tricare|TRICARE EAST REGION|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Medicaid|SUPERIOR HEALTHPLAN CHIP|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Medicaid|MEDICAID|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Medicaid|MEDICAID HMO|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Managed Medicaid|MEDICAID AMERIGROUP|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Managed Medicaid|MEDICAID SUPERIOR|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Cigna|CIGNA|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Aetna|AETNA PPO|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross PPO Specialty|BCBSTX PPO|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|60.75||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||118.75||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.75||||118.75||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicaid|MEDICAID|118.75||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||118.75||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicare|MEDICARE ACUTE|118.75||||118.75||| 9506056|ERX|0258|FAT EMULSION 20% 500ML|Medicare|MEDICARE ACUTE|||||110.04||| 9506056|ERX|0258|FAT EMULSION 20% 500ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|110.04||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|21.50||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|21.50||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.50||||21.50||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21.50||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Medicaid|MEDICAID HMO|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Medicare|MEDICARE ACUTE|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Managed Medicaid|MEDICAID AMERIGROUP|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Cigna|CIGNA|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|44.25||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.25||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Humana Medicare Advantage|HUMANA MA|44.25||||44.25||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.25||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|United Medicare Advantage|UHC MEDICARE GOLD MA|44.25||||44.25||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|44.25||||44.25||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Medicare|MEDICARE ACUTE|44.25||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Medicare|MEDICARE ACUTE|47.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|UTMB|UTMB CORRECTIONAL MANAGED CARE|47.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|United Medicare Advantage|UHC MEDICARE GOLD MA|47.75||||||| 9506205|ERX|0250|VENLAFAXINE XL 150MG CAPS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||47.75||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.16||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.16||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Medicare|MEDICARE ACUTE|0.16||||0.16||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|United Healthcare|UNITED HEALTHCARE|0.05||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.05||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.05||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Medicare|MEDICARE ACUTE|39.25||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|16.50||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.50||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|16.50||||||| 9506312|ERX|0250|ESCITALOPRAM 5MG TABLET|Medicare|MEDICARE ACUTE|0.30||||0.30||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Humana Medicare Advantage|HUMANA MA|32.25||||32.25||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||32.25||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|32.25||||32.25||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|32.25||||32.25||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Medicare|MEDICARE ACUTE|32.25||||32.25||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|32.25||||||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|28.50||||||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|28.50||||||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||28.50||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|28.50||||||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||28.50||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|28.50||||||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|28.50||||||| 9506346|ERX|0250|MEMANTINE HCL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|28.50||||28.50||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Humana Medicare Advantage|HUMANA MA|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Cigna|CIGNA|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aetna|AETNA PPO|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|UNITED HEALTHCARE|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|UNITED HEALTHCARE|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Tricare|TRICARE EAST REGION|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|MEDICAID|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicare|HEALTHSPRING MA|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicare|MEDICARE ACUTE|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.45||||0.45||| 9506395|ERX|0250|DINOPROSTONE 10MG VAG INS|Medicaid|MEDICAID|2,533.50||||||| 9506395|ERX|0250|DINOPROSTONE 10MG VAG INS|United Healthcare|UNITED HEALTHCARE|2,533.50||||||| 9506395|ERX|0250|DINOPROSTONE 10MG VAG INS|Tricare|TRICARE EAST REGION|2,533.50||||||| 9506395|ERX|0250|DINOPROSTONE 10MG VAG INS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2,533.50||||||| 9506395|ERX|0250|DINOPROSTONE 10MG VAG INS|Blue Cross PPO Specialty|BCBSTX PPO|2,533.50||||||| 9506395|ERX|0250|DINOPROSTONE 10MG VAG INS|Managed Medicaid|MEDICAID AMERIGROUP|2,533.50||||2,533.50||| 9506395|ERX|0250|DINOPROSTONE 10MG VAG INS|Managed Medicaid|MEDICAID SUPERIOR|2,533.50||||||| 9506395|ERX|0250|DINOPROSTONE 10MG VAG INS|Cigna|CIGNA|2,533.50||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Humana Medicare Advantage|HUMANA MA|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Cigna|CIGNA|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.63||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Healthcare|UNITED HEALTHCARE|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Tricare|TRICARE EAST REGION|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|MEDICAID|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|HEALTHSPRING MA|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicare|MEDICARE ACUTE|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicare|MEDICARE PART B ONLY IP|1.63||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|WELLCARE CHOICE MA|1.63||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.63||||1.63||| 9506585|ERX|0250|LACTULOSE 10 G/15ML, 240M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|209.50||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicare|MEDICARE ACUTE|29.75||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicare|MEDICARE PART B ONLY IP|29.75||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicare|BCBS MEDICARE PPO MA|29.75||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.75||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Blue Cross HMO Specialty|BCBSTX HMO|||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|29.75||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Humana Medicare Advantage|HUMANA MA|||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29.75||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.75||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||29.75||| 9506668|ERX|0250|K PHOS,MONOBASIC 500MG TA|Humana Medicare Advantage|HUMANA 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|Medicare|MEDICARE ACUTE|2.75||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Medicare|MEDICARE ACUTE|||||24.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Managed Medicaid|MEDICAID AMERIGROUP|||||24.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||24.50||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.16||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Humana Medicare Advantage|HUMANA MA|||||0.16||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|United Medicare Advantage|UHC MEDICARE GOLD MA|0.16||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Medicaid|MEDICAID|||||0.16||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Medicare|MEDICARE ACUTE|||||0.16||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Managed Medicare|HEALTHSPRING MA|||||0.16||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|Medicare|MEDICARE ACUTE|865.84||||||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|Tricare|TRICARE EAST REGION|||||865.84||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||865.84||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||865.84||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|Managed Medicaid|MEDICAID SUPERIOR|||||865.84||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|Blue Cross PPO Specialty|BCBSTX PPO|865.84||||865.84||| 9506783|ERX|0250|METHYLENE BLUE 10MG/ML, 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||865.84||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|46.25||||46.25||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Humana Medicare Advantage|HUMANA MA|46.25||||46.25||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.25||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|46.25||||46.25||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|46.25||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Medicare|MEDICARE ACUTE|46.25||||46.25||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Medicare|MEDICARE ACUTE|467.40||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|||||467.40||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||467.40||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||467.40||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||467.40||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||467.40||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||467.40||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX PPO|||||467.40||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||467.40||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Cigna|CIGNA|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Tricare|TRICARE EAST REGION|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|MEDICAID|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicare|HEALTHSPRING MA|0.13||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Medicare|MEDICARE ACUTE|8.50||||8.50||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|8.50||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|8.50||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.50||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.50||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|UTMB|UTMB CORRECTIONAL MANAGED CARE|28.75||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.75||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Medicare|MEDICARE ACUTE|28.75||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|28.75||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|||||1.15||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.15||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.15||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Medicare|MEDICARE ACUTE|1.15||||1.15||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Medicaid|MEDICAID|||||1.15||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||16.75||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||16.75||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|16.75||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|16.75||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Medicaid|MEDICAID|||||16.75||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||16.75||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||16.75||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9507369|ERX|0250|CHARCOAL-SORBITOL 50 G, 2|Managed Medicaid|MEDICAID SUPERIOR|||||216.75||| 9507369|ERX|0250|CHARCOAL-SORBITOL 50 G, 2|Aetna|AETNA OTHER|||||216.75||| 9507369|ERX|0250|CHARCOAL-SORBITOL 50 G, 2|Medicaid|MEDICAID|||||216.75||| 9507369|ERX|0250|CHARCOAL-SORBITOL 50 G, 2|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||216.75||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|United Healthcare|UNITED HEALTHCARE|||||216.75||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||216.75||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|Aetna|AETNA OTHER|||||216.75||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Humana Medicare Advantage|HUMANA MA|||||11.50||| 9507435|ERX|0250|ASPIRIN 600MG SUPP|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.50||||||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||44.25||| 9507450|ERX|0250|PROMETHAZINE 25MG SUPP|Medicare|MEDICARE ACUTE|44.25||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Medicaid|MEDICAID HMO|||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Cigna|CIGNA|||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.05||| 9507567|ERX|0250|MEDROXYPROGESTERONE 10MG|Blue Cross PPO Specialty|BCBSTX PPO|||||22.50||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Medicare|MEDICARE ACUTE|6.75||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|United Healthcare|UNITED HEALTHCARE|||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|6.75||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|United Healthcare|UNITED HEALTHCARE|6.75||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6.75||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.75||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Cigna|CIGNA|6.75||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Humana Medicare Advantage|HUMANA MA|6.75||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.75||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.75||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Aetna|AETNA PPO|6.75||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|6.75||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|6.75||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|6.75||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.75||||||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|Blue Cross PPO Specialty|BCBSTX PPO|27.50||||||| 9507633|ERX|0250|ASPIRIN-DIPYRIDAMOLE 25-2|Managed Medicare|HEALTHSPRING MA|27.50||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Tricare|TRICARE EAST REGION|||||40.50||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|40.50||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||40.50||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicare|HEALTHSPRING MA|||||40.50||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Medicare|MEDICARE ACUTE|40.50||||40.50||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|40.50||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||40.50||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Humana Medicare Advantage|HUMANA MA|40.50||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||40.50||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||40.50||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|40.50||||40.50||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40.50||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Humana Medicare Advantage|HUMANA MA|||||610.50||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|610.50||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|610.50||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicare|HEALTHSPRING MA|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicaid|MEDICAID|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicare|MEDICARE ACUTE|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicare|WELLCARE CHOICE MA|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Aetna|AETNA PPO|||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Humana Medicare Advantage|HUMANA MA|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||31.25||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Humana Medicare Advantage|HUMANA MA|||||24.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||24.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||24.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Medicare|MEDICARE PART B ONLY IP|24.50||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Managed Medicare|HEALTHSPRING MA|||||5.25||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Humana Medicare Advantage|HUMANA MA|||||5.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Veterans Affairs|VETERANS ADMINISTRATION|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Aetna|AETNA PPO|13.75||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.75||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Blue Cross PPO Specialty|BCBSTX OTHER|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|13.75||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.75||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Cigna|CIGNA|13.75||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Humana Medicare Advantage|HUMANA MA|13.75||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.75||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID SUPERIOR|13.75||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.75||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|13.75||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Healthcare|UNITED HEALTHCARE|13.75||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|13.75||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|13.75||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicaid|MEDICAID HMO|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Medicare|MEDICARE ACUTE|13.75||||13.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|MEDICAID|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicare|MEDICARE ACUTE|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Tricare|TRICARE EAST REGION|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Tricare|TRICARE FOR LIFE|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Healthcare|UNITED HEALTHCARE|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Cigna|CIGNA|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Humana Medicare Advantage|HUMANA MA|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicare|HEALTHSPRING MA|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID SUPERIOR|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|||||27.75||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Cigna|CIGNA|||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9508169|ERX|0250|PHENOBARBITAL 130MG/1ML|Medicare|MEDICARE ACUTE|53.50||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.37||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicaid|MEDICAID SUPERIOR|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicaid|MEDICAID AMERIGROUP|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Blue Cross PPO Specialty|BCBSTX PPO|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Tricare|TRICARE EAST REGION|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.37||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Medicare|MEDICARE ACUTE|||||0.37||| 9508193|ERX|0250|CHLORPROMAZINE 25MG/1ML,|Managed Medicare|HEALTHSPRING MA|||||105.50||| 9508193|ERX|0250|CHLORPROMAZINE 25MG/1ML,|Medicare|MEDICARE ACUTE|105.50||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|227.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicaid|MEDICAID SUPERIOR|||||227.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||227.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Medicare|MEDICARE ACUTE|227.25||||227.25||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|24.50||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|24.50||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 9508243|ERX|0250|ALPRAZOLAM 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Blue Cross HMO Specialty|BCBSTX HMO|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 UNITED HEALTHCARE|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Medicare|MEDICARE ACUTE|2.50||||||| 9508284|ERX|0250|SULFAMETH-TRIMETH 400-80M|Blue Cross PPO Specialty|BCBSTX PPO|9.50||||||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|NON CONTRACTED|COMMERCIAL OTHER 2|||||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|Managed Medicaid|MEDICAID AMERIGROUP|||||2.75||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Blue Cross PPO Specialty|BCBSTX PPO|||||2.75||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Blue Cross PPO Specialty|BCBSTX PPO|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Aenta Medicare Advantage|AETNA MEDICARE MA|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Humana Medicare Advantage|HUMANA MA|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID AMERIGROUP|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID SUPERIOR|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|ChampVA|CHAMPVA CENTER|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid|MEDICAID|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicare|HEALTHSPRING MA|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicare|BCBS MEDICARE PPO MA|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicare|MEDICARE PART B ONLY IP|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicare|MEDICARE ACUTE|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Healthcare|UNITED HEALTHCARE|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Tricare|TRICARE EAST REGION|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|NON CONTRACTED|COMMERCIAL OTHER 1|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Medicare Advantage|UHC MEDICARE GOLD MA|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.50||||38.50||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.25||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicare|MEDICARE ACUTE|4.25||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Humana Medicare Advantage|HUMANA MA|4.25||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|4.25||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicaid|MEDICAID AMERIGROUP|4.25||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|4.25||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Humana Medicare Advantage|HUMANA MA|0.09||||0.09||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicare|HEALTHSPRING MA|||||0.09||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|||||0.14||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|25.25||||||| 9508425|ERX|0250|CEPHALEXIN 250MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||25.25||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|United Healthcare|UNITED HEALTHCARE|0.56||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Medicare|MEDICARE ACUTE|0.56||||0.56||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||0.57||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.57||||0.57||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.57||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicare|MEDICARE ACUTE|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.57||||0.57||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|114.25||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Medicare|MEDICARE ACUTE|114.25||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|114.25||||||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||114.25||| 9508466|ERX|0250|FLUOXETINE 40MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|114.25||||||| 9508516|ERX|0250|PENICILLIN VK 250MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.05||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|Managed Medicare|HEALTHSPRING MA|||||7.75||| 9508532|ERX|0250|HALOPERIDOL 1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||7.75||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Medicare|MEDICARE ACUTE|||||14.50||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.37||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicare|HEALTHSPRING MA|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Healthcare|UNITED HEALTHCARE|||||7.50||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||7.50||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||7.50||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Cigna|CIGNA|||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Humana Medicare Advantage|HUMANA MA|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Aetna|AETNA PPO|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|United Healthcare|UNITED HEALTHCARE|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicaid|MEDICAID|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicare|MEDICARE ACUTE|0.07||||0.07||| 9508862|ERX|0250|GEMFIBROZIL 600MG TABLET|Medicare|MEDICARE ACUTE|0.15||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.50||||||| 9508870|ERX|0250|PENTOXIFYLLINE 400MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|9.50||||||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicare|HEALTHSPRING MA|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicare|MEDICARE ACUTE|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|United Medicare Advantage|UHC MEDICARE GOLD MA|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Workers Compensation|WORKERS COMPENSATION OTHER|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Veterans Affairs|VETERANS ADMINISTRATION|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Blue Cross HMO Specialty|BCBSTX HMO|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Aetna|AETNA PPO|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Blue Cross PPO Specialty|BCBSTX PPO|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Blue Cross PPO Specialty|BCBSTX OTHER|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Aenta Medicare Advantage|AETNA MEDICARE MA|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicaid|MEDICAID SUPERIOR|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Managed Medicaid|MEDICAID AMERIGROUP|||||306.75||| 9509209|ERX|0250|LUBRICANT EYE DROP, 15ML|Medicare|MEDICARE ACUTE|93.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Cigna|CIGNA|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Humana Medicare Advantage|HUMANA MA|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicaid|MEDICAID SUPERIOR|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicaid|MEDICAID AMERIGROUP|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Blue Cross HMO Specialty|BCBSTX HMO|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Blue Cross PPO Specialty|BCBSTX PPO|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|WORKERS COMPENSATION OTHER|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Veterans Affairs|VETERANS ADMINISTRATION|118.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|UNITED HEALTHCARE|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|UNITED HEALTHCARE OTHER|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|UNITED HEALTHCARE|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Aetna|AETNA PPO|118.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Tricare|TRICARE EAST REGION|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|NON CONTRACTED|COMMERCIAL OTHER 1|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|118.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|MEDICAID|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|BCBS MEDICARE PPO MA|118.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicare|MEDICARE PART B ONLY IP|118.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicare|MEDICARE ACUTE|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|118.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|HEALTHSPRING MA|118.50||||118.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|12.50||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|MEDICAID|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Tricare|TRICARE EAST REGION|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|12.50||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|HEALTHSPRING MA|12.50||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Cigna|CIGNA|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Cigna|CIGNA|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Cigna|CIGNA|||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Humana Medicare Advantage|HUMANA MA|27.50||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|27.50||||||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Medicare|MEDICARE ACUTE|||||27.50||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Medicaid|MEDICAID|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Medicare|MEDICARE PART B ONLY IP|16.75||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Aetna|AETNA PPO|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Cigna|CIGNA|16.75||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Humana Medicare Advantage|HUMANA MA|16.75||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|16.75||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Aetna|AETNA PPO|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|United Healthcare|UNITED HEALTHCARE|||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Tricare|TRICARE EAST REGION|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Medicaid|MEDICAID|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Medicare|MEDICARE ACUTE|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Medicaid|MEDICAID|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Healthcare|UNITED HEALTHCARE|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Humana Medicare Advantage|HUMANA MA|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|40.85||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Veterans Affairs|VETERANS ADMINISTRATION|||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Humana Medicare Advantage|HUMANA MA|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Blue Cross HMO Specialty|BCBSTX HMO|0.37||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.37||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Blue Cross PPO Specialty|BCBSTX PPO|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.37||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Medicare|MEDICARE PART B ONLY IP|0.37||||||| 9509456|ERX|0250|METHYLPREDNIS DEPO 80MG/M|Medicare|MEDICARE ACUTE|||||514.75||| 9509456|ERX|0250|METHYLPREDNIS DEPO 80MG/M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|514.75||||||| 9509464|ERX|0250|DILTIAZEM 50MG 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|39.25||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Cigna|CIGNA|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Humana Medicare Advantage|HUMANA MA|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Aetna|AETNA PPO|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|MEDICAID|21.50||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|21.50||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicare|MEDICARE ACUTE|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|MEDICAID HMO|21.50||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicare|BCBS MEDICARE PPO MA|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicare|HEALTHSPRING MA|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Cigna|CIGNA|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|21.50||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Healthcare|UNITED HEALTHCARE|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Healthcare|UNITED HEALTHCARE|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Tricare|TRICARE EAST REGION|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|21.50||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.50||||21.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||24.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicare|HEALTHSPRING MA|24.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Cigna|CIGNA|||||24.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID SUPERIOR|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aetna|AETNA PPO|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|MEDICAID|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|MEDICAID HMO|16.75||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|WELLCARE CHOICE MA|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|HEALTHSPRING MA|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Cigna|CIGNA|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|16.75||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|16.75||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|UNITED HEALTHCARE|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|16.75||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Tricare|TRICARE EAST REGION|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Healthcare|UNITED HEALTHCARE|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Healthcare|UNITED HEALTHCARE|||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Tricare|TRICARE EAST REGION|||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicare|MEDICARE PART B ONLY IP|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicare|HEALTHSPRING MA|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Medicaid|MEDICAID|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Aetna|AETNA PPO|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|16.75||||||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Cigna|CIGNA|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicaid|MEDICAID SUPERIOR|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Workers Compensation|WORKERS COMPENSATION OTHER|16.75||||16.75||| 9509613|ERX|0250|FENTANYL 250MCG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|1.17||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.17||| 9509670|ERX|0250|PHYSOSTIGMINE 1MG/ML, 2ML|Medicare|MEDICARE ACUTE|57.75||||||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.40||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Humana Medicare Advantage|HUMANA MA|||||5.40||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.40||||||| 9509811|ERX|0250|OFLOXACIN 0.3% EYE DROP,|Managed Medicare|HEALTHSPRING MA|5.40||||||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Medicare|MEDICARE ACUTE|39.75||||||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|39.75||||||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|39.75||||||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|39.75||||||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|||||39.75||| 9509886|ERX|0250|BUPRENORPHINE 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|39.75||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Humana Medicare Advantage|HUMANA MA|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|Managed Medicaid|MEDICAID SUPERIOR|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 UTH UMR|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|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 PPO|||||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||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Cigna|CIGNA|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Healthcare|UNITED HEALTHCARE|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicare|MEDICARE ACUTE|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|MEDICAID|||||2.50||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Medicare|MEDICARE ACUTE|12.25||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Humana Medicare Advantage|HUMANA MA|12.25||||||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Blue Cross PPO Specialty|BCBSTX PPO|||||106.50||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Managed Medicaid|MEDICAID SUPERIOR|||||106.50||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Managed Medicaid|MEDICAID AMERIGROUP|||||106.50||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|40.75||||||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Medicare|MEDICARE ACUTE|40.75||||40.75||| 9510124|ERX|0250|OXYBUTYNIN XL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|40.75||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Managed Medicaid|MEDICAID SUPERIOR|0.20||||0.20||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Blue Cross PPO Specialty|BCBSTX PPO|0.20||||0.20||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Managed Medicare|HEALTHSPRING MA|||||251.50||| 9510181|ERX|0250|METHYLPREDNISOLONE 1000MG|Medicare|MEDICARE ACUTE|||||251.50||| 9510215|ERX|0250|GENTAMICIN EYE OINT, 3.5G|Medicare|MEDICARE ACUTE|194.25||||||| 9510256|ERX|0250||Managed Medicaid|MEDICAID AMERIGROUP|12.93||||||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.68||||||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|United Medicare Advantage|UHC MEDICARE GOLD MA|1.68||||1.68||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Medicare|MEDICARE ACUTE|1.68||||||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Workers Compensation|WORKERS COMPENSATION OTHER|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID AMERIGROUP|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID SUPERIOR|||||9.50||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.14||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|Medicare|MEDICARE ACUTE|2.50||||||| 9510512|ERX|0250|NAPROXEN SODIUM 220MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|2,672.50||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Medicare|MEDICARE ACUTE|2,672.50||||||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.50||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Managed Medicaid|MEDICAID AMERIGROUP|869.25||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Managed Medicaid|MEDICAID SUPERIOR|869.25||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Blue Cross PPO Specialty|BCBSTX PPO|869.25||||||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Managed Medicare|HEALTHSPRING MA|||||57.75||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|United Healthcare|UNITED HEALTHCARE|||||57.75||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|57.75||||||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Aetna|AETNA PPO|||||57.75||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||57.75||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|57.75||||57.75||| 9510801|ERX|0250|CLINDAMYCIN 300MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||57.75||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Humana Medicare Advantage|HUMANA MA|41.50||||41.50||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Aetna|AETNA PPO|41.50||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|41.50||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41.50||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Medicare|MEDICARE ACUTE|41.50||||41.50||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.13||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Humana Medicare Advantage|HUMANA MA|||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.13||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Veterans Affairs|VETERANS ADMINISTRATION|7.25||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Cigna|CIGNA|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Humana Medicare Advantage|HUMANA MA|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID SUPERIOR|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross HMO Specialty|BCBSTX HMO|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross PPO Specialty|BCBSTX PPO|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross PPO Specialty|BCBSTX OTHER|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID AMERIGROUP|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.25||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Aenta Medicare Advantage|AETNA MEDICARE MA|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.25||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|United Medicare Advantage|UHC MEDICARE GOLD MA|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicaid|MEDICAID HMO|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicare|MEDICARE ACUTE|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicare|HEALTHSPRING MA|7.25||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Medicaid|MEDICAID|||||7.25||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Medicare|MEDICARE ACUTE|86.75||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|NON CONTRACTED|COMMERCIAL OTHER 1|||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|United Medicare Advantage|UHC MEDICARE GOLD MA|||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Blue Cross PPO Specialty|BCBSTX PPO|86.75||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|86.75||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Workers Compensation|WORKERS COMPENSATION OTHER|||||86.75||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Medicare|MEDICARE ACUTE|0.09||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Medicare|MEDICARE ACUTE|34.50||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Medicare|MEDICARE PART B ONLY IP|34.50||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Humana Medicare Advantage|HUMANA MA|34.50||||34.50||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34.50||||||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Veterans Affairs|VETERANS ADMINISTRATION|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Blue Cross PPO Specialty|BCBSTX PPO|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Cigna|CIGNA|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Humana Medicare Advantage|HUMANA MA|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Healthcare|UNITED HEALTHCARE|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|NON CONTRACTED|COMMERCIAL OTHER 2|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Medicare|MEDICARE ACUTE|101.75||||101.75||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Medicare|MEDICARE ACUTE|192.50||||192.50||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|United Healthcare|UNITED HEALTHCARE|||||192.50||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||192.50||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|192.50||||192.50||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|192.50||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|192.50||||192.50||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Managed Medicaid|MEDICAID SUPERIOR|192.50||||||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|192.50||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|351.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Managed Medicaid|MEDICAID SUPERIOR|351.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|351.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Medicare|MEDICARE ACUTE|351.75||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.36||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|49.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|49.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Medicare|MEDICARE ACUTE|49.75||||49.75||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||49.75||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|49.75||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Medicare Advantage|AARP UHC WEST COMPLETE MA|174.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|United Medicare Advantage|UHC MEDICARE GOLD MA|174.25||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Medicare|MEDICARE ACUTE|174.25||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Blue Cross PPO Specialty|BCBSTX PPO|174.25||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Humana Medicare Advantage|HUMANA MA|174.25||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicaid|MEDICAID SUPERIOR|174.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Veterans Affairs|VETERANS ADMINISTRATION|174.25||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|127.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Medicare|MEDICARE ACUTE|127.50||||||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|United Medicare Advantage|UHC MEDICARE GOLD MA|127.50||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Medicare|MEDICARE ACUTE|370.50||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|370.50||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|370.50||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|370.50||||370.50||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID SUPERIOR|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID AMERIGROUP|1.98||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Blue Cross PPO Specialty|BCBSTX PPO|1.98||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicare|MEDICARE ACUTE|1.98||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicaid|MEDICAID|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Medicare Advantage|UHC MEDICARE GOLD MA|1.98||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|United Healthcare|UNITED HEALTHCARE|36.75||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|36.75||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Medicare|MEDICARE ACUTE|36.75||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Medicaid|MEDICAID|||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|36.75||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Humana Medicare Advantage|HUMANA MA|36.75||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.75||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.75||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|36.75||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Cigna|CIGNA|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Humana Medicare Advantage|HUMANA MA|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aetna|AETNA OTHER|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aetna|AETNA PPO|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicare|MEDICARE ACUTE|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicare|MEDICARE PART B ONLY IP|0.01||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicare|HEALTHSPRING MA|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|MEDICAID|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|MEDICAID HMO|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|UNITED HEALTHCARE|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Tricare|TRICARE FOR LIFE|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Tricare|TRICARE EAST REGION|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.01||||0.01||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.01||||0.01||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.63||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicare|MEDICARE ACUTE|1.63||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicare|HEALTHSPRING MA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicaid|MEDICAID|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross PPO Specialty|BCBSTX PPO|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Cigna|CIGNA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Humana Medicare Advantage|HUMANA MA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicaid|MEDICAID SUPERIOR|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Veterans Affairs|VETERANS ADMINISTRATION|||||1.63||| 9511866|ERX|0250|NEOMYCIN SULFATE 500MG TA|Medicare|MEDICARE ACUTE|24.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|77.50||||||| 9511882|ERX|0250|CEFUROXIME 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|77.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Healthcare|UMR UNITED MEDICAL RESOURCES|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Tricare|TRICARE EAST REGION|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|Managed Medicare|WELLCARE CHOICE MA|||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|MEDICAID|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|MEDICAID HMO|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aetna|AETNA PPO|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aetna|AETNA OTHER|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||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Access Direct Platinum|HEALTHFIRST TPA UMR|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Cigna|CIGNA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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 AMERIGROUP|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Cigna|CIGNA|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Aetna|AETNA PPO|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicare|MEDICARE ACUTE|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicare|HEALTHSPRING MA|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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.03||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Medicare|MEDICARE ACUTE|0.09||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Humana Medicare Advantage|HUMANA MA|0.04||||0.04||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.04||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Medicare|MEDICARE ACUTE|8.25||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Medicaid|MEDICAID|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.25||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Blue Cross HMO Specialty|BCBSTX HMO|8.25||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Blue Cross PPO Specialty|BCBSTX PPO|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Humana Medicare Advantage|HUMANA MA|8.25||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicaid|MEDICAID SUPERIOR|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicaid|MEDICAID AMERIGROUP|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.25||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Aenta Medicare Advantage|AETNA MEDICARE MA|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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|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|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Medicare|MEDICARE ACUTE|2.50||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicare|MEDICARE ACUTE|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.75||||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||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|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 Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.75||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Humana Medicare Advantage|HUMANA MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|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||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicare|MEDICARE ACUTE|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicare|HEALTHSPRING MA|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicaid|MEDICAID|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.03||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Medicare|MEDICARE ACUTE|0.27||||0.27||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.27||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.27||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.27||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Tricare|TRICARE EAST REGION|0.27||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.27||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Humana Medicare Advantage|HUMANA MA|0.27||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.27||||||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Tricare|TRICARE EAST REGION|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicare|HEALTHSPRING MA|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicaid|MEDICAID|||||0.05||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicare|HEALTHSPRING MA|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Medicaid|MEDICAID|7.50||||7.50||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|||||7.50||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Humana Medicare Advantage|HUMANA MA|7.50||||7.50||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.09||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Blue Cross HMO Specialty|BCBSTX HMO|0.09||||||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Medicare|MEDICARE PART B ONLY IP|||||0.09||| 9512120|ERX|0250|ACETAM-CODEINE 300-60MG T|Medicare|MEDICARE ACUTE|0.09||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.75||||6.75||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6.75||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Medicare|MEDICARE PART B ONLY IP|6.75||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Medicare|MEDICARE ACUTE|6.75||||6.75||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||6.75||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|6.75||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||6.75||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|6.75||||6.75||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.75||||6.75||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.06||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||0.06||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.06||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.06||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.06||||0.06||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.06||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.06||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Medicare|MEDICARE ACUTE|0.06||||0.06||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.06||||||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|||||0.06||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Medicaid|MEDICAID|||||0.06||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|Medicaid|MEDICAID HMO|||||0.06||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.06||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.06||| 9512146|ERX|0250|DICYCLOMINE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.06||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Tricare|TRICARE EAST REGION|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicaid|MEDICAID|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicaid|MEDICAID HMO|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||12.50||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Blue Cross PPO Specialty|BCBSTX PPO|18.25||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.25||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Cigna|CIGNA|||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Humana Medicare Advantage|HUMANA MA|||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID SUPERIOR|||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID AMERIGROUP|||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.25||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Veterans Affairs|VETERANS ADMINISTRATION|||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicare|HEALTHSPRING MA|18.25||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|United Medicare Advantage|UHC MEDICARE GOLD MA|18.25||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.25||||18.25||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.04||||||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Medicare|MEDICARE ACUTE|0.04||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||12.75||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.75||||12.75||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||12.75||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||12.75||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.75||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|United Healthcare|UNITED HEALTHCARE|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||12.75||| 9512203|ERX|0250|LORATADINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.09||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.09||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Medicare|MEDICARE ACUTE|0.09||||||| 9512211|ERX|0250|AMITRIPTYLINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Access Direct Platinum|HEALTHFIRST TPA UMR|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Blue Cross HMO Specialty|BCBSTX HMO|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Aetna|AETNA PPO|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Blue Cross PPO Specialty|BCBSTX PPO|4.75||||4.75||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Cigna|CIGNA|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Humana Medicare Advantage|HUMANA MA|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.75||||4.75||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Medicare|MEDICARE ACUTE|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Managed Medicare|HEALTHSPRING MA|||||4.75||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|United Healthcare|UNITED HEALTHCARE|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|United Healthcare|UNITED HEALTHCARE|4.75||||4.75||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|NON CONTRACTED|COMMERCIAL OTHER 1|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.75||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Healthcare|UNITED HEALTHCARE|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Healthcare|UNITED HEALTHCARE|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|NON CONTRACTED|COMMERCIAL OTHER 1|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicare|HEALTHSPRING MA|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicare|MEDICARE ACUTE|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicare|WELLCARE CHOICE MA|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|MEDICAID|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Medicaid|MEDICAID HMO|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Veterans Affairs|VETERANS ADMINISTRATION|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Cigna|CIGNA|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Humana Medicare Advantage|HUMANA MA|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID SUPERIOR|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Medicare Advantage|UHC MEDICARE GOLD MA|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID AMERIGROUP|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Blue Cross HMO Specialty|BCBSTX HMO|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Aetna|AETNA PPO|0.06||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Aetna|AETNA OTHER|0.06||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Blue Cross PPO Specialty|BCBSTX PPO|0.06||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.06||||0.06||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|0.07||||||| 9512260|ERX|0250|INDOMETHACIN 25MG CAPSULE|Medicare|MEDICARE ACUTE|0.07||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.75||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|4.75||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Medicare|MEDICARE ACUTE|4.75||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||4.75||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Humana Medicare Advantage|HUMANA MA|4.75||||4.75||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.75||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.75||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.09||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Humana Medicare Advantage|HUMANA MA|0.09||||0.09||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||0.09||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.09||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.09||||0.09||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.09||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Aetna|AETNA OTHER|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Aetna|AETNA PPO|5.25||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Cigna|CIGNA|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Cigna|CIGNA|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|ChampVA|CHAMPVA CENTER|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Workers Compensation|WORKERS COMP PHYSICIAN|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|5.25||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|UNITED HEALTHCARE|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|UNITED HEALTHCARE|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Tricare|TRICARE EAST REGION|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.25||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Tricare|TRICARE FOR LIFE|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicare|HEALTHSPRING MA|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicare|MEDICARE PART B ONLY IP|5.25||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|5.25||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|MEDICAID|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|MEDICAID HMO|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicaid|MEDICAID|||||0.05||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicare|HEALTHSPRING MA|||||0.05||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicare|MEDICARE ACUTE|||||0.05||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|United Healthcare|UNITED HEALTHCARE|||||0.05||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.05||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||0.05||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.05||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|United Healthcare|UNITED HEALTHCARE|5.50||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicare|HEALTHSPRING MA|||||5.50||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.50||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||5.50||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||5.50||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.50||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||5.50||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.50||||5.50||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Aetna|AETNA PPO|0.05||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Cigna|CIGNA|0.05||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Cigna|CIGNA|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicaid|MEDICAID|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Aetna|AETNA OTHER|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.05||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.05||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicare|HEALTHSPRING MA|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Healthcare|UNITED HEALTHCARE|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Healthcare|UNITED HEALTHCARE|0.05||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|PHCS|MULTIPLAN PHCS|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Tricare|TRICARE EAST REGION|0.05||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.05||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.05||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicaid|MEDICAID|5.50||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicare|MEDICARE PART B ONLY IP|5.50||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicare|HEALTHSPRING MA|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Humana Medicare Advantage|HUMANA MA|5.50||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.50||||||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.50||| 9512484|ERX|0250|CHLORDIAZEPOXIDE 5MG CAPS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||||| 9512484|ERX|0250|CHLORDIAZEPOXIDE 5MG CAPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.25||||||| 9512492|ERX|0250|CHLORDIAZEPOXIDE 10MG CAP|Medicare|MEDICARE ACUTE|4.50||||4.50||| 9512492|ERX|0250|CHLORDIAZEPOXIDE 10MG CAP|Blue Cross HMO Specialty|BCBSTX HMO|4.50||||||| 9512492|ERX|0250|CHLORDIAZEPOXIDE 10MG CAP|Blue Cross PPO Specialty|BCBSTX PPO|||||4.50||| 9512492|ERX|0250|CHLORDIAZEPOXIDE 10MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.50||| 9512492|ERX|0250|CHLORDIAZEPOXIDE 10MG CAP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.50||||||| 9512492|ERX|0250|CHLORDIAZEPOXIDE 10MG CAP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Cigna|CIGNA|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Humana Medicare Advantage|HUMANA MA|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Cigna|CIGNA|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Healthcare|UNITED HEALTHCARE|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|MEDICAID|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|MEDICAID HMO|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicaid|MEDICAID HMO|||||0.11||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicare|MEDICARE ACUTE|0.11||||0.11||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.11||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.11||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.11||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.11||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.11||||0.11||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.11||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.11||||0.11||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.11||||0.11||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.11||||0.11||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.11||||0.11||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.11||||0.11||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicare|MEDICARE ACUTE|0.11||||0.11||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Medicare|MEDICARE ACUTE|22.50||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Humana Medicare Advantage|HUMANA MA|22.50||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||9.50||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.50||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|9.50||||9.50||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.50||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|9.50||||9.50||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.50||||9.50||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Medicare|MEDICARE ACUTE|9.50||||9.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Healthcare|UNITED HEALTHCARE|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||7.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Healthcare|UNITED HEALTHCARE|||||7.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||7.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Cigna|CIGNA|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|7.50||||7.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||7.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Aetna|AETNA PPO|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||7.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.50||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|11.25||||11.25||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.25||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||11.25||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|11.25||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.25||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.25||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|11.25||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|United Healthcare|UNITED HEALTHCARE|11.25||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.25||||||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicaid|MEDICAID|||||11.25||| 9512609|ERX|0250|TRAZODONE 100MG TABLET|Medicare|MEDICARE ACUTE|11.25||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.10||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.50||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|Medicare|MEDICARE ACUTE|5.50||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|5.50||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|5.50||||||| 9512641|ERX|0250|DOXEPIN 10MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.50||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||||| 9512682|ERX|0250|SIMVASTATIN 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.75||| 9512682|ERX|0250|SIMVASTATIN 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||12.75||| 9512682|ERX|0250|SIMVASTATIN 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9512682|ERX|0250|SIMVASTATIN 40MG TABLET|Medicaid|MEDICAID|12.75||||||| 9512682|ERX|0250|SIMVASTATIN 40MG TABLET|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Medicaid|MEDICAID|||||13.75||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Medicare|MEDICARE ACUTE|||||13.75||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||13.75||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|||||13.75||| 9512807|ERX|0250|PROCHLORPERAZINE 10MG TAB|Managed Medicaid|MEDICAID AMERIGROUP|||||13.75||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Cigna|CIGNA|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Tricare|TRICARE EAST REGION|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicaid|MEDICAID HMO|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicaid|MEDICAID|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicare|MEDICARE ACUTE|8.25||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Aetna|AETNA PPO|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Cigna|CIGNA|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Humana Medicare Advantage|HUMANA MA|21.25||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|21.25||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|ChampVA|CHAMPVA CENTER|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicaid|MEDICAID HMO|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicaid|MEDICAID|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicare|HEALTHSPRING MA|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicare|MEDICARE ACUTE|21.25||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21.25||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Veterans Affairs|VETERANS ADMINISTRATION|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID SUPERIOR|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Blue Cross HMO Specialty|BCBSTX HMO|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Healthcare|UNITED HEALTHCARE|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Workers Compensation|WORKERS COMPENSATION OTHER|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicaid|MEDICAID|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicare|MEDICARE ACUTE|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Cigna|CIGNA|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicare|HEALTHSPRING MA|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|14.50||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|14.50||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Humana Medicare Advantage|HUMANA MA|||||14.50||| 9513144|ERX|0250|VERAPAMIL 120MG TABLET|Medicare|MEDICARE ACUTE|0.09||||||| 9513144|ERX|0250|VERAPAMIL 120MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Humana Medicare Advantage|HUMANA MA|0.13||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.13||||||| 9513151|ERX|0250|ATENOLOL 50MG TABLET|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Medicaid|MEDICAID|||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.11||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Medicare|MEDICARE ACUTE|0.11||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Healthcare|UNITED HEALTHCARE|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Aetna|AETNA PPO|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.11||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicare|HEALTHSPRING MA|||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.11||||0.11||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||45.50||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|45.50||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Medicare|MEDICARE ACUTE|45.50||||45.50||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|45.50||||45.50||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Medicaid|MEDICAID|||||45.50||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||45.50||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|45.50||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|45.50||||45.50||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|45.50||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|45.50||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|45.50||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Healthcare|UNITED HEALTHCARE|45.50||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|45.50||||45.50||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|45.50||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45.50||||||| 9513177|ERX|0250|ZOLPIDEM 10MG TABLET|Cigna|CIGNA|45.50||||45.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Cigna|CIGNA|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Tricare|TRICARE EAST REGION|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicaid|MEDICAID|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|United Healthcare|UNITED HEALTHCARE|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.50||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Humana Medicare Advantage|HUMANA MA|0.11||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.11||||||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Medicare|MEDICARE ACUTE|0.11||||0.11||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.11||| 9513201|ERX|0250|DILTIAZEM 60MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.11||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|12.75||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|Medicare|MEDICARE ACUTE|12.75||||||| 9513219|ERX|0250|DILTIAZEM 90MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||||| 9513235|ERX|0250|CARBIDOPA-LEVODOPA 10-100|Medicare|MEDICARE ACUTE|11.25||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Blue Cross PPO Specialty|BCBSTX PPO|0.12||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Humana Medicare Advantage|HUMANA MA|0.12||||0.12||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Veterans Affairs|VETERANS ADMINISTRATION|0.12||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Medicare|MEDICARE ACUTE|0.12||||0.12||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Managed Medicare|HEALTHSPRING MA|0.12||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Medicare|MEDICARE ACUTE|||||0.12||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Humana Medicare Advantage|HUMANA MA|0.12||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.12||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.12||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|11.75||||11.75||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||11.75||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|11.75||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.50||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Medicaid|MEDICAID|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|16.50||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Humana Medicare Advantage|HUMANA MA|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Medicare|MEDICARE ACUTE|16.50||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Tricare|TRICARE EAST REGION|||||16.50||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Humana Medicare Advantage|HUMANA MA|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Blue Cross HMO Specialty|BCBSTX HMO|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Medicare Advantage|UHC MEDICARE GOLD MA|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicaid|MEDICAID|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicare|MEDICARE PART B ONLY IP|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicare|HEALTHSPRING MA|0.09||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Medicare|MEDICARE ACUTE|6.75||||6.75||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.75||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.75||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.75||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.75||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.75||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.75||||||| 9513417|ERX|0250|INDAPAMIDE 2.5MG TABLET|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9513417|ERX|0250|INDAPAMIDE 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Medicare|MEDICARE PART B ONLY IP|11.75||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11.75||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.75||||11.75||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Humana Medicare Advantage|HUMANA MA|11.75||||11.75||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Managed Medicaid|MEDICAID SUPERIOR|11.75||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|11.75||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||8.75||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|||||8.75||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Medicare|MEDICARE ACUTE|8.75||||||| 9513458|ERX|0250|GLYBURIDE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.75||| 9513466|ERX|0250|RANITIDINE 150MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||19.75||| 9513466|ERX|0250|RANITIDINE 150MG TABLET|Medicare|MEDICARE ACUTE|19.75||||19.75||| 9513466|ERX|0250|RANITIDINE 150MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|19.75||||||| 9513466|ERX|0250|RANITIDINE 150MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||19.75||| 9513466|ERX|0250|RANITIDINE 150MG TABLET|United Healthcare|UNITED HEALTHCARE|||||19.75||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Medicare|MEDICARE ACUTE|7.25||||7.25||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7.25||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.25||||7.25||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Medicare|MEDICARE ACUTE|0.15||||||| 9513490|ERX|0250|VERAPAMIL SR 180MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|8.25||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Medicare|MEDICARE ACUTE|8.25||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||8.25||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.25||||8.25||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|8.25||||8.25||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7.75||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Blue Cross HMO Specialty|BCBSTX HMO|7.75||||7.75||| 9513573|ERX|0250|TRIAMTERENE/HCTZ 37.5-25M|Medicare|MEDICARE ACUTE|||||7.75||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.25||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.25||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.25||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Healthcare|UNITED HEALTHCARE|0.25||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicare|MEDICARE ACUTE|0.25||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|MEDICAID HMO|||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Cigna|CIGNA|0.25||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Aetna|AETNA PPO|0.25||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Cigna|CIGNA|||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.25||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.25||||0.25||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.50||||18.50||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|Medicaid|MEDICAID|18.50||||||| 9513664|ERX|0250|SPIRONOLACTONE 100MG TABL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.50||||18.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|13.50||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|13.50||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|PHCS|MULTIPLAN PHCS|||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|13.50||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|13.50||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Cigna|CIGNA|||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.50||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.50||||13.50||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Aetna|AETNA PPO|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Healthcare|UNITED HEALTHCARE|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Healthcare|UNITED HEALTHCARE|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicaid|MEDICAID|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Cigna|CIGNA|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicare|HEALTHSPRING MA|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.15||||0.15||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicaid|MEDICAID|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicare|HEALTHSPRING MA|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicare|BCBS MEDICARE PPO MA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicare|MEDICARE ACUTE|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross HMO Specialty|BCBSTX HMO|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Cigna|CIGNA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Tricare|TRICARE EAST REGION|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Cigna|CIGNA|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID AMERIGROUP|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID SUPERIOR|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Humana Medicare Advantage|HUMANA MA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Veterans Affairs|VETERANS ADMINISTRATION|449.75||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31.25||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Humana Medicare Advantage|HUMANA MA|31.25||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.43||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|4.43||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|4.43||||4.43||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Medicare|MEDICARE ACUTE|4.43||||4.43||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Blue Cross PPO Specialty|BCBSTX PPO|32.25||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|32.25||||||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Medicare|MEDICARE ACUTE|32.25||||32.25||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Humana Medicare Advantage|HUMANA MA|||||32.25||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Blue Cross HMO Specialty|BCBSTX HMO|0.67||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Medicare|MEDICARE ACUTE|0.67||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.67||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Humana Medicare Advantage|HUMANA MA|0.67||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|5.50||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicaid|MEDICAID SUPERIOR|5.50||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicaid|MEDICAID AMERIGROUP|5.50||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Medicare|MEDICARE ACUTE|5.50||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Blue Cross PPO Specialty|BCBSTX PPO|5.50||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7.43||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Medicare|MEDICARE ACUTE|7.43||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.43||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Humana Medicare Advantage|HUMANA MA|7.43||||7.43||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||24.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicaid|MEDICAID AMERIGROUP|24.50||||24.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|ChampVA|CHAMPVA CENTER|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Healthcare|UNITED HEALTHCARE|||||24.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicare|MEDICARE PART B ONLY IP|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||24.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Tricare|TRICARE EAST REGION|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Medicare Advantage|UHC MEDICARE GOLD MA|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|NON CONTRACTED|COMMERCIAL OTHER 1|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|20.50||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|20.50||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|WORKERS COMPENSATION OTHER|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicare|MEDICARE ACUTE|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Veterans Affairs|VETERANS ADMINISTRATION|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|MEDICAID HMO|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicare|BCBS MEDICARE PPO MA|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Healthcare|UNITED HEALTHCARE|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|UT EMPLOYEE INJURY|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicare|HEALTHSPRING MA|20.50||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Cigna|CIGNA|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID AMERIGROUP|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Humana Medicare Advantage|HUMANA MA|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Blue Cross PPO Specialty|BCBSTX PPO|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID SUPERIOR|20.50||||20.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Aetna|AETNA OTHER|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Blue Cross HMO Specialty|BCBSTX HMO|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Cigna|CIGNA|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicaid|MEDICAID SUPERIOR|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|MEDICAID|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicaid|MEDICAID AMERIGROUP|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Veterans Affairs|VETERANS ADMINISTRATION|0.15||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|NON CONTRACTED|COMMERCIAL OTHER 1|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicare|HEALTHSPRING MA|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Tricare|TRICARE EAST REGION|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|NON CONTRACTED|COMMERCIAL OTHER 1|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Tricare|TRICARE EAST REGION|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicare|BCBS MEDICARE PPO MA|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Cigna|CIGNA|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Healthcare|UNITED HEALTHCARE|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Veterans Affairs|VETERANS ADMINISTRATION|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|MEDICAID|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicaid|MEDICAID AMERIGROUP|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicaid|MEDICAID SUPERIOR|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicare|HEALTHSPRING MA|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Access Direct Platinum|HEALTHFIRST TPA UMR|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Aetna|AETNA PPO|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Aenta Medicare Advantage|AETNA MEDICARE MA|0.15||||0.15||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Medicare|MEDICARE ACUTE|47.75||||47.75||| 9514258|ERX|0250|URSODIOL 300MG CAPSULE|Medicaid|MEDICAID|47.75||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||20.25||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicaid|MEDICAID SUPERIOR|||||20.25||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Blue Cross PPO Specialty|BCBSTX PPO|||||20.25||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|United Medicare Advantage|UHC MEDICARE GOLD MA|||||20.25||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicaid|MEDICAID AMERIGROUP|20.25||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Medicare|MEDICARE ACUTE|20.25||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.22||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.22||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Medicare|MEDICARE ACUTE|0.22||||||| 9514340|ERX|0250|METOLAZONE 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.22||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Cigna|CIGNA|||||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|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicare|MEDICARE ACUTE|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|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|Managed Medicare|HEALTHSPRING MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||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 UNITED HEALTHCARE|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|2.50||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|19.25||||||| 9514423|ERX|0250|MIDODRINE 2.5MG TABLET|Medicare|MEDICARE ACUTE|19.25||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|30.25||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|30.25||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|30.25||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|30.25||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|30.25||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Medicare|MEDICARE ACUTE|30.25||||30.25||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|30.25||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Medicare|MEDICARE ACUTE|||||44.75||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||44.75||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Medicare|MEDICARE PART B ONLY IP|44.75||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||44.75||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|85.25||||||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Humana Medicare Advantage|HUMANA MA|||||85.25||| 9514688|ERX|0250|ENALAPRILAT 2.5MG 2ML|Medicare|MEDICARE ACUTE|||||85.25||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.18||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicare|HEALTHSPRING MA|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|MEDICAID|0.18||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.18||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Healthcare|UNITED HEALTHCARE|0.18||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Cigna|CIGNA|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicare|MEDICARE ACUTE|0.18||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.18||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Aetna|AETNA PPO|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|0.18||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Humana Medicare Advantage|HUMANA MA|||||0.18||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicare|MEDICARE ACUTE|||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Humana Medicare Advantage|HUMANA MA|||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||44.75||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||122.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|122.25||||||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Medicare|MEDICARE ACUTE|122.25||||122.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||122.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Veterans Affairs|VETERANS ADMINISTRATION|||||122.25||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|Humana Medicare Advantage|HUMANA MA|||||122.25||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.85||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|1.85||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|1.85||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Veterans Affairs|VETERANS ADMINISTRATION|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Medicaid|MEDICAID|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Medicare|MEDICARE ACUTE|1.85||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Healthcare|UNITED HEALTHCARE|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|PHCS|HUMANA INSURANCE|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.85||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Humana Medicare Advantage|HUMANA MA|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Cigna|CIGNA|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicare|MEDICARE ACUTE|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|HEALTHSPRING MA|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|29.75||||29.75||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|59.25||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Managed Medicaid|MEDICAID SUPERIOR|59.25||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|59.25||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Aetna|AETNA PPO|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.25||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Medicaid|MEDICAID HMO|59.25||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|United Healthcare|UNITED HEALTHCARE|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Aetna|AETNA OTHER|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Cigna|CIGNA|59.25||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||917.75||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Medicaid|MEDICAID|||||917.75||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Medicare|MEDICARE ACUTE|||||917.75||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|44.75||||44.75||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Cigna|CIGNA|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Medicaid|MEDICAID|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Medicare|MEDICARE ACUTE|||||44.75||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Medicare|MEDICARE ACUTE|0.21||||0.21||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Medicare|MEDICARE PART B ONLY IP|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Humana Medicare Advantage|HUMANA MA|||||0.21||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.14||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|Managed Medicaid|MEDICAID SUPERIOR|2.62||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicare|HEALTHSPRING MA|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicare|WELLCARE CHOICE MA|0.16||||0.16||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Medicaid|MEDICAID|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Medicare|MEDICARE ACUTE|0.16||||0.16||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Medicare|MEDICARE PART B ONLY IP|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.16||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Humana Medicare Advantage|HUMANA MA|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Medicare Advantage|UHC MEDICARE GOLD MA|0.16||||0.16||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|NON CONTRACTED|COMMERCIAL OTHER 1|0.16||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|United Medicare Advantage|AARP UHC WEST COMPLETE MA|16.50||||16.50||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Humana Medicare Advantage|HUMANA MA|16.50||||16.50||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|Medicare|MEDICARE ACUTE|16.50||||16.50||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.50||||||| 9515438|ERX|0250|ISOSORBIDE MONONITRATE 60|United Medicare Advantage|UHC MEDICARE GOLD MA|16.50||||16.50||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Medicare|MEDICARE ACUTE|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|13.75||||||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Humana Medicare Advantage|HUMANA MA|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.75||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Humana Medicare Advantage|HUMANA MA|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.04||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.04||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|United Healthcare|UNITED HEALTHCARE|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|0.04||||||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.04||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Managed Medicare|HEALTHSPRING MA|0.04||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Medicare|MEDICARE ACUTE|0.04||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.04||||||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Medicaid|MEDICAID|0.04||||||| 9515693|ERX|0250|OXYCODONE SR 10MG TABLET|Humana Medicare Advantage|HUMANA MA|23.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Medicare|MEDICARE ACUTE|||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||239.25||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|36.75||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Cigna|CIGNA|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|MEDICAID HMO|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|United Healthcare|UNITED HEALTHCARE|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|MEDICAID|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||36.75||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Medicare|MEDICARE ACUTE|0.46||||0.46||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.46||||||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|Medicare|MEDICARE ACUTE|0.18||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|25.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|25.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Humana Medicare Advantage|HUMANA MA|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Cigna|CIGNA|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Healthcare|UNITED HEALTHCARE|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Healthcare|UNITED HEALTHCARE|25.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|25.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|HEALTHSPRING MA|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|MEDICAID HMO|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|MEDICAID|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicare|MEDICARE ACUTE|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicare|MEDICARE PART B ONLY IP|25.75||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|HEALTHSPRING MA|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicaid|MEDICAID|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Humana Medicare Advantage|HUMANA MA|||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||12.50||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Humana Medicare Advantage|HUMANA MA|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Healthcare|UNITED HEALTHCARE|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Healthcare|UNITED HEALTHCARE|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Cigna|CIGNA|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|ChampVA|CHAMPVA CENTER|0.28||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|PHCS|HUMANA INSURANCE|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aetna|AETNA PPO|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Tricare|TRICARE EAST REGION|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicare|HEALTHSPRING MA|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|MEDICAID HMO|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicare|MEDICARE ACUTE|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|MEDICAID|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicare|MEDICARE PART B ONLY IP|0.28||||||| 9516469|ERX|0250|NEOMYC-POLYMYX-HC ,10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|776.50||||||| 9516469|ERX|0250|NEOMYC-POLYMYX-HC ,10ML|Managed Medicaid|MEDICAID SUPERIOR|||||776.50||| 9516477|ERX|0250|NEOMYC-POLYMYX-HC EAR,10M|Blue Cross PPO Specialty|BCBSTX PPO|||||776.50||| 9516477|ERX|0250|NEOMYC-POLYMYX-HC EAR,10M|Managed Medicaid|MEDICAID SUPERIOR|||||776.50||| 9516477|ERX|0250|NEOMYC-POLYMYX-HC EAR,10M|Managed Medicaid|MEDICAID AMERIGROUP|||||776.50||| 9516519|ERX|0250|NEOMY-POLYMYXING.U. IRRIG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.08||||||| 9516519|ERX|0250|NEOMY-POLYMYXING.U. IRRIG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.08||| 9516592|ERX|0250|SILVER SULFADIAZINE 1% 2|United Medicare Advantage|UHC MEDICARE GOLD MA|||||86.75||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Medicare|MEDICARE ACUTE|0.15||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.37||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.37||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Managed Medicaid|MEDICAID SUPERIOR|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|0.37||||0.37||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Humana Medicare Advantage|HUMANA MA|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicaid|MEDICAID SUPERIOR|||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Cigna|CIGNA|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|93.50||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Blue Cross PPO Specialty|BCBSTX PPO|93.50||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Blue Cross HMO Specialty|BCBSTX HMO|||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Cigna|CIGNA|93.50||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicaid|MEDICAID AMERIGROUP|||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicare|BCBS MEDICARE PPO MA|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicaid|MEDICAID|||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicare|MEDICARE ACUTE|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Aetna|AETNA PPO|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Medicare Advantage|UHC MEDICARE GOLD MA|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Healthcare|UNITED HEALTHCARE|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|NON CONTRACTED|COMMERCIAL OTHER 1|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicare|HEALTHSPRING MA|93.50||||||| 9516691|ERX|0250|POLYMYXIN B-TMP EYE DROP,|Managed Medicaid|MEDICAID AMERIGROUP|||||341.75||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|65.50||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|65.50||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|65.50||||65.50||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Managed Medicare|HEALTHSPRING MA|65.50||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Medicare|MEDICARE ACUTE|65.50||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|65.50||||65.50||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|Medicare|MEDICARE ACUTE|29.75||||||| 9516824|ERX|0250|ZONISAMIDE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|29.75||||||| 9516907|ERX|0250|CEFADROXIL 500MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|38.25||||38.25||| 9517012|ERX|0250|AMOX-CLAV 200-28.5MG/5ML,|Blue Cross PPO Specialty|BCBSTX PPO|||||182.25||| 9517012|ERX|0250|AMOX-CLAV 200-28.5MG/5ML,|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||182.25||| 9517012|ERX|0250|AMOX-CLAV 200-28.5MG/5ML,|Managed Medicaid|MEDICAID AMERIGROUP|||||182.25||| 9517012|ERX|0250|AMOX-CLAV 200-28.5MG/5ML,|Managed Medicaid|MEDICAID SUPERIOR|||||182.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Managed Medicaid|MEDICAID SUPERIOR|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Managed Medicaid|MEDICAID AMERIGROUP|0.56||||0.56||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Cigna|CIGNA|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX PPO|0.56||||0.56||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Aetna|AETNA PPO|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Medicaid|MEDICAID|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Medicaid|MEDICAID HMO|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Medicare|MEDICARE ACUTE|0.56||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicare|BCBS MEDICARE PPO MA|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|MEDICAID HMO|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|MEDICAID|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicare|MEDICARE ACUTE|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|TML GROUP BENEFITS|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|UNITED HEALTHCARE|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Tricare|TRICARE EAST REGION|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|PHCS|HUMANA INSURANCE|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|44.75||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicare|MEDICARE PART B ONLY IP|44.75||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aetna|AETNA PPO|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aetna|AETNA OTHER|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicare|HEALTHSPRING MA|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Humana Medicare Advantage|HUMANA MA|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Cigna|CIGNA|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|ChampVA|CHAMPVA CENTER|44.75||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||44.75||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Cigna|CIGNA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aetna|AETNA PPO|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Healthcare|TML GROUP BENEFITS|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Healthcare|UNITED HEALTHCARE|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Tricare|TRICARE EAST REGION|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicare|WELLCARE CHOICE MA|59.25||||||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicare|HEALTHSPRING MA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Humana Medicare Advantage|HUMANA MA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|MEDICAID HMO|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|MEDICAID|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|59.25||||||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicare|MEDICARE ACUTE|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicare|MEDICARE PART B ONLY IP|59.25||||||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicare|HEALTHSPRING MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicaid|MEDICAID|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicaid|MEDICAID HMO|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicare|MEDICARE ACUTE|71.25||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicare|MEDICARE PART B ONLY IP|71.25||||||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Healthcare|UNITED HEALTHCARE|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Healthcare|GOLDEN RULE|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Tricare|TRICARE EAST REGION|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|71.25||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Aetna|AETNA OTHER|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Workers Compensation|WORKERS COMP PHYSICIAN|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Cigna|CIGNA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Humana Medicare Advantage|HUMANA MA|71.25||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||71.25||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Managed Medicaid|MEDICAID SUPERIOR|0.59||||0.59||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.59||||||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Cigna|CIGNA|0.59||||||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Managed Medicaid|MEDICAID AMERIGROUP|0.59||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.20||||2.20||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Humana Medicare Advantage|HUMANA MA|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Cigna|CIGNA|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|2.20||||2.20||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicare|MEDICARE ACUTE|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicare|HEALTHSPRING MA|||||2.20||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Aetna|AETNA PPO|2.20||||||| 9517152|ERX|0250|PROTAMINE 50MG/5ML|Medicare|MEDICARE ACUTE|75.75||||||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||38.25||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Aetna|AETNA PPO|||||38.25||| 9517178|ERX|0250|CEFAZOLIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|38.25||||38.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Blue Cross PPO Specialty|BCBSTX PPO|865.25||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicare|BCBS MEDICARE PPO MA|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicare|MEDICARE ACUTE|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicaid|MEDICAID AMERIGROUP|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Humana Medicare Advantage|HUMANA MA|||||865.25||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|0.50||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Medicaid|MEDICAID|||||15.75||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|NON CONTRACTED|COMMERCIAL OTHER 1|15.75||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|15.75||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||15.75||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.75||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||15.75||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Humana Medicare Advantage|HUMANA MA|||||15.75||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||15.75||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.75||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Medicare|MEDICARE ACUTE|15.75||||15.75||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|124.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|124.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|124.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|124.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicare|MEDICARE ACUTE|124.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||124.25||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|0.37||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|0.37||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicare|HEALTHSPRING MA|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicare|MEDICARE PART B ONLY IP|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Healthcare|UNITED HEALTHCARE|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicaid|MEDICAID|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicare|MEDICARE ACUTE|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.63||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.63||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Cigna|CIGNA|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Humana Medicare Advantage|HUMANA MA|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicare|WELLCARE CHOICE MA|1.63||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.63||| 9517392|ERX|0250|PENTAMIDINE NEB 300MG VIA|Medicare|MEDICARE ACUTE|||||975.50||| 9517400|ERX|0250|OFLOXACIN EAR DROPS, 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|140.50||||||| 9517400|ERX|0250|OFLOXACIN EAR DROPS, 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|140.50||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Humana Medicare Advantage|HUMANA MA|93.75||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Blue Cross PPO Specialty|BCBSTX PPO|93.75||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Medicare|MEDICARE ACUTE|93.75||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|93.75||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|United Medicare Advantage|AARP UHC WEST COMPLETE MA|93.75||||93.75||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|United Medicare Advantage|UHC MEDICARE GOLD MA|93.75||||93.75||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Humana Medicare Advantage|HUMANA MA|93.75||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Blue Cross PPO Specialty|BCBSTX PPO|93.75||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Medicaid|COUNTY INDIGENT HEALTH OTHER|93.75||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Medicare|MEDICARE ACUTE|93.75||||93.75||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||93.75||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Medicare|MEDICARE ACUTE|0.20||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Cigna|CIGNA|0.20||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Humana Medicare Advantage|HUMANA MA|||||0.20||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|0.20||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Medicare|MEDICARE PART B ONLY IP|||||0.20||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.20||||||| 9517566|ERX|0250|NALBUPHINE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|0.20||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Humana Medicare Advantage|HUMANA MA|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicaid|MEDICAID AMERIGROUP|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Medicare|MEDICARE ACUTE|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||17.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicaid|COUNTY INDIGENT HEALTH OTHER|79.50||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicare|HEALTHSPRING MA|79.50||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Aetna|AETNA PPO|79.50||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|79.50||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Veterans Affairs|VETERANS ADMINISTRATION|79.50||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|79.50||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Humana Medicare Advantage|HUMANA MA|79.50||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|79.50||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|79.50||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicare|MEDICARE ACUTE|79.50||||79.50||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.51||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Humana Medicare Advantage|HUMANA MA|0.51||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.51||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.51||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.51||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicare|MEDICARE ACUTE|0.51||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||0.51||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Medicare|MEDICARE ACUTE|15.75||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.25||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.25||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Humana Medicare Advantage|HUMANA MA|7.25||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Medicaid|MEDICAID|||||7.25||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Medicare|MEDICARE ACUTE|7.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Medicare|MEDICARE ACUTE|0.08||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||24.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|||||24.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||24.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Managed Medicare|WELLCARE CHOICE MA|||||24.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Medicaid|COUNTY INDIGENT HEALTH OTHER|24.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Medicare|MEDICARE PART B ONLY IP|24.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|29.50||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||29.50||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Humana Medicare Advantage|HUMANA MA|29.50||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Medicare|MEDICARE ACUTE|29.50||||29.50||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.50||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Humana Medicare Advantage|HUMANA MA|||||46.75||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Medicare|MEDICARE ACUTE|46.75||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|34.50||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||34.50||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Tricare|TRICARE EAST REGION|163.50||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Medicare|MEDICARE ACUTE|163.50||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|United Medicare Advantage|UHC MEDICARE GOLD MA|163.50||||163.50||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Aetna|AETNA PPO|163.50||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Blue Cross PPO Specialty|BCBSTX PPO|163.50||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Managed Medicaid|MEDICAID AMERIGROUP|163.50||||||| 9517905|ERX|0250|HYDROCORTISONE 2.5% RECT|Managed Medicaid|MEDICAID SUPERIOR|163.50||||||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Medicare|MEDICARE ACUTE|39.50||||||| 9518101|ERX|0250|PSEUDOEPHEDRINE 30MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Medicare|MEDICARE ACUTE|34.50||||34.50||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|34.50||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|34.50||||34.50||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||34.50||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|34.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Humana Medicare Advantage|HUMANA MA|||||102.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||102.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Medicaid|MEDICAID HMO|||||102.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Medicare|MEDICARE ACUTE|||||102.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Tricare|TRICARE EAST REGION|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Managed Medicare|HEALTHSPRING MA|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Medicare|MEDICARE ACUTE|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||25.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|25.50||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Cigna|CIGNA|0.05||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|0.05||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicare|MEDICARE ACUTE|0.05||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Managed Medicare|BCBS MEDICARE PPO MA|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Medicare|MEDICARE ACUTE|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Blue Cross PPO Specialty|BCBSTX PPO|14.50||||14.50||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.50||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|14.50||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|United Medicare Advantage|UHC MEDICARE GOLD MA|14.50||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Veterans Affairs|VETERANS ADMINISTRATION|14.50||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Tricare|TRICARE EAST REGION|||||14.50||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Medicare|MEDICARE ACUTE|14.50||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Humana Medicare Advantage|HUMANA MA|14.50||||14.50||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Medicare|MEDICARE ACUTE|28.50||||||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Humana Medicare Advantage|HUMANA MA|28.50||||28.50||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Managed Medicaid|MEDICAID AMERIGROUP|||||28.50||| 9518655|ERX|0250|COD LIVER OIL-ZN OXIDE ,3|Managed Medicaid|MEDICAID SUPERIOR|28.50||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.10||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicaid|MEDICAID SUPERIOR|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Medicare|MEDICARE PART B ONLY IP|||||0.10||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Medicare|MEDICARE ACUTE|0.10||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Medicare|MEDICARE ACUTE|541.80||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||541.80||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||541.80||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Veterans Affairs|VETERANS ADMINISTRATION|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|Medicare|MEDICARE ACUTE|2.50||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Medicare|MEDICARE ACUTE|444.25||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Humana Medicare Advantage|HUMANA MA|444.25||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Blue Cross PPO Specialty|BCBSTX PPO|444.25||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|444.25||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Veterans Affairs|VETERANS ADMINISTRATION|12.25||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Humana Medicare Advantage|HUMANA MA|||||12.25||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Managed Medicaid|MEDICAID SUPERIOR|12.25||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.25||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Medicare|MEDICARE ACUTE|12.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.06||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.06||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.27||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Medicare|MEDICARE ACUTE|0.27||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.27||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.27||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Managed Medicaid|MEDICAID SUPERIOR|0.27||||0.27||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.27||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Managed Medicaid|MEDICAID AMERIGROUP|1.14||||||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Managed Medicaid|MEDICAID SUPERIOR|1.14||||||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Aetna|AETNA OTHER|||||1.14||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicare|HEALTHSPRING MA|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Medicare|MEDICARE ACUTE|0.06||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|NON CONTRACTED|COMMERCIAL OTHER 1|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.06||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicare|BCBS MEDICARE PPO MA|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.06||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross PPO Specialty|BCBSTX PPO|0.06||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Humana Medicare Advantage|HUMANA MA|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicaid|MEDICAID AMERIGROUP|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.06||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|152.50||||152.50||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|152.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|152.50||||||| 9519687|ERX|0250|VANCO ORAL SOLN 250MG/5ML|Medicare|MEDICARE ACUTE|152.50||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Tricare|TRICARE EAST REGION|16.50||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Medicaid|MEDICAID|16.50||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Managed Medicaid|MEDICAID SUPERIOR|16.50||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|16.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Managed Medicaid|MEDICAID SUPERIOR|24.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|24.50||||||| 9519851|ERX|0250|MISOPROSTOL 200MCG TABLET|Medicaid|MEDICAID|24.50||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||12.75||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Medicare|MEDICARE PART B ONLY IP|12.75||||||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||12.75||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|Humana Medicare Advantage|HUMANA MA|12.75||||12.75||| 9519919|ERX|0250|CHOLECALCIFEROL 2000 UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||12.75||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||25.50||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||25.50||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||25.50||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|25.50||||25.50||| 9519950|ERX|0250|CELECOXIB 100MG CAPSULE|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicare|HEALTHSPRING MA|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Medicare|MEDICARE ACUTE|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||12.75||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Humana Medicare Advantage|HUMANA MA|12.75||||12.75||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.75||||||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Blue Cross PPO Specialty|BCBSTX PPO|||||7.25||| 9520065|ERX|0250|BACITRACIN ZINC 500 UNIT,|Medicare|MEDICARE ACUTE|||||7.25||| 9520222|ERX|0250|NYSTATIN 500000 UNIT,5ML|Medicare|MEDICARE ACUTE|0.11||||||| 9520222|ERX|0250|NYSTATIN 500000 UNIT,5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.11||||||| 9520222|ERX|0250|NYSTATIN 500000 UNIT,5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.11||||||| 9520222|ERX|0250|NYSTATIN 500000 UNIT,5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.11||||||| 9520222|ERX|0250|NYSTATIN 500000 UNIT,5ML|Blue Cross PPO Specialty|BCBSTX PPO|0.11||||||| 9520222|ERX|0250|NYSTATIN 500000 UNIT,5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.11||||||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|Medicare|MEDICARE ACUTE|30.25||||||| 9520370|ERX|0250|NIACIN SR 250MG CAPSULE|Medicare|MEDICARE ACUTE|||||12.75||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Veterans Affairs|VETERANS ADMINISTRATION|||||111.25||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Medicare|MEDICARE ACUTE|||||111.25||| 9520834|ERX|0250|DABIGATRAN 75MG CAPSULE|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9520875|ERX|0636||Aetna|AETNA PPO|98.25||||||| 9520875|ERX|0636||Blue Cross HMO Specialty|BCBSTX HMO|98.25||||||| 9520875|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|98.25||||98.25||| 9520875|ERX|0636||Aetna|AETNA OTHER|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross PPO Specialty|BCBSTX PPO|98.25||||||| 9520875|ERX|0636||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|98.25||||98.25||| 9520875|ERX|0636||Access Direct Platinum|HEALTHFIRST TPA UMR|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Aenta Medicare Advantage|AETNA MEDICARE MA|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Cigna|CIGNA|98.25||||98.25||| 9520875|ERX|0636||Blue Cross PPO Specialty|BCBSTX PPO|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|98.25||||||| 9520875|ERX|0636||Humana Medicare Advantage|HUMANA MA|98.25||||98.25||| 9520875|ERX|0636||Cigna|CIGNA|98.25||||98.25||| 9520875|ERX|0636||Workers Compensation|WORKERS COMPENSATION OTHER|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Veterans Affairs|VETERANS ADMINISTRATION|98.25||||||| 9520875|ERX|0636||United Medicare Advantage|UHC MEDICARE GOLD MA|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID SUPERIOR|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID AMERIGROUP|98.25||||||| 9520875|ERX|0636||Cigna|CIGNA|||||98.25||| 9520875|ERX|0636||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID UNITED HEALTHCARE|98.25||||||| 9520875|ERX|0636||United Medicare Advantage|AARP UHC WEST COMPLETE MA|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Medicare Advantage|UHC MEDICARE GOLD MA|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Medicare Advantage|AARP UHC WEST COMPLETE MA|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|98.25||||||| 9520875|ERX|0636||UTMB|UTMB CORRECTIONAL MANAGED CARE|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Humana Medicare Advantage|HUMANA MA|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|UNITED HEALTHCARE|98.25||||98.25||| 9520875|ERX|0636||NON CONTRACTED|COMMERCIAL OTHER 1|98.25||||98.25||| 9520875|ERX|0636||Medicare|MEDICARE ACUTE|98.25||||98.25||| 9520875|ERX|0636||United Healthcare|UNITED HEALTHCARE|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicare|HEALTHSPRING MA|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|MEDICAID HMO|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|NON CONTRACTED|COMMERCIAL OTHER 1|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|MOLINA HEALTHCARE OF TEXAS|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||98.25||| 9520875|ERX|0636||Managed Medicaid|MEDICAID UNITED HEALTHCARE|98.25||||||| 9520875|ERX|0636||Managed Medicaid|MEDICAID SUPERIOR|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|MEDICAID|98.25||||||| 9520875|ERX|0636||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|98.25||||||| 9520875|ERX|0636||Managed Medicaid|MEDICAID AMERIGROUP|98.25||||||| 9520875|ERX|0636||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicare|MEDICARE ACUTE|98.25||||98.25||| 9520875|ERX|0636||Medicaid|MEDICAID|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|98.25||||||| 9520875|ERX|0636||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicare|MEDICARE PART B ONLY IP|98.25||||||| 9520875|ERX|0636||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||98.25||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicare|HEALTHSPRING MA|6.69||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Medicare|MEDICARE ACUTE|6.69||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Blue Cross PPO Specialty|BCBSTX PPO|6.69||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Aenta Medicare Advantage|AETNA MEDICARE MA|6.69||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|36.75||||||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||36.75||| 9521246|ERX|0250|PAROXETINE 10MG TABLET|Medicare|MEDICARE ACUTE|36.75||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|39.25||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Medicare|MEDICARE ACUTE|39.25||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|39.25||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|39.25||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|39.25||||||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||61.25||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||61.25||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Medicare|MEDICARE ACUTE|61.25||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicare|HEALTHSPRING MA|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicaid|MEDICAID|83.75||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicare|MEDICARE ACUTE|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|83.75||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|83.75||||||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Humana Medicare Advantage|HUMANA MA|83.75||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||83.75||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Cigna|CIGNA|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Humana Medicare Advantage|HUMANA MA|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicaid|MEDICAID AMERIGROUP|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicaid|MEDICAID SUPERIOR|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Aetna|AETNA PPO|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Blue Cross PPO Specialty|BCBSTX PPO|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Workers Compensation|WORKERS COMPENSATION OTHER|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicare|BCBS MEDICARE PPO MA|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicare|HEALTHSPRING MA|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Medicare|MEDICARE ACUTE|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|United Healthcare|UNITED HEALTHCARE|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Tricare|TRICARE FOR LIFE|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Tricare|TRICARE EAST REGION|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Medicaid|MEDICAID|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|NON CONTRACTED|COMMERCIAL OTHER 1|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||99.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Medicare|MEDICARE ACUTE|565.25||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Medicaid|MEDICAID|565.25||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicare|HEALTHSPRING MA|565.25||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|United Medicare Advantage|UHC MEDICARE GOLD MA|565.25||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|565.25||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Aenta Medicare Advantage|AETNA MEDICARE MA|565.25||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Blue Cross PPO Specialty|BCBSTX PPO|565.25||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|565.25||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Cigna|CIGNA|||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Humana Medicare Advantage|HUMANA MA|565.25||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|565.25||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|565.25||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicaid|MEDICAID AMERIGROUP|565.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Humana Medicare Advantage|HUMANA MA|252.25||||252.25||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Blue Cross HMO Specialty|BCBSTX HMO|252.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|United Medicare Advantage|AARP UHC WEST COMPLETE MA|252.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Medicare|MEDICARE ACUTE|252.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Medicare|MEDICARE PART B ONLY IP|252.25||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Medicare|MEDICARE ACUTE|477.50||||477.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||477.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicare|HEALTHSPRING MA|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Blue Cross HMO Specialty|BCBSTX HMO|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Blue Cross PPO Specialty|BCBSTX PPO|||||477.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||477.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Humana Medicare Advantage|HUMANA MA|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||477.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|477.50||||||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Cigna|CIGNA|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|0.06||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|0.06||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Aetna|AETNA PPO|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.06||||||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|United Healthcare|UNITED HEALTHCARE|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Tricare|TRICARE EAST REGION|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|MEDICAID|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|MEDICAID HMO|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.06||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Medicare|MEDICARE ACUTE|135.25||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|135.25||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Humana Medicare Advantage|HUMANA MA|135.25||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|135.25||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Cigna|CIGNA|135.25||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||24.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||24.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||65.25||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|65.25||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||65.25||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|65.25||||||| 9521691|ERX|0250|TRAMADOL/ACETAMIN 37.5-32|Medicare|MEDICARE ACUTE|18.50||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Workers Compensation|WORKERS COMP PHYSICIAN|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Cigna|CIGNA|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Humana Medicare Advantage|HUMANA MA|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Aetna|AETNA PPO|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Aetna|AETNA OTHER|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Healthcare|UNITED HEALTHCARE|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|PHCS|MULTIPLAN PHCS|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Tricare|TRICARE EAST REGION|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicare|HEALTHSPRING MA|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|MEDICAID|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicare|WELLCARE CHOICE MA|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.33||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Medicare|MEDICARE ACUTE|1.33||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|1.33||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.33||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Humana Medicare Advantage|HUMANA MA|1.33||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.33||||1.33||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||247.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||247.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Humana Medicare Advantage|HUMANA MA|247.50||||247.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|247.50||||247.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Aetna|AETNA PPO|||||247.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|247.50||||247.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||247.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Medicaid|MEDICAID|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Medicare|MEDICARE ACUTE|247.50||||247.50||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Medicare|MEDICARE ACUTE|1,035.75||||||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|United Healthcare|UNITED HEALTHCARE|||||1,035.75||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,035.75||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,035.75||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,035.75||| 9521915|ERX|0250|PENICILLIN G POTASSIUM 5|Managed Medicaid|MEDICAID SUPERIOR|65.50||||||| 9521949|ERX|0250|GLIPIZIDE XL 5MG TABLET|Medicare|MEDICARE ACUTE|0.09||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.20||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||0.20||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.20||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Medicare|MEDICARE ACUTE|||||0.20||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Tricare|TRICARE EAST REGION|163.75||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|163.75||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|163.75||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicaid|MEDICAID SUPERIOR|163.75||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicaid|MEDICAID AMERIGROUP|163.75||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||163.75||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|163.75||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|117.50||||117.50||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|117.50||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|117.50||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|117.50||||117.50||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||117.50||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|117.50||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Medicaid|MEDICAID HMO|||||117.50||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Medicare|MEDICARE ACUTE|117.50||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Medicare|MEDICARE ACUTE|261.25||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|261.25||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.45||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.45||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Cigna|CIGNA|||||1.45||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Humana Medicare Advantage|HUMANA MA|1.45||||1.45||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.45||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicare|HEALTHSPRING MA|1.45||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.45||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Medicare|MEDICARE ACUTE|1.45||||1.45||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||1.45||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Medicare|MEDICARE ACUTE|||||0.65||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|0.65||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.65||||0.65||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|36.75||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|36.75||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|36.75||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|36.75||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.75||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.75||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|ChampVA|CHAMPVA CENTER|36.75||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|36.75||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicaid|MEDICAID|||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicare|WELLCARE CHOICE MA|||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|36.75||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicare|MEDICARE ACUTE|36.75||||36.75||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Medicare|MEDICARE ACUTE|36.75||||36.75||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|36.75||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.75||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Aetna|AETNA PPO|36.75||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||36.75||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36.75||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|36.75||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|36.75||||||| 9522160|ERX|0250|SERTRALINE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|36.75||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|196.25||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|196.25||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Cigna|CIGNA|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Humana Medicare Advantage|HUMANA MA|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|UNITED HEALTHCARE|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Tricare|TRICARE EAST REGION|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|196.25||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|196.25||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|HEALTHSPRING MA|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicare|MEDICARE ACUTE|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|196.25||||196.25||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|Managed Medicare|HEALTHSPRING MA|313.50||||||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|Medicare|MEDICARE ACUTE|313.50||||||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|UTMB|UTMB CORRECTIONAL MANAGED CARE|313.50||||||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|Humana Medicare Advantage|HUMANA MA|313.50||||||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|313.50||||313.50||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|313.50||||||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|313.50||||||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|313.50||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Aetna|AETNA OTHER|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Healthcare|UNITED HEALTHCARE|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Tricare|TRICARE EAST REGION|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|MEDICAID HMO|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|MEDICAID|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicare|HEALTHSPRING MA|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicare|MEDICARE ACUTE|0.04||||0.04||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Medicare|MEDICARE ACUTE|0.06||||0.06||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|United Healthcare|UNITED HEALTHCARE|||||0.06||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|||||0.06||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||0.06||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.06||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||0.06||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.06||| 9522319|ERX|0250|PREDNISONE 50MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.06||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Medicare Advantage|UHC MEDICARE GOLD MA|85.75||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|85.75||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|85.75||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Blue Cross PPO Specialty|BCBSTX PPO|85.75||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Humana Medicare Advantage|HUMANA MA|85.75||||85.75||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||85.75||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|85.75||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||85.75||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Medicaid|MEDICAID|85.75||||85.75||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Medicare|MEDICARE ACUTE|85.75||||85.75||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Medicare|MEDICARE ACUTE|0.18||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Humana Medicare Advantage|HUMANA MA|||||0.18||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.09||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.09||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||0.09||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||0.09||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||0.09||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.50||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||15.50||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|Medicare|MEDICARE ACUTE|0.35||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.75||||||| 9522699|ERX|0250|METHADONE 5MG TABLET|Medicare|MEDICARE ACUTE|6.75||||6.75||| 9522699|ERX|0250|METHADONE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|6.75||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Medicare|MEDICARE ACUTE|7.50||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|7.50||||7.50||| 9522707|ERX|0250|METHADONE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Medicare|MEDICARE ACUTE|14.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||0.15||| 9522756|ERX|0250|WARFARIN 5MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.15||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.15||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.15||||||| 9522764|ERX|0250|WARFARIN 7.5MG TABLET|Medicare|MEDICARE ACUTE|18.25||||||| 9522962|ERX|0250|BRINZOLAMIDE 1% EYE DROP,|Medicare|MEDICARE ACUTE|649.25||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||606.25||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Medicare|MEDICARE ACUTE|0.94||||0.94||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicaid|MEDICAID SUPERIOR|0.94||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.94||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|||||0.94||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||26.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||26.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Aetna|AETNA PPO|||||26.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Humana Medicare Advantage|HUMANA MA|||||26.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicaid|MEDICAID SUPERIOR|26.25||||26.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicaid|MEDICAID|||||26.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicare|MEDICARE ACUTE|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Healthcare|UNITED HEALTHCARE|||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|MEDICAID HMO|||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicare|HEALTHSPRING MA|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicare|MEDICARE ACUTE|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|COUNTY INDIGENT HEALTH OTHER|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicare|MEDICARE PART B ONLY IP|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Cigna|CIGNA|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Humana Medicare Advantage|HUMANA MA|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID SUPERIOR|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|MEDICAID|||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Access Direct Platinum|HEALTHFIRST TPA UMR|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|26.25||||26.25||| 9523317|ERX|0250|RIFAMPIN 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.32||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||||| 9523390|ERX|0250|AMLODIPINE 2.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Healthcare|UNITED HEALTHCARE|||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Tricare|TRICARE EAST REGION|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid|MEDICAID|||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Managed Medicare|HEALTHSPRING MA|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Medicare|MEDICARE ACUTE|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|PHCS|MULTIPLAN PHCS|||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||29.50||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.05||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Humana Medicare Advantage|HUMANA MA|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Aetna|AETNA OTHER|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|1.05||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.05||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Healthcare|UNITED HEALTHCARE|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Tricare|TRICARE EAST REGION|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|MEDICAID HMO|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|MEDICAID|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicare|MEDICARE ACUTE|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.05||||1.05||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||31.50||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Medicare|MEDICARE ACUTE|31.50||||31.50||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Healthcare|UNITED HEALTHCARE|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|31.50||||31.50||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||31.50||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||31.50||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||31.50||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|31.50||||31.50||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31.50||||31.50||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicaid|MEDICAID|||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicare|HEALTHSPRING MA|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicare|MEDICARE ACUTE|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Cigna|CIGNA|||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.45||||0.45||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.45||||0.45||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicare|HEALTHSPRING MA|0.45||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicare|BCBS MEDICARE PPO MA|0.45||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.45||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicare|MEDICARE ACUTE|0.45||||0.45||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.45||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.45||||0.45||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.45||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.45||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.45||||0.45||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.45||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.45||||0.45||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.45||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.45||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Humana Medicare Advantage|HUMANA MA|0.45||||0.45||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.45||||0.45||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||7.50||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|7.50||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.13||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicare|BCBS MEDICARE PPO MA|||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Tricare|TRICARE EAST REGION|0.13||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.13||||0.13||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Aetna|AETNA PPO|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicare|HEALTHSPRING MA|||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Healthcare|UNITED HEALTHCARE|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Tricare|TRICARE EAST REGION|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||24.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Medicare|MEDICARE ACUTE|24.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||24.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||24.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||24.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||24.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||24.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Medicare|MEDICARE ACUTE|24.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||24.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|24.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||24.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Humana Medicare Advantage|HUMANA MA|20.25||||20.25||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.25||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.25||||20.25||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|20.25||||20.25||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||20.25||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|20.25||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Medicare|MEDICARE ACUTE|20.25||||20.25||| 9523705|ERX|0250|PHENYTOIN 100MG/4ML, 30ML|Blue Cross HMO Specialty|BCBSTX HMO|||||72.75||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.18||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Medicare|MEDICARE ACUTE|0.18||||0.18||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.18||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.18||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.18||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.18||||0.18||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||184.50||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Medicare|MEDICARE ACUTE|||||184.50||| 9523788|ERX|0250|HYDROCOD-IBUPR 7.5-200MG|Medicaid|MEDICAID|27.75||||||| 9523788|ERX|0250|HYDROCOD-IBUPR 7.5-200MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.75||||||| 9523788|ERX|0250|HYDROCOD-IBUPR 7.5-200MG|Managed Medicaid|MEDICAID SUPERIOR|27.75||||||| 9523788|ERX|0250|HYDROCOD-IBUPR 7.5-200MG|Managed Medicaid|MEDICAID AMERIGROUP|27.75||||||| 9523788|ERX|0250|HYDROCOD-IBUPR 7.5-200MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.75||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Medicare|MEDICARE ACUTE|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.59||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Medicare|MEDICARE ACUTE|24.50||||||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|Veterans Affairs|VETERANS ADMINISTRATION|14.75||||||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|Medicare|MEDICARE ACUTE|14.75||||||| 9524091|ERX|0250|DIVALPROEX SPRINKLE 125MG|Humana Medicare Advantage|HUMANA MA|14.75||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||24.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||24.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Managed Medicare|HEALTHSPRING MA|||||24.50||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||24.50||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||36.75||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||36.75||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Medicare|MEDICARE ACUTE|36.75||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||36.75||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.75||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Humana Medicare Advantage|HUMANA MA|36.75||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.30||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Medicare|MEDICARE ACUTE|0.30||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Humana Medicare Advantage|HUMANA MA|||||0.30||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.30||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.30||||0.30||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross HMO Specialty|BCBSTX HMO|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Humana Medicare Advantage|HUMANA MA|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID SUPERIOR|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID AMERIGROUP|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Cigna|CIGNA|||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|MEDICAID|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross PPO Specialty|BCBSTX PPO|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|BCBS MEDICARE PPO MA|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|HEALTHSPRING MA|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicare|MEDICARE ACUTE|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicare|MEDICARE PART B ONLY IP|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Healthcare|UNITED HEALTHCARE|||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Tricare|TRICARE EAST REGION|||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|NON CONTRACTED|COMMERCIAL OTHER 1|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Veterans Affairs|VETERANS ADMINISTRATION|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.37||||3.37||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Medicare|MEDICARE ACUTE|493.75||||493.75||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||493.75||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Veterans Affairs|VETERANS ADMINISTRATION|||||493.75||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Workers Compensation|WORKERS COMPENSATION OTHER|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||493.75||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Blue Cross HMO Specialty|BCBSTX HMO|||||493.75||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Blue Cross PPO Specialty|BCBSTX PPO|493.75||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Tricare|TRICARE EAST REGION|606.75||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Medicare Advantage|UHC MEDICARE GOLD MA|606.75||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Veterans Affairs|VETERANS ADMINISTRATION|||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Blue Cross HMO Specialty|BCBSTX HMO|606.75||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Blue Cross PPO Specialty|BCBSTX PPO|606.75||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|606.75||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Aenta Medicare Advantage|AETNA MEDICARE MA|606.75||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Humana Medicare Advantage|HUMANA MA|606.75||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|606.75||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|606.75||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicare|HEALTHSPRING MA|||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Managed Medicare|BCBS MEDICARE PPO MA|||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Medicare|MEDICARE PART B ONLY IP|606.75||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Medicare|MEDICARE ACUTE|606.75||||606.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|758.75||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|758.75||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Medicare|MEDICARE ACUTE|758.75||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicare|HEALTHSPRING MA|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Humana Medicare Advantage|HUMANA MA|758.75||||758.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|252.75||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|252.75||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Medicare Advantage|UHC MEDICARE GOLD MA|252.75||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Veterans Affairs|VETERANS ADMINISTRATION|||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Blue Cross HMO Specialty|BCBSTX HMO|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Blue Cross PPO Specialty|BCBSTX PPO|252.75||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Aenta Medicare Advantage|AETNA MEDICARE MA|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Humana Medicare Advantage|HUMANA MA|252.75||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|252.75||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|252.75||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Tricare|TRICARE EAST REGION|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicare|MEDICARE ACUTE|252.75||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicaid|MEDICAID|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicare|HEALTHSPRING MA|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Healthcare|UNITED HEALTHCARE|252.75||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Healthcare|UNITED HEALTHCARE OTHER|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Humana Medicare Advantage|HUMANA MA|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Medicare|MEDICARE ACUTE|809.50||||809.50||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Blue Cross PPO Specialty|BCBSTX PPO|809.50||||809.50||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicare|HEALTHSPRING MA|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Tricare|TRICARE EAST REGION|809.50||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,011.75||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|1,011.75||||||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Medicare|MEDICARE ACUTE|||||1,011.75||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|||||1,011.75||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,011.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Medicaid|MEDICAID|76.75||||76.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Cigna|CIGNA|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Managed Medicaid|MEDICAID AMERIGROUP|76.75||||76.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Access Direct Platinum|HEALTHFIRST TPA UMR|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Blue Cross PPO Specialty|BCBSTX PPO|76.75||||76.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Aetna|AETNA PPO|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Managed Medicaid|MEDICAID SUPERIOR|76.75||||||| 9524562|ERX|0250|RIVASTIGMINE 1.5MG CAPSUL|Medicare|MEDICARE ACUTE|38.25||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|25.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9524828|ERX|0250|VALSARTAN 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||24.50||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.75||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|21.75||||21.75||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|21.75||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Medicare|MEDICARE ACUTE|21.75||||||| 9524919|ERX|0250|OXCARBAZEPINE 150MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||21.75||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|Medicare|MEDICARE PART B ONLY IP|||||0.62||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.62||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.62||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.62||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Medicare|MEDICARE ACUTE|8.25||||||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.25||| 9524950|ERX|0250|CARBAMAZEPINE 100MG TABLE|Humana Medicare Advantage|HUMANA MA|8.25||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Medicaid|MEDICAID|3.70||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Medicaid|MEDICAID HMO|3.70||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Aetna|AETNA OTHER|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Aetna|AETNA PPO|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross PPO Specialty|BCBSTX PPO|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.70||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID AMERIGROUP|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID SUPERIOR|3.70||||3.70||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Managed Medicaid|MEDICAID SUPERIOR|386.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicaid|MEDICAID HMO|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicaid|MEDICAID|91.50||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicare|HEALTHSPRING MA|91.50||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicare|MEDICARE ACUTE|91.50||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|91.50||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Cigna|CIGNA|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Humana Medicare Advantage|HUMANA MA|91.50||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|91.50||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|91.50||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|91.50||||91.50||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicaid|MEDICAID SUPERIOR|||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|United Medicare Advantage|UHC MEDICARE GOLD MA|323.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Medicare|MEDICARE ACUTE|323.25||||323.25||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicare|HEALTHSPRING MA|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Medicare|MEDICARE ACUTE|63.75||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Humana Medicare Advantage|HUMANA MA|63.75||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|United Healthcare|UNITED HEALTHCARE|||||63.75||| 9525379|ERX|0250|K BICARB-CIT AC 25 MEQ TA|Blue Cross PPO Specialty|BCBSTX PPO|16.50||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Medicare|MEDICARE ACUTE|34.50||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||34.50||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||34.50||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Cigna|CIGNA|34.50||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|34.50||||||| 9525403|ERX|0250|TRAZODONE 150MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|34.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Medicare|MEDICARE ACUTE|29.50||||29.50||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|29.50||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||29.50||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Humana Medicare Advantage|HUMANA MA|29.50||||||| 9525437|ERX|0250|BUSPIRONE 15MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.50||||29.50||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Aetna|AETNA PPO|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Healthcare|UNITED HEALTHCARE|||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicare|HEALTHSPRING MA|0.15||||||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.15||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Medicare|MEDICARE ACUTE|0.23||||0.23||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.23||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|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|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicare|MEDICARE ACUTE|0.56||||0.56||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Aetna|AETNA PPO|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Medicaid|MEDICAID|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.56||||0.56||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.56||||0.56||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Humana Medicare Advantage|HUMANA MA|0.56||||0.56||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicaid|MEDICAID SUPERIOR|0.56||||0.56||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.56||||0.56||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Veterans Affairs|VETERANS ADMINISTRATION|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.56||||0.56||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.56||||0.56||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.56||||0.56||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Aetna|AETNA PPO|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Aetna|AETNA OTHER|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicare|HEALTHSPRING MA|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Medicare|MEDICARE ACUTE|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Healthcare|UNITED HEALTHCARE|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Tricare|TRICARE EAST REGION|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Cigna|CIGNA|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|||||2.78||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Healthcare|UNITED HEALTHCARE|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicaid|MEDICAID HMO|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicaid|MEDICAID|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicare|HEALTHSPRING MA|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicare|MEDICARE ACUTE|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|163.75||||||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Aetna|AETNA PPO|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Cigna|CIGNA|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Humana Medicare Advantage|HUMANA MA|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicaid|MEDICAID AMERIGROUP|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Veterans Affairs|VETERANS ADMINISTRATION|||||163.75||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Blue Cross PPO Specialty|BCBSTX PPO|11.75||||||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Medicare|MEDICARE ACUTE|31.25||||||| 9525817|ERX|0250|SOTALOL 120MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|31.25||||||| 9525825|ERX|0250||Blue Cross HMO Specialty|BCBSTX HMO|||||2.43||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Medicaid|MEDICAID|||||60.75||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||60.75||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Managed Medicaid|MEDICAID AMERIGROUP|60.75||||60.75||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Managed Medicaid|MEDICAID SUPERIOR|60.75||||60.75||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Blue Cross PPO Specialty|BCBSTX PPO|||||60.75||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Blue Cross PPO Specialty|BCBSTX PPO|||||1.87||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.87||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Managed Medicaid|MEDICAID SUPERIOR|1.87||||1.87||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Managed Medicaid|MEDICAID AMERIGROUP|||||1.87||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.87||| 9525908|ERX|0250|CEPHALEXIN 250MG/5ML,100M|Medicaid|MEDICAID HMO|||||1.87||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.30||||||| 9525957|ERX|0250|TORSEMIDE 100MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||0.30||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Cigna|CIGNA|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Humana Medicare Advantage|HUMANA MA|7.50||||7.50||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicaid|MEDICAID SUPERIOR|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicaid|MEDICAID AMERIGROUP|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Veterans Affairs|VETERANS ADMINISTRATION|7.50||||7.50||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|MEDICAID HMO|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|MEDICAID|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7.50||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|118.75||||118.75||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.75||||||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|118.75||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Medicaid|MEDICAID|25.25||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Medicare|MEDICARE ACUTE|25.25||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|25.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|United Healthcare|UNITED HEALTHCARE OTHER|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Tricare|TRICARE EAST REGION|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|MEDICAID|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|MEDICAID HMO|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicare|MEDICARE ACUTE|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Cigna|CIGNA|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Managed Medicaid|MEDICAID SUPERIOR|0.07||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Managed Medicaid|MEDICAID AMERIGROUP|0.07||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Aetna|AETNA PPO|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Blue Cross PPO Specialty|BCBSTX PPO|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.07||||||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|United Medicare Advantage|UHC MEDICARE GOLD MA|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.22||||||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Blue Cross PPO Specialty|BCBSTX PPO|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Cigna|CIGNA|0.22||||||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Humana Medicare Advantage|HUMANA MA|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Managed Medicaid|MEDICAID SUPERIOR|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Managed Medicaid|MEDICAID AMERIGROUP|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Medicaid|MEDICAID|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Medicare|MEDICARE ACUTE|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|United Healthcare|UNITED HEALTHCARE|0.22||||||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.22||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Medicaid|MEDICAID|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Medicare|MEDICARE ACUTE|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Cigna|CIGNA|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Managed Medicaid|MEDICAID SUPERIOR|0.28||||||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Managed Medicaid|MEDICAID AMERIGROUP|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Blue Cross PPO Specialty|BCBSTX PPO|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.28||| 9526534|ERX|0250|NON-FORMULARY DRUG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|Blue Cross HMO Specialty|BCBSTX HMO|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Blue Cross PPO Specialty|BCBSTX PPO|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|Humana Medicare Advantage|HUMANA MA|0.31||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|MEDICAID SUPERIOR|||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Medicare|MEDICARE ACUTE|0.31||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|Medicare|MEDICARE PART B ONLY IP|0.31||||||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||11.75||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|United Healthcare|UNITED HEALTHCARE|11.75||||||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|NON CONTRACTED|COMMERCIAL OTHER 1|11.75||||11.75||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|Cigna|CIGNA|11.75||||||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|Managed Medicaid|MEDICAID SUPERIOR|11.75||||11.75||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|Managed Medicaid|MEDICAID AMERIGROUP|11.75||||11.75||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|11.75||||||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|Aetna|AETNA PPO|11.75||||||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|Aetna|AETNA OTHER|||||11.75||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|Blue Cross PPO Specialty|BCBSTX PPO|11.75||||11.75||| 9526708|ERX|0250|PROMETHAZINE 25 MG/0.5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.75||||11.75||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|United Medicare Advantage|UHC MEDICARE GOLD MA|2.10||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.10||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Veterans Affairs|VETERANS ADMINISTRATION|2.10||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.10||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Blue Cross PPO Specialty|BCBSTX PPO|2.10||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.10||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Managed Medicaid|MEDICAID SUPERIOR|2.10||||2.10||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.10||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Medicaid|MEDICAID|2.10||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Medicare|MEDICARE ACUTE|2.10||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Medicare|MEDICARE PART B ONLY IP|2.10||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Managed Medicare|HEALTHSPRING MA|61.50||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Medicare|MEDICARE PART B ONLY IP|||||61.50||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Medicare|MEDICARE ACUTE|61.50||||61.50||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Humana Medicare Advantage|HUMANA MA|61.50||||61.50||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|61.50||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|61.50||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|61.50||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|61.50||||61.50||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||61.50||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Humana Medicare Advantage|HUMANA MA|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Medicare|MEDICARE ACUTE|||||11.75||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Medicare|MEDICARE ACUTE|||||40.25||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|40.25||||40.25||| 9526914|ERX|0250||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||152.25||| 9526914|ERX|0250||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||152.25||| 9526914|ERX|0250||United Medicare Advantage|UHC MEDICARE GOLD MA|152.25||||152.25||| 9526914|ERX|0250||Managed Medicaid|MEDICAID UNITED HEALTHCARE|152.25||||152.25||| 9526914|ERX|0250||Humana Medicare Advantage|HUMANA MA|152.25||||152.25||| 9526914|ERX|0250||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|152.25||||152.25||| 9526914|ERX|0250||Managed Medicaid|MEDICAID SUPERIOR|152.25||||152.25||| 9526914|ERX|0250||Managed Medicaid|MEDICAID AMERIGROUP|152.25||||152.25||| 9526914|ERX|0250||Aenta Medicare Advantage|AETNA MEDICARE MA|||||152.25||| 9526914|ERX|0250||Blue Cross HMO Specialty|BCBSTX HMO|152.25||||152.25||| 9526914|ERX|0250||Aetna|AETNA PPO|152.25||||||| 9526914|ERX|0250||Aetna|AETNA OTHER|152.25||||||| 9526914|ERX|0250||Blue Cross PPO Specialty|BCBSTX PPO|152.25||||152.25||| 9526914|ERX|0250||United Healthcare|UNITED HEALTHCARE|||||152.25||| 9526914|ERX|0250||NON CONTRACTED|COMMERCIAL OTHER 1|||||152.25||| 9526914|ERX|0250||UTMB|UTMB CORRECTIONAL MANAGED CARE|152.25||||152.25||| 9526914|ERX|0250||Medicaid|MEDICAID|152.25||||||| 9526914|ERX|0250||Managed Medicare|HEALTHSPRING MA|152.25||||||| 9526914|ERX|0250||Medicare|MEDICARE ACUTE|152.25||||152.25||| 9527003|ERX|0250|IBUPROFEN INFT 50 MG/1.25|Medicaid|MEDICAID HMO|||||47.50||| 9527003|ERX|0250|IBUPROFEN INFT 50 MG/1.25|Managed Medicaid|MEDICAID SUPERIOR|47.50||||47.50||| 9527003|ERX|0250|IBUPROFEN INFT 50 MG/1.25|Managed Medicaid|MEDICAID AMERIGROUP|47.50||||47.50||| 9527037|ERX|0250|BUDESONIDE 180 MCG INHALE|Blue Cross PPO Specialty|BCBSTX PPO|921.75||||||| 9527037|ERX|0250|BUDESONIDE 180 MCG INHALE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|921.75||||||| 9527037|ERX|0250|BUDESONIDE 180 MCG INHALE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|921.75||||||| 9527037|ERX|0250|BUDESONIDE 180 MCG INHALE|Humana Medicare Advantage|HUMANA MA|921.75||||||| 9527037|ERX|0250|BUDESONIDE 180 MCG INHALE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|921.75||||||| 9527037|ERX|0250|BUDESONIDE 180 MCG INHALE|Tricare|TRICARE EAST REGION|921.75||||||| 9527037|ERX|0250|BUDESONIDE 180 MCG INHALE|Medicare|MEDICARE ACUTE|921.75||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|MEDICAID|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|MEDICAID HMO|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|HEALTHSPRING MA|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|BCBS MEDICARE PPO MA|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicare|MEDICARE ACUTE|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicare|MEDICARE PART B ONLY IP|0.19||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|UNITED HEALTHCARE|0.19||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|UNITED HEALTHCARE|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Tricare|TRICARE EAST REGION|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|WELLCARE CHOICE MA|0.19||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Veterans Affairs|VETERANS ADMINISTRATION|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Cigna|CIGNA|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Humana Medicare Advantage|HUMANA MA|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicaid|MEDICAID SUPERIOR|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicaid|MEDICAID AMERIGROUP|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Aenta Medicare Advantage|AETNA MEDICARE MA|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross HMO Specialty|BCBSTX HMO|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Aetna|AETNA OTHER|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||0.19||| 9527235|ERX|0250|WARFARIN 4MG TABLET|Medicare|MEDICARE ACUTE|||||13.25||| 9527300|ERX|0250|PHENAZOPYRIDINE 200MG TAB|Medicare|MEDICARE ACUTE|||||0.11||| 9527334|ERX|0250|AZITHROMYCIN 100MG/5ML-15|Blue Cross PPO Specialty|BCBSTX PPO|||||211.75||| 9527334|ERX|0250|AZITHROMYCIN 100MG/5ML-15|Managed Medicaid|MEDICAID SUPERIOR|||||211.75||| 9527334|ERX|0250|AZITHROMYCIN 100MG/5ML-15|Managed Medicaid|MEDICAID AMERIGROUP|211.75||||211.75||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Medicare|MEDICARE ACUTE|48.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|48.50||||48.50||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||48.50||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Humana Medicare Advantage|HUMANA MA|48.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|48.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|48.50||||||| 9527441|ERX|0250|MOXIFLOXACIN 0.5% EYE DRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||533.50||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||44.75||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|Managed Medicare|HEALTHSPRING MA|44.75||||||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|Medicare|MEDICARE ACUTE|44.75||||44.75||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|Humana Medicare Advantage|HUMANA MA|||||44.75||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Workers Compensation|WORKERS COMPENSATION OTHER|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|United Medicare Advantage|UHC MEDICARE GOLD MA|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Aenta Medicare Advantage|AETNA MEDICARE MA|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Blue Cross HMO Specialty|BCBSTX HMO|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Blue Cross PPO Specialty|BCBSTX PPO|0.11||||0.11||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.11||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.11||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Humana Medicare Advantage|HUMANA MA|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Managed Medicaid|MEDICAID SUPERIOR|0.11||||0.11||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.11||||0.11||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|NON CONTRACTED|COMMERCIAL OTHER 1|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Medicare|MEDICARE PART B ONLY IP|0.11||||||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Medicare|MEDICARE ACUTE|0.11||||0.11||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Medicaid|MEDICAID|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|United Healthcare|UNITED HEALTHCARE|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Cigna|CIGNA|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Humana Medicare Advantage|HUMANA MA|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID SUPERIOR|103.25||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID AMERIGROUP|103.25||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Workers Compensation|WORKERS COMPENSATION OTHER|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.25||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Veterans Affairs|VETERANS ADMINISTRATION|||||103.25||| 9527557|ERX|0250|LIDOCAINE + EPINEPHRINE 2|Blue Cross PPO Specialty|BCBSTX PPO|||||103.25||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||41.75||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41.75||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|41.75||||41.75||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Humana Medicare Advantage|HUMANA MA|41.75||||41.75||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||41.75||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|41.75||||41.75||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|41.75||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||41.75||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|41.75||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Managed Medicare|HEALTHSPRING MA|41.75||||41.75||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Medicare|MEDICARE ACUTE|41.75||||41.75||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|Medicaid|COUNTY INDIGENT HEALTH OTHER|103.25||||||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|United Healthcare|UNITED HEALTHCARE|||||103.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|Blue Cross HMO Specialty|BCBSTX HMO|||||103.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||103.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|Humana Medicare Advantage|HUMANA MA|103.25||||103.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.25||||103.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|Veterans Affairs|VETERANS ADMINISTRATION|||||103.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.25||| 9527623|ERX|0250|AMIODARONE 150MG/100ML D5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Humana Medicare Advantage|HUMANA MA|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Managed Medicaid|MEDICAID SUPERIOR|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Managed Medicaid|MEDICAID AMERIGROUP|||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Blue Cross PPO Specialty|BCBSTX PPO|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Tricare|TRICARE EAST REGION|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Medicaid|MEDICAID|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Managed Medicare|HEALTHSPRING MA|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Medicare|MEDICARE PART B ONLY IP|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Medicare|MEDICARE ACUTE|2.09||||2.09||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Medicaid|MEDICAID|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Medicaid|MEDICAID HMO|||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Managed Medicare|HEALTHSPRING MA|||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.41||||||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Medicare|MEDICARE ACUTE|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|United Healthcare|UNITED HEALTHCARE OTHER|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|United Healthcare|UNITED HEALTHCARE|||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Tricare|TRICARE EAST REGION|||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Managed Medicare|BCBS MEDICARE PPO MA|1.41||||||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Cigna|CIGNA|||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Humana Medicare Advantage|HUMANA MA|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.41||||1.41||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.41||||||| 9527706|ERX|0250|CEFEPIME 1G/100ML NS|Veterans Affairs|VETERANS ADMINISTRATION|||||1.41||| 9527722|ERX|0250|CEFOXITIN 1G/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||103.25||| 9527722|ERX|0250|CEFOXITIN 1G/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|||||103.25||| 9527722|ERX|0250|CEFOXITIN 1G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|103.25||||||| 9527722|ERX|0250|CEFOXITIN 1G/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.25||||||| 9527722|ERX|0250|CEFOXITIN 1G/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||||| 9527722|ERX|0250|CEFOXITIN 1G/100ML NS|Medicare|MEDICARE ACUTE|||||103.25||| 9527730|ERX|0250|CEFTAZIDIME 1G/100ML NS|Medicare|MEDICARE ACUTE|103.75||||||| 9527730|ERX|0250|CEFTAZIDIME 1G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|||||103.75||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Veterans Affairs|VETERANS ADMINISTRATION|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Aetna|AETNA PPO|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Access Direct Platinum|HEALTHFIRST TPA UMR|487.50||||||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|487.50||||||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Cigna|CIGNA|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Humana Medicare Advantage|HUMANA MA|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|United Healthcare|UNITED HEALTHCARE|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|United Healthcare|UNITED HEALTHCARE|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|United Healthcare|TML GROUP BENEFITS|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Tricare|TRICARE EAST REGION|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Medicaid|MEDICAID|||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Managed Medicare|WELLCARE CHOICE MA|487.50||||||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Managed Medicare|HEALTHSPRING MA|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Medicare|MEDICARE ACUTE|487.50||||487.50||| 9527755|ERX|0250|CEFTRIAXONE 1G/100ML NS|Medicare|MEDICARE PART B ONLY IP|||||487.50||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|Medicare|MEDICARE PART B ONLY IP|220.25||||||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|Medicare|MEDICARE ACUTE|220.25||||220.25||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|Humana Medicare Advantage|HUMANA MA|220.25||||220.25||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|||||220.25||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||220.25||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|||||220.25||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|220.25||||||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|220.25||||||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||220.25||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|220.25||||220.25||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|220.25||||||| 9527763|ERX|0250|CEFTRIAXONE 2G/100ML NS|Veterans Affairs|VETERANS ADMINISTRATION|||||220.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Aetna|AETNA OTHER|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|111.25||||||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|111.25||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|United Healthcare|UNITED HEALTHCARE|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicaid|MEDICAID HMO|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicaid|MEDICAID|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicare|MEDICARE ACUTE|||||111.25||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicaid|MEDICAID|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicare|MEDICARE ACUTE|278.50||||||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Tricare|TRICARE EAST REGION|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Cigna|CIGNA|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|278.50||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|278.50||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|278.50||||278.50||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.25||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|103.25||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|||||103.25||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.25||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Humana Medicare Advantage|HUMANA MA|103.25||||103.25||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.25||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Medicaid|COUNTY INDIGENT HEALTH OTHER|103.25||||||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9527862|ERX|0250|DILTIAZEM 125MG/100ML NS|Medicare|MEDICARE PART B ONLY IP|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Medicaid|MEDICAID|103.25||||103.25||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Medicare|MEDICARE ACUTE|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Medicare|MEDICARE PART B ONLY IP|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Tricare|TRICARE EAST REGION|||||103.25||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Humana Medicare Advantage|HUMANA MA|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Managed Medicaid|MEDICAID AMERIGROUP|||||103.25||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Managed Medicaid|MEDICAID SUPERIOR|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Blue Cross PPO Specialty|BCBSTX PPO|||||103.25||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|United Medicare Advantage|UHC MEDICARE GOLD MA|103.25||||||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.95||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|Blue Cross PPO Specialty|BCBSTX PPO|3.95||||||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.95||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|Humana Medicare Advantage|HUMANA MA|3.95||||||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.95||||||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|Managed Medicaid|MEDICAID AMERIGROUP|||||3.95||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.95||||3.95||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|Managed Medicaid|MEDICAID SUPERIOR|3.95||||3.95||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|United Healthcare|UNITED HEALTHCARE|||||3.95||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|United Healthcare|UNITED HEALTHCARE OTHER|||||3.95||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|3.95||||||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.95||||3.95||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.95||| 9527946|ERX|0250|INSULIN,REG 100UNIT/100ML|Medicare|MEDICARE ACUTE|3.95||||3.95||| 9527995|ERX|0250|NAFCILLIN 1G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|||||103.25||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.25||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Blue Cross PPO Specialty|BCBSTX PPO|||||103.25||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Humana Medicare Advantage|HUMANA MA|||||103.25||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||103.25||| 9528019|ERX|0250|NOREPINEPHRINE 4MG/250ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.25||| 9528100|ERX|0250|TOBRAMYCIN 80MG/100ML NS|Humana Medicare Advantage|HUMANA MA|103.25||||||| 9528100|ERX|0250|TOBRAMYCIN 80MG/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||||| 9528118|ERX|0250|UNASYN 1.5G/100ML NS|Medicare|MEDICARE ACUTE|103.25||||||| 9528126|ERX|0250|UNASYN 3G/100ML NS|Humana Medicare Advantage|HUMANA MA|121.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|United Healthcare|UNITED HEALTHCARE OTHER|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicare|BCBS MEDICARE PPO MA|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Medicare|MEDICARE PART B ONLY IP|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Veterans Affairs|VETERANS ADMINISTRATION|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicare|HEALTHSPRING MA|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Blue Cross HMO Specialty|BCBSTX HMO|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Aetna|AETNA PPO|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Cigna|CIGNA|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Humana Medicare Advantage|HUMANA MA|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicaid|MEDICAID SUPERIOR|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicaid|MEDICAID AMERIGROUP|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.25||||103.25||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Humana Medicare Advantage|HUMANA MA|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.29||||1.29||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Medicare|MEDICARE ACUTE|1.29||||1.29||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|United Healthcare|UNITED HEALTHCARE OTHER|||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|United Healthcare|UNITED HEALTHCARE|||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicare|BCBS MEDICARE PPO MA|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicare|HEALTHSPRING MA|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Medicare|MEDICARE ACUTE|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Medicare|MEDICARE PART B ONLY IP|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Veterans Affairs|VETERANS ADMINISTRATION|||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Aetna|AETNA PPO|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Cigna|CIGNA|||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Humana Medicare Advantage|HUMANA MA|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|ChampVA|CHAMPVA CENTER|1.41||||||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Humana Medicare Advantage|HUMANA MA|1.76||||1.76||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.76||||||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|1.76||||||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|1.76||||1.76||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.76||||||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Managed Medicare|HEALTHSPRING MA|1.76||||||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Medicare|MEDICARE ACUTE|1.76||||1.76||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.76||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Healthcare|UNITED HEALTHCARE|||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|NON CONTRACTED|COMMERCIAL OTHER 1|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|MEDICAID|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicare|HEALTHSPRING MA|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicare|MEDICARE ACUTE|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|COUNTY INDIGENT HEALTH OTHER|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Veterans Affairs|VETERANS ADMINISTRATION|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Medicare Advantage|UHC MEDICARE GOLD MA|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Aenta Medicare Advantage|AETNA MEDICARE MA|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross HMO Specialty|BCBSTX HMO|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Aetna|AETNA PPO|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross PPO Specialty|BCBSTX PPO|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Humana Medicare Advantage|HUMANA MA|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID SUPERIOR|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID AMERIGROUP|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.50||||103.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID SUPERIOR|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID AMERIGROUP|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross HMO Specialty|BCBSTX HMO|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Aetna|AETNA PPO|59.50||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross PPO Specialty|BCBSTX OTHER|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross PPO Specialty|BCBSTX PPO|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Humana Medicare Advantage|HUMANA MA|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicaid|MEDICAID HMO|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicare|HEALTHSPRING MA|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicare|MEDICARE ACUTE|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Healthcare|UNITED HEALTHCARE|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Healthcare|UNITED HEALTHCARE OTHER|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|NON CONTRACTED|COMMERCIAL OTHER 1|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|59.50||||59.50||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|59.50||||59.50||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Medicare|MEDICARE ACUTE|59.50||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|59.50||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Blue Cross PPO Specialty|BCBSTX PPO|59.50||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Humana Medicare Advantage|HUMANA MA|0.55||||0.55||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.55||||0.55||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicaid|MEDICAID SUPERIOR|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.55||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Aetna|AETNA PPO|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Blue Cross PPO Specialty|BCBSTX PPO|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.55||||0.55||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|United Medicare Advantage|UHC MEDICARE GOLD MA|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.55||||0.55||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Medicaid|MEDICAID|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Managed Medicare|HEALTHSPRING MA|||||0.55||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Medicare|MEDICARE ACUTE|0.55||||0.55||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.55||||||| 9528258|ERX|0250|CEPACOL LOZENGE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicare|MEDICARE ACUTE|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Blue Cross PPO Specialty|BCBSTX PPO|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Humana Medicare Advantage|HUMANA MA|0.11||||||| 9528340|ERX|0250|PEPTO-BISMOL LIQUID, 118M|Medicare|MEDICARE ACUTE|15.50||||||| 9528357|ERX|0250|PHENOBARBITOL UD 20ML/5ML|Medicare|MEDICARE ACUTE|0.11||||||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Humana Medicare Advantage|HUMANA MA|261.50||||261.50||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|261.50||||261.50||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|261.50||||261.50||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Managed Medicaid|MEDICAID SUPERIOR|261.50||||||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|261.50||||||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|261.50||||261.50||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|261.50||||||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|261.50||||261.50||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|261.50||||261.50||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Tricare|TRICARE EAST REGION|||||261.50||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||261.50||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|261.50||||||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Managed Medicare|BCBS MEDICARE PPO MA|261.50||||||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Medicare|MEDICARE PART B ONLY IP|261.50||||||| 9528431|ERX|0250|CEFEPIME 2G IN 100ML NS|Medicare|MEDICARE ACUTE|261.50||||261.50||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|459.75||||||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|Medicare|MEDICARE ACUTE|459.75||||459.75||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|Medicare|MEDICARE PART B ONLY IP|459.75||||||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|459.75||||||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|459.75||||||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|459.75||||||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||459.75||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|Humana Medicare Advantage|HUMANA MA|459.75||||||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|459.75||||||| 9528456|ERX|0250|ERTAPENEM 1G IN 100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|459.75||||||| 9528464|ERX|0250|PENICILLIN G 5MU IN 100ML|Managed Medicaid|MEDICAID SUPERIOR|103.25||||103.25||| 9528464|ERX|0250|PENICILLIN G 5MU IN 100ML|Managed Medicaid|MEDICAID AMERIGROUP|103.25||||||| 9528464|ERX|0250|PENICILLIN G 5MU IN 100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.25||||||| 9528464|ERX|0250|PENICILLIN G 5MU IN 100ML|Aetna|AETNA PPO|103.25||||||| 9528464|ERX|0250|PENICILLIN G 5MU IN 100ML|Aetna|AETNA OTHER|103.25||||||| 9528464|ERX|0250|PENICILLIN G 5MU IN 100ML|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||||| 9528464|ERX|0250|PENICILLIN G 5MU IN 100ML|Tricare|TRICARE EAST REGION|103.25||||||| 9528464|ERX|0250|PENICILLIN G 5MU IN 100ML|Medicaid|MEDICAID|103.25||||||| 9528498|ERX|0250|PHENYLEPHRINE 1% NASAL SP|Medicare|MEDICARE ACUTE|36.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|103.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Healthcare|UNITED HEALTHCARE|||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicare|MEDICARE ACUTE|103.25||||||| 9528639|ERX|0250|MORPHINE 8MG/1ML SYRINGE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||42.50||| 9528639|ERX|0636||Managed Medicaid|MEDICAID AMERIGROUP|||||42.50||| 9528639|ERX|0250|MORPHINE 8MG/1ML SYRINGE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||42.50||| 9528639|ERX|0636||UTMB|UTMB CORRECTIONAL MANAGED CARE|||||42.50||| 9528639|ERX|0636||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||42.50||| 9528639|ERX|0636||NON CONTRACTED|COMMERCIAL OTHER 1|||||42.50||| 9528639|ERX|0636||Medicare|MEDICARE ACUTE|42.50||||42.50||| 9528639|ERX|0636||Blue Cross PPO Specialty|BCBSTX PPO|42.50||||42.50||| 9528639|ERX|0250|MORPHINE 8MG/1ML SYRINGE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||42.50||| 9528639|ERX|0636||Cigna|CIGNA|||||42.50||| 9528639|ERX|0250|MORPHINE 8MG/1ML SYRINGE|Blue Cross HMO Specialty|BCBSTX HMO|||||42.50||| 9528639|ERX|0250|MORPHINE 8MG/1ML SYRINGE|Blue Cross PPO Specialty|BCBSTX PPO|42.50||||||| 9528639|ERX|0250|MORPHINE 8MG/1ML SYRINGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||42.50||| 9528639|ERX|0250|MORPHINE 8MG/1ML SYRINGE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|42.50||||||| 9528639|ERX|0636||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.50||||||| 9528639|ERX|0636||United Medicare Advantage|UHC MEDICARE GOLD MA|||||42.50||| 9528647|ERX|0250|MONSEL'S SOLUTION, 8ML|Blue Cross PPO Specialty|BCBSTX PPO|||||85.75||| 9528647|ERX|0250|MONSEL'S SOLUTION, 8ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||85.75||| 9528647|ERX|0250|MONSEL'S SOLUTION, 8ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||85.75||| 9528647|ERX|0250|MONSEL'S SOLUTION, 8ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||85.75||| 9528647|ERX|0250|MONSEL'S SOLUTION, 8ML|United Healthcare|UNITED HEALTHCARE|||||85.75||| 9528654|ERX|0250|ROXANOL 20MG/1ML ORAL SYR|Medicare|MEDICARE ACUTE|||||0.11||| 9528662|ERX|0250|AMOXICILLIN 125MG/5ML, 10|Managed Medicaid|MEDICAID SUPERIOR|||||30.25||| 9528662|ERX|0250|AMOXICILLIN 125MG/5ML, 10|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||30.25||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Medicare|MEDICARE ACUTE|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Veterans Affairs|VETERANS ADMINISTRATION|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Cigna|CIGNA|||||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|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|Managed Medicaid|MEDICAID AMERIGROUP|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aetna|AETNA PPO|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross HMO Specialty|BCBSTX HMO|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aetna|AETNA OTHER|||||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||| 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 UMR|||||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|Cigna|CIGNA|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|United Healthcare|UNITED HEALTHCARE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|GOLDEN RULE|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|UNITED HEALTHCARE|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Tricare|TRICARE EAST REGION|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP 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|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|MEDICAID|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||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|HEALTHSPRING MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicare|MEDICARE PART B ONLY IP|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicare|MEDICARE ACUTE|0.16||||0.16||| 9528902|ERX|0250|CEFAZOLIN 2G IN 100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.75||||||| 9528902|ERX|0250|CEFAZOLIN 2G IN 100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||95.75||| 9528902|ERX|0250|CEFAZOLIN 2G IN 100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Medicaid|MEDICAID|95.75||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Medicare|MEDICARE ACUTE|95.75||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Managed Medicare|HEALTHSPRING MA|||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|United Healthcare|UNITED HEALTHCARE|||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95.75||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|95.75||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Cigna|CIGNA|||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Humana Medicare Advantage|HUMANA MA|||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Managed Medicaid|MEDICAID SUPERIOR|95.75||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95.75||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||95.75||| 9528928|ERX|0250|CEFOXITIN 2G IN 100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||95.75||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.10||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Managed Medicare|HEALTHSPRING MA|0.10||||||| 9528969|ERX|0250|GUAIFENESIN 100MG 5ML UD|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9528993|ERX|0250|CEFTRIAXONE 500MG IN 50ML|Medicare|MEDICARE ACUTE|222.25||||||| 9528993|ERX|0250|CEFTRIAXONE 500MG IN 50ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||222.25||| 9528993|ERX|0250|CEFTRIAXONE 500MG IN 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||222.25||| 9528993|ERX|0250|CEFTRIAXONE 500MG IN 50ML|Humana Medicare Advantage|HUMANA MA|||||222.25||| 9528993|ERX|0250|CEFTRIAXONE 500MG IN 50ML|Managed Medicaid|MEDICAID SUPERIOR|222.25||||222.25||| 9528993|ERX|0250|CEFTRIAXONE 500MG IN 50ML|Managed Medicaid|MEDICAID AMERIGROUP|222.25||||||| 9528993|ERX|0250|CEFTRIAXONE 500MG IN 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||222.25||| 9529009|ERX|0250|VANCOMYCIN 500MG IN 100ML|Humana Medicare Advantage|HUMANA MA|95.75||||95.75||| 9529009|ERX|0250|VANCOMYCIN 500MG IN 100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||||| 9529009|ERX|0250|VANCOMYCIN 500MG IN 100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|95.75||||||| 9529009|ERX|0250|VANCOMYCIN 500MG IN 100ML|Medicare|MEDICARE ACUTE|95.75||||95.75||| 9529017|ERX|0250|MEROPENEM 500MG IN 100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.20||||||| 9529017|ERX|0250|MEROPENEM 500MG IN 100ML|United Healthcare|UNITED HEALTHCARE|||||2.20||| 9529017|ERX|0250|MEROPENEM 500MG IN 100ML|Medicare|MEDICARE ACUTE|2.20||||||| 9529017|ERX|0250|MEROPENEM 500MG IN 100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.20||||2.20||| 9529017|ERX|0250|MEROPENEM 500MG IN 100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.20||||||| 9529017|ERX|0250|MEROPENEM 500MG IN 100ML|Humana Medicare Advantage|HUMANA MA|2.20||||||| 9529025|ERX|0250|MEROPENEM 1G IN 100ML NS|Humana Medicare Advantage|HUMANA MA|439.75||||439.75||| 9529025|ERX|0250|MEROPENEM 1G IN 100ML NS|Managed Medicaid|MEDICAID SUPERIOR|439.75||||||| 9529025|ERX|0250|MEROPENEM 1G IN 100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|439.75||||||| 9529025|ERX|0250|MEROPENEM 1G IN 100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|439.75||||||| 9529025|ERX|0250|MEROPENEM 1G IN 100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|439.75||||||| 9529025|ERX|0250|MEROPENEM 1G IN 100ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|439.75||||||| 9529025|ERX|0250|MEROPENEM 1G IN 100ML NS|Medicare|MEDICARE PART B ONLY IP|439.75||||||| 9529025|ERX|0250|MEROPENEM 1G IN 100ML NS|Medicare|MEDICARE ACUTE|439.75||||439.75||| 9529025|ERX|0250|MEROPENEM 1G IN 100ML NS|United Healthcare|UNITED HEALTHCARE|||||439.75||| 9529041|ERX|0250|GUAIFENSESIN SF 100MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.50||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Healthcare|UNITED HEALTHCARE|||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Tricare|TRICARE EAST REGION|||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|490.20||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicare|MEDICARE ACUTE|490.20||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|490.20||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|490.20||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|490.20||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Humana Medicare Advantage|HUMANA MA|490.20||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|490.20||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|490.20||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|490.20||||490.20||| 9529298|ERX|0250|TRAVOPROST 0.004% (PF) DR|United Medicare Advantage|UHC MEDICARE GOLD MA|773.48||||773.48||| 9529298|ERX|0250|TRAVOPROST 0.004% (PF) DR|Medicare|MEDICARE ACUTE|773.48||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Medicare|MEDICARE ACUTE|82.24||||||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Humana Medicare Advantage|HUMANA MA|||||82.24||| 9529355|ERX|0250|OSELTAMIVIR 30 MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||82.24||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|AARP UHC WEST COMPLETE MA|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aenta Medicare Advantage|AETNA MEDICARE MA|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC MEDICARE GOLD MA|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%|Access Direct Platinum|HEALTHFIRST TPA UMR|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%|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Cigna|CIGNA|877.20||||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%|Managed Medicaid|MEDICAID UNITED HEALTHCARE|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID SUPERIOR|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|UNITED HEALTHCARE|||||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||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicare|MEDICARE ACUTE|877.20||||877.20||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Medicaid|MEDICAID|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicare|HEALTHSPRING MA|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Managed Medicare|BCBS MEDICARE PPO MA|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|NON CONTRACTED|COMMERCIAL OTHER 1|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Medicare|MEDICARE ACUTE|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Humana Medicare Advantage|HUMANA MA|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Blue Cross PPO Specialty|BCBSTX PPO|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Cigna|CIGNA|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8,168.25||| 95810|EAP|0920|POLYSOMNOGRAM DIAGNOSTIC|Veterans Affairs|VETERANS ADMINISTRATION|||||8,168.25||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM SPLIT NIGHT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Veterans Affairs|VETERANS ADMINISTRATION|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM SPLIT NIGHT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Blue Cross HMO Specialty|BCBSTX HMO|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM SPLIT NIGHT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Humana Medicare Advantage|HUMANA MA|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Blue Cross PPO Specialty|BCBSTX PPO|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM SPLIT NIGHT|Blue Cross PPO Specialty|BCBSTX PPO|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|NON CONTRACTED|COMMERCIAL OTHER 1|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Medicare|MEDICARE ACUTE|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM SPLIT NIGHT|Medicare|MEDICARE ACUTE|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM SPLIT NIGHT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM SPLIT NIGHT|Managed Medicaid|MEDICAID SUPERIOR|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM SPLIT NIGHT|Medicaid|MEDICAID|||||88.48||| 95811|EAP|0920|POLYSOMNOGRAM THERAPUTIC|Managed Medicare|HEALTHSPRING MA|||||88.48||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Medicaid|COUNTY INDIGENT HEALTH OTHER|293.75||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Medicare|MEDICARE ACUTE|293.75||||293.75||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Humana Medicare Advantage|HUMANA MA|293.75||||293.75||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||293.75||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||293.75||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|293.75||||||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|United Healthcare|UNITED HEALTHCARE|||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|Tricare|TRICARE EAST REGION|0.10||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|Medicaid|MEDICAID HMO|||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|Medicaid|MEDICAID|||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|Managed Medicaid|MEDICAID SUPERIOR|0.10||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||0.10||| 9582966|ERX|0250|DIPHENHYDRAMINE 12.5MG 5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.10||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|ChampVA|CHAMPVA CENTER|0.13||||||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Veterans Affairs|VETERANS ADMINISTRATION|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Blue Cross PPO Specialty|BCBSTX PPO|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Medicaid|MEDICAID|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Managed Medicare|HEALTHSPRING MA|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.13||||||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Medicare|MEDICARE PART B ONLY IP|0.13||||||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Healthcare|UNITED HEALTHCARE|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Healthcare|UNITED HEALTHCARE OTHER|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Healthcare|UNITED HEALTHCARE|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Tricare|TRICARE EAST REGION|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.13||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Medicare|MEDICARE ACUTE|12.25||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Humana Medicare Advantage|HUMANA MA|12.25||||12.25||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||12.25||| 9583055|ERX|0250|ROPINIROLE 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||||| 9583055|ERX|0250|ROPINIROLE 0.5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.10||| 9583055|ERX|0250|ROPINIROLE 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9583055|ERX|0250|ROPINIROLE 0.5MG TABLET|Medicare|MEDICARE ACUTE|0.10||||||| 9583063|ERX|0250|OLMESARTAN 20MG TABLET|Medicare|MEDICARE ACUTE|29.50||||||| 9583063|ERX|0250|OLMESARTAN 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|29.50||||||| 9583063|ERX|0250|OLMESARTAN 20MG TABLET|Humana Medicare Advantage|HUMANA MA|||||29.50||| 9583063|ERX|0250|OLMESARTAN 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||29.50||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||0.10||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Humana Medicare Advantage|HUMANA MA|0.10||||0.10||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||0.10||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicaid|MEDICAID AMERIGROUP|||||0.10||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicaid|MEDICAID SUPERIOR|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Tricare|TRICARE EAST REGION|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicaid|MEDICAID|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|MEDICAID|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicare|HEALTHSPRING MA|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|UNITED HEALTHCARE|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|NON CONTRACTED|COMMERCIAL OTHER 1|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|UNITED HEALTHCARE|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross HMO Specialty|BCBSTX HMO|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST TPA UMR|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicare|MEDICARE ACUTE|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Cigna|CIGNA|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Humana Medicare Advantage|HUMANA MA|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID AMERIGROUP|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID SUPERIOR|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|WORKERS COMPENSATION OTHER|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|AARP UHC WEST COMPLETE MA|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|95.75||||||| 9583246|ERX|0250|MORPHINE O/S 10MG/5ML 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.10||||||| 9583246|ERX|0250|MORPHINE O/S 10MG/5ML 5ML|Medicare|MEDICARE ACUTE|||||0.10||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||95.75||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|||||95.75||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||95.75||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Humana Medicare Advantage|HUMANA MA|||||95.75||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Medicare|MEDICARE ACUTE|95.75||||95.75||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|United Healthcare|UNITED HEALTHCARE|||||95.75||| 9583329|ERX|0250|FLEET ENEMA (ADULT) 4.5OZ|Medicare|MEDICARE ACUTE|||||13.50||| 9583469|ERX|0250|ALBUTEROL 2MG/5ML SYRUP 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9583485|ERX|0250|CYCLOBENZAPRINE 5MG TABLE|Medicare|MEDICARE ACUTE|0.13||||||| 9583485|ERX|0250|CYCLOBENZAPRINE 5MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||0.13||| 9583485|ERX|0250|CYCLOBENZAPRINE 5MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9583485|ERX|0250|CYCLOBENZAPRINE 5MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9583485|ERX|0250|CYCLOBENZAPRINE 5MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9583485|ERX|0250|CYCLOBENZAPRINE 5MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.13||||||| 9583568|ERX|0250|DEXTROSE 10% 250ML BAG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||95.75||| 9583568|ERX|0250|DEXTROSE 10% 250ML BAG|Cigna|CIGNA|||||95.75||| 9583568|ERX|0250|DEXTROSE 10% 250ML BAG|Medicare|MEDICARE ACUTE|95.75||||||| 9583576|ERX|0250|PROMETHAZINE W.COD 6.25MG|Medicare|MEDICARE ACUTE|||||0.10||| 9583576|ERX|0250|PROMETHAZINE W.COD 6.25MG|Managed Medicaid|MEDICAID SUPERIOR|||||0.10||| 9583667|ERX|0250|MICONAZOLE VAGINAL CREAM|Managed Medicaid|MEDICAID SUPERIOR|||||84.75||| 9583709|ERX|0250|PIOGLITAZONE 30MG TABLET|Medicare|MEDICARE ACUTE|39.50||||||| 9583709|ERX|0250|PIOGLITAZONE 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|39.50||||||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Blue Cross PPO Specialty|BCBSTX PPO|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Managed Medicaid|MEDICAID AMERIGROUP|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Managed Medicaid|MEDICAID SUPERIOR|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Medicaid|MEDICAID|||||585.25||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Medicare|MEDICARE ACUTE|46.75||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|46.75||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||46.75||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|Managed Medicaid|MEDICAID SUPERIOR|||||0.10||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.10||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.10||||||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|United Healthcare|UNITED HEALTHCARE|0.10||||||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|Managed Medicare|HEALTHSPRING MA|0.10||||||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|Medicaid|MEDICAID HMO|||||0.10||| 9584129|ERX|0250|VALPROATE SOD LIQ 250MG/5|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9584202|ERX|0250|FENOFIBRATE 48 TABLET|Humana Medicare Advantage|HUMANA MA|||||0.15||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Tricare|TRICARE EAST REGION|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Medicaid|MEDICAID|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Medicaid|MEDICAID HMO|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|United Healthcare|UNITED HEALTHCARE|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.75||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Aetna|AETNA PPO|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Blue Cross PPO Specialty|BCBSTX PPO|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Cigna|CIGNA|0.75||||||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.75||||0.75||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Managed Medicaid|MEDICAID AMERIGROUP|0.75||||0.75||| 9584251|ERX|0250|ERYTHROMYCIN .5% OPHR OIN|Managed Medicaid|MEDICAID SUPERIOR|0.75||||0.75||| 9584277|ERX|0250|CITALOPRAM 10MG TABLET|Humana Medicare Advantage|HUMANA MA|19.25||||||| 9584277|ERX|0250|CITALOPRAM 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|19.25||||||| 9584277|ERX|0250|CITALOPRAM 10MG TABLET|Medicare|MEDICARE ACUTE|19.25||||19.25||| 9584335|ERX|0250|GENTAMICIN 120MG/100ML NS|Medicare|MEDICARE ACUTE|95.75||||||| 9584335|ERX|0250|GENTAMICIN 120MG/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95.75||||||| 9584335|ERX|0250|GENTAMICIN 120MG/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||95.75||| 9584335|ERX|0250|GENTAMICIN 120MG/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|95.75||||||| 9584335|ERX|0250|GENTAMICIN 120MG/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|95.75||||||| 9584343|ERX|0250|AMPICILLIN 2G IN 100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|95.75||||||| 9584343|ERX|0250|AMPICILLIN 2G IN 100ML NS|Managed Medicaid|MEDICAID SUPERIOR|95.75||||95.75||| 9584343|ERX|0250|AMPICILLIN 2G IN 100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||||| 9584343|ERX|0250|AMPICILLIN 2G IN 100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|95.75||||||| 9584343|ERX|0250|AMPICILLIN 2G IN 100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||||| 9584343|ERX|0250|AMPICILLIN 2G IN 100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.75||||||| 9584343|ERX|0250|AMPICILLIN 2G IN 100ML NS|Medicaid|MEDICAID|95.75||||||| 9584343|ERX|0250|AMPICILLIN 2G IN 100ML NS|Medicaid|MOLINA HEALTHCARE OF TEXAS|95.75||||95.75||| 9584343|ERX|0250|AMPICILLIN 2G IN 100ML NS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|NON CONTRACTED|COMMERCIAL OTHER 1|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicaid|MEDICAID|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicaid|MEDICAID HMO|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicare|WELLCARE CHOICE MA|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicare|BCBS MEDICARE PPO MA|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Medicare|MEDICARE ACUTE|95.75||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|95.75||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|United Medicare Advantage|UHC MEDICARE GOLD MA|95.75||||||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Veterans Affairs|VETERANS ADMINISTRATION|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Blue Cross HMO Specialty|BCBSTX HMO|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Blue Cross PPO Specialty|BCBSTX PPO|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.75||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Humana Medicare Advantage|HUMANA MA|95.75||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicaid|MEDICAID AMERIGROUP|||||95.75||| 9584475|ERX|0250|CEFEPIME 1G D5W 50ML DUPL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||95.75||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicare|MEDICARE ACUTE|0.10||||||| 9584582|ERX|0250|SULFA-TRIMETH LIQUID 200-|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.10||| 9584582|ERX|0250|SULFA-TRIMETH LIQUID 200-|Managed Medicaid|MEDICAID SUPERIOR|||||0.10||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Medicare|MEDICARE ACUTE|95.75||||||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||95.75||| 9584624|ERX|0250|DILTIAZEM 100MG IN 100ML|Humana Medicare Advantage|HUMANA MA|95.75||||||| 9584640|ERX|0250|DEXTROSE 5% NS KCI 40MEQ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95.75||||||| 9584640|ERX|0250|DEXTROSE 5% NS KCI 40MEQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||||| 9584640|ERX|0250|DEXTROSE 5% NS KCI 40MEQ|Blue Cross HMO Specialty|BCBSTX HMO|95.75||||||| 9584640|ERX|0250|DEXTROSE 5% NS KCI 40MEQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.75||||||| 9584640|ERX|0250|DEXTROSE 5% NS KCI 40MEQ|NON CONTRACTED|COMMERCIAL OTHER 1|||||95.75||| 9584640|ERX|0250|DEXTROSE 5% NS KCI 40MEQ|Medicare|MEDICARE ACUTE|95.75||||||| 9584665|ERX|0636|ZIDOVUDINE 10MG/ML 20ML V|Managed Medicaid|MEDICAID AMERIGROUP|1.97||||||| 9584673|ERX|0250|ZIDOVUDINE ORAL SYRUP 50M|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|United Healthcare|UMR UNITED MEDICAL RESOURCES|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Tricare|TRICARE EAST REGION|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Medicaid|MEDICAID|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Medicaid|MEDICAID HMO|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|United Healthcare|UNITED HEALTHCARE|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Medicare|MEDICARE ACUTE|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Aetna|AETNA OTHER|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Aetna|AETNA PPO|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Access Direct Platinum|HEALTHFIRST TPA UMR|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Cigna|CIGNA|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.27||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.27||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.27||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.27||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.27||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.27||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicaid|MEDICAID|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicare|WELLCARE CHOICE MA|0.27||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicare|MEDICARE ACUTE|0.27||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Tricare|TRICARE EAST REGION|0.27||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.27||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|United Healthcare|UNITED HEALTHCARE|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Tricare|TRICARE EAST REGION|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|NON CONTRACTED|COMMERCIAL OTHER 1|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Medicaid|MEDICAID|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Medicaid|MEDICAID HMO|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Aetna|AETNA PPO|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Aetna|AETNA OTHER|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Blue Cross PPO Specialty|BCBSTX PPO|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Access Direct Platinum|HEALTHFIRST TPA UMR|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Cigna|CIGNA|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Managed Medicaid|MEDICAID AMERIGROUP|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Managed Medicaid|MEDICAID SUPERIOR|0.38||||||| 9585068|ERX|0636|PAMIDRONATE 90MG/10ML SDV|Blue Cross PPO Specialty|BCBSTX PPO|2.42||||||| 9585068|ERX|0636|PAMIDRONATE 90MG/10ML SDV|Medicare|MEDICARE ACUTE|2.42||||||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Medicaid|MEDICAID|28.25||||||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Medicare|MEDICARE ACUTE|28.25||||||| 9585126|ERX|0250|GENTAMICIN 100MG/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||95.75||| 9585126|ERX|0250|GENTAMICIN 100MG/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|95.75||||||| 9585126|ERX|0250|GENTAMICIN 100MG/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||||| 9585126|ERX|0250|GENTAMICIN 100MG/100ML NS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|95.75||||||| 9585126|ERX|0250|GENTAMICIN 100MG/100ML NS|Medicare|MEDICARE ACUTE|95.75||||||| 9585274|ERX|0250|VANCOMYCIN 750 MG VIAL|Medicare|MEDICARE ACUTE|||||39.50||| 9585274|ERX|0250|VANCOMYCIN 750 MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|39.50||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Humana Medicare Advantage|HUMANA MA|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Aenta Medicare Advantage|AETNA MEDICARE MA|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Blue Cross HMO Specialty|BCBSTX HMO|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Tricare|TRICARE EAST REGION|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|NON CONTRACTED|COMMERCIAL OTHER 1|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Medicare|MEDICARE ACUTE|95.75||||95.75||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Managed Medicare|HEALTHSPRING MA|95.75||||||| 9585472|ERX|0250|LOPERMIDE 1 MG/ 5ML UD|Medicare|MEDICARE PART B ONLY IP|12.75||||||| 9585753|ERX|0250|PENICILLIN G 2.5MU IN 100|Aetna|AETNA OTHER|95.75||||||| 9585753|ERX|0250|PENICILLIN G 2.5MU IN 100|Aetna|AETNA PPO|95.75||||||| 9585753|ERX|0250|PENICILLIN G 2.5MU IN 100|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||||| 9585753|ERX|0250|PENICILLIN G 2.5MU IN 100|Managed Medicaid|MEDICAID SUPERIOR|95.75||||||| 9585753|ERX|0250|PENICILLIN G 2.5MU IN 100|Managed Medicaid|MEDICAID AMERIGROUP|95.75||||||| 9585753|ERX|0250|PENICILLIN G 2.5MU IN 100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||||| 9585753|ERX|0250|PENICILLIN G 2.5MU IN 100|Tricare|TRICARE EAST REGION|95.75||||||| 9585753|ERX|0250|PENICILLIN G 2.5MU IN 100|Medicaid|MEDICAID|95.75||||||| 9585944|ERX|0250|ACYCLOVIR 1G IN 250ML NS|Medicare|MEDICARE ACUTE|1.89||||||| 9585944|ERX|0250|ACYCLOVIR 1G IN 250ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.89||||||| 9585969|ERX|0250|FLUCONAZOLE 150MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|39.50||||||| 9585969|ERX|0250|FLUCONAZOLE 150MG TABLET|Humana Medicare Advantage|HUMANA MA|||||39.50||| 9585969|ERX|0250|FLUCONAZOLE 150MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||39.50||| 9585969|ERX|0250|FLUCONAZOLE 150MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|39.50||||39.50||| 9585969|ERX|0250|FLUCONAZOLE 150MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|39.50||||||| 9585969|ERX|0250|FLUCONAZOLE 150MG TABLET|Medicare|MEDICARE ACUTE|39.50||||39.50||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9586033|ERX|0250|LOMOTIL 2.5-.025MG/5ML UD|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.10||| 9586157|ERX|0250|CEFDINIR 125MG/5ML UD|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||0.10||| 9586157|ERX|0250|CEFDINIR 125MG/5ML UD|Managed Medicaid|MEDICAID SUPERIOR|||||0.10||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Managed Medicare|HEALTHSPRING MA|9.75||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Medicare|MEDICARE ACUTE|9.75||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||9.75||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|9.75||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|9.75||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.75||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Humana Medicare Advantage|HUMANA MA|||||9.75||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|9.75||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|9.75||||||| 9586330|ERX|0250|NIFEDIPINE XL 60MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|17.25||||||| 9586330|ERX|0250|NIFEDIPINE XL 60MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||17.25||| 9586330|ERX|0250|NIFEDIPINE XL 60MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||17.25||| 9586330|ERX|0250|NIFEDIPINE XL 60MG TABLET|Medicare|MEDICARE ACUTE|17.25||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Healthcare|UNITED HEALTHCARE|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Tricare|TRICARE EAST REGION|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Medicaid|MEDICAID HMO|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Medicaid|MEDICAID|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicare|HEALTHSPRING MA|0.12||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Medicare|MEDICARE ACUTE|0.12||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Medicare|MEDICARE PART B ONLY IP|0.12||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.12||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Veterans Affairs|VETERANS ADMINISTRATION|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.12||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.12||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Aetna|AETNA PPO|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross PPO Specialty|BCBSTX PPO|0.12||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.12||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Cigna|CIGNA|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Humana Medicare Advantage|HUMANA MA|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.12||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|MEDICAID SUPERIOR|||||0.12||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Humana Medicare Advantage|HUMANA MA|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||564.93||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Blue Cross PPO Specialty|BCBSTX PPO|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Workers Compensation|WORKERS COMPENSATION OTHER|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|United Medicare Advantage|UHC MEDICARE GOLD MA|564.93||||||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|Medicare|MEDICARE ACUTE|564.93||||564.93||| 9586629|ERX|0250|VILANTEROL-FLUTICASONE 10|UTMB|UTMB CORRECTIONAL MANAGED CARE|564.93||||||| 9589219|ERX|0250|HEPARIN LOCK 100 UNIT/ML,|Medicare|MEDICARE ACUTE|||||15.75||| 9589219|ERX|0250|HEPARIN LOCK 100 UNIT/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|15.75||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Blue Cross PPO Specialty|BCBSTX PPO|||||20.75||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Medicare|MEDICARE ACUTE|20.75||||||| 9589656|ERX|0250|LIDOCAINE 2% URO-JET, ML|Medicare|MEDICARE ACUTE|||||41.50||| 9589656|ERX|0250|LIDOCAINE 2% URO-JET, ML|Managed Medicaid|MEDICAID SUPERIOR|||||41.50||| 9589656|ERX|0250|LIDOCAINE 2% URO-JET, ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||41.50||| 9589730|ERX|0250|IRON POLYSACCHARIDES COMP|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.50||||||| 9589730|ERX|0250|IRON POLYSACCHARIDES COMP|Medicare|MEDICARE ACUTE|9.50||||||| 9589920|ERX|0250|MIDAZOLAM 10 MG/2ML, 2 ML|Blue Cross PPO Specialty|BCBSTX PPO|9.50||||||| 9589920|ERX|0250|MIDAZOLAM 10 MG/2ML, 2 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.50||| 9589920|ERX|0250|MIDAZOLAM 10 MG/2ML, 2 ML|Medicare|MEDICARE ACUTE|||||9.50||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|United Healthcare|UNITED HEALTHCARE|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Tricare|TRICARE EAST REGION|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Medicaid|MEDICAID HMO|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Medicaid|MEDICAID|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Medicare|MEDICARE ACUTE|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Cigna|CIGNA|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Managed Medicaid|MEDICAID SUPERIOR|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Managed Medicaid|MEDICAID AMERIGROUP|0.92||||0.92||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Access Direct Platinum|HEALTHFIRST TPA UMR|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Blue Cross HMO Specialty|BCBSTX HMO|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Aetna|AETNA PPO|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Aetna|AETNA OTHER|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Blue Cross PPO Specialty|BCBSTX PPO|0.92||||||| 9589938|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.92||||||| 9590019|ERX|0250|ACYCLOVIR 5% OINT, 5GM|Managed Medicaid|MEDICAID SUPERIOR|652.75||||||| 9590027|ERX|0636||Managed Medicaid|MEDICAID SUPERIOR|558.25||||558.25||| 9590027|ERX|0636||Managed Medicaid|MEDICAID AMERIGROUP|558.25||||||| 9590027|ERX|0250||Medicare|MEDICARE ACUTE|558.25||||||| 9590027|ERX|0636||Medicare|MEDICARE ACUTE|558.25||||||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.92||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.92||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.92||||0.92||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|Veterans Affairs|VETERANS ADMINISTRATION|0.92||||||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|Blue Cross PPO Specialty|BCBSTX PPO|0.92||||||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|Humana Medicare Advantage|HUMANA MA|0.92||||||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.92||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.92||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.92||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|Medicaid|MEDICAID|||||0.92||| 9590035|ERX|0250|PANTOPRAZOLE 80 MG/100 ML|Medicare|MEDICARE ACUTE|0.92||||0.92||| 9590746|ERX|0250|TETRAC-BENZOCAINE-BUTAM,|Managed Medicaid|MEDICAID AMERIGROUP|||||3.62||| 9590746|ERX|0250|TETRAC-BENZOCAINE-BUTAM,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.62||||||| 9590746|ERX|0250|TETRAC-BENZOCAINE-BUTAM,|Blue Cross PPO Specialty|BCBSTX PPO|||||3.62||| 9590779|ERX|0250|SULFAMETH-TRIMET 800-160M|Blue Cross PPO Specialty|BCBSTX PPO|||||34.56||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Medicaid|MEDICAID HMO|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Medicaid|MEDICAID|||||716.40||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|716.40||||641.83||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Managed Medicaid|MEDICAID SUPERIOR|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Managed Medicare|HEALTHSPRING MA|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Managed Medicare|BCBS MEDICARE PPO MA|||||641.83||| 96360|EAP|0450|IV INFUSION HYDRATION UP|UTMB|UTMB CORRECTIONAL MANAGED CARE|567.25||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Medicare|MEDICARE PART B ONLY IP|567.25||||||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Medicare|MEDICARE ACUTE|567.25||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|NON CONTRACTED|COMMERCIAL OTHER 1|||||716.40||| 96360|EAP|0450|IV INFUSION HYDRATION UP|United Healthcare|UNITED HEALTHCARE|||||716.40||| 96360|EAP|0450|IV INFUSION HYDRATION UP|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||716.40||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Tricare|TRICARE EAST REGION|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Workers Compensation|WORKERS COMPENSATION OTHER|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|United Medicare Advantage|UHC MEDICARE GOLD MA|567.25||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||716.40||| 96360|EAP|0450|IV INFUSION HYDRATION UP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||716.40||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Veterans Affairs|VETERANS ADMINISTRATION|||||716.40||| 96360|EAP|0260|IV INFUSION 1ST HOUR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||737.56||| 96360|EAP|0260|IV INFUSION 1ST HOUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||737.56||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Medicare|MEDICARE ACUTE|||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Cigna|CIGNA|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Blue Cross PPO Specialty|BCBSTX PPO|641.83||||716.40||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|716.40||||567.25||| 96360|EAP|0260|IV HYDRATION UP TO 1 HR|Humana Medicare Advantage|HUMANA MA|||||701.25||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Humana Medicare Advantage|HUMANA MA|||||567.25||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||737.56||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Managed Medicaid|MEDICAID SUPERIOR|567.25||||737.56||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Managed Medicaid|MEDICAID AMERIGROUP|||||575.63||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Medicare|MEDICARE ACUTE|||||5.84||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Managed Medicaid|MEDICAID AMERIGROUP|||||716.40||| 96360|EAP|0260|IV HYDRATION UP TO 1 HR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||701.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Cigna|CIGNA|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Humana Medicare Advantage|HUMANA MA|716.40||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||716.40||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||716.40||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||737.56||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Blue Cross HMO Specialty|BCBSTX HMO|||||716.40||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Aetna|BOON CHAPMAN|||||5.84||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Aetna|AETNA PPO|||||273.50||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||716.40||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Aetna|AETNA PPO|||||567.25||| 96360|EAP|0450|IV INFUSION HYDRATION UP|Aetna|AETNA OTHER|||||716.40||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Blue Cross PPO Specialty|BCBSTX PPO|5.84||||5.84||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Blue Cross PPO Specialty|BCBSTX PPO|5.84||||567.25||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||660.78||| 96360|EAP|0260|IV INFUSION 1ST HOUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||567.25||| 96360|EAP|0260|IV HYDRATION UP TO 1 HR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||701.25||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|356.47||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Aenta Medicare Advantage|AETNA MEDICARE MA|356.47||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Blue Cross HMO Specialty|BCBSTX HMO|356.47||||319.36||| 96361|EAP|0260|IV INFUSE EA ADDL|Aetna|AETNA OTHER|||||73.75||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|319.36||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Access Direct Platinum|HEALTHFIRST TPA UMR|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Aetna|AETNA PPO|356.47||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||291.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Blue Cross PPO Specialty|BCBSTX OTHER|||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Cigna|CIGNA|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||282.25||| 96361|EAP|0260|IV HYDRATION EACH HR UP T|Humana Medicare Advantage|HUMANA MA|||||349.25||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Humana Medicare Advantage|HUMANA MA|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Blue Cross PPO Specialty|BCBSTX PPO|282.25||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Managed Medicaid|MEDICAID SUPERIOR|||||73.75||| 96361|EAP|0260|IV INFUSE EA ADDL|Managed Medicaid|MEDICAID AMERIGROUP|||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Managed Medicaid|MEDICAID AMERIGROUP|||||291.25||| 96361|EAP|0260|IV HYDRATION EACH HR UP T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||349.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|ChampVA|CHAMPVA CENTER|282.25||||||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Cigna|CIGNA|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Humana Medicare Advantage|HUMANA MA|356.47||||356.47||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Workers Compensation|WORKERS COMPENSATION OTHER|||||291.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Workers Compensation|WORKERS COMPENSATION OTHER|282.25||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|United Medicare Advantage|UHC MEDICARE GOLD MA|282.25||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|282.25||||319.36||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|United Medicare Advantage|AARP UHC WEST COMPLETE MA|356.47||||356.47||| 96361|EAP|0260|IV INFUSE EA ADDL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||73.75||| 96361|EAP|0260|IV INFUSE EA ADDED HR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||286.75||| 96361|EAP|0260|IV INFUSE EA ADDED HR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||291.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Cigna|CIGNA|||||356.47||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||291.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Veterans Affairs|VETERANS ADMINISTRATION|356.47||||356.47||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Medicare|MEDICARE ACUTE|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|UTMB|UTMB CORRECTIONAL MANAGED CARE|282.25||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Medicare|MEDICARE PART B ONLY IP|282.25||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Medicare|MEDICARE ACUTE|282.25||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|NON CONTRACTED|COMMERCIAL OTHER 2|||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|NON CONTRACTED|COMMERCIAL OTHER 1|282.25||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|PHCS|HUMANA INSURANCE|||||319.36||| 96361|EAP|0260|IV INFUSE EA ADDL|Cigna|CIGNA|||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDED HR|Blue Cross PPO Specialty|BCBSTX PPO|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|United Healthcare|UNITED HEALTHCARE OTHER|||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|United Healthcare|UNITED HEALTHCARE|356.47||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|United Healthcare|UNITED HEALTHCARE|||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|282.25||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|United Healthcare|TML GROUP BENEFITS|||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Tricare|TRICARE EAST REGION|||||356.47||| 96361|EAP|0260|IV INFUSE EA ADDL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||73.75||| 96361|EAP|0260|IV INFUSE EA ADDL|Medicaid|MEDICAID|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Medicaid|MEDICAID|282.25||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Medicaid|MEDICAID TEXAS CHILDRENS|||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Medicaid|MEDICAID HMO|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Managed Medicaid|MEDICAID UNITED HEALTHCARE|282.25||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Managed Medicaid|MEDICAID SUPERIOR|282.25||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|282.25||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Managed Medicaid|MEDICAID AMERIGROUP|282.25||||319.36||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Managed Medicare|WELLCARE CHOICE MA|356.47||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||282.25||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Managed Medicare|HEALTHSPRING MA|282.25||||356.47||| 96361|EAP|0450|IV INF HYDRATION EA ADL H|Managed Medicare|BCBS MEDICARE PPO MA|||||282.25||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||477.25||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Managed Medicare|HEALTHSPRING MA|||||589.50||| 96365|EAP|0940|IV INFUSION 1ST HOUR THER|Managed Medicaid|MEDICAID SUPERIOR|||||433.51||| 96365|EAP|0940|IV INFUSION 1ST HOUR THER|Managed Medicaid|MEDICAID AMERIGROUP|||||433.51||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Medicaid|MEDICAID HMO|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Medicaid|MEDICAID|602.74||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|477.25||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicaid|MEDICAID AMERIGROUP|||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicare|HEALTHSPRING MA|477.25||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|477.25||||477.25||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|Medicare|MEDICARE ACUTE|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|UTMB|UTMB CORRECTIONAL MANAGED CARE|477.25||||477.25||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Medicare|MEDICARE ACUTE|||||589.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Medicare|MEDICARE PART B ONLY IP|602.74||||||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Medicare|MEDICARE ACUTE|602.74||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|NON CONTRACTED|COMMERCIAL OTHER 1|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Healthcare|UNITED HEALTHCARE OTHER|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Healthcare|UNITED HEALTHCARE|602.74||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Healthcare|UNITED HEALTHCARE|||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Healthcare|TML GROUP BENEFITS|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Tricare|TRICARE EAST REGION|602.74||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Medicare Advantage|UHC MEDICARE GOLD MA|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|602.74||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Medicare Advantage|AARP UHC WEST COMPLETE MA|602.74||||602.74||| 96365|EAP|0940|IV INFUSION 1ST HOUR THER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||343.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||602.74||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||589.50||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||533.38||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Veterans Affairs|VETERANS ADMINISTRATION|602.74||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|PHCS|HUMANA INSURANCE|||||602.74||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||589.50||| 96365|EAP|0940|IV INFUSION 1ST HOUR THER|Blue Cross PPO Specialty|BCBSTX PPO|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Blue Cross PPO Specialty|BCBSTX PPO|602.74||||540.00||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|602.74||||||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicare|BCBS MEDICARE PPO MA|602.74||||602.74||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|Humana Medicare Advantage|HUMANA MA|||||744.50||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Managed Medicaid|MEDICAID SUPERIOR|3.30||||589.50||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Managed Medicaid|MEDICAID AMERIGROUP|||||589.50||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|Managed Medicaid|MEDICAID SUPERIOR|3.30||||744.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicaid|MEDICAID SUPERIOR|477.25||||602.74||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||477.25||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|Managed Medicaid|MEDICAID AMERIGROUP|||||589.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Cigna|CIGNA|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Cigna|CIGNA|||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Humana Medicare Advantage|HUMANA MA|477.25||||602.74||| 96365|EAP|0940|IV INFUSION 1ST HOUR THER|Cigna|CIGNA|||||433.51||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||589.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|477.25||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Aenta Medicare Advantage|AETNA MEDICARE MA|||||602.74||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Blue Cross HMO Specialty|BCBSTX HMO|||||589.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Blue Cross HMO Specialty|BCBSTX HMO|602.74||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|540.00||||602.74||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Aetna|AETNA PPO|||||602.74||| 96365|EAP|0940|IV INFUSION 1ST HOUR THER|Aetna|AETNA OTHER|||||343.25||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|Blue Cross PPO Specialty|BCBSTX PPO|||||6.67||| 96365|EAP|0260|IV INFUSE UP TO 1 HOUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||477.25||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||589.50||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||327.42||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Blue Cross HMO Specialty|BCBSTX HMO|||||2.08||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Blue Cross HMO Specialty|BCBSTX HMO|327.42||||259.25||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|259.25||||||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||259.25||| 96366|EAP|0940|IV INF @HR UP TO 8|Aetna|AETNA OTHER|||||2.08||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|Blue Cross PPO Specialty|BCBSTX PPO|||||259.25||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|Humana Medicare Advantage|HUMANA MA|||||313.54||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Blue Cross PPO Specialty|BCBSTX PPO|293.34||||327.42||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|Managed Medicaid|MEDICAID SUPERIOR|||||367.83||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|Managed Medicaid|MEDICAID AMERIGROUP|||||291.25||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Humana Medicare Advantage|HUMANA MA|259.25||||259.25||| 96366|EAP|0450|IV INF THER PROPH DX EA A|United Medicare Advantage|UHC MEDICARE GOLD MA|||||259.25||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||259.25||| 96366|EAP|0450|IV INF THER PROPH DX EA A|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|327.42||||259.25||| 96366|EAP|0940|IV INF @HR UP TO 8|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.08||| 96366|EAP|0940|IV INF @HR UP TO 8|Blue Cross PPO Specialty|BCBSTX PPO|||||259.25||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|United Medicare Advantage|UHC MEDICARE GOLD MA|||||275.25||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||259.25||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.08||| 96366|EAP|0450|IV INF THER PROPH DX EA A|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||293.34||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Medicare|MEDICARE ACUTE|||||2.08||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|Medicare|MEDICARE ACUTE|||||259.25||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Medicare|MEDICARE ACUTE|259.25||||259.25||| 96366|EAP|0450|IV INF THER PROPH DX EA A|United Healthcare|UNITED HEALTHCARE|327.42||||||| 96366|EAP|0450|IV INF THER PROPH DX EA A|United Healthcare|UNITED HEALTHCARE|||||259.25||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|NON CONTRACTED|COMMERCIAL OTHER 1|||||291.25||| 96366|EAP|0260|IV INFUSION THERAPY EA AD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||259.25||| 96366|EAP|0940|IV INF @HR UP TO 8|Managed Medicaid|MEDICAID SUPERIOR|||||262.69||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Medicaid|MEDICAID|||||327.42||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||327.42||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Managed Medicaid|MEDICAID SUPERIOR|||||293.34||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Managed Medicaid|MEDICAID AMERIGROUP|||||259.25||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Managed Medicare|BCBS MEDICARE PPO MA|327.42||||||| 96366|EAP|0450|IV INF THER PROPH DX EA A|Managed Medicare|HEALTHSPRING MA|||||327.42||| 96367|EAP|0260|IV INFUSION SEQUENTIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||231.25||| 96367|EAP|0940|IV EACH ADDITIONAL HOUR|Managed Medicaid|MEDICAID SUPERIOR|||||394.04||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||231.25||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|231.25||||||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|Managed Medicare|BCBS MEDICARE PPO MA|292.06||||||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|UTMB|UTMB CORRECTIONAL MANAGED CARE|231.25||||231.25||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|Managed Medicaid|MEDICAID SUPERIOR|231.25||||||| 96367|EAP|0260|IV INFUSION SEQUENTIAL|Medicare|MEDICARE ACUTE|||||261.25||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|Medicare|MEDICARE ACUTE|292.06||||231.25||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|United Healthcare|UNITED HEALTHCARE|||||292.06||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|United Medicare Advantage|UHC MEDICARE GOLD MA|292.06||||||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|261.66||||261.66||| 96367|EAP|0260|IV INFUSION SEQUENTIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||291.25||| 96367|EAP|0260|IV INFUSION SEQUENTIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||291.25||| 96367|EAP|0260|IV INFUSION SEQUENTIAL|Humana Medicare Advantage|HUMANA MA|||||367.83||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|Humana Medicare Advantage|HUMANA MA|231.25||||231.25||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|Blue Cross PPO Specialty|BCBSTX PPO|292.06||||261.66||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|Blue Cross HMO Specialty|BCBSTX HMO|292.06||||231.25||| 96367|EAP|0450|IV INF TX DX ADDL SEQ UP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|231.25||||||| 96367|EAP|0260|IV INFUSION SEQUENTIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||231.25||| 96368|EAP|0450|IV INF TX DX CONCURRENT|Blue Cross PPO Specialty|BCBSTX PPO|129.25||||163.24||| 96368|EAP|0450|IV INF TX DX CONCURRENT|Humana Medicare Advantage|HUMANA MA|129.25||||129.25||| 96368|EAP|0450|IV INF TX DX CONCURRENT|United Medicare Advantage|UHC MEDICARE GOLD MA|163.24||||163.24||| 96368|EAP|0450|IV INF TX DX CONCURRENT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|129.25||||||| 96368|EAP|0450|IV INF TX DX CONCURRENT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||129.25||| 96368|EAP|0450|IV INF TX DX CONCURRENT|Medicare|MEDICARE ACUTE|129.25||||129.25||| 96368|EAP|0450|IV INF TX DX CONCURRENT|NON CONTRACTED|COMMERCIAL OTHER 1|||||129.25||| 96368|EAP|0450|IV INF TX DX CONCURRENT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||163.24||| 96368|EAP|0450|IV INF TX DX CONCURRENT|Managed Medicare|HEALTHSPRING MA|||||163.24||| 96368|EAP|0450|IV INF TX DX CONCURRENT|Managed Medicaid|MEDICAID SUPERIOR|129.25||||||| 96368|EAP|0450|IV INF TX DX CONCURRENT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||163.24||| 96368|EAP|0450|IV INF TX DX CONCURRENT|Managed Medicaid|MEDICAID AMERIGROUP|||||129.25||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||329.50||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Managed Medicaid|MEDICAID SUPERIOR|||||387.09||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Managed Medicaid|MEDICAID AMERIGROUP|||||387.09||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicaid|MEDICAID SUPERIOR|||||367.83||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicaid|MEDICAID SUPERIOR|||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicaid|MEDICAID AMERIGROUP|||||367.83||| 96372|EAP|0450|INJ SUBQ/IM|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Medicaid|MEDICAID|329.50||||416.14||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||329.54||| 96372|EAP|0450|INJ SUBQ/IM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Managed Medicare|HEALTHSPRING MA|329.50||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Managed Medicare|BCBS MEDICARE PPO MA|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|416.14||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Managed Medicaid|MEDICAID SUPERIOR|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|416.14||||372.82||| 96372|EAP|0450|INJ SUBQ/IM|Managed Medicaid|MEDICAID AMERIGROUP|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|UTMB|UTMB CORRECTIONAL MANAGED CARE|329.50||||329.50||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||306.50||| 96372|EAP|0450|INJ SUBQ/IM|Medicare|MEDICARE ACUTE|416.14||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|NON CONTRACTED|COMMERCIAL OTHER 2|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|NON CONTRACTED|COMMERCIAL OTHER 1|372.82||||372.82||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Medicare|MEDICARE ACUTE|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Medicare|MEDICARE ACUTE|||||291.25||| 96372|EAP|0450|INJ SUBQ/IM|United Healthcare|UNITED HEALTHCARE OTHER|||||372.82||| 96372|EAP|0450|INJ SUBQ/IM|United Healthcare|UNITED HEALTHCARE|||||372.82||| 96372|EAP|0450|INJ SUBQ/IM|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|United Healthcare|GOLDEN RULE|||||416.14||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|United Healthcare|UNITED HEALTHCARE|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|United Healthcare|UNITED HEALTHCARE|||||367.83||| 96372|EAP|0450|INJ SUBQ/IM|Tricare|TRICARE FOR LIFE|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Tricare|TRICARE EAST REGION|416.14||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Workers Compensation|WORKERS COMPENSATION OTHER|||||416.14||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Workers Compensation|WORKERS COMPENSATION OTHER|||||306.50||| 96372|EAP|0450|INJ SUBQ/IM|United Medicare Advantage|UHC MEDICARE GOLD MA|329.50||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|416.14||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|United Healthcare|UNITED HEALTHCARE|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|372.82||||416.14||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||387.09||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||329.50||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|PHCS|HUMANA INSURANCE|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Medicare|MEDICARE PART B ONLY IP|329.50||||||| 96372|EAP|0940|INJ ADM THERAPEUTIC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||310.38||| 96372|EAP|0940|INJ ADM THERAPEUTIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||291.25||| 96372|EAP|0450|INJ SUBQ/IM|Veterans Affairs|VETERANS ADMINISTRATION|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Workers Compensation|WORKERS COMP PHYSICIAN|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|372.82||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||291.25||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||387.09||| 96372|EAP|0450|INJ SUBQ/IM|Aenta Medicare Advantage|AETNA MEDICARE MA|416.14||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Blue Cross HMO Specialty|BCBSTX HMO|||||416.14||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Blue Cross HMO Specialty|BCBSTX HMO|||||387.09||| 96372|EAP|0450|INJ SUBQ/IM|Medicaid|MEDICAID HMO|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|416.14||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|329.50||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Aetna|AETNA PPO|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicaid|MEDICAID AMERIGROUP|||||291.25||| 96372|EAP|0450|INJ SUBQ/IM|Aetna|AETNA OTHER|||||416.14||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Aetna|AETNA PPO|||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Aetna|AETNA OTHER|||||291.25||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||306.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||291.25||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Blue Cross PPO Specialty|BCBSTX PPO|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Blue Cross PPO Specialty|BCBSTX PPO|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Blue Cross PPO Specialty|BCBSTX PPO|||||291.25||| 96372|EAP|0450|INJ SUBQ/IM|Blue Cross PPO Specialty|BCBSTX PPO|416.14||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Blue Cross PPO Specialty|BCBSTX OTHER|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Cigna|CIGNA|||||416.14||| 96372|EAP|0450|INJ SUBQ/IM|Cigna|CIGNA|||||329.50||| 96372|EAP|0450|INJ SUBQ/IM|Humana Medicare Advantage|HUMANA MA|329.50||||416.14||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Humana Medicare Advantage|HUMANA MA|||||291.25||| 96372|EAP|0940|INJ. THERAPEUTIC MEDS IM/|Humana Medicare Advantage|HUMANA MA|||||387.09||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|414.25||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Blue Cross PPO Specialty|BCBSTX PPO|3.28||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Blue Cross PPO Specialty|BCBSTX OTHER|||||3.28||| 96374|EAP|0260|INJ ADM IV PUSH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||322.63||| 96374|EAP|0260|INJ ADM IV PUSH|Managed Medicaid|MEDICAID SUPERIOR|||||3.28||| 96374|EAP|0260|INJ ADM IV PUSH|Managed Medicaid|MEDICAID AMERIGROUP|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|ChampVA|CHAMPVA CENTER|3.28||||||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Cigna|CIGNA|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Humana Medicare Advantage|HUMANA MA|414.25||||3.28||| 96374|EAP|0940|IV PUSH|Humana Medicare Advantage|HUMANA MA|||||489.07||| 96374|EAP|0940|IV PUSH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||438.16||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Aenta Medicare Advantage|AETNA MEDICARE MA|371.13||||3.28||| 96374|EAP|0940|IV PUSH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||387.25||| 96374|EAP|0260|INJ ADM IV PUSH|Aetna|AETNA PPO|||||317.25||| 96374|EAP|0940|IV PUSH|Blue Cross HMO Specialty|BCBSTX HMO|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|371.13||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.28||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Aetna|AETNA PPO|414.25||||3.28||| 96374|EAP|0260|INJ ADM IV PUSH|Blue Cross PPO Specialty|BCBSTX PPO|||||400.67||| 96374|EAP|0940|IV PUSH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||408.54||| 96374|EAP|0940|IV PUSH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||387.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Workers Compensation|WORKERS COMPENSATION OTHER|3.28||||371.13||| 96374|EAP|0940|IV PUSH|Workers Compensation|WORKERS COMPENSATION OTHER|||||387.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.28||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|371.13||||414.25||| 96374|EAP|0940|IV PUSH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||489.07||| 96374|EAP|0940|IV PUSH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||408.54||| 96374|EAP|0940|IV PUSH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||489.07||| 96374|EAP|0260|INJ ADM IV PUSH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||317.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Veterans Affairs|VETERANS ADMINISTRATION|414.25||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.28||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Medicare|MEDICARE PART B ONLY IP|414.25||||371.13||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Medicare|MEDICARE ACUTE|371.13||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|NON CONTRACTED|COMMERCIAL OTHER 2|||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|United Medicare Advantage|UHC MEDICARE GOLD MA|3.28||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|NON CONTRACTED|COMMERCIAL OTHER 1|3.28||||414.25||| 96374|EAP|0260|INJ ADM IV PUSH|United Healthcare|UNITED HEALTHCARE|||||400.67||| 96374|EAP|0940|IV PUSH|NON CONTRACTED|COMMERCIAL OTHER 1|||||489.07||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|PHCS|HUMANA INSURANCE|||||371.13||| 96374|EAP|0260|INJ ADM IV PUSH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.28||| 96374|EAP|0940|IV PUSH|Medicare|MEDICARE ACUTE|||||387.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|United Healthcare|UNITED HEALTHCARE OTHER|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Aetna|AETNA OTHER|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|United Healthcare|UNITED HEALTHCARE|414.25||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|United Healthcare|UNITED HEALTHCARE|||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|United Healthcare|TML GROUP BENEFITS|||||414.25||| 96374|EAP|0940|IV PUSH|United Healthcare|UNITED HEALTHCARE|||||387.25||| 96374|EAP|0940|IV PUSH|United Healthcare|UNITED HEALTHCARE|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Blue Cross HMO Specialty|BCBSTX HMO|3.28||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Tricare|TRICARE EAST REGION|414.25||||371.13||| 96374|EAP|0260|INJ ADM IV PUSH|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||400.67||| 96374|EAP|0260|INJ ADM IV PUSH|Medicaid|MEDICAID|||||3.28||| 96374|EAP|0260|INJ ADM IV PUSH|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||358.96||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|414.25||||3.28||| 96374|EAP|0940|IV PUSH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.28||| 96374|EAP|0940|IV PUSH|Managed Medicaid|MEDICAID SUPERIOR|||||489.07||| 96374|EAP|0940|IV PUSH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||438.16||| 96374|EAP|0940|IV PUSH|Managed Medicaid|MEDICAID AMERIGROUP|||||387.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Cigna|CIGNA|||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Medicaid|MEDICAID|3.28||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Medicaid|MEDICAID HMO|||||371.13||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Medicaid|MEDICAID TEXAS CHILDRENS|||||414.25||| 96374|EAP|0940|IV PUSH|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|414.25||||||| 96374|EAP|0940|IV PUSH|Blue Cross PPO Specialty|BCBSTX PPO|||||489.07||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Managed Medicare|WELLCARE CHOICE MA|414.25||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|414.25||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Managed Medicare|HEALTHSPRING MA|3.28||||414.25||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Managed Medicare|BCBS MEDICARE PPO MA|||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.28||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Managed Medicaid|MEDICAID SUPERIOR|371.13||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.28||||3.28||| 96374|EAP|0450|INJ IV PUSH INITIAL DRUG|Managed Medicaid|MEDICAID AMERIGROUP|3.28||||371.13||| 96374|EAP|0940|IV PUSH|Managed Medicare|HEALTHSPRING MA|||||3.28||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||264.48||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicaid|MEDICAID|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicare|WELLCARE CHOICE MA|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Medicaid|MEDICAID|233.75||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|295.21||||||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|233.75||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Managed Medicare|HEALTHSPRING MA|233.75||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Managed Medicare|BCBS MEDICARE PPO MA|295.21||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID SUPERIOR|233.75||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|233.75||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID AMERIGROUP|||||295.21||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicare|MEDICARE ACUTE|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Medicare|MEDICARE PART B ONLY IP|295.21||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|NON CONTRACTED|COMMERCIAL OTHER 2|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|NON CONTRACTED|COMMERCIAL OTHER 1|233.75||||295.21||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Healthcare|UNITED HEALTHCARE|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|United Healthcare|UNITED HEALTHCARE OTHER|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|United Healthcare|UNITED HEALTHCARE|295.21||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|United Healthcare|UNITED HEALTHCARE|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|United Healthcare|TML GROUP BENEFITS|||||264.48||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Tricare|TRICARE EAST REGION|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Tricare|TRICARE EAST REGION|295.21||||295.21||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Workers Compensation|WORKERS COMPENSATION OTHER|233.75||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|UHC MEDICARE GOLD MA|233.75||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|233.75||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|295.21||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|UHC MEDICARE GOLD MA|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||295.21||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Veterans Affairs|VETERANS ADMINISTRATION|295.21||||295.21||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Aenta Medicare Advantage|AETNA MEDICARE MA|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|PHCS|HUMANA INSURANCE|||||264.48||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|295.21||||264.48||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Aenta Medicare Advantage|AETNA MEDICARE MA|233.75||||295.21||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Blue Cross HMO Specialty|BCBSTX HMO|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Blue Cross HMO Specialty|BCBSTX HMO|233.75||||295.21||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Aetna|AETNA OTHER|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|264.48||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|233.75||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Medicare|MEDICARE ACUTE|233.75||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Aetna|AETNA PPO|295.21||||295.21||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Blue Cross PPO Specialty|BCBSTX PPO|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Cigna|CIGNA|||||295.21||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Cigna|CIGNA|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Managed Medicare|WELLCARE CHOICE MA|295.21||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Medicaid|MEDICAID HMO|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Humana Medicare Advantage|HUMANA MA|||||295.21||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|295.21||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Managed Medicaid|MEDICAID SUPERIOR|0.71||||317.25||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Managed Medicaid|MEDICAID AMERIGROUP|||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID SUPERIOR|0.71||||295.21||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID SUPERIOR|0.71||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||264.48||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID AMERIGROUP|||||264.48||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID AMERIGROUP|||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Blue Cross PPO Specialty|BCBSTX PPO|264.48||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|ChampVA|CHAMPVA CENTER|233.75||||||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Cigna|CIGNA|233.75||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Cigna|CIGNA|||||264.48||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Humana Medicare Advantage|HUMANA MA|233.75||||233.75||| 96375|EAP|0450|INJ IV PUSH ADDL SEQ NEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||233.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Blue Cross PPO Specialty|BCBSTX OTHER|||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Blue Cross PPO Specialty|BCBSTX PPO|||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Blue Cross PPO Specialty|BCBSTX PPO|||||254.80||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Cigna|CIGNA|||||254.80||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Humana Medicare Advantage|HUMANA MA|228.28||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Humana Medicare Advantage|HUMANA MA|||||254.80||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Cigna|CIGNA|||||254.80||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|201.75||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Aenta Medicare Advantage|AETNA MEDICARE MA|||||228.28||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Blue Cross HMO Specialty|BCBSTX HMO|254.80||||254.80||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Blue Cross HMO Specialty|BCBSTX HMO|||||228.28||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|201.75||||228.28||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Access Direct Platinum|HEALTHFIRST TPA UMR|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Aetna|AETNA PPO|254.80||||||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Aetna|AETNA OTHER|||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|UHC MEDICARE GOLD MA|201.75||||254.80||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|201.75||||228.28||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|UHC MEDICARE GOLD MA|||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||254.80||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Veterans Affairs|VETERANS ADMINISTRATION|254.80||||228.28||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Workers Compensation|WORKERS COMPENSATION OTHER|201.75||||||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|AARP UHC WEST COMPLETE MA|201.75||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||228.28||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Medicare|MEDICARE ACUTE|201.75||||254.80||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|NON CONTRACTED|COMMERCIAL OTHER 1|201.75||||228.28||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|NON CONTRACTED|COMMERCIAL OTHER 1|||||228.28||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Medicare|MEDICARE ACUTE|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|United Healthcare|UNITED HEALTHCARE|||||254.80||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|United Healthcare|UNITED HEALTHCARE|||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|United Healthcare|UNITED HEALTHCARE|||||254.80||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID SUPERIOR|||||254.80||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID AMERIGROUP|||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Managed Medicaid|MEDICAID SUPERIOR|||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Managed Medicaid|MEDICAID AMERIGROUP|||||254.80||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Blue Cross PPO Specialty|BCBSTX PPO|201.75||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Medicaid|MEDICAID|||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Medicaid|MEDICAID|||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Managed Medicare|HEALTHSPRING MA|||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|228.28||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID SUPERIOR|228.28||||201.75||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||228.28||| 96376|EAP|0450|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID AMERIGROUP|||||228.28||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||201.75||| 96376|EAP|0940|IV PUSH EA ADD SEQ SAME D|Managed Medicare|HEALTHSPRING MA|||||201.75||| 96523|EAP|0361|IRRIGATION DRUG DELIVERY|Medicare|MEDICARE ACUTE|||||182.25||| 96523|EAP|0361|IRRIGATION DRUG DELIVERY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||182.25||| 96523|EAP|0361|IRRIGATION DRUG DELIVERY|Humana Medicare Advantage|HUMANA MA|||||182.25||| 96900|EAP|0940|BILIRUBIN LIGHT 24HRS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|797.88||||||| 96900|EAP|0940|BILIRUBIN LIGHT 24HRS|Blue Cross PPO Specialty|BCBSTX PPO|613.75||||||| 96900|EAP|0940|BILIRUBIN LIGHT 24HRS|Managed Medicaid|MEDICAID SUPERIOR|797.88||||||| 96900|EAP|0940|BILIRUBIN LIGHT 24HRS|Medicaid|MEDICAID|797.88||||||| 96900|EAP|0940|BILIRUBIN LIGHT 24HRS|United Healthcare|UNITED HEALTHCARE|||||613.75||| 97001|EAP|0424||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.33||| 97001|EAP|0424||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.33||| 97001|EAP|0424||Managed Medicaid|MEDICAID AMERIGROUP|||||3.33||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|United Medicare Advantage|UHC MEDICARE GOLD MA|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|289.75||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|289.75||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Veterans Affairs|VETERANS ADMINISTRATION|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Humana Medicare Advantage|HUMANA MA|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|289.75||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Blue Cross PPO Specialty|BCBSTX PPO|289.75||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Medicare|MEDICARE ACUTE|289.75||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Managed Medicaid|MEDICAID SUPERIOR|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Managed Medicaid|MEDICAID AMERIGROUP|||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Managed Medicare|BCBS MEDICARE PPO MA|289.75||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Managed Medicare|HEALTHSPRING MA|289.75||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Managed Medicaid|MEDICAID AMERIGROUP|||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Managed Medicaid|MEDICAID SUPERIOR|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Managed Medicare|HEALTHSPRING MA|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Managed Medicare|BCBS MEDICARE PPO MA|||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Medicare|MEDICARE ACUTE|312.50||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|United Healthcare|UNITED HEALTHCARE|||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|312.50||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Blue Cross PPO Specialty|BCBSTX PPO|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Aenta Medicare Advantage|AETNA MEDICARE MA|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Blue Cross HMO Specialty|BCBSTX HMO|||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|312.50||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Cigna|CIGNA|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Humana Medicare Advantage|HUMANA MA|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|United Medicare Advantage|UHC MEDICARE GOLD MA|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|312.50||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|312.50||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Veterans Affairs|VETERANS ADMINISTRATION|312.50||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|United Medicare Advantage|UHC MEDICARE GOLD MA|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Veterans Affairs|VETERANS ADMINISTRATION|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Cigna|CIGNA|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Humana Medicare Advantage|HUMANA MA|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Aenta Medicare Advantage|AETNA MEDICARE MA|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Blue Cross HMO Specialty|BCBSTX HMO|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Blue Cross PPO Specialty|BCBSTX PPO|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Medicare|MEDICARE PART B ONLY IP|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Medicare|MEDICARE ACUTE|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|NON CONTRACTED|COMMERCIAL OTHER 1|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|United Healthcare|UNITED HEALTHCARE|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Managed Medicaid|MEDICAID SUPERIOR|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.33||||3.33||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Managed Medicare|HEALTHSPRING MA|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Managed Medicare|BCBS MEDICARE PPO MA|3.33||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Managed Medicaid|MEDICAID SUPERIOR|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Medicare|MEDICARE ACUTE|231.25||||||| 97530|EAP|0430|THERAPEUTIC ACT EA 15M1-1|Medicare|MEDICARE ACUTE|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Aenta Medicare Advantage|AETNA MEDICARE MA|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|231.25||||||| 97530|EAP|0430|THERAPEUTIC ACT EA 15M1-1|Blue Cross PPO Specialty|BCBSTX PPO|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Humana Medicare Advantage|HUMANA MA|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||231.25||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|231.25||||||| 97530|EAP|0430|THERAPEUTIC ACT EA 15M1-1|United Medicare Advantage|UHC MEDICARE GOLD MA|231.25||||||| 97597|EAP|0450|DEBRIDE SKIN PARTIAL THIC|Blue Cross PPO Specialty|BCBSTX PPO|722.80||||||| 97597|EAP|0450|DEBRIDE SKIN PARTIAL THIC|Medicare|MEDICARE ACUTE|||||722.80||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Managed Medicaid|MEDICAID SUPERIOR|||||79.30||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||79.30||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Medicaid|MEDICAID HMO|||||79.30||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Medicare|MEDICARE ACUTE|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|United Healthcare|UNITED HEALTHCARE|||||79.30||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|United Healthcare|UNITED HEALTHCARE|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Blue Cross PPO Specialty|BCBSTX PPO|||||70.15||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|125,464.99|31268.27|31268.27|31268.27|||| 988|DRG||NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Medicare|MEDICARE ACUTE|56,900.76|10610.355|10610.355|10610.355|||| 99100|EAP|0964||Workers Compensation|WORKERS COMPENSATION OTHER|||||596.25||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.43||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.43||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.43||| 99100|EAP|0964|CRNA FIELD AVOIDANCE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||310.50||| 99100|EAP|0964||United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||596.25||| 99100|EAP|0964||United Medicare Advantage|UHC MEDICARE GOLD MA|||||596.25||| 99100|EAP|0964||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||596.25||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|Veterans Affairs|VETERANS ADMINISTRATION|||||1.43||| 99100|EAP|0964||Blue Cross PPO Specialty|BCBSTX PPO|||||596.25||| 99100|EAP|0964|CRNA FIELD AVOIDANCE|Blue Cross PPO Specialty|BCBSTX PPO|||||310.50||| 99100|EAP|0964||Humana Medicare Advantage|HUMANA MA|||||596.25||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|Humana Medicare Advantage|HUMANA MA|||||1.43||| 99100|EAP|0964|CRNA FIELD AVOIDANCE|Humana Medicare Advantage|HUMANA MA|||||310.50||| 99100|EAP|0964|CRNA FIELD AVOIDANCE|Cigna|CIGNA|||||310.50||| 99100|EAP|0964||Cigna|CIGNA|||||596.25||| 99100|EAP|0964||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||596.25||| 99100|EAP|0964|CRNA FIELD AVOIDANCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||310.50||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.43||| 99100|EAP|0964||Aenta Medicare Advantage|AETNA MEDICARE MA|||||596.25||| 99100|EAP|0964|CRNA FIELD AVOIDANCE|Blue Cross HMO Specialty|BCBSTX HMO|||||310.50||| 99100|EAP|0964||Blue Cross HMO Specialty|BCBSTX HMO|||||596.25||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|Blue Cross PPO Specialty|BCBSTX PPO|||||1.43||| 99100|EAP|0964||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||596.25||| 99100|EAP|0964||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||596.25||| 99100|EAP|0964||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||596.25||| 99100|EAP|0964||Access Direct Platinum|HEALTHFIRST TPA UMR|||||596.25||| 99100|EAP|0964||NON CONTRACTED|COMMERCIAL OTHER 1|||||596.25||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|Medicare|MEDICARE ACUTE|||||1.43||| 99100|EAP|0964|CRNA FIELD AVOIDANCE|Medicare|MEDICARE ACUTE|||||310.50||| 99100|EAP|0964||Medicare|MEDICARE ACUTE|||||596.25||| 99100|EAP|0964|CRNA FIELD AVOIDANCE|United Healthcare|UNITED HEALTHCARE|||||310.50||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1.43||| 99100|EAP|0964||United Healthcare|UNITED HEALTHCARE|||||596.25||| 99100|EAP|0964||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||596.25||| 99100|EAP|0964||Managed Medicaid|MEDICAID SUPERIOR|||||596.25||| 99100|EAP|0964||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||596.25||| 99100|EAP|0964|CRNA FIELD AVOIDANCE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||310.50||| 99100|EAP|0964||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||596.25||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.43||| 99100|EAP|0964|CRNA MOD EXTREME AGE ANES|Managed Medicare|HEALTHSPRING MA|||||1.43||| 99100|EAP|0964||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||596.25||| 99100|EAP|0964||Managed Medicare|HEALTHSPRING MA|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Managed Medicaid|MEDICAID SUPERIOR|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Managed Medicare|HEALTHSPRING MA|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Managed Medicare|BCBS MEDICARE PPO MA|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Managed Medicaid|MEDICAID AMERIGROUP|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|NON CONTRACTED|COMMERCIAL OTHER 1|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Medicare|MEDICARE ACUTE|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|United Healthcare|UNITED HEALTHCARE OTHER|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Blue Cross HMO Specialty|BCBSTX HMO|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Medicaid|MEDICAID|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Blue Cross PPO Specialty|BCBSTX PPO|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Humana Medicare Advantage|HUMANA MA|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Workers Compensation|WORKERS COMPENSATION OTHER|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|596.25||||596.25||| 99135|EAP|0964|CRNA MOD CONTROLLED HYPOT|Veterans Affairs|VETERANS ADMINISTRATION|||||596.25||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Blue Cross PPO Specialty|BCBSTX PPO|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Workers Compensation|WORKERS COMPENSATION OTHER|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Humana Medicare Advantage|HUMANA MA|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Cigna|CIGNA|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Access Direct Platinum|HEALTHFIRST TPA UMR|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|NON CONTRACTED|COMMERCIAL OTHER 1|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Medicare|MEDICARE ACUTE|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|United Healthcare|UNITED HEALTHCARE|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Tricare|TRICARE EAST REGION|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Managed Medicaid|MEDICAID SUPERIOR|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||177.50||| 99140|EAP|0964|CRNA MOD EMERGENCY ANESTH|Managed Medicaid|MEDICAID AMERIGROUP|||||177.50||| 99152|EAP|0450|CONSCIOUS SEDATION INITIA|Blue Cross HMO Specialty|BCBSTX HMO|||||3.85||| 99195|EAP|0940|THERAPEUTIC PHLEBOTOMY|Managed Medicare|HEALTHSPRING MA|||||2.59||| 99195|EAP|0940|THERAPEUTIC PHLEBOTOMY|Medicare|MEDICARE ACUTE|||||2.59||| 99195|EAP|0940|THERAPEUTIC PHLEBOTOMY|Blue Cross PPO Specialty|BCBSTX PPO|||||2.59||| 99195|EAP|0940|THERAPEUTIC PHLEBOTOMY|Humana Medicare Advantage|HUMANA MA|||||2.59||| 99195|EAP|0940|THERAPEUTIC PHLEBOTOMY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.59||| 99195|EAP|0940|THERAPEUTIC PHLEBOTOMY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.59||| 99203|EAP|0510|EVAL/NP L-3 30 MIN|Managed Medicaid|MEDICAID SUPERIOR|3.10||||3.10||| 99205|EAP|0510|EVAL/NP L-5 60 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||679.75||| 99211|EAP|0761|OUTPATIENT ROOM FEE|NON CONTRACTED|COMMERCIAL OTHER 1|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Medicare|MEDICARE ACUTE|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|United Healthcare|UNITED HEALTHCARE|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Tricare|TRICARE EAST REGION|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Managed Medicaid|MEDICAID SUPERIOR|314.50||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Managed Medicaid|MEDICAID AMERIGROUP|314.50||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Medicaid|MEDICAID HMO|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Medicaid|MEDICAID|314.50||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Workers Compensation|WORKERS COMPENSATION OTHER|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Blue Cross PPO Specialty|BCBSTX PPO|314.50||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Cigna|CIGNA|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|314.50||||314.50||| 99211|EAP|0510|PICC LINE REMOVAL|Blue Cross HMO Specialty|BCBSTX HMO|||||1.25||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Blue Cross HMO Specialty|BCBSTX HMO|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Aetna|AETNA PPO|||||314.50||| 99211|EAP|0761|OUTPATIENT ROOM FEE|Aetna|AETNA OTHER|||||314.50||| 99214|EAP|0510|TREATMENT ROOM EST PT L-4|Managed Medicaid|MEDICAID SUPERIOR|6.38||||6.38||| 99214|EAP|0510|TREATMENT ROOM EST PT L-4|Medicare|MEDICARE ACUTE|||||6.38||| 99215|EAP|0510|TREATMENT ROOM EST PT L-5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.38||| 99215|EAP|0510|TREATMENT ROOM EST PT L-5|Medicare|MEDICARE ACUTE|||||6.38||| 99215|EAP|0510|TREATMENT ROOM EST PT L-5|Managed Medicaid|MEDICAID SUPERIOR|6.38||||6.38||| 99281|EAP|0450|ER VISIT LEVEL 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||239.87||| 99281|EAP|0450|ER VISIT LEVEL 1|Veterans Affairs|VETERANS ADMINISTRATION|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross PPO Specialty|BCBSTX PPO|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||239.87||| 99281|EAP|0450|ER VISIT LEVEL 1|Cigna|CIGNA|||||239.87||| 99281|EAP|0450|ER VISIT LEVEL 1|Cigna|CIGNA|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Humana Medicare Advantage|HUMANA MA|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Aenta Medicare Advantage|AETNA MEDICARE MA|||||239.87||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross HMO Specialty|BCBSTX HMO|||||231.69||| 99281|EAP|0450|ER VISIT LEVEL 1|Aetna|AETNA PPO|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|MEDICAID HMO|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|United Healthcare|UNITED HEALTHCARE OTHER|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|United Healthcare|UNITED HEALTHCARE|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicare|HEALTHSPRING MA|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicare|MEDICARE ACUTE|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID SUPERIOR|223.50||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|MEDICAID|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||239.87||| 99281|EAP|0450|ER VISIT LEVEL 1|Workers Compensation|UT EMPLOYEE INJURY|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||239.87||| 99281|EAP|0450|ER VISIT LEVEL 1|Tricare|TRICARE EAST REGION|||||239.87||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID AMERIGROUP|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Workers Compensation|WORKERS COMPENSATION OTHER|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|239.87||||223.50||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross PPO Specialty|BCBSTX PPO|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||391.84||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|United Healthcare|UNITED HEALTHCARE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Cigna|CIGNA|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicare|MEDICARE ACUTE|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Veterans Affairs|VETERANS ADMINISTRATION|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicaid|MEDICAID|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Humana Medicare Advantage|HUMANA MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Managed Medicaid|MEDICAID SUPERIOR|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|United Healthcare|UNITED HEALTHCARE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Managed Medicaid|MEDICAID AMERIGROUP|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|MEDICAID HMO|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Workers Compensation|WORKERS COMPENSATION OTHER|||||391.84||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicare|MEDICARE ACUTE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Workers Compensation|WORKERS COMPENSATION OTHER|||||391.84||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Aetna|AETNA PPO|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Aetna|AETNA PPO|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Tricare|TRICARE EAST REGION|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||391.84||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross HMO Specialty|BCBSTX HMO|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicare|HEALTHSPRING MA|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Aetna|AETNA OTHER|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Cigna|CIGNA|||||391.84||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||391.84||| 99282|EAP|0450|ER VISIT LEVEL 2|Humana Medicare Advantage|HUMANA MA|||||391.84||| 99282|EAP|0450|ER VISIT LEVEL 2|Tricare|TRICARE EAST REGION|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Managed Medicare|HEALTHSPRING MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Blue Cross HMO Specialty|BCBSTX HMO|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 1|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 2|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|MEDICAID|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID SUPERIOR|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Blue Cross PPO Specialty|BCBSTX PPO|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID AMERIGROUP|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicaid|MEDICAID HMO|||||405.68||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||405.68||| 99283|EAP|0450|ER VISIT LEVEL 3|PHCS|HUMANA INSURANCE|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|NON CONTRACTED|COMMERCIAL OTHER 2|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Healthcare|UNITED HEALTHCARE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 2|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3|PHCS|MULTIPLAN PHCS|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicare|MEDICARE ACUTE|1,140.28||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3|Aetna|AETNA OTHER|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3|Aenta Medicare Advantage|AETNA MEDICARE MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|NON CONTRACTED|COMMERCIAL OTHER 1|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|HEALTHSPRING MA|11.00||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Tricare|TRICARE EAST REGION|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Tricare|TRICARE FOR LIFE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|UNITED HEALTHCARE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Tricare|TRICARE FOR LIFE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Humana Medicare Advantage|HUMANA MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Workers Compensation|WORKERS COMPENSATION OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Tricare|TRICARE EAST REGION|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Veterans Affairs|VETERANS ADMINISTRATION|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross PPO Specialty|BCBSTX OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|UT EMPLOYEE INJURY|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Healthcare|UNITED HEALTHCARE OTHER|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Cigna|CIGNA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Veterans Affairs|VETERANS ADMINISTRATION|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|TML GROUP BENEFITS|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross PPO Specialty|BCBSTX PPO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|PHCS|HUMANA INSURANCE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3|ChampVA|CHAMPVA CENTER|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Managed Medicaid|MEDICAID AMERIGROUP|1,140.28||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Humana Medicare Advantage|HUMANA MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Cigna|CIGNA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|UNITED HEALTHCARE|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicare|MEDICARE ACUTE|1,140.28||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 1|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID SUPERIOR|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|UNITED HEALTHCARE OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Managed Medicare|HEALTHSPRING MA|11.00||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicaid|MEDICAID|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Blue Cross HMO Specialty|BCBSTX HMO|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicaid|MEDICAID HMO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross HMO Specialty|BCBSTX HMO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Aetna|AETNA PPO|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Managed Medicaid|MEDICAID SUPERIOR|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST TPA UMR|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID TEXAS CHILDRENS|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Aetna|AETNA PPO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|BCBS MEDICARE PPO MA|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,180.55||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID CSHCN|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Blue Cross PPO Specialty|BCBSTX PPO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Healthcare|UNITED HEALTHCARE|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Managed Medicare|BCBS MEDICARE PPO MA|||||1,140.28||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID HMO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID AMERIGROUP|1,140.28||||11.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,467.14||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross HMO Specialty|BCBSTX HMO|23.80||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross HMO Specialty|BCBSTX HMO|23.80||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Aetna|AETNA PPO|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Aetna|AETNA OTHER|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2,467.14||| 99284|EAP|0450|ER VISIT LEVEL 4|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UMR|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Humana Medicare Advantage|HUMANA MA|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Cigna|CIGNA|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Cigna|CIGNA|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Workers Compensation|UT EMPLOYEE INJURY|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross PPO Specialty|BCBSTX OTHER|||||2,467.14||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross PPO Specialty|BCBSTX PPO|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Workers Compensation|UT EMPLOYEE INJURY|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,554.27||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Workers Compensation|WORKERS COMP PHYSICIAN|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicare|MEDICARE ACUTE|23.80||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Workers Compensation|WORKERS COMPENSATION OTHER|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Workers Compensation|WORKERS COMPENSATION OTHER|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Veterans Affairs|VETERANS ADMINISTRATION|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|UHC MEDICARE GOLD MA|2,554.27||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Healthcare|UNITED HEALTHCARE OTHER|||||2,467.14||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Healthcare|UNITED HEALTHCARE|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Healthcare|UNITED HEALTHCARE|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|United Healthcare|UNITED HEALTHCARE|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|PHCS|MULTIPLAN PHCS|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|United Healthcare|UNITED HEALTHCARE OTHER|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 2|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|PHCS|HUMANA INSURANCE|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,554.27||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicare|MEDICARE ACUTE|2,554.27||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Healthcare|TML GROUP BENEFITS|||||2,467.14||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Tricare|TRICARE EAST REGION|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Tricare|TRICARE EAST REGION|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicare|MEDICARE PART B ONLY IP|2,554.27||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Medicare Advantage|UHC MEDICARE GOLD MA|2,554.27||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Veterans Affairs|VETERANS ADMINISTRATION|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross PPO Specialty|BCBSTX PPO|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Humana Medicare Advantage|HUMANA MA|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|MEDICAID TEXAS CHILDRENS|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Tricare|TRICARE FOR LIFE|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Aetna|AETNA OTHER|||||2,467.14||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross PPO Specialty|BCBSTX OTHER|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Access Direct Platinum|HEALTHFIRST TPA UMR|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|MEDICAID|23.80||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|MEDICAID HMO|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicaid|MEDICAID SUPERIOR|23.80||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Tricare|TRICARE FOR LIFE|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|MEDICAID|23.80||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicare|BCBS MEDICARE PPO MA|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicare|BCBS MEDICARE PPO MA|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicare|HEALTHSPRING MA|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23.80||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID SUPERIOR|23.80||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|23.80||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23.80||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicare|HEALTHSPRING MA|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23.80||||23.80||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID AMERIGROUP|10.05||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|MEDICAID HMO|||||2,554.27||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicaid|MEDICAID AMERIGROUP|10.05||||23.80||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,013.86||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross HMO Specialty|BCBSTX HMO|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Aenta Medicare Advantage|AETNA MEDICARE MA|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross PPO Specialty|BCBSTX OTHER|||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Aenta Medicare Advantage|AETNA MEDICARE MA|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross HMO Specialty|BCBSTX HMO|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,876.93||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UMR|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Cigna|CIGNA|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Aetna|AETNA PPO|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross PPO Specialty|BCBSTX PPO|37.40||||3,876.93||| 99285|EAP|0450|ER VISIT LEVEL 5|Cigna|CIGNA|||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Cigna|CIGNA|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross PPO Specialty|BCBSTX PPO|37.40||||3,876.93||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Cigna|CIGNA|||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Aetna|AETNA PPO|4,013.86||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,876.93||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Medicare Advantage|UHC MEDICARE GOLD MA|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|PHCS|HUMANA INSURANCE|||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicare|HEALTHSPRING MA|37.40||||3,876.93||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicare|BCBS MEDICARE PPO MA|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicaid|MEDICAID SUPERIOR|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicaid|MEDICAID AMERIGROUP|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID SUPERIOR|3,876.93||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID AMERIGROUP|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicare|MEDICARE PART B ONLY IP|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|UTMB|UTMB CORRECTIONAL MANAGED CARE|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|UTMB|UTMB CORRECTIONAL MANAGED CARE|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicare|MEDICARE ACUTE|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Humana Medicare Advantage|HUMANA MA|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicare|MEDICARE ACUTE|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|MEDICAID HMO|||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|United Healthcare|UNITED HEALTHCARE|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicare|HEALTHSPRING MA|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|MEDICAID|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 2|||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicare|MEDICARE PART B ONLY IP|4,013.86||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 1|3,876.93||||3,876.93||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3,876.93||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,876.93||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|4,013.86||||||| 99285|EAP|0450|ER VISIT LEVEL 5|NON CONTRACTED|COMMERCIAL OTHER 1|3,876.93||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicare|WELLCARE CHOICE MA|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Healthcare|UNITED HEALTHCARE|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|MEDICAID HMO|||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Tricare|TRICARE EAST REGION|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|United Healthcare|UNITED HEALTHCARE|4,013.86||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|MEDICAID|37.40||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Healthcare|UNITED HEALTHCARE OTHER|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|United Healthcare|GOLDEN RULE|||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|ChampVA|CHAMPVA CENTER|37.40||||||| 99285|EAP|0450|ER VISIT LEVEL 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Workers Compensation|WORKERS COMPENSATION OTHER|37.40||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Veterans Affairs|VETERANS ADMINISTRATION|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|Humana Medicare Advantage|HUMANA MA|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4,013.86||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|United Medicare Advantage|UHC MEDICARE GOLD MA|4,013.86||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Veterans Affairs|VETERANS ADMINISTRATION|4,013.86||||3,876.93||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||37.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Tricare|TRICARE EAST REGION|4,013.86||||4,013.86||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||4,013.86||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Blue Cross HMO Specialty|BCBSTX HMO|||||2,471.37||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,471.37||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Blue Cross PPO Specialty|BCBSTX PPO|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Humana Medicare Advantage|HUMANA MA|2,387.06||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,387.06||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,471.37||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||2,387.06||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Medicare|MEDICARE ACUTE|2,471.37||||2,471.37||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Managed Medicare|HEALTHSPRING MA|||||2,471.37||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Veterans Affairs|VETERANS ADMINISTRATION|2,471.37||||||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|United Medicare Advantage|UHC MEDICARE GOLD MA|2,471.37||||2,471.37||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Managed Medicaid|MEDICAID SUPERIOR|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,471.37||||2,387.06||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Managed Medicare|BCBS MEDICARE PPO MA|||||2,471.37||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Medicaid|MEDICAID HMO|||||2,387.06||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Managed Medicare|WELLCARE CHOICE MA|||||2,471.37||| 998|DRG||PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS|Medicaid|MEDICAID|24,754.89|4793.19|4793.19|4793.19|||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|United Medicare Advantage|UHC MEDICARE GOLD MA|||||12.50||| A4216|ERX|0250|NORMAL SALINE SOLUTION, 1|Managed Medicaid|MEDICAID SUPERIOR|6.25||||6.25||| A4216|ERX|0250|NORMAL SALINE SOLUTION, 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.25||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross PPO Specialty|BCBSTX PPO|||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Medicare|MEDICARE ACUTE|||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Workers Compensation|WORKERS COMPENSATION OTHER|||||12.50||| A4216|ERX|0250|NORMAL SALINE SOLUTION, 1|Medicare|MEDICARE ACUTE|||||6.25||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|UTMB|UTMB CORRECTIONAL MANAGED CARE|118.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicare|MEDICARE ACUTE|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Tricare|TRICARE FOR LIFE|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Tricare|TRICARE EAST REGION|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|UMR UNITED MEDICAL RESOURCES|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|MEDICAID|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicare|HEALTHSPRING MA|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|MEDICAID HMO|||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicare|BCBS MEDICARE PPO MA|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicare|MEDICARE ACUTE|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|UNITED HEALTHCARE|||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|HEALTHSPRING MA|||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|116.75||||||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|UNITED HEALTHCARE|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|PHCS|HUMANA INSURANCE|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|118.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross HMO Specialty|BCBSTX HMO|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Aetna|AETNA OTHER|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aetna|AETNA PPO|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aetna|AETNA OTHER|116.75||||||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross HMO Specialty|BCBSTX HMO|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Aetna|AETNA PPO|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Cigna|CIGNA|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|BCBS MEDICARE PPO MA|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross PPO Specialty|BCBSTX PPO|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Cigna|CIGNA|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Humana Medicare Advantage|HUMANA MA|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|NON CONTRACTED|COMMERCIAL OTHER 1|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicaid|MEDICAID|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|MEDICAID|116.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|MOLINA HEALTHCARE OF TEXAS|116.75||||||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID SUPERIOR|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Tricare|TRICARE EAST REGION|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross PPO Specialty|BCBSTX PPO|118.75||||118.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Humana Medicare Advantage|HUMANA MA|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID AMERIGROUP|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID SUPERIOR|118.75||||118.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|ChampVA|CHAMPVA CENTER|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Healthcare|UNITED HEALTHCARE OTHER|||||12.50||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Healthcare|UNITED HEALTHCARE|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|UHC MEDICARE GOLD MA|116.75||||||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Veterans Affairs|VETERANS ADMINISTRATION|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Cigna|CIGNA|||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID AMERIGROUP|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||12.50||| A4264|EAP|0272|FILSHIE CLIP TUBAL|Managed Medicaid|MEDICAID AMERIGROUP|||||5,230.75||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.19||||||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.19||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Blue Cross HMO Specialty|BCBSTX HMO|||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Aenta Medicare Advantage|AETNA MEDICARE MA|0.19||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|ChampVA|CHAMPVA CENTER|0.19||||||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Medicare|MEDICARE ACUTE|0.19||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|United Healthcare|UNITED HEALTHCARE|||||0.19||| A4344|EAP|0274|CATH,FOLEY 18FR 5CC DISP|Humana Medicare Advantage|HUMANA MA|||||0.57||| A4344|EAP|0274|CATH,FOLEY 18FR 5CC DISP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.57||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.73||||||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|NON CONTRACTED|COMMERCIAL OTHER 1|0.73||||||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.73||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Aenta Medicare Advantage|AETNA MEDICARE MA|0.19||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Medicare|MEDICARE PART B ONLY IP|0.73||||||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Medicare|MEDICARE ACUTE|0.73||||0.73||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Medicare|MEDICARE ACUTE|0.19||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.73||||||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Medicaid|MEDICAID|0.73||||||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Cigna|CIGNA|0.73||||||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Humana Medicare Advantage|HUMANA MA|0.19||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.73||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Humana Medicare Advantage|HUMANA MA|0.73||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|United Healthcare|UNITED HEALTHCARE|||||0.73||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Managed Medicaid|MEDICAID SUPERIOR|0.73||||0.19||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Managed Medicaid|MEDICAID AMERIGROUP|0.73||||0.19||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Managed Medicaid|MEDICAID SUPERIOR|0.73||||0.73||| A4461|EAP|0270|BINDER ABDOMINAL|Blue Cross PPO Specialty|BCBSTX PPO|1.34||||||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|Medicare|MEDICARE ACUTE|0.96||||0.96||| A4550|EAP|0272||Medicaid|MEDICAID|29.50||||29.50||| A4550|EAP|0272|TRAY,DRESSING CENTRAL LIN|Medicare|MEDICARE ACUTE|79.25||||79.25||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|United Healthcare|UNITED HEALTHCARE|||||0.96||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|Medicaid|MEDICAID|29.50||||0.96||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.96||| A4550|EAP|0272||NON CONTRACTED|COMMERCIAL OTHER 1|||||29.50||| A4550|EAP|0272||Veterans Affairs|VETERANS ADMINISTRATION|||||61.50||| A4550|EAP|0272|TRAY,DRESSING CENTRAL LIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|79.25||||||| A4550|EAP|0272|TRAY,DRESSING CENTRAL LIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|79.25||||0.96||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.90||||0.96||| A4550|EAP|0272|KIT CVP MULTI LUMEN 7FR D|Humana Medicare Advantage|HUMANA MA|6.90||||||| A4550|EAP|0272|TRAY,DRESSING CENTRAL LIN|Managed Medicaid|MEDICAID SUPERIOR|79.25||||29.50||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.96||| A4550|EAP|0272||Managed Medicaid|MEDICAID SUPERIOR|0.96||||29.50||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|Managed Medicaid|MEDICAID AMERIGROUP|||||0.96||| A4550|EAP|0272|TRAY,DRESSING CENTRAL LIN|Blue Cross HMO Specialty|BCBSTX HMO|79.25||||79.25||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|Blue Cross PPO Specialty|BCBSTX PPO|0.96||||0.96||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|United Medicare Advantage|UHC MEDICARE GOLD MA|79.25||||0.96||| A4550|EAP|0272|TRAY,DRESSING CENTRAL LIN|Blue Cross PPO Specialty|BCBSTX PPO|79.25||||0.96||| A4550|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|29.50||||29.50||| A4550|EAP|0272||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||29.50||| A4550|EAP|0272|PACK LITHOTOMY I DISP EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.90||||0.96||| A4556|EAP|0272|ELECTRODE,CONNECT SPIRAL|Medicaid|MEDICAID|64.75||||||| A4556|EAP|0272|ELECTRODE,CONNECT SPIRAL|Managed Medicaid|MEDICAID SUPERIOR|64.75||||||| A4556|EAP|0272|ELECTRODE,CONNECT SPIRAL|Managed Medicaid|MEDICAID AMERIGROUP|64.75||||||| A4556|EAP|0272|ELECTRODE,CONNECT SPIRAL|United Healthcare|UNITED HEALTHCARE|64.75||||||| A4556|EAP|0272|ELECTRODE,CONNECT SPIRAL|Blue Cross PPO Specialty|BCBSTX PPO|64.75||||||| A4556|EAP|0272|ELECTRODE,CONNECT SPIRAL|Cigna|CIGNA|64.75||||||| A4565|EAP|0271|SLING ARM X-LGE EA|United Medicare Advantage|UHC MEDICARE GOLD MA|54.25||||54.25||| A4565|EAP|0271|SLING ARM PEDI EA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||58.50||| A4565|EAP|0271|SLING ARM X-LGE EA|Cigna|CIGNA|||||54.25||| A4565|EAP|0271|SLING ARM X-LGE EA|Humana Medicare Advantage|HUMANA MA|54.25||||54.25||| A4565|EAP|0271|SLING ARM X-LGE EA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||54.25||| A4565|EAP|0271|SLING ARM MEDIUM EA|Managed Medicaid|MEDICAID AMERIGROUP|||||43.25||| A4565|EAP|0271|SLING ARM LARGE EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||43.25||| A4565|EAP|0271|SLING ARM PEDI EA|Managed Medicaid|MEDICAID AMERIGROUP|||||58.50||| A4565|EAP|0271|SLING ARM MEDIUM EA|Aenta Medicare Advantage|AETNA MEDICARE MA|43.25||||43.25||| A4565|EAP|0271|SLING ARM LARGE EA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||43.25||| A4565|EAP|0271|SLING ARM MEDIUM EA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|54.25||||43.25||| A4565|EAP|0271|SLING ARM X-LGE EA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||54.25||| A4565|EAP|0271|SLING ARM PEDI EA|Aetna|AETNA PPO|||||58.50||| A4565|EAP|0271|SLING ARM X-LGE EA|Blue Cross PPO Specialty|BCBSTX PPO|43.25||||54.25||| A4565|EAP|0271|SLING ARM MEDIUM EA|Aetna|AETNA OTHER|||||43.25||| A4565|EAP|0271|SLING ARM LARGE EA|Aenta Medicare Advantage|AETNA MEDICARE MA|43.25||||43.25||| A4565|EAP|0271|SLING ARM X-LGE EA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|54.25||||54.25||| A4565|EAP|0271|SLING ARM PEDI EA|Blue Cross PPO Specialty|BCBSTX PPO|43.25||||58.50||| A4565|EAP|0271|SLING ARM MEDIUM EA|Blue Cross PPO Specialty|BCBSTX PPO|43.25||||43.25||| A4565|EAP|0271|SLING ARM MEDIUM EA|Managed Medicaid|MEDICAID SUPERIOR|||||43.25||| A4565|EAP|0271|SLING ARM LARGE EA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||43.25||| A4565|EAP|0271|SLING ARM DISP SMALL EA|Blue Cross PPO Specialty|BCBSTX PPO|43.25||||43.25||| A4565|EAP|0271|SLING ARM LARGE EA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54.25||||43.25||| A4565|EAP|0271|SLING ARM X-LGE EA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54.25||||54.25||| A4565|EAP|0271|SLING ARM LARGE EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54.25||||43.25||| A4565|EAP|0271|SLING ARM PEDI EA|Managed Medicaid|MEDICAID SUPERIOR|||||58.50||| A4565|EAP|0271|SLING ARM LARGE EA|Humana Medicare Advantage|HUMANA MA|54.25||||43.25||| A4565|EAP|0271|SLING ARM X-LGE EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||54.25||| A4565|EAP|0271|SLING ARM LARGE EA|Blue Cross PPO Specialty|BCBSTX PPO|43.25||||43.25||| A4565|EAP|0271|SLING ARM MEDIUM EA|Medicare|MEDICARE ACUTE|54.25||||43.25||| A4565|EAP|0271|SLING ARM LARGE EA|United Healthcare|GOLDEN RULE|||||43.25||| A4565|EAP|0271|SLING ARM X-LGE EA|Medicaid|MEDICAID|||||54.25||| A4565|EAP|0271|SLING ARM LARGE EA|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||43.25||| A4565|EAP|0271|SLING ARM X-LGE EA|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||54.25||| A4565|EAP|0271|SLING ARM LARGE EA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||43.25||| A4565|EAP|0271|SLING ARM LARGE EA|Medicaid|MEDICAID|||||43.25||| A4565|EAP|0271|SLING ARM MEDIUM EA|United Healthcare|UNITED HEALTHCARE|||||43.25||| A4565|EAP|0271|SLING ARM MEDIUM EA|United Healthcare|UNITED HEALTHCARE OTHER|||||43.25||| A4565|EAP|0271|SLING ARM PEDI EA|Medicare|MEDICARE ACUTE|54.25||||58.50||| A4565|EAP|0271|SLING ARM LARGE EA|Medicare|MEDICARE ACUTE|54.25||||43.25||| A4565|EAP|0271|SLING ARM X-LGE EA|Medicare|MEDICARE ACUTE|54.25||||54.25||| A4565|EAP|0271|SLING ARM X-LGE EA|Tricare|TRICARE EAST REGION|||||54.25||| A4565|EAP|0271|SLING ARM LARGE EA|Workers Compensation|WORKERS COMPENSATION OTHER|||||43.25||| A4565|EAP|0271|SLING ARM X-LGE EA|NON CONTRACTED|COMMERCIAL OTHER 1|||||54.25||| A4565|EAP|0271|SLING ARM PEDI EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54.25||||58.50||| A4565|EAP|0271|SLING ARM X-LGE EA|United Medicare Advantage|UHC MEDICARE GOLD MA|43.25||||54.25||| A4565|EAP|0271|SLING ARM X-LGE EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54.25||||54.25||| A4565|EAP|0271|SLING ARM LARGE EA|NON CONTRACTED|COMMERCIAL OTHER 1|||||43.25||| A4565|EAP|0271|SLING ARM X-LGE EA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||54.25||| A4649|EAP|0270||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,051.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Aenta Medicare Advantage|AETNA MEDICARE MA|310.25||||310.25||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Aenta Medicare Advantage|AETNA MEDICARE MA|46.50||||46.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|310.25||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Access Direct Platinum|HEALTHFIRST TPA UMR|310.25||||310.25||| A4649|EAP|0272|WATERBUG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.50||||0.68||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|46.50||||46.50||| A4649|EAP|0272|RETRACTOR RING DISP (LONE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||101.75||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Blue Cross HMO Specialty|BCBSTX HMO|||||310.25||| A4649|EAP|0272|ELASTIC STAYS (LONESTAR)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||109.75||| A4649|EAP|0270||Aetna|AETNA PPO|||||1,051.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Aetna|AETNA PPO|310.25||||||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Aetna|AETNA PPO|0.19||||46.50||| A4649|EAP|0272|SYSTEM INTRAUTERINE PRES|Aetna|AETNA PPO|7.70||||46.50||| A4649|EAP|0272|SYSTEM INTRAUTERINE PRES|Aetna|AETNA OTHER|7.70||||||| A4649|EAP|0270||Blue Cross PPO Specialty|BCBSTX PPO|||||1,051.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Blue Cross PPO Specialty|BCBSTX PPO|310.25||||310.25||| A4649|EAP|0272|PLUME-AWAY LAP SES ULTRA|Blue Cross PPO Specialty|BCBSTX PPO|7.70||||76.75||| A4649|EAP|0272|LEGGINGS|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||28.75||| A4649|EAP|0272|UTILITY DRAPE W/TAPE 15X2|Blue Cross PPO Specialty|BCBSTX PPO|1.50||||1.50||| A4649|EAP|0272|WATERBUG|Blue Cross PPO Specialty|BCBSTX PPO|1.50||||0.68||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Blue Cross PPO Specialty|BCBSTX PPO|46.50||||46.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.70||||46.50||| A4649|EAP|0272|WATERBUG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|46.50||||0.68||| A4649|EAP|0272|PLUME-AWAY LAP SES ULTRA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||76.75||| A4649|EAP|0272|UTILITY DRAPE W/TAPE 15X2|Cigna|CIGNA|||||1.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Cigna|CIGNA|||||46.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Cigna|CIGNA|7.70||||46.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Humana Medicare Advantage|HUMANA MA|310.25||||310.25||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Humana Medicare Advantage|HUMANA MA|46.50||||46.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|310.25||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicaid|MEDICAID SUPERIOR|310.25||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|310.25||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicaid|MEDICAID AMERIGROUP|310.25||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Cigna|CIGNA|310.25||||310.25||| A4649|EAP|0272|UTILITY DRAPE W/TAPE 15X2|Managed Medicaid|MEDICAID SUPERIOR|16.50||||1.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Managed Medicaid|MEDICAID UNITED HEALTHCARE|46.50||||46.50||| A4649|EAP|0272|WATERBUG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.50||||0.68||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||46.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Managed Medicaid|MEDICAID SUPERIOR|0.19||||46.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Managed Medicaid|MEDICAID AMERIGROUP|76.75||||46.50||| A4649|EAP|0272|SYSTEM INTRAUTERINE PRES|Managed Medicaid|MEDICAID AMERIGROUP|7.70||||46.50||| A4649|EAP|0272|PLUME-AWAY LAP SES ULTRA|Managed Medicaid|MEDICAID AMERIGROUP|16.50||||76.75||| A4649|EAP|0272|CLAMP UMB CORD DISP EA|Managed Medicaid|MEDICAID AMERIGROUP|0.19||||16.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|ChampVA|CHAMPVA CENTER|310.25||||||| A4649|EAP|0272|SYSTEM INTRAUTERINE PRES|Managed Medicaid|MEDICAID SUPERIOR|7.70||||0.68||| A4649|EAP|0272|PLUME-AWAY LAP SES ULTRA|Managed Medicaid|MEDICAID SUPERIOR|1.12||||76.75||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Workers Compensation|WORKERS COMPENSATION OTHER|||||310.25||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Workers Compensation|WORKERS COMPENSATION OTHER|46.50||||46.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.50||||46.50||| A4649|EAP|0270|OXYGEN PER HOUR IN ER|United Medicare Advantage|UHC MEDICARE GOLD MA|2.15||||||| A4649|EAP|0270|OXYGEN PER HOUR IN ER|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.15||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|310.25||||||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|United Medicare Advantage|UHC MEDICARE GOLD MA|310.25||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|310.25||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|310.25||||310.25||| A4649|EAP|0272|WATERBUG|Managed Medicaid|MEDICAID SUPERIOR|76.75||||0.68||| A4649|EAP|0272|UTILITY DRAPE W/TAPE 15X2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|46.50||||1.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|United Healthcare|UNITED HEALTHCARE|310.25||||310.25||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|46.50||||||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|United Medicare Advantage|AARP UHC WEST COMPLETE MA|46.50||||46.50||| A4649|EAP|0270|OXYGEN PER HOUR IN ER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.15||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|310.25||||||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|UTMB|UTMB CORRECTIONAL MANAGED CARE|46.50||||||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.50||||46.50||| A4649|EAP|0272|PLUME-AWAY LAP SES ULTRA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.50||||76.75||| A4649|EAP|0272|AMNIHOOK OB DISP EA|Cigna|CIGNA|0.19||||||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|United Medicare Advantage|UHC MEDICARE GOLD MA|46.50||||46.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|United Healthcare|UNITED HEALTHCARE|||||310.25||| A4649|EAP|0272|ELASTIC STAYS (LONESTAR)|United Healthcare|UNITED HEALTHCARE|0.19||||109.75||| A4649|EAP|0272|UTILITY DRAPE W/TAPE 15X2|Medicare|MEDICARE ACUTE|1.50||||0.68||| A4649|EAP|0272|WATERBUG|Tricare|TRICARE EAST REGION|||||0.68||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Medicare|MEDICARE ACUTE|76.75||||46.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|310.25||||310.25||| A4649|EAP|0272|PLUME-AWAY LAP SES ULTRA|Medicare|MEDICARE ACUTE|1.12||||76.75||| A4649|EAP|0272|WATERBUG|Medicare|MEDICARE ACUTE|0.68||||0.68||| A4649|EAP|0272|UTILITY DRAPE W/TAPE 15X2|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||1.50||| A4649|EAP|0272|RETRACTOR RING DISP (LONE|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||101.75||| A4649|EAP|0272|PLUME-AWAY LAP SES ULTRA|Medicaid|MEDICAID|0.19||||76.75||| A4649|EAP|0272|SYSTEM INTRAUTERINE PRES|Medicaid|MEDICAID|7.70||||46.50||| A4649|EAP|0270|OXYGEN PER HOUR IN ER|Medicaid|MEDICAID|2.15||||||| A4649|EAP|0272|ELASTIC STAYS (LONESTAR)|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||109.75||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Medicaid|COUNTY INDIGENT HEALTH OTHER|310.25||||310.25||| A4649|EAP|0272|AMNIHOOK OB DISP EA|Aetna|AETNA OTHER|0.19||||||| A4649|EAP|0272|AMNIHOOK OB DISP EA|Medicaid|MEDICAID HMO|0.19||||||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||46.50||| A4649|EAP|0272|PLUME-AWAY LAP SES ULTRA|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||76.75||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Blue Cross HMO Specialty|BCBSTX HMO|1.50||||46.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Tricare|TRICARE EAST REGION|||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicare|BCBS MEDICARE PPO MA|||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||310.25||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Medicaid|MEDICAID|16.50||||46.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||46.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||46.50||| A4649|EAP|0272|PLUME-AWAY LAP SES ULTRA|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||76.75||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|46.50||||||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Medicaid|MEDICAID HMO|310.25||||||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|NON CONTRACTED|COMMERCIAL OTHER 1|0.19||||46.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Medicaid|MEDICAID|310.25||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicare|HEALTHSPRING MA|||||310.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Medicare|MEDICARE ACUTE|310.25||||310.25||| A4649|EAP|0272|WATERBUG|Medicare|MEDICARE ACUTE|46.50||||0.68||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Tricare|TRICARE EAST REGION|||||46.50||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|Managed Medicare|BCBS MEDICARE PPO MA|46.50||||46.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|NON CONTRACTED|COMMERCIAL OTHER 1|310.25||||310.25||| A4649|EAP|0270|OXYGEN PER HOUR IN ER|Medicare|MEDICARE ACUTE|2.15||||2.15||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|United Healthcare|UNITED HEALTHCARE|||||46.50||| A4649|EAP|0272|RETRACTOR RING DISP (LONE|United Healthcare|UNITED HEALTHCARE|0.19||||101.75||| A4649|EAP|0272|TOURNIQUETS/DISPOSABLE 24|United Healthcare|UNITED HEALTHCARE|0.19||||46.50||| A6223|EAP|0272|DRESSING XEROFORM PETROL|Workers Compensation|WORKERS COMPENSATION OTHER|1.56||||||| A6223|EAP|0272|DRESSING XEROFORM PETROL|Aetna|AETNA PPO|||||1.56||| A6223|EAP|0272|DRESSING XEROFORM PETROL|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||1.56||| A6223|EAP|0272|DRESSING XEROFORM PETROL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.56||||||| A6223|EAP|0272|DRESSING XEROFORM PETROL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.56||||||| A6223|EAP|0272|DRESSING XEROFORM PETROL|Medicare|MEDICARE ACUTE|13.50||||1.56||| A6223|EAP|0272|DRESSING XEROFORM PETROL|United Healthcare|UNITED HEALTHCARE OTHER|||||1.56||| A6223|EAP|0272|DRESSING XEROFORM PETROL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.56||| A6223|EAP|0272|DRESSING XEROFORM PETROL|Managed Medicaid|MEDICAID SUPERIOR|||||1.56||| A6223|EAP|0272|DRESSING XEROFORM PETROL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.50||||||| A6257|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|||||5.50||| A6261|EAP|0270|DRESSING WOUND HYDROGEL 1|Medicare|MEDICARE ACUTE|0.52||||||| A6266|EAP|0272|STRIP, NUGAUZE PACK 1/4 X|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||60.25||| A6266|EAP|0272|STRIP, NUGAUZE PACK 1/4 X|Medicare|MEDICARE ACUTE|60.25||||||| A6402|EAP|0272|BANDAGE,SOF KLING 2in.|Medicaid|MEDICAID|||||0.03||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Medicaid|MEDICAID|||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Medicaid|COUNTY INDIGENT HEALTH OTHER|8.75||||||| A6402|EAP|0272||Managed Medicare|HEALTHSPRING MA|||||8.75||| A6402|EAP|0272|"GAUZE,STRIP PLAIN 1/2"" X"|Medicare|MEDICARE ACUTE|65.25||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Medicare|MEDICARE ACUTE|8.75||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 2in.|Medicare|MEDICARE ACUTE|0.03||||0.03||| A6402|EAP|0272||Medicare|MEDICARE ACUTE|8.75||||8.75||| A6402|EAP|0272|"GAUZE,STRIP PLAIN 1/2"" X"|NON CONTRACTED|COMMERCIAL OTHER 1|||||65.25||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.75||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.03||||8.75||| A6402|EAP|0272||United Medicare Advantage|UHC MEDICARE GOLD MA|8.75||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Medicare|MEDICARE PART B ONLY IP|8.75||||||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|8.75||||||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|United Medicare Advantage|UHC MEDICARE GOLD MA|8.75||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Aenta Medicare Advantage|AETNA MEDICARE MA|8.75||||||| A6402|EAP|0272|"GAUZE,STRIP PLAIN 1/2"" X"|Blue Cross HMO Specialty|BCBSTX HMO|65.25||||||| A6402|EAP|0272|"GAUZE,STRIP PLAIN 1/2"" X"|Blue Cross PPO Specialty|BCBSTX PPO|65.25||||||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Blue Cross PPO Specialty|BCBSTX PPO|8.75||||||| A6402|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|8.75||||||| A6402|EAP|0272||Medicare|MEDICARE PART B ONLY IP|8.75||||||| A6402|EAP|0272|BANDAGE,SOF KLING 2in.|Blue Cross PPO Specialty|BCBSTX PPO|0.03||||||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.75||||||| A6402|EAP|0272|BANDAGE,SOF KLING 2in.|Workers Compensation|WORKERS COMPENSATION OTHER|0.03||||||| A6402|EAP|0272|BANDAGE,SOF KLING 2in.|Humana Medicare Advantage|HUMANA MA|8.75||||0.03||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Humana Medicare Advantage|HUMANA MA|8.75||||8.75||| A6402|EAP|0272||Humana Medicare Advantage|HUMANA MA|0.03||||8.75||| A6402|EAP|0272|"GAUZE,STRIP PLAIN 1/2"" X"|Managed Medicaid|MEDICAID SUPERIOR|8.75||||65.25||| A6402|EAP|0272|"GAUZE,STRIP PLAIN 1/2"" X"|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.75||||65.25||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|8.75||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Medicaid|MEDICAID HMO|||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 2in.|Managed Medicaid|MEDICAID SUPERIOR|8.75||||0.03||| A6402|EAP|0272|BANDAGE,SOF KLING 2in.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.03||||0.03||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Managed Medicaid|MEDICAID AMERIGROUP|65.25||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 2in.|Managed Medicaid|MEDICAID AMERIGROUP|65.25||||0.03||| A6402|EAP|0272|BANDAGE,SOF KLING 2in.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.03||||0.03||| A6402|EAP|0272||Managed Medicaid|MEDICAID SUPERIOR|0.03||||8.75||| A6402|EAP|0272||Managed Medicaid|MEDICAID AMERIGROUP|8.75||||8.75||| A6402|EAP|0272|BANDAGE,SOF KLING 4in.|Managed Medicaid|MEDICAID SUPERIOR|8.75||||8.75||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Cigna|CIGNA|||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Humana Medicare Advantage|HUMANA MA|1.50||||1.50||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|Humana Medicare Advantage|HUMANA MA|15.25||||15.25||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.50||||15.25||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|Managed Medicaid|MEDICAID SUPERIOR|15.25||||15.25||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.25||||15.25||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.50||||15.25||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Managed Medicaid|MEDICAID SUPERIOR|1.50||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Managed Medicaid|MEDICAID AMERIGROUP|||||1.50||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|Aenta Medicare Advantage|AETNA MEDICARE MA|15.25||||||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Aenta Medicare Advantage|AETNA MEDICARE MA|1.50||||||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|Blue Cross HMO Specialty|BCBSTX HMO|15.25||||||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|Blue Cross PPO Specialty|BCBSTX PPO|15.25||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Blue Cross PPO Specialty|BCBSTX PPO|1.50||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.50||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.25||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Veterans Affairs|VETERANS ADMINISTRATION|||||1.50||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|United Medicare Advantage|UHC MEDICARE GOLD MA|1.50||||15.25||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.25||||15.25||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|United Medicare Advantage|UHC MEDICARE GOLD MA|1.50||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.50||||1.50||| A6403|EAP|0272|GAUZE,KERLIX 4.1YD ROLL|Medicare|MEDICARE ACUTE|15.25||||15.25||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.50||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Medicare|MEDICARE PART B ONLY IP|1.50||||||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Medicare|MEDICARE ACUTE|1.50||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|United Healthcare|UNITED HEALTHCARE|||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Managed Medicare|HEALTHSPRING MA|||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.50||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|NON CONTRACTED|COMMERCIAL OTHER 1|15.25||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|Medicaid|MEDICAID HMO|||||1.50||| A6403|EAP|0272|BANDAGE TELFA 3/8 EA|United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| A6405|EAP|0272||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.03||| A6405|EAP|0272|BANDAGE,SOF KLING 3in.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||8.75||| A6405|EAP|0272||UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.03||| A6405|EAP|0272||Medicare|MEDICARE ACUTE|||||8.75||| A6405|EAP|0272||United Healthcare|UNITED HEALTHCARE OTHER|||||8.75||| A6405|EAP|0272||NON CONTRACTED|COMMERCIAL OTHER 1|||||0.03||| A6405|EAP|0272|BANDAGE,SOF KLING 3in.|Blue Cross HMO Specialty|BCBSTX HMO|||||8.75||| A6405|EAP|0272||Blue Cross HMO Specialty|BCBSTX HMO|||||8.75||| A6405|EAP|0272||Aetna|AETNA PPO|||||0.03||| A6405|EAP|0272|BANDAGE,SOF KLING 3in.|Aetna|AETNA OTHER|||||8.75||| A6405|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|||||0.03||| A6405|EAP|0272|BANDAGE,SOF KLING 3in.|Blue Cross PPO Specialty|BCBSTX PPO|||||8.75||| A6405|EAP|0272||United Healthcare|UNITED HEALTHCARE|||||0.03||| A6405|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|||||8.75||| A6405|EAP|0272||United Healthcare|UNITED HEALTHCARE|||||8.75||| A6405|EAP|0272|BANDAGE,SOF KLING 3in.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.75||| A6405|EAP|0272||Cigna|CIGNA|||||8.75||| A6405|EAP|0272|BANDAGE,SOF KLING 3in.|United Healthcare|UNITED HEALTHCARE|||||8.75||| A6405|EAP|0272||Cigna|CIGNA|||||0.03||| A6406|EAP|0272||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.25||| A6406|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|||||15.25||| A6406|EAP|0272||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.25||| A6406|EAP|0272||United Healthcare|UNITED HEALTHCARE|||||15.25||| A6406|EAP|0272||NON CONTRACTED|COMMERCIAL OTHER 1|||||15.25||| A6550|EAP|0272|PREVENA PEEL IN PLACE WOU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||20.66||| A6550|EAP|0272|PREVENA PEEL IN PLACE WOU|Blue Cross HMO Specialty|BCBSTX HMO|||||20.66||| A6550|EAP|0272|PREVENA PEEL IN PLACE WOU|Blue Cross PPO Specialty|BCBSTX PPO|20.66||||||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Managed Medicare|HEALTHSPRING MA|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Managed Medicare|WELLCARE CHOICE MA|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Medicare|MEDICARE ACUTE|0.38||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Medicare|MEDICARE ACUTE|0.38||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 8.0 DIS|Medicare|MEDICARE ACUTE|0.38||||0.38||| A7521|EAP|0274|TUBE TRACH CUFFED 8.0 DIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.38||||||| A7521|EAP|0274|TUBE TRACH CUFFED 8.0 DIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.38||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 6.0 DIS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||34.25||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Access Direct Platinum|HEALTHFIRST TPA UMR|49.75||||||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Blue Cross PPO Specialty|BCBSTX PPO|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 6.5 DIS|Blue Cross PPO Specialty|BCBSTX PPO|||||0.38||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 6.5 DIS|Managed Medicaid|MEDICAID AMERIGROUP|||||0.38||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Cigna|CIGNA|0.01||||0.03||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Humana Medicare Advantage|HUMANA MA|0.03||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Cigna|CIGNA|||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.01||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.03||||0.03||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID AMERIGROUP|0.03||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|ChampVA|CHAMPVA CENTER|0.01||||||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Cigna|CIGNA|||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|0.01||||||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID SUPERIOR|0.03||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|0.01||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Aetna|AETNA PPO|0.03||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Aetna|AETNA PPO|0.01||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross PPO Specialty|BCBSTX PPO|0.03||||0.03||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|0.01||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.03||||0.03||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.01||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|0.01||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Medicare Advantage|UHC MEDICARE GOLD MA|0.03||||0.03||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.03||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Healthcare|UNITED HEALTHCARE|0.03||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Healthcare|UNITED HEALTHCARE|||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|0.01||||||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.01||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Healthcare|UNITED HEALTHCARE|0.03||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.01||||||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Humana Medicare Advantage|HUMANA MA|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.01||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.01||||0.03||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Tricare|TRICARE EAST REGION|0.03||||||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Tricare|TRICARE EAST REGION|0.01||||||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.01||||||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|0.01||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|MEDICAID HMO|0.03||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|MEDICAID|0.01||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicare|HEALTHSPRING MA|0.01||||0.03||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicare|BCBS MEDICARE PPO MA|0.01||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicare|WELLCARE CHOICE MA|||||0.01||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.01||||||| A9270|EAP|0990||Medicaid|MEDICAID|||||15.60||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicare|MEDICARE ACUTE|0.03||||0.03||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicare|MEDICARE PART B ONLY IP|0.01||||||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.03||||||| A9270|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicare|MEDICARE ACUTE|0.01||||0.01||| A9270|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|MEDICAID|0.03||||0.03||| A9500|EAP|0255|DOSE SESTANIBI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Medicare|MEDICARE ACUTE|648.25||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Tricare|TRICARE EAST REGION|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Managed Medicare|BCBS MEDICARE PPO MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Veterans Affairs|VETERANS ADMINISTRATION|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||648.25||| A9500|EAP|0343|TC99M SESTAMIBI|Medicare|MEDICARE ACUTE|6.49||||6.49||| A9500|EAP|0255|DOSE SESTANIBI|United Healthcare|UNITED HEALTHCARE|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Blue Cross HMO Specialty|BCBSTX HMO|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Blue Cross PPO Specialty|BCBSTX PPO|648.25||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Managed Medicare|HEALTHSPRING MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Humana Medicare Advantage|HUMANA MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Managed Medicaid|MEDICAID SUPERIOR|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Managed Medicaid|MEDICAID AMERIGROUP|||||648.25||| A9502|EAP|0343|TC99 MYOVIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Cigna|CIGNA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Humana Medicare Advantage|HUMANA MA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|ChampVA|CHAMPVA CENTER|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Blue Cross HMO Specialty|BCBSTX HMO|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Aetna|AETNA PPO|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Aetna|AETNA OTHER|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Veterans Affairs|VETERANS ADMINISTRATION|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|NON CONTRACTED|COMMERCIAL OTHER 2|||||725.40||| A9502|EAP|0343|TC99 MYOVIEW|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|PHCS|HUMANA INSURANCE|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|United Healthcare|UNITED HEALTHCARE OTHER|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|United Healthcare|UNITED HEALTHCARE|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|United Healthcare|TML GROUP BENEFITS|||||641.70||| A9502|EAP|0343|TC99 MYOVIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||641.70||| A9502|EAP|0343|TC99 MYOVIEW|Tricare|TRICARE FOR LIFE|||||641.70||| A9502|EAP|0343|TC99 MYOVIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Tricare|TRICARE EAST REGION|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Medicare|MEDICARE ACUTE|5.58||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Managed Medicaid|MEDICAID SUPERIOR|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||725.40||| A9502|EAP|0343|TC99 MYOVIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Medicaid|MEDICAID|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Managed Medicare|HEALTHSPRING MA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.58||| A9502|EAP|0343|TC99 MYOVIEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||725.40||| A9503|EAP|0255|BONE DOSE TC MDP|Medicare|MEDICARE ACUTE|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|Humana Medicare Advantage|HUMANA MA|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|Blue Cross PPO Specialty|BCBSTX PPO|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.57||| A9512|EAP|0343|DOSE PERTECHNETATE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|284.50||||||| A9516|EAP|0255|I-123 CAPSULE DIAGNOSTIC|Medicare|MEDICARE ACUTE|||||347.25||| A9521|EAP|0255|DOSE CERETE|Medicare|MEDICARE ACUTE|||||29.08||| A9537|EAP|0255|TC CHOLETEC|Humana Medicare Advantage|HUMANA MA|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Managed Medicaid|MEDICAID AMERIGROUP|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Managed Medicaid|MEDICAID SUPERIOR|3.79||||3.79||| A9537|EAP|0255|TC CHOLETEC|Blue Cross HMO Specialty|BCBSTX HMO|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Aetna|BOON CHAPMAN|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Blue Cross PPO Specialty|BCBSTX PPO|3.79||||3.79||| A9537|EAP|0255|TC CHOLETEC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.79||| A9537|EAP|0255|TC CHOLETEC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.79||| A9537|EAP|0255|TC CHOLETEC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Medicare|MEDICARE ACUTE|||||3.79||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|Managed Medicare|HEALTHSPRING MA|185.75||||||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|Medicare|MEDICARE ACUTE|185.75||||185.75||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||185.75||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|185.75||||||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|United Medicare Advantage|UHC MEDICARE GOLD MA|185.75||||||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|Humana Medicare Advantage|HUMANA MA|||||185.75||| A9541|EAP|0255|TECHNETIUM TC-99M SUL 3MC|Humana Medicare Advantage|HUMANA MA|||||3.24||| A9541|EAP|0255|TECHNETIUM TC-99M SUL 3MC|Medicare|MEDICARE ACUTE|||||3.24||| A9560|EAP|0343|DOSE MUGA ULTRTAG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|413.75||||||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-111|Medicare|MEDICARE ACUTE|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Medicare|MEDICARE ACUTE|||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|United Healthcare|UNITED HEALTHCARE|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|United Healthcare|UNITED HEALTHCARE|||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-111|United Healthcare|UNITED HEALTHCARE|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|United Healthcare|GEHA|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|United Healthcare|TML GROUP BENEFITS|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-111|Managed Medicare|BCBS MEDICARE PPO MA|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Managed Medicare|HEALTHSPRING MA|9.87||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Managed Medicare|BCBS MEDICARE PPO MA|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Medicare|MEDICARE ACUTE|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-111|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Blue Cross HMO Specialty|BCBSTX HMO|||||9.87||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-111|Blue Cross PPO Specialty|BCBSTX PPO|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Blue Cross PPO Specialty|BCBSTX PPO|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Blue Cross PPO Specialty|BCBSTX PPO|||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Humana Medicare Advantage|HUMANA MA|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Humana Medicare Advantage|HUMANA MA|||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-111|Humana Medicare Advantage|HUMANA MA|||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-111|Managed Medicaid|MEDICAID SUPERIOR|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Managed Medicaid|MEDICAID AMERIGROUP|||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.24||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.24||| A9576|EAP|0255|PROHANCE 5ML NDC 0270-111|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.24||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.87||| B4086|EAP|0272||Medicare|MEDICARE ACUTE|||||3.22||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|805.13||||273.67||| C1713|EAP|0278|PALACOS BONE CEMENT (ZIMM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|365.50||||||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.55||||||| C1713|EAP|0278|BONE CEMENT ANTIBOTIC SIM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|790.75||||||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.55||||273.67||| C1713|EAP|0278|BONE GRAFT MATRIX|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|790.75||||2,496.75||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Workers Compensation|WORKERS COMPENSATION OTHER|197.79||||45.95||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|United Medicare Advantage|UHC MEDICARE GOLD MA|790.75||||427.00||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Cigna|CIGNA|||||360.60||| C1713|EAP|0278|THREADED PIN 3.0MMX305MM|Humana Medicare Advantage|HUMANA MA|3.99||||401.14||| C1713|EAP|0278|BONE CEMENT ANTIBOTIC SIM|Humana Medicare Advantage|HUMANA MA|790.75||||401.14||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|Humana Medicare Advantage|HUMANA MA|1.55||||401.14||| C1713|EAP|0278|PALACOS BONE CEMENT (ZIMM|Humana Medicare Advantage|HUMANA MA|365.50||||401.14||| C1713|EAP|0278|WASHER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||76.50||| C1713|EAP|0278|WASHER|Managed Medicaid|MEDICAID AMERIGROUP|||||76.50||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||314.90||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||612.06||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Managed Medicaid|MEDICAID AMERIGROUP|||||9.66||| C1713|EAP|0278|FIBERWIRE #2 (ARTHREX)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||927.25||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.55||| C1713|EAP|0278|CORTICAL SCREWS 4.5 (ZIMM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||93.75||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,060.83||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Blue Cross HMO Specialty|BCBSTX HMO|3,749.50||||226.40||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|Blue Cross HMO Specialty|BCBSTX HMO|1.55||||226.40||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.55||||2,494.50||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.55||||2,437.50||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|Managed Medicaid|MEDICAID AMERIGROUP|||||1.55||| C1713|EAP|0278|BONE GRAFT MATRIX|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,496.75||| C1713|EAP|0278|WASHER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||76.50||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.55||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Access Direct Platinum|HEALTHFIRST TPA UMR|137.50||||||| C1713|EAP|0278|FIBERWIRE #2 (ARTHREX)|Managed Medicaid|MEDICAID AMERIGROUP|||||927.25||| C1713|EAP|0278|FIBERWIRE #2 (ARTHREX)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||927.25||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Blue Cross PPO Specialty|BCBSTX PPO|2.80||||473.16||| C1713|EAP|0278|FIBERWIRE #2 (ARTHREX)|Blue Cross PPO Specialty|BCBSTX PPO|927.25||||927.25||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Humana Medicare Advantage|HUMANA MA|253.72||||401.14||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|Blue Cross PPO Specialty|BCBSTX PPO|1.55||||1.55||| C1713|EAP|0278|2.5MM REVERSE GUIDE PIN|Blue Cross PPO Specialty|BCBSTX PPO|790.75||||5.34||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Humana Medicare Advantage|HUMANA MA|5.34||||401.14||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|790.75||||2,494.50||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,442.56||||2,494.50||| C1713|EAP|0272|DRILL BIT 3.3MM (ZIMMER)|Medicare|MEDICARE ACUTE|603.75||||||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|United Healthcare|UNITED HEALTHCARE|||||333.94||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Medicare|MEDICARE ACUTE|183.25||||2,356.95||| C1713|EAP|0278|FIBERWIRE #2 (ARTHREX)|Medicare|MEDICARE ACUTE|927.25||||2,356.95||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|Medicare|MEDICARE ACUTE|68.50||||1.55||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|United Medicare Advantage|UHC MEDICARE GOLD MA|1.55||||427.00||| C1713|EAP|0278|FIBERLOOP (ARTHREX)|Medicare|MEDICARE ACUTE|1.55||||2,356.95||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Tricare|TRICARE EAST REGION|||||235.47||| C1713|EAP|0278|PALACOS BONE CEMENT (ZIMM|Medicare|MEDICARE ACUTE|365.50||||2,356.95||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Medicare|MEDICARE ACUTE|619.88||||2,356.95||| C1713|EAP|0278|BONE CEMENT ANTIBOTIC SIM|Medicare|MEDICARE ACUTE|790.75||||2,356.95||| C1713|EAP|0278|THREADED PIN 3.0MMX305MM|United Healthcare|UNITED HEALTHCARE|3.99||||776.67||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|United Healthcare|UNITED HEALTHCARE|1,978.50||||776.67||| C1713|EAP|0272|DRILL BIT 2.5MM NCB-PT (Z|Medicare|MEDICARE ACUTE|603.75||||||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|NON CONTRACTED|COMMERCIAL OTHER 1|||||743.44||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||82.55||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||186.40||| C1713|EAP|0278|THREADED PIN 3.0MMX305MM|Medicare|MEDICARE ACUTE|3.99||||2,356.95||| C1729|EAP|0272|CHEST TUBE-TROCAR|Medicare|MEDICARE ACUTE|||||128.50||| C1769|EAP|0272|K-WIRES|Blue Cross PPO Specialty|BCBSTX PPO|||||0.79||| C1769|EAP|0272|.054 WIRES (ACUMED)|Blue Cross PPO Specialty|BCBSTX PPO|||||50.50||| C1769|EAP|0272|K-WIRES|Cigna|CIGNA|0.79||||||| C1769|EAP|0272|BEAD TIP GUIDEWIRE 2.6MMX|Humana Medicare Advantage|HUMANA MA|3.99||||||| C1769|EAP|0272|K-WIRES|Managed Medicaid|MEDICAID AMERIGROUP|||||0.79||| C1769|EAP|0272|K-WIRES|Medicaid|MEDICAID|||||0.79||| C1769|EAP|0272|K-WIRES|Medicare|MEDICARE ACUTE|||||0.79||| C1769|EAP|0272|K-WIRES|Tricare|TRICARE EAST REGION|||||0.79||| C1769|EAP|0272|K-WIRES|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.79||| C1769|EAP|0272|K-WIRES|Aetna|AETNA PPO|||||0.79||| C1771|EAP|0272|OBTRYX-HALO MID URETHRAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,081.25||| C1776|EAP|0272|CAPIO SUTURE|NON CONTRACTED|COMMERCIAL OTHER 1|||||60.25||| C1776|EAP|0272|V-LOC ENDO RELOAD 2.0|Medicare|MEDICARE ACUTE|1.58||||306.38||| C1776|EAP|0272|NEEDLE & SUTURE CAPTURE|Medicare|MEDICARE ACUTE|325.50||||1,124.75||| C1776|EAP|0272|2.8 DISPOSABLE Q-FIX IMPL|Medicare|MEDICARE ACUTE|183.25||||389.40||| C1776|EAP|0272|DRILL BIT 3.5MM QC|Medicare|MEDICARE ACUTE|2.53||||0.85||| C1776|EAP|0272|SMARTSTITCH PP CONNECTOR|Medicare|MEDICARE ACUTE|294.25||||306.38||| C1776|EAP|0272|DRILL BIT 2.0MM|Medicare|MEDICARE ACUTE|53.25||||122.75||| C1776|EAP|0272|CAPIO SUTURE DEVICE|United Healthcare|UNITED HEALTHCARE|202.75||||630.25||| C1776|EAP|0272|CAPIO SUTURE|United Healthcare|UNITED HEALTHCARE|202.75||||60.25||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Medicare|MEDICARE ACUTE|24.72||||1,401.28||| C1776|EAP|0272|NEEDLE & SUTURE CAPTURE|Tricare|TRICARE EAST REGION|||||1,124.75||| C1776|EAP|0272|2.8MM Q-FIX IMPLANT|Tricare|TRICARE EAST REGION|||||5.08||| C1776|EAP|0272|2.8 DISPOSABLE Q-FIX IMPL|Tricare|TRICARE EAST REGION|||||389.40||| C1776|EAP|0272|V-LOC ENDO RELOAD 2.0|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.58||| C1776|EAP|0272|V-LOC ENDO RELOAD 2.0|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.58||| C1776|EAP|0272|CAPIO SUTURE DEVICE|NON CONTRACTED|COMMERCIAL OTHER 1|||||630.25||| C1776|EAP|0272||Managed Medicare|BCBS MEDICARE PPO MA|790.75||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|26.00||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicare|HEALTHSPRING MA|26.00||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|1,467.78||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,843.75||||38.30||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.33||||||| C1776|EAP|0278|CERCLAGE CABLE W/CRIMP 1.|United Medicare Advantage|UHC MEDICARE GOLD MA|590.75||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Veterans Affairs|VETERANS ADMINISTRATION|26.00||||||| C1776|EAP|0272|V-LOC ENDO RELOAD 2.0|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.92||||1.58||| C1776|EAP|0272|GUIDE WIRE TEAR DROP 3MMX|United Medicare Advantage|AARP UHC WEST COMPLETE MA|325.50||||||| C1776|EAP|0272|V-LOC 2.0 ENDOSTITCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.92||||294.25||| C1776|EAP|0272|2.8 DISPOSABLE Q-FIX IMPL|Cigna|CIGNA|||||389.40||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Cigna|CIGNA|26.00||||||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Humana Medicare Advantage|HUMANA MA|1.01||||0.10||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Humana Medicare Advantage|HUMANA MA|25.75||||||| C1776|EAP|0272|SMARTSTITCH PP CONNECTOR|Humana Medicare Advantage|HUMANA MA|1.01||||306.38||| C1776|EAP|0278|CERCLAGE CABLE W/CRIMP 1.|Humana Medicare Advantage|HUMANA MA|590.75||||||| C1776|EAP|0272|V-LOC ENDO RELOAD 2.0|Managed Medicaid|MEDICAID SUPERIOR|1,598.50||||1.58||| C1776|EAP|0272|V-LOC 2.0 ENDOSTITCH|Managed Medicaid|MEDICAID SUPERIOR|1,598.50||||294.25||| C1776|EAP|0272|SMARTSTITCH PP CONNECTOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||306.38||| C1776|EAP|0272|NEEDLE & SUTURE CAPTURE|Managed Medicaid|MEDICAID SUPERIOR|1,598.50||||1,124.75||| C1776|EAP|0272|GUIDE PIN PARTIAL THREAD|Managed Medicaid|MEDICAID SUPERIOR|1,598.50||||197.75||| C1776|EAP|0272|FLOSEAL|Managed Medicaid|MEDICAID AMERIGROUP|||||1,598.50||| C1776|EAP|0272|FLEXIBLE PASSING PIN 1|Managed Medicaid|MEDICAID AMERIGROUP|||||189.25||| C1776|EAP|0272|2.8MM Q-FIX IMPLANT|Cigna|CIGNA|||||5.08||| C1776|EAP|0272|ENDOBUTTON ULTRA 1.2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||531.50||| C1776|EAP|0272|ENDOBUTTON ULTRA 1.2|Managed Medicaid|MEDICAID AMERIGROUP|||||531.50||| C1776|EAP|0272|CANNULATED SCREW 3.5X24MM|Managed Medicaid|MEDICAID SUPERIOR|1,598.50||||231.50||| C1776|EAP|0272|SMARTSTITCH PP CONNECTOR|Cigna|CIGNA|||||306.38||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.10||| C1776|EAP|0272|NEEDLE & SUTURE CAPTURE|Humana Medicare Advantage|HUMANA MA|1.01||||1,124.75||| C1776|EAP|0272|FLEXIBLE PASSING PIN 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||189.25||| C1776|EAP|0272|2.8 DISPOSABLE Q-FIX IMPL|Humana Medicare Advantage|HUMANA MA|202.75||||389.40||| C1776|EAP|0272|2.8MM Q-FIX IMPLANT|Humana Medicare Advantage|HUMANA MA|1.01||||5.08||| C1776|EAP|0272|NEEDLE & SUTURE CAPTURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,124.75||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Managed Medicaid|MEDICAID SUPERIOR|1,598.50||||0.10||| C1776|EAP|0272|SMARTSTITCH PP CONNECTOR|Tricare|TRICARE EAST REGION|||||306.38||| C1776|EAP|0272|2.8MM Q-FIX IMPLANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.08||| C1776|EAP|0272|2.8 DISPOSABLE Q-FIX IMPL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||389.40||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.65||||||| C1776|EAP|0270|KNOTLESS FIXATION DEVICE|Managed Medicaid|MEDICAID SUPERIOR|||||4,627.50||| C1776|EAP|0272|BALL TIP GUIDE WIRE 2.4X7|Cigna|CIGNA|202.75||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicaid|MEDICAID SUPERIOR|37.29||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|35.67||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicaid|MEDICAID AMERIGROUP|||||601.50||| C1776|EAP|0272|NEEDLE & SUTURE CAPTURE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,124.75||| C1776|EAP|0272|2.8MM Q-FIX IMPLANT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.08||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|2,876.75||||||| C1776|EAP|0272|CAPIO SUTURE DEVICE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||630.25||| C1776|EAP|0272|KNOT PUSHER & CUTTER (ART|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||342.25||| C1776|EAP|0272|ENDOBUTTON ULTRA 10MM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||460.75||| C1776|EAP|0272|2.8 DISPOSABLE Q-FIX IMPL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||389.40||| C1776|EAP|0272|V-LOC ENDO RELOAD 2.0|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.58||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.10||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.10||| C1776|EAP|0272|2.8 DISPOSABLE Q-FIX IMPL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||389.40||| C1776|EAP|0272|NEEDLE & SUTURE CAPTURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,124.75||| C1776|EAP|0272|SMARTSTITCH PP CONNECTOR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||306.38||| C1776|EAP|0272|V-LOC 2.0 ENDOSTITCH|Tricare|TRICARE EAST REGION|||||294.25||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|26.00||||||| C1776|EAP|0272|ENDOBUTTON ULTRA 1.2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||531.50||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.10||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Tricare|TRICARE EAST REGION|||||0.10||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicare|BCBS MEDICARE PPO MA|3,283.88||||||| C1776|EAP|0272|V-LOC 2.0 ENDOSTITCH|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||294.25||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.00||||||| C1776|EAP|0272|CAPIO SUTURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||60.25||| C1776|EAP|0272|KNOTLESS TIGHT ROPE REPAI|Blue Cross HMO Specialty|BCBSTX HMO|||||1,952.25||| C1776|EAP|0272|FAST-FIX 360 CURVED NDL D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||618.75||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Blue Cross HMO Specialty|BCBSTX HMO|1,728.50||||||| C1776|EAP|0272|SMARTSTITCH PP CONNECTOR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||306.38||| C1776|EAP|0272|FLEXIBLE PASSING PIN 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||189.25||| C1776|EAP|0272|2.8MM Q-FIX IMPLANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.08||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2,028.71||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,629.50||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Access Direct Platinum|HEALTHFIRST TPA UMR|4,484.75||||||| C1776|EAP|0270|KNOTLESS FIXATION DEVICE|Blue Cross PPO Specialty|BCBSTX PPO|||||4,627.50||| C1776|EAP|0272|V-LOC ENDO RELOAD 2.0|Blue Cross PPO Specialty|BCBSTX PPO|1,573.75||||1.58||| C1776|EAP|0272|V-LOC 2.0 ENDOSTITCH|Blue Cross PPO Specialty|BCBSTX PPO|1,573.75||||294.25||| C1776|EAP|0272|NEEDLE & SUTURE CAPTURE|Blue Cross PPO Specialty|BCBSTX PPO|1,573.75||||1,124.75||| C1776|EAP|0272|SMARTSTITCH PP CONNECTOR|Blue Cross PPO Specialty|BCBSTX PPO|1,573.75||||306.38||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Medicare|MEDICARE ACUTE|167.75||||0.10||| C1776|EAP|0272|2.8MM Q-FIX IMPLANT|Medicare|MEDICARE ACUTE|202.75||||5.08||| C1776|EAP|0272|KNOTLESS TIGHT ROPE REPAI|Blue Cross PPO Specialty|BCBSTX PPO|1,573.75||||1,952.25||| C1776|EAP|0272|FLEXIBLE PASSING PIN 1|Blue Cross PPO Specialty|BCBSTX PPO|1,573.75||||189.25||| C1776|EAP|0272|ENDOBUTTON ULTRA 10MM|Blue Cross PPO Specialty|BCBSTX PPO|1,573.75||||460.75||| C1776|EAP|0272|ENDOBUTTON ULTRA 1.2|Blue Cross PPO Specialty|BCBSTX PPO|53.25||||531.50||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Blue Cross PPO Specialty|BCBSTX PPO|188.25||||0.10||| C1776|EAP|0272|2.8MM Q-FIX IMPLANT|Blue Cross PPO Specialty|BCBSTX PPO|231.50||||5.08||| C1776|EAP|0272|2.8 DISPOSABLE Q-FIX IMPL|Blue Cross PPO Specialty|BCBSTX PPO|230.50||||389.40||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Blue Cross PPO Specialty|BCBSTX PPO|25.47||||12.28||| C1776|EAP|0272|V-LOC 2.0 ENDOSTITCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|202.75||||294.25||| C1776|EAP|0272|CANNULA DISP/6.0MM X 75MM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|202.75||||0.10||| C1776|EAP|0272|2.8MM Q-FIX IMPLANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|202.75||||5.08||| C1776|EAP|0272|V-LOC ENDO RELOAD 2.0|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|202.75||||1.58||| C1776|EAP|0272|2.8 DISPOSABLE Q-FIX IMPL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|202.75||||389.40||| C1776|EAP|0272|NEEDLE & SUTURE CAPTURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|202.75||||1,124.75||| C8924|EAP|0483||Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,515.62||| C8924|EAP|0483||Humana Medicare Advantage|HUMANA MA|||||1,339.81||| C8924|EAP|0483||Managed Medicare|HEALTHSPRING MA|||||1,515.62||| C8924|EAP|0483||Medicare|MEDICARE ACUTE|||||1,515.62||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Medicare|MEDICARE ACUTE|||||3,044.43||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Tricare|TRICARE EAST REGION|||||3,044.43||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||27.68||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Humana Medicare Advantage|HUMANA MA|||||27.68||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,044.43||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,906.22||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,044.43||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,906.22||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Managed Medicare|BCBS MEDICARE PPO MA|||||27.68||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Managed Medicare|HEALTHSPRING MA|||||27.68||| C8929|EAP|0483|ECHOCARDIO 2D M DOPLR MAP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2,906.22||| C8930|EAP|0483||Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,352.22||| C8930|EAP|0483||Blue Cross PPO Specialty|BCBSTX PPO|||||3,044.43||| C8930|EAP|0483||Humana Medicare Advantage|HUMANA MA|||||3,044.43||| C8930|EAP|0483||United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||16.60||| C8930|EAP|0483||United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,044.43||| C8930|EAP|0483||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,044.43||| C8930|EAP|0483||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||16.60||| C8930|EAP|0483||Managed Medicare|HEALTHSPRING MA|||||3,044.43||| C8930|EAP|0483||Managed Medicare|BCBS MEDICARE PPO MA|||||16.60||| C8930|EAP|0483||Medicare|MEDICARE ACUTE|||||27.68||| C8930|EAP|0483||Tricare|TRICARE EAST REGION|||||16.60||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Medicare|MEDICARE ACUTE|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Tricare|TRICARE EAST REGION|||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|HEALTHSPRING MA|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID SUPERIOR|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|BCBS MEDICARE PPO MA|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC MEDICARE GOLD MA|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Veterans Affairs|VETERANS ADMINISTRATION|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Blue Cross PPO Specialty|BCBSTX PPO|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Humana Medicare Advantage|HUMANA MA|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Cigna|CIGNA|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,786.50||||||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,786.50||||||| G0103|EAP|0300|PSA SCREENING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.35||| G0103|EAP|0300|PSA SCREENING|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.56||| G0103|EAP|0300|PSA SCREENING|Blue Cross PPO Specialty|BCBSTX PPO|||||1.35||| G0103|EAP|0300|PSA SCREENING|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.35||| G0103|EAP|0300|PSA SCREENING|Humana Medicare Advantage|HUMANA MA|||||1.35||| G0103|EAP|0300|PSA SCREENING|Blue Cross HMO Specialty|BCBSTX HMO|||||1.35||| G0103|EAP|0300|PSA SCREENING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.35||| G0103|EAP|0300|PSA SCREENING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.35||| G0103|EAP|0300|PSA SCREENING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.35||| G0103|EAP|0300|PSA SCREENING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.35||| G0103|EAP|0300|PSA SCREENING|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.77||||1.35||| G0103|EAP|0300|PSA SCREENING|Managed Medicare|HEALTHSPRING MA|||||1.35||| G0103|EAP|0300|PSA SCREENING|Medicare|MEDICARE ACUTE|1.77||||1.35||| G0103|EAP|0300|PSA SCREENING|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.35||| G0103|EAP|0300|PSA SCREENING|United Healthcare|UNITED HEALTHCARE|||||1.35||| G0103|EAP|0300|PSA SCREENING|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.35||| G0104|EAP|0750|SIGMOIDOSCOPY SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,710.50||| G0105|EAP|0750|COLONOSCOPY SCREEN HIGH R|Medicare|MEDICARE ACUTE|||||3,402.25||| G0105|EAP|0750|COLONOSCOPY SCREEN HIGH R|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,402.25||| G0105|EAP|0750|COLONOSCOPY SCREEN HIGH R|Managed Medicare|HEALTHSPRING MA|||||3,402.25||| G0105|EAP|0750|COLONOSCOPY SCREEN HIGH R|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,402.25||| G0105|EAP|0750|COLONOSCOPY SCREEN HIGH R|Blue Cross PPO Specialty|BCBSTX PPO|||||3,402.25||| G0105|EAP|0750|COLONOSCOPY SCREEN HIGH R|Humana Medicare Advantage|HUMANA MA|||||3,402.25||| G0105|EAP|0750|COLONOSCOPY SCREEN HIGH R|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,402.25||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Blue Cross PPO Specialty|BCBSTX PPO|||||102.75||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Humana Medicare Advantage|HUMANA MA|||||102.75||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Cigna|CIGNA|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||102.75||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Managed Medicaid|MEDICAID SUPERIOR|||||118.17||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||102.75||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Managed Medicaid|MEDICAID AMERIGROUP|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Medicaid|MEDICAID TEXAS CHILDRENS|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Managed Medicare|HEALTHSPRING MA|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|NON CONTRACTED|COMMERCIAL OTHER 1|||||133.58||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|Medicare|MEDICARE ACUTE|||||102.75||| G0108|EAP|0942|DIABETES SELF-MGMT INDIVI|United Healthcare|UNITED HEALTHCARE|||||133.58||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|NON CONTRACTED|COMMERCIAL OTHER 1|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|United Healthcare|UNITED HEALTHCARE|||||77.35||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|United Healthcare|UNITED HEALTHCARE|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Medicare|MEDICARE ACUTE|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Managed Medicaid|MEDICAID AMERIGROUP|||||77.35||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Managed Medicare|HEALTHSPRING MA|||||68.43||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Blue Cross PPO Specialty|BCBSTX PPO|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Humana Medicare Advantage|HUMANA MA|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||77.35||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Blue Cross HMO Specialty|BCBSTX HMO|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||59.50||| G0109|EAP|0942|DIABETES SELF-MGMT GROUP|Access Direct Platinum|HEALTHFIRST TPA UMR|||||59.50||| G0121|EAP|0750|COLONOSCOPY SCREEN LOW RI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,402.25||| G0121|EAP|0750|COLONOSCOPY SCREEN LOW RI|Blue Cross PPO Specialty|BCBSTX PPO|||||3,402.25||| G0121|EAP|0750|COLONOSCOPY SCREEN LOW RI|Humana Medicare Advantage|HUMANA MA|||||3,402.25||| G0121|EAP|0750|COLONOSCOPY SCREEN LOW RI|Cigna|CIGNA|||||3,402.25||| G0121|EAP|0750|COLONOSCOPY SCREEN LOW RI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,402.25||| G0121|EAP|0750|COLONOSCOPY SCREEN LOW RI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,402.25||| G0121|EAP|0750|COLONOSCOPY SCREEN LOW RI|Managed Medicare|HEALTHSPRING MA|||||3,402.25||| G0121|EAP|0750|COLONOSCOPY SCREEN LOW RI|Medicare|MEDICARE ACUTE|||||3,402.25||| G0202|EAP|0403||Medicare|MEDICARE ACUTE|||||5.35||| G0202|EAP|0403||Humana Medicare Advantage|HUMANA MA|||||5.35||| G0297|EAP|0350|CT LUNG SCREENING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.95||| G0297|EAP|0350|CT LUNG SCREENING|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.95||| G0297|EAP|0350|CT LUNG SCREENING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.95||| G0297|EAP|0350|CT LUNG SCREENING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.95||| G0297|EAP|0350|CT LUNG SCREENING|Blue Cross PPO Specialty|BCBSTX PPO|||||1.95||| G0297|EAP|0350|CT LUNG SCREENING|Cigna|CIGNA|||||1.95||| G0297|EAP|0350|CT LUNG SCREENING|Humana Medicare Advantage|HUMANA MA|||||1.95||| G0297|EAP|0350|CT LUNG SCREENING|Managed Medicare|HEALTHSPRING MA|||||1.50||| G0297|EAP|0350|CT LUNG SCREENING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.50||| G0297|EAP|0350|CT LUNG SCREENING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.95||| G0297|EAP|0350|CT LUNG SCREENING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.50||| G0297|EAP|0350|CT LUNG SCREENING|Medicare|MEDICARE ACUTE|||||1.95||| G0297|EAP|0350|CT LUNG SCREENING|United Healthcare|UNITED HEALTHCARE|||||1.50||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|UTMB|UTMB CORRECTIONAL MANAGED CARE|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|NON CONTRACTED|COMMERCIAL OTHER 1|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicare|MEDICARE ACUTE|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|United Healthcare|UNITED HEALTHCARE|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|United Healthcare|UNITED HEALTHCARE|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Tricare|TRICARE EAST REGION|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Managed Medicaid|MEDICAID UNITED HEALTHCARE|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Managed Medicaid|MEDICAID SUPERIOR|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Managed Medicaid|MEDICAID AMERIGROUP|156.75||||156.75||| G0378|EAP|0762||Managed Medicaid|MEDICAID UNITED HEALTHCARE|156.75||||247.75||| G0378|EAP|0762||Managed Medicaid|MEDICAID SUPERIOR|247.75||||247.75||| G0378|EAP|0762||Managed Medicaid|MEDICAID AMERIGROUP|247.75||||247.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid|MEDICAID HMO|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid|MEDICAID|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||156.75||| G0378|EAP|0762||Medicaid|MEDICAID HMO|156.75||||247.75||| G0378|EAP|0762||Medicaid|MEDICAID|156.75||||247.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Managed Medicare|HEALTHSPRING MA|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Managed Medicare|WELLCARE CHOICE MA|||||156.75||| G0378|EAP|0762||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|156.75||||247.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Blue Cross PPO Specialty|BCBSTX PPO|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Humana Medicare Advantage|HUMANA MA|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Cigna|CIGNA|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicare|MEDICARE PART B ONLY IP|156.75||||||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Aenta Medicare Advantage|AETNA MEDICARE MA|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Blue Cross HMO Specialty|BCBSTX HMO|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Aetna|AETNA PPO|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Aetna|AETNA OTHER|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Workers Compensation|WORKERS COMPENSATION OTHER|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|United Medicare Advantage|UHC MEDICARE GOLD MA|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|United Medicare Advantage|AARP UHC WEST COMPLETE MA|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Veterans Affairs|VETERANS ADMINISTRATION|156.75||||156.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Aetna|AETNA PPO|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Aetna|AETNA OTHER|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Blue Cross PPO Specialty|BCBSTX PPO|247.75||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Humana Medicare Advantage|HUMANA MA|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Cigna|CIGNA|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Managed Medicaid|MEDICAID SUPERIOR|247.75||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Managed Medicaid|MEDICAID AMERIGROUP|247.75||||||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Medicaid|MEDICAID|247.75||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|United Medicare Advantage|UHC MEDICARE GOLD MA|247.75||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Medicaid|MEDICAID HMO|247.75||||||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|NON CONTRACTED|COMMERCIAL OTHER 1|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Medicare|MEDICARE ACUTE|247.75||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|United Healthcare|UNITED HEALTHCARE|247.75||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|United Healthcare|UNITED HEALTHCARE|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Tricare|TRICARE EAST REGION|||||247.75||| G0463|EAP|0510|EVAL/NP L-4 45 MIN|Medicare|MEDICARE ACUTE|||||409.50||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Medicare|MEDICARE ACUTE|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|United Healthcare|UNITED HEALTHCARE|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Tricare|TRICARE EAST REGION|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Managed Medicaid|MEDICAID SUPERIOR|1,135.75||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Managed Medicaid|MEDICAID AMERIGROUP|1,135.75||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Medicaid|MEDICAID|1,135.75||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Blue Cross PPO Specialty|BCBSTX PPO|1,135.75||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Cigna|CIGNA|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,135.75||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Blue Cross HMO Specialty|BCBSTX HMO|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Aetna|AETNA PPO|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Aetna|AETNA OTHER|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,135.75||| G0463|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,135.75||| G0480|EAP|0300|SALICYLATES|United Medicare Advantage|UHC MEDICARE GOLD MA|2.72||||316.14||| G0480|EAP|0300|SALICYLATES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||316.14||| G0480|EAP|0301|ACETAMINOPHEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||901.07||| G0480|EAP|0301||United Medicare Advantage|UHC MEDICARE GOLD MA|4.14||||481.19||| G0480|EAP|0301||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.14||| G0480|EAP|0301||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||481.19||| G0480|EAP|0301|ACETAMINOPHEN|United Medicare Advantage|UHC MEDICARE GOLD MA|775.25||||901.07||| G0480|EAP|0301|ACETAMINOPHEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||901.07||| G0480|EAP|0300|SALICYLATES|Humana Medicare Advantage|HUMANA MA|||||316.14||| G0480|EAP|0300|SALICYLATES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||316.14||| G0480|EAP|0301|ACETAMINOPHEN|Humana Medicare Advantage|HUMANA MA|||||901.07||| G0480|EAP|0301||Humana Medicare Advantage|HUMANA MA|||||481.19||| G0480|EAP|0300|SALICYLATES|Managed Medicare|BCBS MEDICARE PPO MA|||||316.14||| G0480|EAP|0300|SALICYLATES|Managed Medicare|HEALTHSPRING MA|||||316.14||| G0480|EAP|0301|ACETAMINOPHEN|Managed Medicare|BCBS MEDICARE PPO MA|||||901.07||| G0480|EAP|0301||Managed Medicare|HEALTHSPRING MA|||||481.19||| G0480|EAP|0301||Managed Medicare|BCBS MEDICARE PPO MA|||||481.19||| G0480|EAP|0301|ACETAMINOPHEN|Managed Medicare|HEALTHSPRING MA|||||901.07||| G0480|EAP|0300|SALICYLATES|Medicare|MEDICARE ACUTE|316.14||||545.70||| G0480|EAP|0301|ACETAMINOPHEN|Medicare|MEDICARE ACUTE|901.07||||775.25||| G0480|EAP|0301||Medicare|MEDICARE ACUTE|901.07||||4.14||| J0131|ERX|0636||Medicare|MEDICARE ACUTE|98.25||||98.25||| J0131|ERX|0636||Tricare|TRICARE EAST REGION|||||98.25||| J0131|ERX|0636||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|98.25||||98.25||| J0131|ERX|0250||Medicaid|MEDICAID|||||98.25||| J0131|ERX|0636||Managed Medicaid|MEDICAID AMERIGROUP|||||98.25||| J0131|ERX|0636||Managed Medicaid|MEDICAID SUPERIOR|98.25||||98.25||| J0131|ERX|0636||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||98.25||| J0131|ERX|0250||Managed Medicare|BCBS MEDICARE PPO MA|||||98.25||| J0131|ERX|0250||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||98.25||| J0131|ERX|0250||Managed Medicare|HEALTHSPRING MA|||||98.25||| J0131|ERX|0636||Medicaid|MEDICAID|||||98.25||| J0131|ERX|0636||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||98.25||| J0131|ERX|0636||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||98.25||| J0131|ERX|0250||Medicare|MEDICARE ACUTE|98.25||||98.25||| J0131|ERX|0250||Aenta Medicare Advantage|AETNA MEDICARE MA|||||98.25||| J0131|ERX|0636||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||98.25||| J0131|ERX|0250||Blue Cross PPO Specialty|BCBSTX PPO|98.25||||98.25||| J0131|ERX|0250||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98.25||||98.25||| J0131|ERX|0636||Blue Cross PPO Specialty|BCBSTX PPO|||||98.25||| J0131|ERX|0250||Medicaid|COUNTY INDIGENT HEALTH OTHER|||||98.25||| J0131|ERX|0250||Humana Medicare Advantage|HUMANA MA|||||98.25||| J0131|ERX|0250||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||98.25||| J0131|ERX|0250||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||98.25||| J0131|ERX|0250||Managed Medicaid|MEDICAID SUPERIOR|98.25||||98.25||| J0131|ERX|0250||Tricare|TRICARE EAST REGION|||||98.25||| J0131|ERX|0250||Managed Medicaid|MEDICAID AMERIGROUP|98.25||||98.25||| J0131|ERX|0636||Humana Medicare Advantage|HUMANA MA|||||98.25||| J0131|ERX|0250||Workers Compensation|WORKERS COMPENSATION OTHER|||||98.25||| J0131|ERX|0636||Workers Compensation|WORKERS COMPENSATION OTHER|||||98.25||| J0131|ERX|0250||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||98.25||| J0131|ERX|0250||United Medicare Advantage|UHC MEDICARE GOLD MA|||||98.25||| J0131|ERX|0250||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|98.25||||98.25||| J0131|ERX|0636||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||98.25||| J0131|ERX|0636||United Medicare Advantage|UHC MEDICARE GOLD MA|||||98.25||| J0131|ERX|0636||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||98.25||| J0153|ERX|0636|ADENOSINE 3MG/ML, 2ML VIA|Veterans Affairs|VETERANS ADMINISTRATION|||||123.75||| J0153|ERX|0636|ADENOSINE 3MG/ML, 2ML VIA|Humana Medicare Advantage|HUMANA MA|||||123.75||| J0153|ERX|0636|ADENOSINE 3MG/ML, 2ML VIA|Blue Cross HMO Specialty|BCBSTX HMO|||||123.75||| J0153|ERX|0636|ADENOSINE 3MG/ML, 2ML VIA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||123.75||| J0153|ERX|0636|ADENOSINE 3MG/ML, 2ML VIA|Medicare|MEDICARE ACUTE|123.75||||123.75||| J0153|ERX|0636|ADENOSINE 3MG/ML, 2ML VIA|United Healthcare|UNITED HEALTHCARE|||||123.75||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Managed Medicaid|MEDICAID AMERIGROUP|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Managed Medicaid|MEDICAID SUPERIOR|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Medicaid|MEDICAID|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Blue Cross HMO Specialty|BCBSTX HMO|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||42.79||| J0690|ERX|0250||Workers Compensation|WORKERS COMPENSATION OTHER|||||95.75||| J0690|ERX|0250||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||95.75||| J0690|ERX|0250||Humana Medicare Advantage|HUMANA MA|||||95.75||| J0690|ERX|0250||Aenta Medicare Advantage|AETNA MEDICARE MA|||||95.75||| J0690|ERX|0250||Medicare|MEDICARE ACUTE|||||95.75||| J0690|ERX|0250||Managed Medicare|BCBS MEDICARE PPO MA|||||95.75||| J0690|ERX|0250||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||95.75||| J0690|ERX|0250||Tricare|TRICARE EAST REGION|||||95.75||| J0692|ERX|0250||Medicare|MEDICARE ACUTE|||||31.25||| J0692|ERX|0250||United Medicare Advantage|UHC MEDICARE GOLD MA|||||31.25||| J0696|ERX|0250|CEFTRIAXONE 2 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||2.43||| J0696|ERX|0250|CEFTRIAXONE 2 G VIAL|Medicare|MEDICARE ACUTE|||||2.43||| J0840|ERX|0250|ANTIVENIN,CROTALIDAE 1 VI|Veterans Affairs|VETERANS ADMINISTRATION|12,912.75||||||| J0840|ERX|0250|ANTIVENIN,CROTALIDAE 1 VI|Managed Medicaid|MEDICAID SUPERIOR|||||12,912.75||| J0885|ERX|0636|EPOETIN 20000 UNIT/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||133.90||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Medicare|MEDICARE ACUTE|||||73.35||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||73.35||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||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|Humana Medicare Advantage|HUMANA MA|||||73.35||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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|Humana Medicare Advantage|HUMANA MA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.28||||38.28||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|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||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|UNITED HEALTHCARE|12.50||||||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Tricare|TRICARE EAST REGION|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|MEDICAID|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|MEDICAID HMO|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|HEALTHSPRING MA|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicare|MEDICARE PART B ONLY IP|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|BCBS MEDICARE PPO MA|12.50||||||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Aetna|AETNA PPO|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|PHCS|HUMANA INSURANCE|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Cigna|CIGNA|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Cigna|CIGNA|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|ChampVA|CHAMPVA CENTER|12.50||||||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||12.50||| J1200|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|||||12.50||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Workers Compensation|WORKERS COMPENSATION OTHER|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Humana Medicare Advantage|HUMANA MA|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Medicaid|MEDICAID|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Medicaid|MOLINA HEALTHCARE OF TEXAS|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Medicare|MEDICARE ACUTE|103.25||||103.25||| J1610|ERX|0250|GLUCAGON 1MG VIAL|Medicare|MEDICARE ACUTE|||||891.50||| J1610|ERX|0250|GLUCAGON 1MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||891.50||| J1610|ERX|0250|GLUCAGON 1MG VIAL|Humana Medicare Advantage|HUMANA MA|||||891.50||| J1726|ERX|0636|HYDROXYPROGESTERONE CAP 2|Blue Cross PPO Specialty|BCBSTX PPO|||||146.47||| J1726|ERX|0636|HYDROXYPROGESTERONE CAP 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||146.47||| J1726|ERX|0636|HYDROXYPROGESTERONE CAP 2|Managed Medicaid|MEDICAID SUPERIOR|||||146.47||| J1726|ERX|0636|HYDROXYPROGESTERONE CAP 2|Managed Medicaid|MEDICAID AMERIGROUP|||||146.47||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||193.63||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Medicare|MEDICARE ACUTE|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 CIGNA HEALTHSPRING|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|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Humana Medicare Advantage|HUMANA MA|193.63||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.80||| J1756|ERX|0636||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||558.25||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Blue Cross PPO Specialty|BCBSTX PPO|||||4.80||| J1756|ERX|0250|IRON SUCROSE 200 MG IN 10|Managed Medicaid|MEDICAID SUPERIOR|||||558.25||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID SUPERIOR|||||4.80||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID AMERIGROUP|||||4.80||| J1756|ERX|0636||Managed Medicaid|MEDICAID SUPERIOR|||||558.25||| J1756|ERX|0250|IRON SUCROSE 200 MG IN 10|Medicare|MEDICARE ACUTE|||||558.25||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Medicare|MEDICARE ACUTE|||||4.80||| J1756|ERX|0636||Medicare|MEDICARE ACUTE|||||558.25||| J1953|ERX|0636|LEVETIRACETAM 500MG IN 10|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||2.61||| J1953|ERX|0636|LEVETIRACETAM 500MG IN 10|Medicare|MEDICARE ACUTE|2.61||||2.61||| J1953|ERX|0636|LEVETIRACETAM 500MG IN 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.61||| J1953|ERX|0636|LEVETIRACETAM 500MG IN 10|Medicaid|MEDICAID|||||2.61||| J1953|ERX|0636|LEVETIRACETAM 500MG IN 10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.61||| J1953|ERX|0636|LEVETIRACETAM 500MG IN 10|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.61||| J1953|ERX|0636|LEVETIRACETAM 500MG IN 10|Humana Medicare Advantage|HUMANA MA|2.61||||2.61||| J1953|ERX|0636|LEVETIRACETAM 500MG IN 10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.61||| J1953|ERX|0636|LEVETIRACETAM 500MG IN 10|Blue Cross HMO Specialty|BCBSTX HMO|2.61||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Aenta Medicare Advantage|AETNA MEDICARE MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Blue Cross PPO Specialty|BCBSTX PPO|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Humana Medicare Advantage|HUMANA MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Medicare|MEDICARE ACUTE|4.80||||||| 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 UNITED HEALTHCARE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicaid|MEDICAID AMERIGROUP|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|MEDICAID|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|Managed Medicare|HEALTHSPRING MA|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|BCBS MEDICARE PPO MA|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|NON CONTRACTED|COMMERCIAL OTHER 2|||||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|Medicare|MEDICARE PART B ONLY IP|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicare|MEDICARE ACUTE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Healthcare|UNITED HEALTHCARE|||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Workers Compensation|WORKERS COMPENSATION OTHER|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Medicare Advantage|AARP UHC WEST COMPLETE 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|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|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|ChampVA|CHAMPVA CENTER|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|Cigna|CIGNA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Cigna|CIGNA|||||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|Blue Cross HMO Specialty|BCBSTX HMO|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Aetna|AETNA PPO|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 UTH UMR|||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.16||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Aetna|AETNA PPO|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|ChampVA|CHAMPVA CENTER|16.80||||||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Humana Medicare Advantage|HUMANA MA|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Cigna|CIGNA|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|16.80||||||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Medicare|MEDICARE PART B ONLY IP|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Medicare|MEDICARE ACUTE|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Cigna|CIGNA|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|PHCS|HUMANA INSURANCE|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|United Healthcare|UNITED HEALTHCARE|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|United Healthcare|UNITED HEALTHCARE|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|United Healthcare|TML GROUP BENEFITS|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Tricare|TRICARE EAST REGION|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Medicaid|MEDICAID|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Medicaid|MEDICAID HMO|||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|16.80||||||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Managed Medicare|WELLCARE CHOICE MA|16.80||||||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Managed Medicare|HEALTHSPRING MA|16.80||||16.80||| J2405|ERX|0636|ONDANSETRON 4MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|16.80||||16.80||| J2430|ERX|0636|PAMIDRONATE 30MG/10ML|Medicare|MEDICARE ACUTE|493.75||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|98.38||||||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|||||98.38||| J2675|ERX|0250|MEDROXYPROGEST DEPO 150MG|Blue Cross PPO Specialty|BCBSTX PPO|12.93||||||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Managed Medicaid|MEDICAID SUPERIOR|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Medicaid|MEDICAID|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Managed Medicare|BCBS MEDICARE PPO MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|PHCS|HUMANA INSURANCE|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|United Healthcare|UNITED HEALTHCARE OTHER|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|United Healthcare|UNITED HEALTHCARE|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Tricare|TRICARE FOR LIFE|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Tricare|TRICARE EAST REGION|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Medicare|MEDICARE ACUTE|1,442.50||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Veterans Affairs|VETERANS ADMINISTRATION|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Managed Medicare|HEALTHSPRING MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Blue Cross PPO Specialty|BCBSTX PPO|1,442.50||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|ChampVA|CHAMPVA CENTER|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Humana Medicare Advantage|HUMANA MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Cigna|CIGNA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Blue Cross HMO Specialty|BCBSTX HMO|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Aetna|AETNA PPO|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Aetna|AETNA OTHER|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1,442.50||| J2790|ERX|0636|RHOGAM|Aetna|AETNA PPO|2,225.25||||||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Aetna|AETNA PPO|373.25||||||| J2790|ERX|0636|RHOGAM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,225.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||373.25||| J2790|ERX|0636|RHOGAM|Blue Cross PPO Specialty|BCBSTX PPO|2,225.25||||571.50||| J2790|ERX|0636|RHOGAM|Blue Cross PPO Specialty|BCBSTX PPO|373.25||||571.50||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Managed Medicaid|MEDICAID AMERIGROUP|373.25||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Managed Medicaid|MEDICAID SUPERIOR|373.25||||||| J2790|ERX|0636|RHOGAM|Managed Medicaid|MEDICAID AMERIGROUP|2,225.25||||1,398.38||| J2790|ERX|0636|RHOGAM|Managed Medicaid|MEDICAID SUPERIOR|2,225.25||||||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Medicaid|MEDICAID HMO|373.25||||||| J2790|ERX|0636|RHOGAM|Medicaid|MEDICAID HMO|2,225.25||||||| J2790|ERX|0636|RHOGAM|Medicaid|MEDICAID|||||2,225.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Medicaid|MEDICAID|||||373.25||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|Medicare|MEDICARE ACUTE|||||1.71||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.71||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.71||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|Humana Medicare Advantage|HUMANA MA|||||1.71||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|Managed Medicaid|MEDICAID SUPERIOR|1.71||||1.71||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|Managed Medicaid|MEDICAID AMERIGROUP|||||1.71||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.71||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|Aetna|BOON CHAPMAN|||||1.71||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|Blue Cross PPO Specialty|BCBSTX PPO|1.71||||1.71||| J2805|EAP|0250|KINEVAC INJ SINCALIDE 5 M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.71||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Aenta Medicare Advantage|AETNA MEDICARE MA|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross PPO Specialty|BCBSTX PPO|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross PPO Specialty|BCBSTX OTHER|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Cigna|CIGNA|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Humana Medicare Advantage|HUMANA MA|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID AMERIGROUP|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Workers Compensation|WORKERS COMPENSATION OTHER|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|UHC MEDICARE GOLD MA|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Veterans Affairs|VETERANS ADMINISTRATION|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID SUPERIOR|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|UTMB|UTMB CORRECTIONAL MANAGED CARE|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Healthcare|UNITED HEALTHCARE OTHER|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Healthcare|UNITED HEALTHCARE|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross HMO Specialty|BCBSTX HMO|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Healthcare|UNITED HEALTHCARE|62.50||||||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Tricare|TRICARE EAST REGION|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|NON CONTRACTED|COMMERCIAL OTHER 1|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|MEDICAID HMO|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|COUNTY INDIGENT HEALTH OTHER|62.50||||||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|MEDICAID|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|MEDICAID TEXAS CHILDRENS|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|BCBS MEDICARE PPO MA|62.50||||||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|HEALTHSPRING MA|62.50||||62.50||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicare|MEDICARE ACUTE|62.50||||62.50||| J2997|ERX|0636|ALTEPLASE 100MG IN 100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||254.49||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Medicare|MEDICARE ACUTE|||||281.61||| J2997|ERX|0636|ALTEPLASE 100MG IN 100ML|Medicare|MEDICARE ACUTE|||||254.49||| J2997|ERX|0636|ALTEPLASE 100MG IN 100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||254.49||| J2997|ERX|0636|ALTEPLASE 100MG IN 100ML|Blue Cross PPO Specialty|BCBSTX PPO|||||254.49||| J3370|ERX|0250|VANCOMYCIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|14.50||||||| J3370|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||14.50||| J3370|ERX|0250|VANCOMYCIN 500MG VIAL|Medicare|MEDICARE ACUTE|||||14.50||| J3370|ERX|0250|VANCOMYCIN 500MG VIAL|Tricare|TRICARE EAST REGION|14.50||||||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.52||||||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Medicare|MEDICARE ACUTE|0.52||||0.52||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.52||||0.52||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.52||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.52||||||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Humana Medicare Advantage|HUMANA MA|0.52||||0.52||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.52||||||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.52||||||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Blue Cross PPO Specialty|BCBSTX PPO|0.52||||||| J3420|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.52||||||| J3489|ERX|0636|ZOLEDRONIC ACID 5 MG/100M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,777.20||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|UTMB|UTMB CORRECTIONAL MANAGED CARE|11.50||||||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|United Healthcare|UNITED HEALTHCARE|11.50||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicare|MEDICARE ACUTE|2.10||||11.50||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|NON CONTRACTED|COMMERCIAL OTHER 1|11.50||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicare|HEALTHSPRING MA|11.50||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Aenta Medicare Advantage|AETNA MEDICARE MA|11.50||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.50||||11.50||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|11.50||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross HMO Specialty|BCBSTX HMO|11.50||||||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross PPO Specialty|BCBSTX PPO|11.50||||11.50||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||11.50||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Humana Medicare Advantage|HUMANA MA|11.50||||11.50||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Humana Medicare Advantage|HUMANA MA|2.10||||11.50||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicare|MEDICARE ACUTE|11.50||||11.50||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.50||||2.10||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Managed Medicaid|MEDICAID AMERIGROUP|||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicaid|MEDICAID SUPERIOR|2.10||||11.50||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicaid|MEDICAID SUPERIOR|11.50||||11.50||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.50||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Workers Compensation|WORKERS COMPENSATION OTHER|||||11.50||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||11.50||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.50||||||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|United Medicare Advantage|UHC MEDICARE GOLD MA|11.50||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Veterans Affairs|VETERANS ADMINISTRATION|11.50||||||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Medicare Advantage|UHC MEDICARE GOLD MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Veterans Affairs|VETERANS ADMINISTRATION|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Cigna|CIGNA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Humana Medicare Advantage|HUMANA MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicaid|MEDICAID SUPERIOR|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicaid|MEDICAID AMERIGROUP|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|ChampVA|CHAMPVA CENTER|0.85||||||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST TPA UMR|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross HMO Specialty|BCBSTX HMO|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aetna|AETNA PPO|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aetna|AETNA OTHER|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross PPO Specialty|BCBSTX PPO|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aenta Medicare Advantage|AETNA MEDICARE MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MEDICAID HMO|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.85||||||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MEDICAID|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|WELLCARE CHOICE MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|HEALTHSPRING MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|BCBS MEDICARE PPO MA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicare|MEDICARE ACUTE|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicare|MEDICARE PART B ONLY IP|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|TML GROUP BENEFITS|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|UNITED HEALTHCARE OTHER|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|UNITED HEALTHCARE|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|PHCS|HUMANA INSURANCE|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Tricare|TRICARE EAST REGION|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|NON CONTRACTED|COMMERCIAL OTHER 1|0.85||||0.85||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicare|MEDICARE PART B ONLY IP|0.26||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicare|MEDICARE ACUTE|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|PHCS|HUMANA INSURANCE|||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|MEDICAID|||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|HEALTHSPRING MA|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|MEDICAID HMO|||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|BCBS MEDICARE PPO MA|0.26||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Aetna|AETNA PPO|0.26||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross PPO Specialty|BCBSTX PPO|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Cigna|CIGNA|||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Humana Medicare Advantage|HUMANA MA|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID AMERIGROUP|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID SUPERIOR|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.26||||0.26||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Veterans Affairs|VETERANS ADMINISTRATION|0.26||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.26||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Veterans Affairs|VETERANS ADMINISTRATION|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Cigna|CIGNA|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Humana Medicare Advantage|HUMANA MA|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID SUPERIOR|0.26||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID AMERIGROUP|0.26||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.26||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross HMO Specialty|BCBSTX HMO|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross PPO Specialty|BCBSTX PPO|0.26||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|WELLCARE CHOICE MA|||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|HEALTHSPRING MA|||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.26||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicare|MEDICARE ACUTE|0.26||||0.26||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|NON CONTRACTED|COMMERCIAL OTHER 1|0.26||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicare|MEDICARE ACUTE|117.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicare|MEDICARE ACUTE|160.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Tricare|TRICARE EAST REGION|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 500ML|Medicaid|MEDICAID HMO|||||165.25||| J7060|ERX|0258|DEXTROSE 5%-WATER 100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|160.50||||0.24||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross HMO Specialty|BCBSTX HMO|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross PPO Specialty|BCBSTX PPO|160.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Humana Medicare Advantage|HUMANA MA|160.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicaid|MEDICAID AMERIGROUP|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicaid|MEDICAID SUPERIOR|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicaid|MEDICAID AMERIGROUP|165.25||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|117.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|160.50||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|172.75||||172.75||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|154.75||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|178.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.83||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|172.75||||178.50||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Medicare Advantage|UHC MEDICARE GOLD MA|1.83||||1.83||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|188.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|154.75||||172.75||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.83||||188.50||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Veterans Affairs|VETERANS ADMINISTRATION|||||1.83||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Cigna|CIGNA|178.50||||||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Cigna|CIGNA|||||178.50||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Humana Medicare Advantage|HUMANA MA|172.75||||172.75||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Humana Medicare Advantage|HUMANA MA|188.50||||178.50||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Humana Medicare Advantage|HUMANA MA|1.83||||1.83||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|178.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|172.75||||178.50||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|178.50||||188.50||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.83||||1.83||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicaid|MEDICAID SUPERIOR|188.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|188.50||||188.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|154.75||||178.50||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicaid|MEDICAID SUPERIOR|172.75||||172.75||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID SUPERIOR|1.83||||1.83||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|172.75||||178.50||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|1.83||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|ChampVA|CHAMPVA CENTER|172.75||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||172.75||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Access Direct Platinum|HEALTHFIRST TPA UMR|178.50||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|172.75||||||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|178.50||||||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|178.50||||||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Aetna|AETNA PPO|162.25||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Aetna|AETNA OTHER|178.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Aetna|AETNA PPO|178.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|178.50||||||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|178.50||||178.50||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Blue Cross PPO Specialty|BCBSTX PPO|1.83||||1.83||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|154.75||||178.50||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|154.75||||188.50||| J7070|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|Blue Cross PPO Specialty|BCBSTX PPO|162.25||||162.25||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Managed Medicaid|MEDICAID SUPERIOR|178.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|172.75||||172.75||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|188.50||||188.50||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|178.50||||188.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|178.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||178.50||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||188.50||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicaid|MEDICAID|178.50||||188.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicaid|MEDICAID HMO|178.50||||||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|178.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicaid|MEDICAID|178.50||||178.50||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.83||||||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicare|BCBS MEDICARE PPO MA|154.75||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|178.50||||172.75||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Humana Medicare Advantage|HUMANA MA|154.75||||188.50||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicare|HEALTHSPRING MA|154.75||||||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicare|HEALTHSPRING MA|188.50||||||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|162.25||||178.50||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|172.75||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicare|BCBS MEDICARE PPO MA|1.83||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.83||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|172.75||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Healthcare|UNITED HEALTHCARE|||||1.83||| J7070|ERX|0258|DEX 5%-1/2NS KCL 40 MEQ 1|United Healthcare|UNITED HEALTHCARE|||||162.25||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|188.50||||172.75||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|178.50||||||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|United Healthcare|UNITED HEALTHCARE OTHER|||||188.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|United Healthcare|UNITED HEALTHCARE|178.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicare|MEDICARE ACUTE|172.75||||178.50||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicare|MEDICARE ACUTE|162.25||||172.75||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Tricare|TRICARE EAST REGION|188.50||||||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Tricare|TRICARE EAST REGION|178.50||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicare|MEDICARE ACUTE|1.83||||1.83||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Medicare|MEDICARE ACUTE|188.50||||154.75||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Medicare|MEDICARE ACUTE|154.75||||154.75||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicare|MEDICARE ACUTE|178.50||||188.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.83||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|178.50||||178.50||| J7120|ERX|0258|LACTATED RINGERS 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|UNITED HEALTHCARE|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Tricare|TRICARE EAST REGION|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicare|MEDICARE PART B ONLY IP|173.25||||||| J7120|ERX|0258|LACTATED RINGERS 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|MEDICAID|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|HEALTHSPRING MA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|BCBS MEDICARE PPO MA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|173.25||||||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UMR|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|MEDICAID HMO|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Aetna|AETNA PPO|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Aetna|AETNA OTHER|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicare|MEDICARE ACUTE|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Cigna|CIGNA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|UNITED HEALTHCARE|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Cigna|CIGNA|173.25||||||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Humana Medicare Advantage|HUMANA MA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicaid|MEDICAID SUPERIOR|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Workers Compensation|WORKERS COMPENSATION OTHER|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|173.25||||||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|173.25||||||| K0403|EAP|0272||Workers Compensation|WORKERS COMPENSATION OTHER|||||1.50||| K0405|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|||||8.75||| K0405|EAP|0272||Workers Compensation|WORKERS COMPENSATION OTHER|||||8.75||| K0405|EAP|0272||Workers Compensation|WORKERS COMPENSATION OTHER|||||0.03||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|United Healthcare|UNITED HEALTHCARE|||||240.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Workers Compensation|WORKERS COMPENSATION OTHER|||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Workers Compensation|UT EMPLOYEE INJURY|||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|United Medicare Advantage|UHC MEDICARE GOLD MA|||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Cigna|CIGNA|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Humana Medicare Advantage|HUMANA MA|357.50||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Humana Medicare Advantage|HUMANA MA|357.50||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Managed Medicaid|MEDICAID SUPERIOR|||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Managed Medicaid|MEDICAID AMERIGROUP|||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" STRA"|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||348.75||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Blue Cross PPO Specialty|BCBSTX OTHER|||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Blue Cross PPO Specialty|BCBSTX PPO|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|267.25||||||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Medicare|MEDICARE ACUTE|357.50||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Medicare|MEDICARE ACUTE|357.50||||357.50||| L3265|EAP|0270|SHOE PO WOMENS LGE EA|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||85.25||| L3265|EAP|0270|SHOE PO WOMEN MED EA|Medicare|MEDICARE ACUTE|||||85.25||| L3265|EAP|0270|SHOE PO WOMEN MED EA|Blue Cross PPO Specialty|BCBSTX PPO|||||85.25||| L3265|EAP|0270|SHOE PO WOMENS LGE EA|Humana Medicare Advantage|HUMANA MA|||||85.25||| L3265|EAP|0270|SHOE PO WOMENS LGE EA|Managed Medicaid|MEDICAID SUPERIOR|||||85.25||| L3265|EAP|0270|SHOE PO WOMEN MED EA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||85.25||| L3808|EAP|0274|SPLINT WRIST COCKUP L EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||180.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|Managed Medicaid|MEDICAID SUPERIOR|||||172.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|Managed Medicaid|MEDICAID AMERIGROUP|||||172.75||| L3808|EAP|0274|SPLINT WRIST COCKUP L EA|Managed Medicaid|MEDICAID SUPERIOR|||||180.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|Blue Cross PPO Specialty|BCBSTX PPO|||||172.75||| L3808|EAP|0274|SPLINT WRIST COCKUP L EA|Blue Cross PPO Specialty|BCBSTX PPO|||||180.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||172.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||172.75||| L3808|EAP|0274|SPLINT WRIST COCKUP L EA|Medicaid|MEDICAID HMO|||||180.75||| L3808|EAP|0274|SPLINT WRIST COCKUP L EA|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||180.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|United Healthcare|UNITED HEALTHCARE|||||172.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||172.75||| L3808|EAP|0274|SPLINT WRIST COCKUP L EA|Medicare|MEDICARE ACUTE|||||180.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|Medicare|MEDICARE ACUTE|||||172.75||| L4350|EAP|0274|BRACE ANKLE LEFT EA|Medicare|MEDICARE ACUTE|||||226.75||| L4350|EAP|0274|BRACE ANKLE LEFT EA|Blue Cross PPO Specialty|BCBSTX PPO|||||226.75||| L4350|EAP|0274|BRACE ANKLE LEFT EA|Humana Medicare Advantage|HUMANA MA|||||226.75||| L4350|EAP|0274|BRACE ANKLE RIGHT EA|Managed Medicaid|MEDICAID AMERIGROUP|||||226.75||| L4350|EAP|0274|BRACE ANKLE LEFT EA|Managed Medicaid|MEDICAID AMERIGROUP|||||226.75||| L8699|EAP|0278|MAGNUM 2 IMPLANT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||89.25||| L8699|EAP|0278|MAGNUM 2 IMPLANT|Humana Medicare Advantage|HUMANA MA|||||12.75||| L8699|EAP|0278|MAGNUM 2 IMPLANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.75||| L8699|EAP|0278|MAGNUM 2 IMPLANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.75||| L8699|EAP|0278|MAGNUM 2 IMPLANT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||12.75||| L8699|EAP|0278|MAGNUM 2 IMPLANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||12.75||| L8699|EAP|0278|MAGNUM 2 IMPLANT|Blue Cross PPO Specialty|BCBSTX PPO|||||12.75||| L8699|EAP|0278|MAGNUM 2 IMPLANT|Medicare|MEDICARE ACUTE|||||12.75||| L8699|EAP|0278|MAGNUM 2 IMPLANT|Tricare|TRICARE EAST REGION|||||12.75||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|686.36||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|686.36||||686.36||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Veterans Affairs|VETERANS ADMINISTRATION|686.36||||||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Medicaid|MEDICAID|8.58||||686.36||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Managed Medicare|HEALTHSPRING MA|||||686.36||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|686.36||||772.18||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Managed Medicaid|MEDICAID SUPERIOR|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|8.58||||||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|686.36||||686.36||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Managed Medicaid|MEDICAID AMERIGROUP|8.58||||686.36||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Medicare|MEDICARE ACUTE|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,085.63||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Aenta Medicare Advantage|AETNA MEDICARE MA|8.58||||||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,313.25||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Aetna|AETNA PPO|8.58||||||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Blue Cross PPO Specialty|BCBSTX PPO|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Humana Medicare Advantage|HUMANA MA|686.36||||686.36||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|United Medicare Advantage|UHC MEDICARE GOLD MA|686.36||||772.18||| P9017|EAP|0383|PLASMA FRESH FROZEN PER U|United Medicare Advantage|UHC MEDICARE GOLD MA|2,107.14||||||| P9017|EAP|0383|PLASMA FRESH FROZEN PER U|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2,107.14||||||| P9017|EAP|0383|PLASMA FRESH FROZEN PER U|Veterans Affairs|VETERANS ADMINISTRATION|2,107.14||||||| P9017|EAP|0383|PLASMA FRESH FROZEN PER U|Aetna|AETNA PPO|20.82||||||| P9017|EAP|0383|PLASMA FRESH FROZEN PER U|Medicare|MEDICARE ACUTE|20.82||||20.82||| P9017|EAP|0383|PLASMA FRESH FROZEN PER U|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2,107.14||||||| P9017|EAP|0383|PLASMA FRESH FROZEN PER U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||20.82||| P9017|EAP|0383|PLASMA FRESH FROZEN PER U|Managed Medicaid|MEDICAID SUPERIOR|2,107.14||||||| P9035|EAP|0384|PLATELETS SINGLE DONOR PH|Managed Medicaid|MEDICAID SUPERIOR|2,387.49||||||| P9035|EAP|0384|PLATELETS SINGLE DONOR PH|Humana Medicare Advantage|HUMANA MA|23.59||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,155.75||||||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Blue Cross PPO Specialty|BCBSTX PPO|||||1,155.75||| P9047|ERX|0636|ALBUMIN 25% 12.5G/50ML|Medicare|MEDICARE ACUTE|1,155.75||||||| P9612|EAP|0300|CATH URETHRA NON-INDWELLI|Managed Medicare|WELLCARE CHOICE MA|0.77||||||| Q0138|ERX|0250|FERUMOXYTOL 30MG/ML 17ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.93||| Q0138|ERX|0250|FERUMOXYTOL 30MG/ML 17ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.93||| Q0138|ERX|0250|FERUMOXYTOL 30MG/ML 17ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4.93||| Q0138|ERX|0250|FERUMOXYTOL 30MG/ML 17ML|Medicare|MEDICARE ACUTE|||||4.93||| Q2009|ERX|0636|FOSPHENYTOIN 1000MG/100 M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.25||| Q5105|ERX|0636|RETACRIT 40000 UNIT/1ML (|Medicare|MEDICARE ACUTE|||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicare|MEDICARE ACUTE|||||4.74||| Q5105|ERX|0636|RETACRIT 40000 UNIT/1ML (|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.74||| Q5105|ERX|0636|RETACRIT 40000 UNIT/1ML (|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.74||| Q5105|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.74||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|47.43||||||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||47.43||| Q5106|ERX|0636|RETACRIT 40000 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||||47.43||| Q5106|ERX|0636|RETACRIT 40000 UNIT/1ML (|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||47.43||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|United Medicare Advantage|UHC MEDICARE GOLD MA|||||47.43||| Q5106|ERX|0636|RETACRIT 40000 UNIT/1ML (|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|47.43||||47.43||| Q5106|ERX|0636|RETACRIT 40000 UNIT/1ML (|Medicare|MEDICARE ACUTE|||||47.43||| Q5106|ERX|0636|RETACRIT 10000 UNIT/1ML (|Medicare|MEDICARE ACUTE|||||47.43||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.35||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||529.24||| Q9957|ERX|0636|PERFLUTREN PROTEIN-A MICR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.90||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Managed Medicare|HEALTHSPRING MA|||||482.12||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Medicare|MEDICARE PART B ONLY IP|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Medicare|MEDICARE ACUTE|4.35||||529.24||| Q9957|ERX|0636|PERFLUTREN PROTEIN-A MICR|Medicare|MEDICARE ACUTE|||||9.90||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|PHCS|HUMANA INSURANCE|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|United Healthcare|UNITED HEALTHCARE|||||482.12||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|United Healthcare|GOLDEN RULE|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|United Healthcare|UNITED HEALTHCARE|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Tricare|TRICARE EAST REGION|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|482.12||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||529.24||| Q9957|ERX|0636|PERFLUTREN PROTEIN-A MICR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.90||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Managed Medicare|BCBS MEDICARE PPO MA|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Veterans Affairs|VETERANS ADMINISTRATION|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||482.12||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|4.35||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Humana Medicare Advantage|HUMANA MA|482.12||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Cigna|CIGNA|||||482.12||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Cigna|CIGNA|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||482.12||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4.35||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Aetna|BOON CHAPMAN|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Aetna|AETNA PPO|||||529.24||| Q9957|EAP|0483|DEFINITY 1.3ML VIAL|Aetna|AETNA OTHER|||||529.24||| Q9957|ERX|0636|PERFLUTREN PROTEIN-A MICR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.90||| Q9967|EAP|0255|ISOVUE 370 PER ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Aenta Medicare Advantage|AETNA MEDICARE MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Blue Cross HMO Specialty|BCBSTX HMO|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Blue Cross HMO Specialty|BCBSTX HMO|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Aetna|AETNA PPO|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Blue Cross PPO Specialty|BCBSTX PPO|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Blue Cross PPO Specialty|BCBSTX PPO|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Cigna|CIGNA|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Cigna|CIGNA|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Humana Medicare Advantage|HUMANA MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Humana Medicare Advantage|HUMANA MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Managed Medicaid|MEDICAID SUPERIOR|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Managed Medicaid|MEDICAID AMERIGROUP|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicaid|MEDICAID SUPERIOR|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicaid|MEDICAID AMERIGROUP|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Medicare Advantage|UHC MEDICARE GOLD MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|ChampVA|CHAMPVA CENTER|0.75||||||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Veterans Affairs|VETERANS ADMINISTRATION|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Veterans Affairs|VETERANS ADMINISTRATION|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Healthcare|UNITED HEALTHCARE OTHER|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|United Healthcare|UNITED HEALTHCARE|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Healthcare|UNITED HEALTHCARE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Healthcare|UNITED HEALTHCARE|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Tricare|TRICARE EAST REGION|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Aetna|AETNA PPO|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Tricare|TRICARE EAST REGION|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|NON CONTRACTED|COMMERCIAL OTHER 1|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Medicaid|MEDICAID|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Medicaid|MEDICAID HMO|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Medicaid|MEDICAID|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Managed Medicare|HEALTHSPRING MA|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Managed Medicare|WELLCARE CHOICE MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicare|HEALTHSPRING MA|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicare|BCBS MEDICARE PPO MA|0.75||||||| Q9967|EAP|0255|ISOVUE 370 PER ML|Medicare|MEDICARE ACUTE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Medicare|MEDICARE PART B ONLY IP|0.75||||||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Medicare|MEDICARE ACUTE|0.75||||0.75||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Managed Medicaid|MEDICAID SUPERIOR|0.25||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Medicaid|MEDICAID|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Managed Medicare|HEALTHSPRING MA|0.25||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|NON CONTRACTED|ZZZZZ LIABILITY INS OTHER 1|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Medicare|MEDICARE ACUTE|0.25||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|PHCS|HUMANA INSURANCE|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|United Healthcare|UNITED HEALTHCARE|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|United Healthcare|TML GROUP BENEFITS|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Tricare|TRICARE FOR LIFE|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Tricare|TRICARE EAST REGION|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.25||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.25||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.25||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Managed Medicare|BCBS MEDICARE PPO MA|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Veterans Affairs|VETERANS ADMINISTRATION|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Blue Cross PPO Specialty|BCBSTX PPO|0.25||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|ChampVA|CHAMPVA CENTER|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Humana Medicare Advantage|HUMANA MA|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Cigna|CIGNA|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Blue Cross HMO Specialty|BCBSTX HMO|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Aetna|BOON CHAPMAN|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Aetna|AETNA PPO|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Aetna|AETNA OTHER|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.25||| Q9969|EAP|0636|NON HEU TC99 ADD ON DOSE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.25||| U0001|EAP|0300|COVID - 19PCR|Blue Cross PPO Specialty|BCBSTX PPO|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Humana Medicare Advantage|HUMANA MA|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|AARP UHC WEST COMPLETE MA|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Medicare|MEDICARE ACUTE|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.80||| U0001|EAP|0300|COVID - 19PCR|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.80||| U0001|EAP|0300|COVID - 19PCR|United Healthcare|UNITED HEALTHCARE|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Tricare|TRICARE EAST REGION|||||1.80||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|MEDICAID|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||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|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicare|MEDICARE ACUTE|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|NON CONTRACTED|COMMERCIAL OTHER 2|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Healthcare|UNITED HEALTHCARE OTHER|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Healthcare|UNITED HEALTHCARE|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||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|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|Workers Compensation|UT EMPLOYEE INJURY|||||1.54||| 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|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Veterans Affairs|VETERANS ADMINISTRATION|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Cigna|CIGNA|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|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 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 SUPERIOR|||||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|Medicaid|MEDICAID HMO|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicaid|MEDICAID AMERIGROUP|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross HMO Specialty|BCBSTX HMO|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Aetna|AETNA PPO|||||1.54||| 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 LAB TEST NON-CDC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.54|||